January 2013 Issue

Parenteral Nutrition Home-Starts — Learn How RDs Can Help Patients Safely Begin PN Care at Home
By Sandra I. Austhof, MS, RD, LD, CNSC
Today’s Dietitian
Vol. 15 No. 1 P. 14

People unable to use their gastrointestinal (GI) tract due to intestinal failure require parenteral nutrition (PN). PN, the administration of IV nutrients, is a potentially lifesaving therapy that, when required long-term, can be administered safely in the home to allow people to live higher-quality lives.1

Some clinicians believe PN should always be started in a hospital setting where patients can be closely monitored to avoid potential complications such as refeeding syndrome, which causes electrolyte imbalances of serum phosphorous, potassium, and magnesium that can potentially lead to heart failure or other life-threatening conditions.

However, many home infusion companies have safely and successfully started PN at home in patients with mild to moderate electrolyte abnormalities by correcting these electrolytes before PN infusion.2 This allows the patient to be more comfortable and avoids the risk of possible exposure to hospital-acquired infections while reducing overall healthcare costs.

One of the earliest reports on transitioning PN from the hospital to the home was documented 40 years ago.3 Due to technological advances in access devices, infusion pumps, home care agency creation, and reimbursement strategies, select patients have been starting PN in the comfort of their homes for the past 20 years.4 In fact, data spanning the last 10 years have estimated that 39,000 patients receive PN at home each year.1 Home-start PN can save nearly $2,000 per day in healthcare costs compared with receiving IV feeding in the hospital.5

Whether a patient begins PN in the hospital or at home, a knowledgeable interdisciplinary team must develop a care plan with the patient that includes the indication for home PN, the approximate length of time the therapy is needed, the end point of therapy, and nutritional goals.6

This article will take a closer look at home-start PN and evaluate its benefits in comparison with hospital-start PN as well as discuss the role dietitians can play in preparing the patient and family for PN care in the home setting.

Evaluating the Home Environment
Once a physician determines a patient is a good candidate for home PN, a home infusion nurse first assesses the patient’s home environment for cleanliness, sanitary water supply, electricity, refrigeration, adequate storage space for supplies, and telephone access.7 The nurse also assesses whether the patient or caregiver is capable of administering home PN therapy and verifies insurance coverage. If the patient is in the hospital, a social worker, PN nurse, and nurse case manager meet with the patient and family at the bedside to assess the home environment and insurance coverage for home PN care.

Home PN Education
Once it’s considered safe to administer home PN, qualified healthcare nurses begin educating the patient and family about what it entails. The patient or a family member is chosen as the primary caregiver who must demonstrate competence in preparing and administering PN, which includes infection control, caring for the vascular access device, connecting and disconnecting the IV tubing, safely incorporating additives, and properly storing supplies.7 For hospital-start PN patients, the PN nurse educates the patient and family at the bedside, and a visiting nurse continues the instruction at home.

All patients receive three consecutive days of lessons in the home. Once the home infusion nurse determines the primary caregiver can implement PN procedures, the nurse will make weekly visits.

Advantages of Hospital-Start PN
Most patients discharged from the hospital on PN weren’t admitted specifically to start PN but for unrelated medical or surgical reasons that resulted in the need for home PN care.

Due to safety concerns, clinicians often prefer hospital-start PN. High-risk patients who would benefit from hospital-start PN include infants, the elderly, IV drug users, patients with fluid and electrolyte disorders, those with uncontrolled diabetes or major organ dysfunction, or those at high risk of refeeding syndrome.7,8

Replacing fluid and electrolytes before initiating PN and then starting PN with a low carbohydrate load can prevent refeeding syndrome. Rex Speerhas, RPh, BCNSP, a clinical nutrition specialist at the Cleveland Clinic, says, “The patient can be treated much more promptly and effectively in the hospital setting with frequent intravenous electrolyte supplementation.” The bedside nurse and primary care physician also can closely monitor the patient.

Another concern is hyperglycemia, the most common side effect in preparing a patient for cyclic home PN.9 “When a patient is initiated in the hospital setting, blood glucose levels can be monitored much more frequently, thus episodes of hyperglycemia can be immediately treated with insulin or avoided completely,” Speerhas says, adding that to achieve the same quality of care, close monitoring in the home setting would require the presence of a healthcare professional around the clock. The testing supplies needed would quickly become very costly to the patient.

The hospital dietitian’s role in preparing the patient for home PN involves stabilizing and cycling the PN formula by monitoring daily vital signs, electrolytes, glucose levels, intake and output records, and weights. This usually takes three to six days to complete. PN is started at full protein needs with one-half of the dextrose load infused continuously over 24 hours. Lipids usually are given separately. Shortening the infusion time by four hours each day over three consecutive days or six hours each day for two consecutive days can cycle PN from 24 to 12 hours. In stable, select patients, PN can be cycled from 24 to 12 hours over one day.

Advantages of Home-Start PN
While hospital-start PN has its advantages, home-start PN also has its benefits. Home-start PN enables patients to learn about PN in the comfort of their home plus they have fewer hospital expenses and don’t have to worry about hospital-acquired infections.10 The decision to initiate PN in the home depends on patients’ clinical stability, whether they have a need for PN, whether a nurse can evaluate them in their home, and whether a caregiver can safely administer the therapy.7

Patients who can receive home PN care are those who either don’t have a chronic illness or have a chronic illness that’s well controlled, such as cancer, HIV, hyperemesis gravidarum, or GI disorders; those with bariatric surgery complications; or those with failed enteral nutrition.8,10

Many home infusion companies that provide home-start PN services have experienced dietitians, nurses, and pharmacists working for them who can offer quality care to patients and have a track record of successfully initiating PN in the home, bypassing hospital admission.

Walgreens Infusion Services, the nation’s largest infusion provider, initiates home PN with at least one patient almost every day. According to Noreen Luszcz, RD, MBA, CNSC, Walgreens’ nutrition program director, the key to the company’s success is its multidisciplinary team approach, slow progression of starting PN, and ongoing communication with the team, patient, and physician. Slow progression means that macronutrients, especially dextrose, are started at a reduced concentration to prevent complications such as hyperglycemia or electrolyte imbalances.

Once Walgreens receives a referral from a physician’s office or clinic, a dietitian and a nurse become actively involved in the initial home visit. The dietitian completes a comprehensive nutrition assessment and determines needs and formula recommendations.

Choosing appropriate patients for home-start PN is essential. Luszcz reports that high-risk patients, such as those with uncontrolled diabetes, high GI losses, or multiple organ failure, usually are referred to hospital-start PN. When beginning PN in the home, however, Luszcz says Walgreens’ patients begin with reduced protein, dextrose, and lipids infused over 24 hours. Daily weights, lab data, and intake and output records are closely monitored.

Once the patient is stabilized, which can take several days, PN is slowly increased to provide the full amount of macronutrients. PN is reduced to 18 hours and eventually to eight to 12 hours once the patient is stabilized on full PN. Some home infusion companies, such as ThriveRx, start low-calorie PN over 12 to 18 hours at a reduced rate for younger, stable patients, according to Donna Kloth, RN, CRNI, CNSC, a nutrition liaison with ThriveRx. “By carefully monitoring the patient, we slowly advance the PN formulation to goal, which usually takes a week,” she explains.

To prevent refeeding syndrome, home infusion companies usually have protocols that involve administering replacement fluids and electrolytes in the home before starting PN. In one study, Walgreens showed that patients at risk of refeeding syndrome can safely begin home PN, eliminating the need for hospital admission.2 In this small, retrospective study, 15 high-risk patients were started on 25% of dextrose needs for the first three to four days. Once the patients were stabilized, 50% of dextrose needs were given for another three to four days. Researchers closely monitored lab results, and patients reached their PN goal needs.

Safe Alternative
Patients have been started safely on PN in the hospital setting and at home for many years. The key to this success has been the experience of knowledgeable interdisciplinary healthcare teams consisting of physicians, dietitians, nurses, and pharmacists. With the advances in standards of care, equipment, and specialized home infusion services, patients can start IV nutrition at home, allowing for continued daily activities and increased quality of life.

— Sandra I. Austhof, MS, RD, LD, CNSC, is a nutrition support dietitian at the Cleveland Clinic and has worked in the field for more than 30 years.

 

Acknowledgement
The author would like to extend a special thanks to Kaylee Adams, a PharmD candidate at Ohio Northern University, for her assistance in the research of this article.

 

References
1. Ireton-Jones C, DeLegge MH, Epperson LA, Alexander J. Management of the home parenteral nutrition patient. Nutr Clin Pract. 2003;18(4):310-317.

2. Jansson L, Brand S, Monahan R, Knowles S. Home start parenteral nutrition—yes we can! Presented at: American Society for Parenteral and Enteral Nutrition Clinical Nutrition Week; January 21-24, 2012; Orlando, FL.

3. Jeejeebhoy KN, Zohrab WJ, Langer B, Phillips MJ, Kuksis A, Anderson GH. Total parenteral nutrition at home for 23 months, without complication, and with good rehabilitation. A study of technical and metabolic features. Gastroenterology. 1973;65(5):811-820.

4. Sanville MH. Initiating parenteral nutrition therapy in the home. J Intraven Nurs. 1994;17(3):119-126.

5. Ireton-Jones C, Hamilton KS, DeLegge MH. Improving clinical and financial outcomes with parenteral nutrition therapy. Support Line. 2009;31(1):23-25.

6. Kirby DF, Corrigan ML, Speerhas RA, Emery DM. Home parenteral nutrition tutorial. JPEN J Parenter Enteral Nutr. 2012;36(6):632-644.

7. Kovacevich DS, Frederick A, Kelly D, Nishikawa R, Young L. Standards for specialized nutrition support: home care patients. Nutr Clin Pract. 2005;20(5):579-590.

8. Crocker KS, Ricciardi C, DiLeso M. Initiating total parenteral nutrition at home. Nutr Clin Pract. 1999;14:124-129.

9. Suryadevara S, Celestin J, DeChicco R, et al. Type and prevalence of adverse events during the parenteral nutrition cycling process in patients being prepared for discharge. Nutr Clin Pract. 2012;27(2):268-273.

10. Newton AF, DeLegge MH. Home initiation of parenteral nutrition. Nutr Clin Pract. 2007;22(1):57-64.

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