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“PICC”ING a Non-Traditional Aproach to Initiating and Managing Total Parenteral Nutrition (TPN)
Summer 1997
"PICC"ING A NON-TRADITIONAL APROACH TO INITIATING AND MANAGING TOTAL PARENTERAL NUTRITION (TPN)
B
eing proactive in the initiation and management of TPN for secondary exacerbations of Crohn's/Colitis in alternative sites promotes patient comfort, compliance and cost efficiency. Maintaining quality care while maximizing available health resource dollars is an ever increasing challenge.
With the
appropriate, well-motivated patient and physician's assessment and management, we minimize an expensive hospitalization.
By
N. Weiner, eRNI, D. Phillips, BSN, P. Farkas, MD-Gastroenterology Apria Healthcare Group CApria)*, Springfie1d, MA, 01107.
c.
~ L..---------------------------------------"7"""'Volume 2 No. 2
•
Summer 1997
Our process includes: •
• • •
• • • •
Advanced patient screening to establish a relationship, discuss plan of care, and set up start of care appointment Assessment, teaching and PICC insertion visit at physician's office or out-patient department X-ray confirmation of superior vena cava endpoint and initiation of therapy with an ambulatory pump Continuous TPN infusion for 3-5 days, then titration every other day by 4 hours to a 10-12 hour cyclic regime Set up and infusion independence achieved in 3-4 days PICC maintenance, assessment, and lab draws twice per week Maintenance of PICC for 10-14 days after therapy complete PICC removal at home if ordered by physician
This approach reduces cost to the third party payors. PICC placement costs approximately $200-$300 versus the $1,500$2,000 for central line placement and saves about $1,200$1,700 per hospital day depending on region and payor plan. The co-payments and intangible costs incurred by patient and family with hospitalization can also be reduced. Patients are able to return to work sooner. The patient's level and perception of "wellness" is optimized by getting him/her involved at the outset and returning him to "normal" activities. This process is a viable alternative to traditional TPN initiation management. Apria's team approach (clinical, sales, management) works with physicians and managed care organizations to develop pathways of care. Highly skilled clinical professionals act as patient advocates and make decisions to effect positive outcomes. As partners focusing on the patient's sphere of needs, we help develop community healthcare practices.
PICC'ing to Avoid Hospitalizations PICC (Peripherally inserted central catheter): Outpatient use as part of a strategy to avoid hospitalization The use of central venous catheters (CVCs) has become commonplace for increasing numbers of hospital and outpatient clients.! It has been estimated that 5 million CVCs are used in the United States each year. 2 As insertion of traditional "central lines" has been associated with major complications such as pneumothorax or hemothorax, there
-. o
~
Volume 2 No. 2
has been recent increasing interest in the use of peripherally inserted central catheters (PICCs) to achieve the same therapeutic benefits without their high rate of complications. These are thin (2,3,4, and 5Fr.) silicon, polyurethane or hydrophilic catheters generally inserted in the antecubital region and advanced until the tip is in the superior vena cava (SVC). Although inserted peripherally, they permit the administration of even highly concentrated solutions like total parenteral nutrition (TPN) because of the large diameter of the vessel. Some of the additional benefits of PICC use are the reduced cost and the ability to have the device inserted in the physician's office, avoiding any hospitalization.
Case Presentation MJ was a 43 year old male with a ten year history of Crohn's Disease who presented with increased symptoms of abdominal pain, nausea, anorexia, and diarrhea. He was taking Asacol 2 tabs BID, along with multivitamins. There was no other remarkable medical history. Physical examination was unremarkable except for a somewhat diffusely tender abdomen without masses, guarding, rebound, or rigidity. Rectal examination showed some brown, heme-negative stool. Laboratory studies included stools negative for culture and Clostridia Difficile Toxin, slightly elevated WEC of 15,800/mm3.3 A KUB was unremarkable. He was started on a clear liquid diet and 60mg of Prednisone a day. A re-evaluation was done in two days which revealed no significant improvement. MJ complained of increasing anorexia and the physical exam was essentially unchanged. The patient was offered hospitalization or out-patient management with parenteral medications and TPN. He was strongly in favor of trying home therapy. The home infusion company referral was made. They met the patient the follOWing day in the office. After discussion of the plan and the patient's agreement, a PICC was inserted, an x-ray for placement taken, and the patient started on TPN and Solumedrol 20mg IV TID. Over the next week patient experienced dramatic improvement. Oral steroids were re-instituted in a few days. MJ remained on TPN for a week, then was slowly weaned.
Protocol The start-up protocol used involves: • Advanced patient screening by the physician to determine medical suitability for out-patient management. • Nurses from the home infusion team meeting with the patient at the phYSician's office for initial discussion and explanation of the therapy plan. • Insertion of the PICC and radiographic confirmation of
Summer 1997
• •
tip placement in the SVc. Initiation of continuous TPN on an ambulatory pump and possibly initial steroid dosing. Initial patient teaching for parenteral medication, TPN, alarms and potential problem troubleshooting.
The continuing protocol includes: • Follow-up teaching in the home until the patient is comfortable and independent. • 24-hour on-call pharmacy, nursing, and delivery services. • Infusion of continuous TPN for 3-5 days, then titration every other day until able to establish a 10-12 hour regime. • PICC maintenance, patient assessment, and lab draws once or twice per week as ordered by the physician (generally 2-3 times the first week, then once thereafter). The PICC will generally be left in place for a period of time after completion. Although some authors have reported problems with PICC removal, i.e. vascular spasms,' fibrin formation and or endothelial thrombosis,5 usually the line can be removed by the home infusion team in the patient's home.
Benefits and Considerations Traditional central line placement generally involves surgical consultation and placement in a hospital or surgical center with total costs ranging from $1,500-$2,000 depending on payor plan and location. Hospitalization for therapy can cost several hundred dollars per day along with incidental costs to patient and family not covered by most plans. PICC placement by a trained nurse in the physician's office can cost variably between $200-$300. Radiographic confirmation and line maintenance costs are comparable for each type of line. Although safer than traditional subclavian or internal jugular catheters, PICe's can be associated with complications. In addition to the risks of occlusion of the line, infection, and mechanical defects in the catheter,6 development of thrombus,' and catheter fracture have been reported. In a study of 322 consecutively inserted PICC lines, Loughran and Borzatta8 reported rates of infection and central venous thrombosis of less than 1%. PWebitis occurred in 9.7% of patients and catheter fracture occurred in 9.7% also.
they effect posItIve outcomes and help develop new community practices. PICCs allow out-patient management of patients who might require TPN, prolonged hydration, Safe insertion and chemotherapy, or antibiotics. management of the PICC and therapy involves establishing protocols, careful management by an experienced home infusion team, and close physician cooperation. With this it would seem that out-patient PICC inserti<:m and use has the potential to greatly reduce costs, increase patient comfort, safety. Patient acceptance and compliance has been excellent, aVOiding expensive hospitalization completely.
1.
2.
3.
4.
5.
6. 7.
8.
Baranowski, 1. Central Venous Access Devices: Current technologies, uses and management strategies. J Intravenous Nursing 1993;16(3):167-93. Ryder, M.A. Peripherally inserted central venous catheters. Nurs. Clin. North Amer. 1993; Dec. 28(4):93771. Weiner, N.K., Phillips, D., Farkas, P. "PICC"ing a nontraditional approach to initiating and managing total parenteral nutrition (TPN). NAVAN Conference Abstract Sept. 1995. Marx, M. The management of the difficult peripherally inserted central venous catheter line removal. J Intravenous Nursing 1995; Sept-Oct. 18(5):246-9. Wall, ].1., Kierstead, VL. Peripherally irtserted central catheters: resistance to removal: a rare complication. J Intravenous Nursing 1995; Sept-Oct. 18(5):251-4. Chiat, P.G., Ingram, ]. Peripherally irtserted catheters in children. Radiology 1995 (2), 197(3);775-8. Jepsin S.T. Endothelial thrombus formation: an unusual complication related to peripherally irtserted central catheters. Nutr. Clin. Pract. 1995; June 10(3); 120-2. Loughran, S.c., Borzatta, M. Peripherally inserted catheters: a report of 2506 catheter days. ]. Parenteral Enteral Nutr. 1995; 19(2): 133-6.
Dr. Paul Farkas is a board certified Gastroenterologist in private practice in Springfield, MA.
Darlene A. Phi/lips, RN, BSN, MSH is an Account Executive with Apria Healthcare in Springfield, MA and has had prior experience in critical care and infection control nursing. Nancy K. Weiner, eRN! is a staffnurse with Apria Healthcare in Springfield, MA with 10 years home infUSion experience and prior medical surgical nursing.
Conclusions In this era of managed care, the home infusion team has become an extension of the physician's practice. Together
• Abbey Healthcare/Protocare has merged with Homedco and became Apria since abstract originally submitted. Volume 2 No. 2
"PICC"ING A NON-TRADITIONAL APROACH TO INITIATING AND MANAGING TOTAL PARENTERAL NUTRITION (TPN)
B
eing proactive in the initiation and management of TPN for secondary exacerbations of Crohn's/Colitis in alternative sites promotes patient comfort, compliance and cost efficiency. Maintaining quality care while maximizing available health resource dollars is an ever increasing challenge.
With the
appropriate, well-motivated patient and physician's assessment and management, we minimize an expensive hospitalization.
By
N. Weiner, eRNI, D. Phillips, BSN, P. Farkas, MD-Gastroenterology Apria Healthcare Group CApria)*, Springfie1d, MA, 01107.
c.
~ L..---------------------------------------"7"""'Volume 2 No. 2
•
Summer 1997
Our process includes: •
• • •
• • • •
Advanced patient screening to establish a relationship, discuss plan of care, and set up start of care appointment Assessment, teaching and PICC insertion visit at physician's office or out-patient department X-ray confirmation of superior vena cava endpoint and initiation of therapy with an ambulatory pump Continuous TPN infusion for 3-5 days, then titration every other day by 4 hours to a 10-12 hour cyclic regime Set up and infusion independence achieved in 3-4 days PICC maintenance, assessment, and lab draws twice per week Maintenance of PICC for 10-14 days after therapy complete PICC removal at home if ordered by physician
This approach reduces cost to the third party payors. PICC placement costs approximately $200-$300 versus the $1,500$2,000 for central line placement and saves about $1,200$1,700 per hospital day depending on region and payor plan. The co-payments and intangible costs incurred by patient and family with hospitalization can also be reduced. Patients are able to return to work sooner. The patient's level and perception of "wellness" is optimized by getting him/her involved at the outset and returning him to "normal" activities. This process is a viable alternative to traditional TPN initiation management. Apria's team approach (clinical, sales, management) works with physicians and managed care organizations to develop pathways of care. Highly skilled clinical professionals act as patient advocates and make decisions to effect positive outcomes. As partners focusing on the patient's sphere of needs, we help develop community healthcare practices.
PICC'ing to Avoid Hospitalizations PICC (Peripherally inserted central catheter): Outpatient use as part of a strategy to avoid hospitalization The use of central venous catheters (CVCs) has become commonplace for increasing numbers of hospital and outpatient clients.! It has been estimated that 5 million CVCs are used in the United States each year. 2 As insertion of traditional "central lines" has been associated with major complications such as pneumothorax or hemothorax, there
-. o
~
Volume 2 No. 2
has been recent increasing interest in the use of peripherally inserted central catheters (PICCs) to achieve the same therapeutic benefits without their high rate of complications. These are thin (2,3,4, and 5Fr.) silicon, polyurethane or hydrophilic catheters generally inserted in the antecubital region and advanced until the tip is in the superior vena cava (SVC). Although inserted peripherally, they permit the administration of even highly concentrated solutions like total parenteral nutrition (TPN) because of the large diameter of the vessel. Some of the additional benefits of PICC use are the reduced cost and the ability to have the device inserted in the physician's office, avoiding any hospitalization.
Case Presentation MJ was a 43 year old male with a ten year history of Crohn's Disease who presented with increased symptoms of abdominal pain, nausea, anorexia, and diarrhea. He was taking Asacol 2 tabs BID, along with multivitamins. There was no other remarkable medical history. Physical examination was unremarkable except for a somewhat diffusely tender abdomen without masses, guarding, rebound, or rigidity. Rectal examination showed some brown, heme-negative stool. Laboratory studies included stools negative for culture and Clostridia Difficile Toxin, slightly elevated WEC of 15,800/mm3.3 A KUB was unremarkable. He was started on a clear liquid diet and 60mg of Prednisone a day. A re-evaluation was done in two days which revealed no significant improvement. MJ complained of increasing anorexia and the physical exam was essentially unchanged. The patient was offered hospitalization or out-patient management with parenteral medications and TPN. He was strongly in favor of trying home therapy. The home infusion company referral was made. They met the patient the follOWing day in the office. After discussion of the plan and the patient's agreement, a PICC was inserted, an x-ray for placement taken, and the patient started on TPN and Solumedrol 20mg IV TID. Over the next week patient experienced dramatic improvement. Oral steroids were re-instituted in a few days. MJ remained on TPN for a week, then was slowly weaned.
Protocol The start-up protocol used involves: • Advanced patient screening by the physician to determine medical suitability for out-patient management. • Nurses from the home infusion team meeting with the patient at the phYSician's office for initial discussion and explanation of the therapy plan. • Insertion of the PICC and radiographic confirmation of
Summer 1997
• •
tip placement in the SVc. Initiation of continuous TPN on an ambulatory pump and possibly initial steroid dosing. Initial patient teaching for parenteral medication, TPN, alarms and potential problem troubleshooting.
The continuing protocol includes: • Follow-up teaching in the home until the patient is comfortable and independent. • 24-hour on-call pharmacy, nursing, and delivery services. • Infusion of continuous TPN for 3-5 days, then titration every other day until able to establish a 10-12 hour regime. • PICC maintenance, patient assessment, and lab draws once or twice per week as ordered by the physician (generally 2-3 times the first week, then once thereafter). The PICC will generally be left in place for a period of time after completion. Although some authors have reported problems with PICC removal, i.e. vascular spasms,' fibrin formation and or endothelial thrombosis,5 usually the line can be removed by the home infusion team in the patient's home.
Benefits and Considerations Traditional central line placement generally involves surgical consultation and placement in a hospital or surgical center with total costs ranging from $1,500-$2,000 depending on payor plan and location. Hospitalization for therapy can cost several hundred dollars per day along with incidental costs to patient and family not covered by most plans. PICC placement by a trained nurse in the physician's office can cost variably between $200-$300. Radiographic confirmation and line maintenance costs are comparable for each type of line. Although safer than traditional subclavian or internal jugular catheters, PICe's can be associated with complications. In addition to the risks of occlusion of the line, infection, and mechanical defects in the catheter,6 development of thrombus,' and catheter fracture have been reported. In a study of 322 consecutively inserted PICC lines, Loughran and Borzatta8 reported rates of infection and central venous thrombosis of less than 1%. PWebitis occurred in 9.7% of patients and catheter fracture occurred in 9.7% also.
they effect posItIve outcomes and help develop new community practices. PICCs allow out-patient management of patients who might require TPN, prolonged hydration, Safe insertion and chemotherapy, or antibiotics. management of the PICC and therapy involves establishing protocols, careful management by an experienced home infusion team, and close physician cooperation. With this it would seem that out-patient PICC inserti<:m and use has the potential to greatly reduce costs, increase patient comfort, safety. Patient acceptance and compliance has been excellent, aVOiding expensive hospitalization completely.
1.
2.
3.
4.
5.
6. 7.
8.
Baranowski, 1. Central Venous Access Devices: Current technologies, uses and management strategies. J Intravenous Nursing 1993;16(3):167-93. Ryder, M.A. Peripherally inserted central venous catheters. Nurs. Clin. North Amer. 1993; Dec. 28(4):93771. Weiner, N.K., Phillips, D., Farkas, P. "PICC"ing a nontraditional approach to initiating and managing total parenteral nutrition (TPN). NAVAN Conference Abstract Sept. 1995. Marx, M. The management of the difficult peripherally inserted central venous catheter line removal. J Intravenous Nursing 1995; Sept-Oct. 18(5):246-9. Wall, ].1., Kierstead, VL. Peripherally irtserted central catheters: resistance to removal: a rare complication. J Intravenous Nursing 1995; Sept-Oct. 18(5):251-4. Chiat, P.G., Ingram, ]. Peripherally irtserted catheters in children. Radiology 1995 (2), 197(3);775-8. Jepsin S.T. Endothelial thrombus formation: an unusual complication related to peripherally irtserted central catheters. Nutr. Clin. Pract. 1995; June 10(3); 120-2. Loughran, S.c., Borzatta, M. Peripherally inserted catheters: a report of 2506 catheter days. ]. Parenteral Enteral Nutr. 1995; 19(2): 133-6.
Dr. Paul Farkas is a board certified Gastroenterologist in private practice in Springfield, MA.
Darlene A. Phi/lips, RN, BSN, MSH is an Account Executive with Apria Healthcare in Springfield, MA and has had prior experience in critical care and infection control nursing. Nancy K. Weiner, eRN! is a staffnurse with Apria Healthcare in Springfield, MA with 10 years home infUSion experience and prior medical surgical nursing.
Conclusions In this era of managed care, the home infusion team has become an extension of the physician's practice. Together
• Abbey Healthcare/Protocare has merged with Homedco and became Apria since abstract originally submitted. Volume 2 No. 2