a SLACK Incorporated newspaper
February 1999
NEW YORK CITY - For children, outpatient parenteral antibiotic therapy allows early home discharge. Additionally, it is cost-effective, and many infections can be treated on an outpatient basis as long as skilled nursing care is not required.
"However, safeguards must be incorporated into each home nursing program to guarantee a high standard of care," said John Bradley, MD, at the recent 11th Annual Infectious Diseases in Children Symposium held here.
In this era of managed care, hospitals and physicians are looking for less expensive ways to administer antibiotics, and an outpatient location is less expensive than an inpatient location.
"However, you must keep in mind that you need to use safe drugs. Using a more toxic drug just so you can go outpatient doesn't really make sense. Having toxicities adds to the cost of the care of the patient. If you fail in outpatient therapy, the child will need to be retreated. That's an extra cost in addition to being unethical," added Bradley, director of the division of infectious diseases at Children's Hospital of San Diego and associate professor of pediatrics at the University of California at San Diego.
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When determining which children are candidates for outpatient parenteral antibiotic therapy, both medical and social criteria must be met. "The patients must be clinically stable and cannot need skilled nursing observation and care. So, you can have the unskilled but caring parent observe a child," he said.
In terms of social criteria, the parents need to be interested and motivated. In addition, they need to be capable of observing the child.
"Some very nice, well-meaning parents may not have the ability to closely track potential complications and cannot be trusted in this situation," Bradley said.
The home environment must be acceptable. Discharge planning nurses go into some specifics with the parents about what facilities they must have: running water, refrigerator, stove. Parents should also be able to contact the healthcare provider if there is a problem. They are not required to have phones in their homes; one close by would do. Additionally, parents must have transportation available to get back to the hospital if needed, he explained.
Bradley said that at Children's Hospital of San Diego, the doctor makes the decision of whether the patient is stable enough for home antibiotic therapy. A discharge planning evaluator then interacts with both the physicians and the parents.
"Once the patient is stable enough, the parents are agreeable and the discharge planning nurse sees that everything will work, then the home care nurse is contacted. This may be either our hospital's own home care nursing service or another nursing service. Costs for home nursing visits come close to but don't exceed that of a day of hospitalization. However, physicians need to understand that the quality of people in these home nursing care agencies is not standardized, and there is no law that says that the home nursing agency needs to tell you if it has a pediatric-trained nurse," he said.
Parents are taught how to infuse the antibiotic in the hospital, and the home care nurse is responsible for keeping the physician informed about the treatment, even if the child does not require daily visits.
Virtually any infection can be treated in the home as long as the patient meets the medical and social criteria. Pneumonia patients are kept in the hospital until they no longer need oxygen.
"If their fevers are coming down, yet we want to keep parenteral therapy going for a little while longer, we send them home on outpatient therapy. We don't always switch them over to oral therapy, which does work in a some cases," Bradley said.
He recommends daily nursing visits for neonatal infections because it ensures that the baby is not having subtle seizures or poor feeding. While outpatient IV therapy has many benefits, it also has risks. "Patients can get worse at home related to the infection, related to the catheter or related to therapy. These happen very rarely, however, and we've had no long-term significant complications in our program. The biggest problem is the family not being at home at the time of the home nursing visits," he said.
Outpatient intravenous (IV) therapy can be used when oral antibiotic therapy is not an option due to noncompliance of the parent or the child.
"We've had a few cases of osteomyelitis over the years where you know what the organism is, you know the medicine works really well, and you give the parent the prescription and he or she doesn't get it filled. Two weeks later, the child is still febrile. In other cases where you know in the beginning the parents are not going to be compliant, parenteral therapy is the only way to go," he explained. "Our job is to make sure that these kids are treated, and we have to do it the best way we know how, not the cheapest way."
Another indication for home paren teral therapy is for the child with vomiting or diarrhea, when absorption of a drug given orally will be hindered. Yet another instance where parenteral therapy is helpful is for patients in whom you cannot get enough drug into the bloodstream to get a response, such as deep tissue infections or abscesses.
For more information:
- Bradley. J. Home IV antibiotic therapy: medical, social and cost considerations. Presented at the 11th Annual Infectious Diseases in Children Symposium. Nov. 21-22, 1998. New York City.
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