Patients’ experiences of community IV therapy Abstract
Aim: To explore patients’ experiences of receiving community intravenous therapy (CIVT) compared with traditional inpatient hospital care. Method: The study used a qualitative descriptive methodology. Semi-structured interviews were conducted with eight participants, transcribed verbatim and thematically analysed. Results: Five themes were identified: ‘finances’; ‘travelling’; ‘hospital admission’; ‘being at home’; and ‘safety’. Discussion: The study revealed that participants felt privileged and valued when they were treated at home. CIVT allowed them the comfort of being in a familiar environment and the convenience of doing what they wanted, when they wanted. Conclusion: This study concurs that patients do prefer to be treated at home rather than being admitted to secondary care. The findings from this study suggest that participants appreciated the opportunity to receive CIVT. Key words: Community intravenous therapy (CIVT) ■ Patient experience Being at home ■ District nurses
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C
ommunity intravenous therapy (CIVT) has been successfully treating patients, either at home or closer to home in community hospital outpatient clinics, since its inception in the 1980s, when it was first developed for children with cystic fibrosis (Nazarko, 2008; Higginson, 2011). Since then, CIVT has evolved for adults with conditions such as cellulitis, osteomyelitis, endocarditis and bronchiectasis to avoid acute admissions and reduce length of stay (LOS) (Higginson, 2011). The Department of Health (DH) (NHS Improvement, 2012) argued that it was necessary to move health and social care provision from an acute hospital environment to a community setting, which is local and more convenient for patients.The Health and Social Care Act (DH, 2012), Quality Innovation Productivity and Performance (QIPP, 2008) and clinical governance all provide the template for CIVT services by promoting the delivery of high-quality, personalised, patient-focused care, delivered closer to, or at home. Acute inpatient beds are expensive commodities (McKernan, 2008).To make savings, the number of acute beds
Becky Stephens is Community IV Therapy Nurse, Gloucestershire Care Service NHS Trust, Gloucester Accepted for publication: October 2013
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has been reduced, although demand remains high (Glasby and Littlechild, 2001; Mckernan, 2008; Nazarko, 2008).This deficit has been addressed by, first, reducing inappropriate admissions (Glasby and Littlechild, 2001; Lomas, 2009; Gloucestershire Care Services (GCS), 2010; NHS Improvement, 2012); second, by reducing the LOS of patients (Glasby and Littlechild, 2001; QIPP, 2008; Lomas, 2009; GCS, 2010; Kayley, 2011; NHS Improvement, 2012); third, by speeding up discharges (Kayley, 2008; GCS, 2010; Bossaer and Lewis, 2012; NHS Improvement, 2012); and, fourth, by the earlier identification of those patients who need multidisciplinary care (GCS, 2010). Three other research studies were identified and critiqued for the purpose of this research study: Esmond et al (2006), Parini et al (2010) and Sheppard et al (2008). Esmond et al (2006) used a quasi-experimental designed pilot study to compare hospital to home IV antibiotic therapy in London for adults with cystic fibrosis, using the CF-QoL (quality of life) questionnaire. Their data came from a sample of 30 patients—15 in hospital, 15 at home— who had previously self-administered home IV therapy. The investigators concluded that there were no differences between the two groups (hospital versus home), probably because acute exacerbations were not effectively treated and/or managed at home. Confusingly, the study went on to suggest that those patients receiving home treatment had greater improvement in QoL during their antibiotic treatment. It was unclear from the study whether the patients were offered home IV therapy or if the patient requested home IV therapy, so it is unclear in turn whether the service was driven by patients or by the healthcare environment. In a similar study, Parini et al (2010) recorded an improvement in QoL for patients receiving enzymereplacement therapy (ERT) at home in Italy. Parini et al (2010) did a national and regional survey of eleven ‘regional reference centres’. The regional survey included all patients receiving ERT for lyposomal storage diseases, such as Hunter syndrome, Gaucher’s disease, and so on. In their sample of 158 patients, 55 had received their treatment at regional centre, 96 in a local hospital and 7 at home. Parini et al (2010) concluded that ERT at home can restore independence, reduce the use of hospital resources and improve QoL for some patients. However, the under-representation of patients who were treated at home—just 7, compared with 151 patients who received ERT in a regional centre—could have skewed the results. Sheppard et al (2008) undertook a review and metaanalysis of the cost-effectiveness of managing patients at
© 2013 MA Healthcare Ltd
Becky Stephens
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 19 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 129.100.058.076 on September 15, 2016. Use for licensed purposes only. No other uses without permission. All rights reserved.
research home rather than through inpatient-hospital based care. Ten random control trials were identified, addressing mortality at 3 and 6 months after treatment, functional ability, cognitive ability and QoL. The research found that home-based care had significantly higher levels of patient satisfaction across a range of different conditions, such as cellulitis and community-acquired pneumonia (Sheppard et al, 2008).
Rationale/justification for this research Although other researchers have studied several different aspects of CIVT—establishing and commissioning CIVT services; cost-effectiveness of CIVT; and safe, effective service delivery—the researcher was unable to find any studies that explicitly explored patients’ experiences of receiving CIVT services. The researcher therefore decided, first, to ascertain what patients’ experiences of CIVT were and, second, to explore how such services benefited them.
Methods Taking into consideration the research aim to understand patients’ experiences of CIVT services, qualitative description was chosen as the research methodology. It is suitable for obtaining ‘straight’, unadorned answers (Sandelowski, 2000) and therefore for finding out what patients really thought about CIVT. Neergaard et al (2009) suggest that qualitative description is well-matched to small independent studies, when time and resources are both limited.
Ethics Ethics approval was granted from the National Research Ethics Service (NRES), GCS and the University of the West of England Faculty of Health and Social Sciences. Pseudonyms were chosen for each research participant that suitably matched their age, gender and personality (Gillham, 2005), as opposed to the assignment of numbers, such Participant 1.
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Sample Purposive sampling techniques were used by the researcher. Silverman (2010) suggests that while purposive sampling might allow the researcher to select a participant, it does not mean that the researcher is free to pick and choose their research participants. Consequently, the research sample was established with certain inclusion/exclusion criteria (Box 1). Those patients who met the inclusion criteria were contacted by telephone by a third party (i.e. not the researcher) and asked if they would be interested in receiving more detailed information about the research study. If the participant agreed, an invitation letter and patient information sheet were posted to them and their name and address passed to the researcher. A ‘cooling-off period’ of 7 to 10 days was left for the participant to discuss the research study with their significant other(s). The participant was then telephoned so that any questions that they might have could be answered, and an appointment was arranged. Eight participants were recruited and interviewed for this study. At the beginning of the interview, the researcher discussed the patient information sheet with the participant and
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 19
Box 1. Inclusion/exclusion criteria Inclusion criteria: ■■ Aged
40–65 years, male or female the care of Gloucestershire Care Services ■■ Referred to, accepted by and received treatment from the CIVT service ■■ Have capacity to consent to participating in the research study ■■ Under
Exclusion criterion ■■ Any
patient who is unable to read and/or speak English to a sufficient level to take part in the semi-structured interviews
Box 2. Interview schedule Question ■■ I understand
that you had antibiotic treatment at home. Could you tell me about your experience(s) of having this treatment at home? ■■ How did your illness affect you on a daily basis? ■■ Have you needed to go into hospital for similar treatment? How did this make you feel? ■■ Were you involved in the decisions concerning or having your antibiotic treatment at home? ■■ If given a choice, which option would you have preferred—hospital or home? ■■ What were your initial thoughts about receiving/continuing your antibiotic treatment at home? And would you say that those thoughts have changed now? ■■ Could you tell me, if at all, how receiving your antibiotic treatment at home was beneficial to you? ■■ Could you tell me, if at all, how receiving your antibiotic treatment at home was not beneficial to you? ■■ Thank you for talking to me today. We have covered a great deal of ground and you have been very patient. But before we end this interview, is there anything else you would like to add?
obtained informed written consent. All the interviews were conducted in the participants’ own home. The mean average length of the interview was 47 minutes. At each interview, the interview schedule was used to guide the interviews (Box 2), which were then digitally recorded, transcribed verbatim (word for word) and thematically analysed. The researcher did reflect on the first interview recording and transcription with her research supervisor. The data tree and its emergent themes were also discussed with the research supervisor.
Results and discussion Ten themes emerged from the initial data analysis. These were refined into five themes from the second and third transcript readings into a data tree. Each theme and its associated sub-themes enabled participants’ experiences to be explored in depth (Table 1).
Theme one: finances This theme encompasses two sub-themes: first, the financial impact on patients and their relatives; and, second, the appropriate use of hospital resources
Sub-theme: Cost to patients and relatives For two participants, John and Mike, finances had two different interpretations. John, who was treated at home for lower limb cellulitis and consequently avoided a hospital
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Conversely, Mike did not mind having to be in at the right time for the district nurses, as he thought that this was an easier option than being in hospital.
Table 1. Core themes Theme
Subtheme
One
Finances
Cost for patients and relatives Using hospital resources appropriately
Two
Travelling
Timekeeping Relatives travelling to visit participants
Three
Hospital admission
Accessing CIVT services Being in hospital Preventing healthcare-acquired infections
Four
Being at home
Camaraderie Normality and conveniences Patient choice
Five
Safety
Patient information District nurse training and competence
Sub-theme: relatives travelling to visit participants
‘basically when you are self-employed and not working you get no money coming in’ (John, lines 891–2).
Sub-theme: using hospital resources appropriately Three participants acknowledged that there is a requirement to use hospital resources appropriately. These participants were all treated for cellulitis at home and avoided admission into an acute inpatient bed. John suggested that ‘you aren’t exactly ill, it’s just that they had to administer antibiotics’ (line 954), while Christine agreed that a ‘big blown leg didn’t warrant a hospital admission’ (line 997) and that ‘it’s on the news today that the NHS are encouraging people to stay at home (Andrea, line 1644) as doing so would ‘leave that bed free for somebody who really, really needs it’ (Christine, line 1068).
And: ‘She couldn’t carry on doing it, I don’t think, she was getting ill as well with it’ (Mike, lines 333–4). As much as they valued their friends and family visiting them, both Neil and Mike could empathise with the effect it had: ‘It must be a real drag to keep coming into hospital’ (Neil, lines 678–9). And: ‘They used to take 30–40 minutes each way to visit me, and I told them not to bother but they did’ (Mike, lines 51–2).
Theme two – travelling
Theme three: hospital admission
Time spent travelling had different ramifications for different participants. However, it did influence the decisions that John and Christine made about being admitted to hospital or not:
Access to the service is facilitated by secondary care consultants or GPs. Participants’ experiences suggest some issues with the method of communication among the primary care, secondary care and CIVT services. Half of the participants discussed the referral process for CIVT. For those being discharged from secondary care, there was always an element of negotiation—and some frustrations.
‘I didn’t want a hospital admission to be honest because of the travelling’ (John, lines 1008–9). Five of the participants were admission-avoidance cases, like John and Christine, who were treated at home for cellulitis. Demographically, the majority of participants lived more than 20 miles (32 km) from the two regional hospitals in Cheltenham or Gloucester. Esmond et al (2006) advocated that families should not have to face enforced separation (sometimes of several miles) to be admitted to a regional hospital.
Sub-theme: timekeeping In exploring patients’ experiences of CIVT, some participants expressed the importance of good timekeeping by the health professionals delivering their treatments. Simon remarked: ‘that this was perhaps the only criticism I could make, that you didn’t know exactly when people were coming or more closely when they were going to come’ (Simon, lines 1856–8).
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‘Well, I made her only come in sort of every other or third day. Really to give her some life’ (Neil, lines 682–3).
Sub-theme: being in hospital Seven of the participants voiced strong opinions about being an inpatient in a secondary care hospital. There were three main areas of concern.The first described by Mike and Sharon was the monotony of hospital routines: ‘You can’t do anything different’ (Mike, line 273); ‘Have to do more or less what they say’ (Sharon, line 1451).The second concern was other patients and their habits: ‘Sharing a ward with five other people at the best of times isn’t fun’ (Neil, line 699). John acknowledged that being at home was better ‘than [having] some old man next to you snoring (line 860). Andrea said that being at home meant that she did not have ‘To worry about anyone bothering her’ (line 1614). The third concern discussed by three participants, John, Sharon and Simon, was that they simply did not want to be admitted in the first place. Equally, Neil described being in hospital as ‘frustrating’ whereas Mike saw it as ‘boring’.
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admission, found that receiving CIVT at home was beneficial as he was self-employed. He said:
The impact of being in hospital for two of the participants meant that they were concerned about the effect that visiting had on their partners. In order to manage this, they imposed restrictions on the frequency of visits. However, enforced separation from friends and family can affect not only a patient’s psychological health, but also their interpersonal relationships. Neil and Mike could clearly see the impact that their hospital admissions were having on their partners:
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research Sub-theme: preventing hospital-acquired infections (HAIs) Over half the participants raised concerns about infections. Participants acknowledged that patients would be better off ‘in your own bugs’ (Mike, line 157) rather that in an hospital environment that potentially has ‘so many superbugs around’ (Sharon, line 717). Similarly, three participants, Mike, Anthony and Christine, directly connected being admitted to hospital with catching something else. Andrea disclosed that her father had meticillin-resistant staphylococcus aureusis (MRSA) and that this first-hand experience made her realise:
Sub-theme: normality and conveniences
To minimise the risk of HAIs, strict universal precautions need to be adhered to: hand hygiene, aseptic and no-touch techniques (Kayley, 2008). However, this research shows that for two participants, Neil and Anthony, this basic level of care was absent:
Simon said he thought that being at home was more ‘normal’ because patients could potentially perceive themselves as more unwell when in hospital than they actually were. Andrea used the word ‘conveniences’, which the researcher has used as a sub-theme to describe the advantages that patients cited while being treated at home. Six participants enjoyed being able to watch TV, read a book or listen to music (Mike, Neil, John, Sharon, Andrea and Simon). Some participants discussed home comforts, which included being more relaxed or ‘chilled out’, having their own things around them and being more comfortable (Mike, Neil, Christine, Sharon and Andrea). Another convenience was having their own food, especially what they wanted when they wanted it (Mike, John, Christine and Simon). For Andrea, who had dietary allergies, this was extremely important:
‘The only issue has been whether people know the aseptic routine, some of them when they first arrived didn’t appear to know the aseptic routine, so I did sort of raise a complaint’ (Neil, lines 310–12).
‘I am lactose-intolerant, so again it is nice to have my own food and to be able to pick and choose what I want to eat, whereas you can’t always do that in hospital’ (Andrea, lines 1663–6).
Higginson (2011) advises that district nurses adhere to strict standard precautions and local policy on infection control, which are essential to preventing disease-causing microbes from entering a susceptible host, resulting in a bloodstream infection. A service review by Lomas (2009) indicated no cases of bloodstream infections, phlebitis or MRSA.
The advantage of a good night’s sleep was acknowledged by three participants. Mike appreciated ‘being able to sleep’ (line 230), as it made him feel ‘so much happier’ (line 257). Equally, after his discharge from hospital, Neil found that he ‘could get some decent sleep at night which was really nice’ (line 687). Sharon recalled a previous unrelated hospital admission:
‘That little things like that, that you think, I am much better off being at home really, as opposed to be being in hospital, and maybe picking up something else’ (Andrea, lines 1608–11).
Theme four: being at home It is clear from the research findings that half the participants appreciated the time spent by the district nurses who delivered their treatment. Their replies suggest that the time was not merely perfunctory, but cathartic. Four of the participants made references to ‘having a laugh’ or a ‘chitchat’ and the ‘friendliness of the nurses’. Christine said: ‘they came and they did it and we had a laugh while they were there, between us’ (Christine, lines 1180–1). John commented: ‘I got an ornament that I hang from the ceiling and I got a coat hanger and she hung it from the coat hanger from there every day in the front room window’ (John, lines 867–96). Andrea valued her time with the district nurse:
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They identified that district nurses spent longer with their patients and were thus able to assess them more thoroughly, signposting them to appropriate services if required.
‘we had a bit of laugh a couple of times about things that went wrong, they hung the coat hanger on a standing lamp and a couple of times it fell off or the cat was playing with the line’ (Andrea, lines 1512–14). Likewise, Serrant-Green et al (2009) carried out an evaluation of patients treated at home for lower-leg cellulitis.
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 19
‘You’ve got your own bed to sleep in, it makes a big difference’ (line 1292).
Theme five: safety Dealey (2005) suggests that patients should be involved not only in the planning of their treatment, but also where they will receive that treatment, either at/or closer to home. This involvement will facilitate patients’ understanding of what is happening to them, allow them to ask questions, and ultimately consent to being treated at home (Depledge and Gracie, 2006). An example of this was highlighted by one participant, Andrea, who felt that secondary care did not explain what her condition was and how it could be treated. This left her feeling frustrated and apprehensive. She recalls: ‘she didn’t explain it at all, to be honest, it is as if she thought I knew and I had never heard of this before. It was totally new to me, so it was a bit confusing. It was a little bit of “what is going to happen next?” [laughs], it was a bit strange’ (Andrea, lines 1520–4).
Sub-theme: patient information Just over half the participants could recount the information provided to them by the district nurses, IV team, GP or secondary care staff. Simon had all the information he
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research needed, as he was contacted by telephone before the IV team attended his home to start his treatment. Similarly, Christine received a full verbal explanation of what was going to happen. Neil had a safety net; if there were any worries, he could contact his consultant, who could arrange an immediate readmission: ‘My consultant was very straight with me: “If you’ve got any worries, then ring me up and come straight back into hospital. If you have any worries about the service, we will make sure you come straight back into hospital and have them here”’ (Anthony, lines 542–5).
Sub-theme: district nurses, training and competence One of the greatest causes of distress for two participants was the district nurses’ ability to undertake the clinical intervention safely. Both Neil and Anthony stated that basic hand hygiene was lacking, and that the IV drug administration was undertaken with poor aseptic technique. Neil and Anthony had both been discharged from secondary care to home, and both commented on the inconsistency of IVAB administration in hospital and at home. For example, an IV antibiotic administered as a bolus in hospital was administered as an infusion in the community. Anthony suggested that: ‘The training wasn’t 100% or consistent…and that maybe the district nurses need to go through another training course or refresher’ (Anthony, lines 1966 and 2092). Neil suggested that those district nurses ‘fresh’ from secondary care: ‘… were on track. They knew exactly the latest thinking, how it should be done. Whereas perhaps the nurses from the community were lacking in that knowledge really’ (Neil, lines 635–7). The development of CIVT services allows a unique opportunity for district nurses to increase their skills in an arena that has long been the domain of the acute care sector (O’Halloran et al, 2008). Unfortunately, both Anthony and Neil could recognise those district nurses who undertook IV drug administration infrequently, either by lack of technique or by lack of confidence. This suggests that district nurses need not only to achieve and maintain their clinical competencies, but also to develop confidence, as these go hand-in-hand in providing good quality care. However, to increase their clinical skills, district nurses need support and training, focusing on the theoretical and practical aspects of IV drug administration in the community (Kayley, 2008).
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Conclusion This study found that participants prefer to be treated at home rather than being admitted to secondary care. It suggests that participants appreciated the opportunity to receive CIVT.
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 19
Key points n Participants reported that receiving community intravenous therapy (CIVT) in the home helped to ‘normalise’ a medical procedure, allowing them greater freedom and relaxation n Participants appreciated the opportunity to ‘have a laugh’ and a chat with the district nurses while receiving their antibiotics n Participants preferred not to be admitted to secondary care for their antibiotic treatment because of travel and separation from family and friends n Participants were aware that CIVT services free up hospital beds for those in most clinical need, reduce length of stays and speed up discharges
They liked the fact that they had the option to remain in a familiar environment with the normality and convenience of being treated at home. CIVT seemed to reduce the carer burden and removed the need for patients and their families BJN to travel to the secondary care hospitals. Conflict of interest: none Bossaer J and Lewis P (2012) Antibiotic use in home health. Home Healthcare Manage Pract 24: 50–5 Dealey C (2005) The factors that influence patient choice of hospital and treatments. Br J Nurs 14(10): 576–9 Department of Health (DH) (2012) The Health and Social Care Act. DH, London Depledge J and Gracie F (2006) Developing a strategic approach for IV therapy in the community. Br J Community Nurs 11(11): 462–8 Esmond G, Butler M, McCormack A (2006) Comparison of hospital and home intravenous antibiotic therapy in adults with cystic fibrosis. J Clin Nurs 15(1): 52–60 Gloucestershire Care Services NHS Trust (GCS) (2010) Changing Healthcare. NHS, Gloucester Glasby J and Littlechild R (2001) Inappropriate hospital admissions: patient participation in research. Br J Nurs 10(11): 738–40 Higginson R (2011) IV therapy and infection control in patients in the community. Br J Nurs 20(3): 152–5 Kayley J (2011) IV therapy in the community. Nurs Times 107(19-20): 15–6, 18 Kayley J (2008) Effective practice in community IV therapy. Br J Community Nurs 13(7): 323–8 Lomas C (2009) Nurse-led community IV therapy service saves the NHS over one million in three years. Nurs Times 12(4): 31–2 McKernan C (2008) Exploring the literature on delivering home IV therapy. Nurs Times 104(34): 28–9 Nazarko L (2008) Providing outpatient antibiotic therapy for cellulitis in primary care. Br J Community Nurs 13(11): 520–4 Neergaard M, Oleson F, Anderson R, Sondergaard J (2009) Qualitative description—the poor cousin of health research? BMC Med Res Methodol 9(52): 1–5 NHS Improvement (2012) eQIPP delivering quality efficiently. http://www. improvement.nhs.uk/Default.aspx?alias=www.improvement.nhs.uk/qipp (accessed 11 October 2013) Parini R, Pozzi K, Mauro S, Furlan F, Rigoldi M (2010) Intravenous enzyme replacement therapy: hospital vs home. Br J Nurs 19(14): 92–8 O’Halloran L, El-Masri M, Fox-Wasylyshyn S (2008) Home intravenous therapy and the ability to perform self-care activities of daily living. J Infus Nurs 31(6): 367–73 Quality Innovation Productivity and Performance (QIPP) (2008) eQIPP: delivering quality efficiently. http://www.improvement.nhs.uk/Default. aspx?alias=www.improvement.nhs.uk/qipp (accessed 11 October 2013) Sandelowski M (2000) Whatever happened to qualitative description? Res Nurs Health 23(4): 334–40 Serrant-Green L, O’Leary L, Rodney A (2009) An evaluation of a pilot nurse led initiative for providing IV therapy for adults with cellulitis of the lower limb in the community. An Evaluation report commissioned by Heart of Birmingham Teaching Primary Care Trust Sheppard S, Doll H, Angus RM, Clarke MJ, Illiffe S, Kalra L, Ricauda NA, Wilson AD (2008) Admission avoidance hospital at home. Cochrane Database Syst Rev 8(4): CD007491 Silverman D (2011) Interpreting Qualitative Data. 4th edn. Sage, London
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Aim: To explore patients’ experiences of receiving community intravenous therapy (CIVT) compared with traditional inpatient hospital care. Method: The study used a qualitative descriptive methodology. Semi-structured interviews were conducted with eight participants, transcribed verbatim and thematically analysed. Results: Five themes were identified: ‘finances’; ‘travelling’; ‘hospital admission’; ‘being at home’; and ‘safety’. Discussion: The study revealed that participants felt privileged and valued when they were treated at home. CIVT allowed them the comfort of being in a familiar environment and the convenience of doing what they wanted, when they wanted. Conclusion: This study concurs that patients do prefer to be treated at home rather than being admitted to secondary care. The findings from this study suggest that participants appreciated the opportunity to receive CIVT. Key words: Community intravenous therapy (CIVT) ■ Patient experience Being at home ■ District nurses
■
C
ommunity intravenous therapy (CIVT) has been successfully treating patients, either at home or closer to home in community hospital outpatient clinics, since its inception in the 1980s, when it was first developed for children with cystic fibrosis (Nazarko, 2008; Higginson, 2011). Since then, CIVT has evolved for adults with conditions such as cellulitis, osteomyelitis, endocarditis and bronchiectasis to avoid acute admissions and reduce length of stay (LOS) (Higginson, 2011). The Department of Health (DH) (NHS Improvement, 2012) argued that it was necessary to move health and social care provision from an acute hospital environment to a community setting, which is local and more convenient for patients.The Health and Social Care Act (DH, 2012), Quality Innovation Productivity and Performance (QIPP, 2008) and clinical governance all provide the template for CIVT services by promoting the delivery of high-quality, personalised, patient-focused care, delivered closer to, or at home. Acute inpatient beds are expensive commodities (McKernan, 2008).To make savings, the number of acute beds
Becky Stephens is Community IV Therapy Nurse, Gloucestershire Care Service NHS Trust, Gloucester Accepted for publication: October 2013
S24
has been reduced, although demand remains high (Glasby and Littlechild, 2001; Mckernan, 2008; Nazarko, 2008).This deficit has been addressed by, first, reducing inappropriate admissions (Glasby and Littlechild, 2001; Lomas, 2009; Gloucestershire Care Services (GCS), 2010; NHS Improvement, 2012); second, by reducing the LOS of patients (Glasby and Littlechild, 2001; QIPP, 2008; Lomas, 2009; GCS, 2010; Kayley, 2011; NHS Improvement, 2012); third, by speeding up discharges (Kayley, 2008; GCS, 2010; Bossaer and Lewis, 2012; NHS Improvement, 2012); and, fourth, by the earlier identification of those patients who need multidisciplinary care (GCS, 2010). Three other research studies were identified and critiqued for the purpose of this research study: Esmond et al (2006), Parini et al (2010) and Sheppard et al (2008). Esmond et al (2006) used a quasi-experimental designed pilot study to compare hospital to home IV antibiotic therapy in London for adults with cystic fibrosis, using the CF-QoL (quality of life) questionnaire. Their data came from a sample of 30 patients—15 in hospital, 15 at home— who had previously self-administered home IV therapy. The investigators concluded that there were no differences between the two groups (hospital versus home), probably because acute exacerbations were not effectively treated and/or managed at home. Confusingly, the study went on to suggest that those patients receiving home treatment had greater improvement in QoL during their antibiotic treatment. It was unclear from the study whether the patients were offered home IV therapy or if the patient requested home IV therapy, so it is unclear in turn whether the service was driven by patients or by the healthcare environment. In a similar study, Parini et al (2010) recorded an improvement in QoL for patients receiving enzymereplacement therapy (ERT) at home in Italy. Parini et al (2010) did a national and regional survey of eleven ‘regional reference centres’. The regional survey included all patients receiving ERT for lyposomal storage diseases, such as Hunter syndrome, Gaucher’s disease, and so on. In their sample of 158 patients, 55 had received their treatment at regional centre, 96 in a local hospital and 7 at home. Parini et al (2010) concluded that ERT at home can restore independence, reduce the use of hospital resources and improve QoL for some patients. However, the under-representation of patients who were treated at home—just 7, compared with 151 patients who received ERT in a regional centre—could have skewed the results. Sheppard et al (2008) undertook a review and metaanalysis of the cost-effectiveness of managing patients at
© 2013 MA Healthcare Ltd
Becky Stephens
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 19 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 129.100.058.076 on September 15, 2016. Use for licensed purposes only. No other uses without permission. All rights reserved.
research home rather than through inpatient-hospital based care. Ten random control trials were identified, addressing mortality at 3 and 6 months after treatment, functional ability, cognitive ability and QoL. The research found that home-based care had significantly higher levels of patient satisfaction across a range of different conditions, such as cellulitis and community-acquired pneumonia (Sheppard et al, 2008).
Rationale/justification for this research Although other researchers have studied several different aspects of CIVT—establishing and commissioning CIVT services; cost-effectiveness of CIVT; and safe, effective service delivery—the researcher was unable to find any studies that explicitly explored patients’ experiences of receiving CIVT services. The researcher therefore decided, first, to ascertain what patients’ experiences of CIVT were and, second, to explore how such services benefited them.
Methods Taking into consideration the research aim to understand patients’ experiences of CIVT services, qualitative description was chosen as the research methodology. It is suitable for obtaining ‘straight’, unadorned answers (Sandelowski, 2000) and therefore for finding out what patients really thought about CIVT. Neergaard et al (2009) suggest that qualitative description is well-matched to small independent studies, when time and resources are both limited.
Ethics Ethics approval was granted from the National Research Ethics Service (NRES), GCS and the University of the West of England Faculty of Health and Social Sciences. Pseudonyms were chosen for each research participant that suitably matched their age, gender and personality (Gillham, 2005), as opposed to the assignment of numbers, such Participant 1.
© 2013 MA Healthcare Ltd
Sample Purposive sampling techniques were used by the researcher. Silverman (2010) suggests that while purposive sampling might allow the researcher to select a participant, it does not mean that the researcher is free to pick and choose their research participants. Consequently, the research sample was established with certain inclusion/exclusion criteria (Box 1). Those patients who met the inclusion criteria were contacted by telephone by a third party (i.e. not the researcher) and asked if they would be interested in receiving more detailed information about the research study. If the participant agreed, an invitation letter and patient information sheet were posted to them and their name and address passed to the researcher. A ‘cooling-off period’ of 7 to 10 days was left for the participant to discuss the research study with their significant other(s). The participant was then telephoned so that any questions that they might have could be answered, and an appointment was arranged. Eight participants were recruited and interviewed for this study. At the beginning of the interview, the researcher discussed the patient information sheet with the participant and
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 19
Box 1. Inclusion/exclusion criteria Inclusion criteria: ■■ Aged
40–65 years, male or female the care of Gloucestershire Care Services ■■ Referred to, accepted by and received treatment from the CIVT service ■■ Have capacity to consent to participating in the research study ■■ Under
Exclusion criterion ■■ Any
patient who is unable to read and/or speak English to a sufficient level to take part in the semi-structured interviews
Box 2. Interview schedule Question ■■ I understand
that you had antibiotic treatment at home. Could you tell me about your experience(s) of having this treatment at home? ■■ How did your illness affect you on a daily basis? ■■ Have you needed to go into hospital for similar treatment? How did this make you feel? ■■ Were you involved in the decisions concerning or having your antibiotic treatment at home? ■■ If given a choice, which option would you have preferred—hospital or home? ■■ What were your initial thoughts about receiving/continuing your antibiotic treatment at home? And would you say that those thoughts have changed now? ■■ Could you tell me, if at all, how receiving your antibiotic treatment at home was beneficial to you? ■■ Could you tell me, if at all, how receiving your antibiotic treatment at home was not beneficial to you? ■■ Thank you for talking to me today. We have covered a great deal of ground and you have been very patient. But before we end this interview, is there anything else you would like to add?
obtained informed written consent. All the interviews were conducted in the participants’ own home. The mean average length of the interview was 47 minutes. At each interview, the interview schedule was used to guide the interviews (Box 2), which were then digitally recorded, transcribed verbatim (word for word) and thematically analysed. The researcher did reflect on the first interview recording and transcription with her research supervisor. The data tree and its emergent themes were also discussed with the research supervisor.
Results and discussion Ten themes emerged from the initial data analysis. These were refined into five themes from the second and third transcript readings into a data tree. Each theme and its associated sub-themes enabled participants’ experiences to be explored in depth (Table 1).
Theme one: finances This theme encompasses two sub-themes: first, the financial impact on patients and their relatives; and, second, the appropriate use of hospital resources
Sub-theme: Cost to patients and relatives For two participants, John and Mike, finances had two different interpretations. John, who was treated at home for lower limb cellulitis and consequently avoided a hospital
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Conversely, Mike did not mind having to be in at the right time for the district nurses, as he thought that this was an easier option than being in hospital.
Table 1. Core themes Theme
Subtheme
One
Finances
Cost for patients and relatives Using hospital resources appropriately
Two
Travelling
Timekeeping Relatives travelling to visit participants
Three
Hospital admission
Accessing CIVT services Being in hospital Preventing healthcare-acquired infections
Four
Being at home
Camaraderie Normality and conveniences Patient choice
Five
Safety
Patient information District nurse training and competence
Sub-theme: relatives travelling to visit participants
‘basically when you are self-employed and not working you get no money coming in’ (John, lines 891–2).
Sub-theme: using hospital resources appropriately Three participants acknowledged that there is a requirement to use hospital resources appropriately. These participants were all treated for cellulitis at home and avoided admission into an acute inpatient bed. John suggested that ‘you aren’t exactly ill, it’s just that they had to administer antibiotics’ (line 954), while Christine agreed that a ‘big blown leg didn’t warrant a hospital admission’ (line 997) and that ‘it’s on the news today that the NHS are encouraging people to stay at home (Andrea, line 1644) as doing so would ‘leave that bed free for somebody who really, really needs it’ (Christine, line 1068).
And: ‘She couldn’t carry on doing it, I don’t think, she was getting ill as well with it’ (Mike, lines 333–4). As much as they valued their friends and family visiting them, both Neil and Mike could empathise with the effect it had: ‘It must be a real drag to keep coming into hospital’ (Neil, lines 678–9). And: ‘They used to take 30–40 minutes each way to visit me, and I told them not to bother but they did’ (Mike, lines 51–2).
Theme two – travelling
Theme three: hospital admission
Time spent travelling had different ramifications for different participants. However, it did influence the decisions that John and Christine made about being admitted to hospital or not:
Access to the service is facilitated by secondary care consultants or GPs. Participants’ experiences suggest some issues with the method of communication among the primary care, secondary care and CIVT services. Half of the participants discussed the referral process for CIVT. For those being discharged from secondary care, there was always an element of negotiation—and some frustrations.
‘I didn’t want a hospital admission to be honest because of the travelling’ (John, lines 1008–9). Five of the participants were admission-avoidance cases, like John and Christine, who were treated at home for cellulitis. Demographically, the majority of participants lived more than 20 miles (32 km) from the two regional hospitals in Cheltenham or Gloucester. Esmond et al (2006) advocated that families should not have to face enforced separation (sometimes of several miles) to be admitted to a regional hospital.
Sub-theme: timekeeping In exploring patients’ experiences of CIVT, some participants expressed the importance of good timekeeping by the health professionals delivering their treatments. Simon remarked: ‘that this was perhaps the only criticism I could make, that you didn’t know exactly when people were coming or more closely when they were going to come’ (Simon, lines 1856–8).
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‘Well, I made her only come in sort of every other or third day. Really to give her some life’ (Neil, lines 682–3).
Sub-theme: being in hospital Seven of the participants voiced strong opinions about being an inpatient in a secondary care hospital. There were three main areas of concern.The first described by Mike and Sharon was the monotony of hospital routines: ‘You can’t do anything different’ (Mike, line 273); ‘Have to do more or less what they say’ (Sharon, line 1451).The second concern was other patients and their habits: ‘Sharing a ward with five other people at the best of times isn’t fun’ (Neil, line 699). John acknowledged that being at home was better ‘than [having] some old man next to you snoring (line 860). Andrea said that being at home meant that she did not have ‘To worry about anyone bothering her’ (line 1614). The third concern discussed by three participants, John, Sharon and Simon, was that they simply did not want to be admitted in the first place. Equally, Neil described being in hospital as ‘frustrating’ whereas Mike saw it as ‘boring’.
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admission, found that receiving CIVT at home was beneficial as he was self-employed. He said:
The impact of being in hospital for two of the participants meant that they were concerned about the effect that visiting had on their partners. In order to manage this, they imposed restrictions on the frequency of visits. However, enforced separation from friends and family can affect not only a patient’s psychological health, but also their interpersonal relationships. Neil and Mike could clearly see the impact that their hospital admissions were having on their partners:
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research Sub-theme: preventing hospital-acquired infections (HAIs) Over half the participants raised concerns about infections. Participants acknowledged that patients would be better off ‘in your own bugs’ (Mike, line 157) rather that in an hospital environment that potentially has ‘so many superbugs around’ (Sharon, line 717). Similarly, three participants, Mike, Anthony and Christine, directly connected being admitted to hospital with catching something else. Andrea disclosed that her father had meticillin-resistant staphylococcus aureusis (MRSA) and that this first-hand experience made her realise:
Sub-theme: normality and conveniences
To minimise the risk of HAIs, strict universal precautions need to be adhered to: hand hygiene, aseptic and no-touch techniques (Kayley, 2008). However, this research shows that for two participants, Neil and Anthony, this basic level of care was absent:
Simon said he thought that being at home was more ‘normal’ because patients could potentially perceive themselves as more unwell when in hospital than they actually were. Andrea used the word ‘conveniences’, which the researcher has used as a sub-theme to describe the advantages that patients cited while being treated at home. Six participants enjoyed being able to watch TV, read a book or listen to music (Mike, Neil, John, Sharon, Andrea and Simon). Some participants discussed home comforts, which included being more relaxed or ‘chilled out’, having their own things around them and being more comfortable (Mike, Neil, Christine, Sharon and Andrea). Another convenience was having their own food, especially what they wanted when they wanted it (Mike, John, Christine and Simon). For Andrea, who had dietary allergies, this was extremely important:
‘The only issue has been whether people know the aseptic routine, some of them when they first arrived didn’t appear to know the aseptic routine, so I did sort of raise a complaint’ (Neil, lines 310–12).
‘I am lactose-intolerant, so again it is nice to have my own food and to be able to pick and choose what I want to eat, whereas you can’t always do that in hospital’ (Andrea, lines 1663–6).
Higginson (2011) advises that district nurses adhere to strict standard precautions and local policy on infection control, which are essential to preventing disease-causing microbes from entering a susceptible host, resulting in a bloodstream infection. A service review by Lomas (2009) indicated no cases of bloodstream infections, phlebitis or MRSA.
The advantage of a good night’s sleep was acknowledged by three participants. Mike appreciated ‘being able to sleep’ (line 230), as it made him feel ‘so much happier’ (line 257). Equally, after his discharge from hospital, Neil found that he ‘could get some decent sleep at night which was really nice’ (line 687). Sharon recalled a previous unrelated hospital admission:
‘That little things like that, that you think, I am much better off being at home really, as opposed to be being in hospital, and maybe picking up something else’ (Andrea, lines 1608–11).
Theme four: being at home It is clear from the research findings that half the participants appreciated the time spent by the district nurses who delivered their treatment. Their replies suggest that the time was not merely perfunctory, but cathartic. Four of the participants made references to ‘having a laugh’ or a ‘chitchat’ and the ‘friendliness of the nurses’. Christine said: ‘they came and they did it and we had a laugh while they were there, between us’ (Christine, lines 1180–1). John commented: ‘I got an ornament that I hang from the ceiling and I got a coat hanger and she hung it from the coat hanger from there every day in the front room window’ (John, lines 867–96). Andrea valued her time with the district nurse:
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They identified that district nurses spent longer with their patients and were thus able to assess them more thoroughly, signposting them to appropriate services if required.
‘we had a bit of laugh a couple of times about things that went wrong, they hung the coat hanger on a standing lamp and a couple of times it fell off or the cat was playing with the line’ (Andrea, lines 1512–14). Likewise, Serrant-Green et al (2009) carried out an evaluation of patients treated at home for lower-leg cellulitis.
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 19
‘You’ve got your own bed to sleep in, it makes a big difference’ (line 1292).
Theme five: safety Dealey (2005) suggests that patients should be involved not only in the planning of their treatment, but also where they will receive that treatment, either at/or closer to home. This involvement will facilitate patients’ understanding of what is happening to them, allow them to ask questions, and ultimately consent to being treated at home (Depledge and Gracie, 2006). An example of this was highlighted by one participant, Andrea, who felt that secondary care did not explain what her condition was and how it could be treated. This left her feeling frustrated and apprehensive. She recalls: ‘she didn’t explain it at all, to be honest, it is as if she thought I knew and I had never heard of this before. It was totally new to me, so it was a bit confusing. It was a little bit of “what is going to happen next?” [laughs], it was a bit strange’ (Andrea, lines 1520–4).
Sub-theme: patient information Just over half the participants could recount the information provided to them by the district nurses, IV team, GP or secondary care staff. Simon had all the information he
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research needed, as he was contacted by telephone before the IV team attended his home to start his treatment. Similarly, Christine received a full verbal explanation of what was going to happen. Neil had a safety net; if there were any worries, he could contact his consultant, who could arrange an immediate readmission: ‘My consultant was very straight with me: “If you’ve got any worries, then ring me up and come straight back into hospital. If you have any worries about the service, we will make sure you come straight back into hospital and have them here”’ (Anthony, lines 542–5).
Sub-theme: district nurses, training and competence One of the greatest causes of distress for two participants was the district nurses’ ability to undertake the clinical intervention safely. Both Neil and Anthony stated that basic hand hygiene was lacking, and that the IV drug administration was undertaken with poor aseptic technique. Neil and Anthony had both been discharged from secondary care to home, and both commented on the inconsistency of IVAB administration in hospital and at home. For example, an IV antibiotic administered as a bolus in hospital was administered as an infusion in the community. Anthony suggested that: ‘The training wasn’t 100% or consistent…and that maybe the district nurses need to go through another training course or refresher’ (Anthony, lines 1966 and 2092). Neil suggested that those district nurses ‘fresh’ from secondary care: ‘… were on track. They knew exactly the latest thinking, how it should be done. Whereas perhaps the nurses from the community were lacking in that knowledge really’ (Neil, lines 635–7). The development of CIVT services allows a unique opportunity for district nurses to increase their skills in an arena that has long been the domain of the acute care sector (O’Halloran et al, 2008). Unfortunately, both Anthony and Neil could recognise those district nurses who undertook IV drug administration infrequently, either by lack of technique or by lack of confidence. This suggests that district nurses need not only to achieve and maintain their clinical competencies, but also to develop confidence, as these go hand-in-hand in providing good quality care. However, to increase their clinical skills, district nurses need support and training, focusing on the theoretical and practical aspects of IV drug administration in the community (Kayley, 2008).
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Conclusion This study found that participants prefer to be treated at home rather than being admitted to secondary care. It suggests that participants appreciated the opportunity to receive CIVT.
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 19
Key points n Participants reported that receiving community intravenous therapy (CIVT) in the home helped to ‘normalise’ a medical procedure, allowing them greater freedom and relaxation n Participants appreciated the opportunity to ‘have a laugh’ and a chat with the district nurses while receiving their antibiotics n Participants preferred not to be admitted to secondary care for their antibiotic treatment because of travel and separation from family and friends n Participants were aware that CIVT services free up hospital beds for those in most clinical need, reduce length of stays and speed up discharges
They liked the fact that they had the option to remain in a familiar environment with the normality and convenience of being treated at home. CIVT seemed to reduce the carer burden and removed the need for patients and their families BJN to travel to the secondary care hospitals. Conflict of interest: none Bossaer J and Lewis P (2012) Antibiotic use in home health. Home Healthcare Manage Pract 24: 50–5 Dealey C (2005) The factors that influence patient choice of hospital and treatments. Br J Nurs 14(10): 576–9 Department of Health (DH) (2012) The Health and Social Care Act. DH, London Depledge J and Gracie F (2006) Developing a strategic approach for IV therapy in the community. Br J Community Nurs 11(11): 462–8 Esmond G, Butler M, McCormack A (2006) Comparison of hospital and home intravenous antibiotic therapy in adults with cystic fibrosis. J Clin Nurs 15(1): 52–60 Gloucestershire Care Services NHS Trust (GCS) (2010) Changing Healthcare. NHS, Gloucester Glasby J and Littlechild R (2001) Inappropriate hospital admissions: patient participation in research. Br J Nurs 10(11): 738–40 Higginson R (2011) IV therapy and infection control in patients in the community. Br J Nurs 20(3): 152–5 Kayley J (2011) IV therapy in the community. Nurs Times 107(19-20): 15–6, 18 Kayley J (2008) Effective practice in community IV therapy. Br J Community Nurs 13(7): 323–8 Lomas C (2009) Nurse-led community IV therapy service saves the NHS over one million in three years. Nurs Times 12(4): 31–2 McKernan C (2008) Exploring the literature on delivering home IV therapy. Nurs Times 104(34): 28–9 Nazarko L (2008) Providing outpatient antibiotic therapy for cellulitis in primary care. Br J Community Nurs 13(11): 520–4 Neergaard M, Oleson F, Anderson R, Sondergaard J (2009) Qualitative description—the poor cousin of health research? BMC Med Res Methodol 9(52): 1–5 NHS Improvement (2012) eQIPP delivering quality efficiently. http://www. improvement.nhs.uk/Default.aspx?alias=www.improvement.nhs.uk/qipp (accessed 11 October 2013) Parini R, Pozzi K, Mauro S, Furlan F, Rigoldi M (2010) Intravenous enzyme replacement therapy: hospital vs home. Br J Nurs 19(14): 92–8 O’Halloran L, El-Masri M, Fox-Wasylyshyn S (2008) Home intravenous therapy and the ability to perform self-care activities of daily living. J Infus Nurs 31(6): 367–73 Quality Innovation Productivity and Performance (QIPP) (2008) eQIPP: delivering quality efficiently. http://www.improvement.nhs.uk/Default. aspx?alias=www.improvement.nhs.uk/qipp (accessed 11 October 2013) Sandelowski M (2000) Whatever happened to qualitative description? Res Nurs Health 23(4): 334–40 Serrant-Green L, O’Leary L, Rodney A (2009) An evaluation of a pilot nurse led initiative for providing IV therapy for adults with cellulitis of the lower limb in the community. An Evaluation report commissioned by Heart of Birmingham Teaching Primary Care Trust Sheppard S, Doll H, Angus RM, Clarke MJ, Illiffe S, Kalra L, Ricauda NA, Wilson AD (2008) Admission avoidance hospital at home. Cochrane Database Syst Rev 8(4): CD007491 Silverman D (2011) Interpreting Qualitative Data. 4th edn. Sage, London
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