Procedure for Inotrope Administration in the home Purpose This purpose of this procedure is to define the care used when administering inotropic agents intravenously in the home This includes: A. Practice and support the following guidelines for administration of inotropic therapy at home. B. Facilitate the hospital discharge of patients with end-stage CHF who: Have not responded to standard oral drug therapy Cannot be weaned off of Inotropic therapy and need continuous intravenous Inotropic therapy. May be on a waiting list for a heart transplant. Have a significant response to intermittent Inotropic therapy. C. Provide a safe and effective use of Dobutamine, Dopamine and Milrinone in the home. BACKGROUND The goal of inotropic agents is to enhance cardiac output by reducing preload and afterload. Patients who cannot be weaned from intravenous to oral therapy may require continuous infusion of inotropic agent such as dobutamine and milrinone. The decision to continue intravenous infusions at home should not be made until all attempts to achieve stability have failed. Dobutamine and Milrinone are the agents used in DHCH Home Health Program. They are positive inotropic agents used for the management of patients with stage III and IV congestive heart failure who have not responded adequately to Digoxin, diuretics, ACE inhibitors, and/or oral vasodilators. Inotropic agents have also found application in the treatment of acute hypotensive and low cardiac output conditions. PROCEDURES: Nursing staff may expect that it is the primary physician's responsibility to determine/order the best maintenance dose that increases cardiac contractility and output and relieves symptoms. Additionally an order for nitropatch should be obtained and placed in the home for use in case of infiltration/extravasation. The maintenance dose will be established and patient stabilized on maintenance dose before first home infusion. Titration of the maintenance dose should not be done in the home setting. Safe doses for the drugs should be fall within the ranges noted below. Dobutamine Milrinone 2.5 mcg minimum to 15 mcg maximum 0.375 minimum to 0.5mcg maximum Any doses falling outside of these ranges should be double checked with the DHCH Pharmacist. Specific physician s orders for inotropic agents must be obtained prior to beginning infusion in the home. Dosing will be adjusted only under the direction of a physician based upon the patient s response. 1
Clinicians should review all of the patient s medications and consult with the pharmacist about the existence of incompatibilities prior to administration of other medications. Clinicians should be aware of the following incompatibilities Inotrope Dobutamine Incompatibilities Heparin Alkaline solutions such as sodium bicarbonate Home Health Nursing Responsibilities All nursing staff caring for patients receiving IV inotropes at home will have successfully completed the online competency module on administers inotropes in the home. Documentation of successful completion of the module will be kept in the nurse s personnel file. Nurses will be aware of and monitor for the common side effects of inotropic therapy include: Hypotension, palpitation, headache, syncope, chest pain. Home health Nursing staff will: Evaluate home environment for safe infusion (i.e., functioning telephone). Provide education and patient teaching Maintain central venous access site according to policy Assess patient/caregiver's ability to understand, accept and demonstrate appropriate catheter and pump procedures; and drug administration procedures Educate patient and caregiver on their responsibilities with care Evaluate patient outcomes Identify and document patient s code status Inotrope infusion in the home will only be done via a long term venous access device (PICC, Hickman, or Portacath preferred.) The patient's residence will have a functioning telephone and safe storage area for supplies Patient should have knowledgeable and willing caregiver in the home. If patient is independent and does not require caregiver, then patient will maintain daily monitoring logs and be in close communication with pharmacist and RN between visits. The physician will be aware that there will be no caregiver and will write an order to this effect. Patient/caregiver will demonstrate a willingness and ability to understand, accept and demonstrate appropriate catheter and infusion pump care and monitoring parameters during the infusion for continuous or intermittent therapy. When patient is receiving continuous infusion of Dobutamine or Milrinone, B/P, heart rate will be monitored by caregiver every AM. Complete cardiac assessment should be completed and documented at each visit to include but not limited to: heart sounds abdominal girth (if applicable) presence and degree of edema cardiac episodes lung sounds (angina/palpitations) fluid intake and output (if ordered presence of dyspnea by physician) Orthopnea/n# of pillows 2
weight gain, or loss pulse oximeter reading) B/P, TPR Document the baseline findings in the clinical note. Vital signs taken by RN should be documented in clinical note and on Home Inotropic Therapy Flow sheet In the event that the patient has experienced medication changed, and increase in weight and/or missed dose, the nurse should contact the DHCH pharmacist immediately. Physician ordered labs may include: BUN, K+, CREATININE, NA, CO2. Physician may order additional labs to be drawn. The RN caring for the patient should record available lab results in the handheld computer and report all alert values per DHCH policy. If infiltration/extravasation at central line site occurs, the Home Care/Hospice RN should notify the physician immediately and follow physician's orders for treatment. Symptomatic control would include warm soaks at site (and extending up the patient's arm if a PICC line is being utilized), and use of a low dose Nitropatch placed near the insertion site to dilate blood vessels and increase blood flow. Physician order required for nitropatch placement. Physician may order low dose Nitroglycerine. Line changing procedure For Home Inotrope infusion a patients Do not use the SASH (Saline, Administer, saline, heparin) method when doing a bag or PICC line dressing change. Never flush a line that is infusing inotropes. 1. Explain the procedure to the patient/caregiver. 2. Wash hands. 3. Assemble all equipment (i.e., Inotropic Drug, Alcohol Wipes, 3.0 cc NS, and other supplies as needed). 4. Obtain pre-infusion change assessment: Heart rate (apical & radial), edema, assess peripheral pulses, B/P, respirations, temperature, 5. Attach new tubing to the inotropic therapy bag and prime the new tubing. 6. Attach inotropic therapy medication to the insertion site. 7. Start infusion. lung sounds, pulse oximeter reading, skin color, abdominal girth capillary refill Patients should be disconnected from the infusion for only the amount of time it takes to remove the catheter cap and to unhook and hook up the new tubing. Care should be taken to not have the patient disconnected for any longer than 4 hours for any reason. In the event that the pump alarm goes off and indicates line occlusion, the nurse should instruct the patient to perform routine maneuvers to make sure there are no kinks in the line of other obvious obstructions. If the alarm still sounds, the patient should call 911 immediately. The nurse should phone the DHCH pharmacist and physician immediately, notifying them of the situation and follow the orders received. 3
Thorough educational instruction to patient and caregiver will be provided during admission process. RNs will reinforce teaching with each visit. Teaching will include importance of pt./caregiver's ability to discontinue therapy if pump infiltration occurs and notifying Home Care/Hospice charge nurse or on-call nurse immediately if the occlusion alarms sound. The patient/caregiver will be instructed to weigh patients prior to breakfast every morning and document weights on the Inotropic Therapy Flow sheet (left in patient's home). If the patient is unable to be weighed on bathroom scales in the home, the physician should be notified for further orders. The caregiver is encouraged to also take B/P, heart rate, respirations, pulse oximeter reading as needed, and record findings on same form. For patients on Continuous Inotropic Therapy, vital signs will be taken every eight hours by nurse or caregiver and recorded on the same form. When form is completed, it will be placed on permanent chart. Vital signs taken by pt./caregiver should be documented on Home Inotropic Therapy Flow sheet. A copy of the Home Inotropic Therapy flow sheet may be placed in the RN field chart for reference purposes. (Pulse oximeter readings) RN is to reinforce signs and symptoms of exacerbation of CHF with patient/caregiver and when to call Home Care/Hospice and/or the physician. If the physician has not established parameters, then the following will be used: PARAMETERS OF WHEN THE CAREGIVER IS TO CONTACT PHYSICIAN Weight Increase or decrease Systolic BP <90 or > 150 or change from baseline BP Increase or decrease of 15 mm Hg Heart rate <60 or > 100 and change from baseline Symptoms Dysrythmia s, chest pain, headache, increase ectopy, increased SOB, nausea, vomiting, anxiety A copy of the parameters will be kept in the home for family to follow. Teaching will be documented. Home instructions will be used and copies given to patient/caregiver. 4
DHCH Inotropic Therapy Flow sheet Patient Name DATE Weightsdone each AM prior to breakfast Heart rate Blood Pressure Respirations Number of pillows used at night Pulse oximeter reading Shortness of breath 5
6