High tech home care: surviving and prospering in a changing environment.

Managed care plans are expanding rapidly into new marketplaces. Reimbursement for home infusion therapy, including parenteral and enteral nutrition, is significantly affected under managed care, especially when capitated payment mechanisms are used. Home care companies have experienced downsizing, mergers, acquisitions, and fierce competition in the managed care environment. Clinicians who are entering the home care setting may find that, in addition to clinical expertise, their marketability depends on a set of new skills and abilities in order to prosper in this new environment.

Current status of home infusion therapy.

The growth of home infusion therapy has been influenced by external forces that have changed the access to and use of health care. As home infusion therapy expands into other alternate care settings, clinicians, regardless of discipline, must be cognizant of how daily clinical practice is affected by regulations, changes in legislation, and consumerism.

Experience with home aerosolized pentamidine treatment in patients with AIDS.

Pneumocystis carinii pneumonia (PCP is the most frequent opportunistic infection in patients with AIDS and is the most common cause of death in these patients. Conventional parenteral trimethoprim/sulfamethoxazole or parenteral pentamidine treatment is often not completed because of frequent incidence of adverse reactions. Aerosolized pentamidine appears to be better tolerated and is considered an alternative treatment for PCP in both hospital and community settings. This report describes our experience with 34 patients with AIDS who received aerosolized pentamidine at home. All patients were over 18 years old and had received either parenteral or aerosolized pentamidine within a medically supervised setting before home treatment was initiated. The Respigard II nebulizer system powered by an oxygen source was used as the delivery system. All patients took two puffs of metaproterenol sulfate 10 minutes prior to two 15-minute sessions of pentamidine inhalation. No relapse or adverse reactions were observed in patients. Large randomized clinical trials currently are underway to compare the value of aerosolized pentamidine with other forms of treatment for PCP.

Clinical evaluation of elastomeric hydrogel peripheral catheters during home infusion therapy.

The use of elastomeric hydrogel (Aquavene, Menlo Care, Menlo Park, Calif.) peripheral catheters in home infusion therapy was prospectively evaluated. Elastomeric hydrogel catheter composition differs from that of conventional peripheral catheters made of Teflon or silicone in that it softens upon insertion and expands two gauge sizes within 30 minutes of insertion. Fifty-four test catheters were successfully placed in 44 home infusion therapy patients, for a total dwell time of 290 days. Average dwell time was 5.37 days, with a range of 1 to 20 days. The extension of dwell time beyond the accepted standard of 72 hours was not associated with an increased incidence of phlebitis when compared to the incidence of phlebitis reported in the scientific literature. The ability to extend peripheral catheter dwell time without increasing the incidence of catheter-related complications may have major clinical and economic advantages for the payors, providers, and consumers of home infusion therapy.

Initiation of a home hemotherapy program using a primary nursing model.

A home hemotherapy pilot study was implemented based on a primary nursing model. Seventy-one patients received a total of 248 units of red blood cells and 104 units of platelets during 137 home transfusions. In no case did a clinical change in patient status require the interruption of the transfusion. Total nursing time for the pretransfusion, transfusion, and posttransfusion follow-up visits for each patient averaged 4.36 hours, while another 4.45 hours accounted for nurse travel to and from the home and the blood bank. Home hemotherapy is a viable option for selected homebound patients. Program success is dependent on staff education, strict clinical guidelines, and an acknowledgment of the time required to provide quality patient care.

Gastrointestinal manifestations of the acquired immunodeficiency syndrome.

AIDS-related gastrointestinal disease is common, presenting a challenge to all nutritional support clinicians. Patients frequently suffer from weight loss, diarrhea, malabsorption, and cachexia. Many factors complicate the course of AIDS-related gastrointestinal disease, including decreased food intake (resulting from fatigue and malaise), increased metabolic demand and nutritional requirements, and identifiable gastrointestinal pathology. Gastrointestinal pathology is well-documented, and in approximately 50% of persons with AIDS-related gastrointestinal disease, a causative agent can be identified. In general, treatment of AIDS-related gastrointestinal disease is not always curative. Much of the chronic gastrointestinal dysfunction is caused by recurring opportunistic pathogens that are resistant to chemotherapy. Often, patient care and long-term management can focus only on fluid and electrolyte balance, nutritional support, and symptom control. Even clinically stable patients have been diagnosed as chronically malnourished and, for reasons that remain unclear, are prone to rapid nutritional deterioration during disease exacerbations. Published reports of nutritional assessment and intervention in persons with AIDS are now appearing in the literature. However, the eventual mortality associated with AIDS still results in a hesitancy on the part of many clinicians to prescribe aggressive nutritional support, especially parenteral nutrition. Who to treat and at what stage of illness becomes the question. As new agents, such as AZT, are prescribed on a more frequent basis for persons with AIDS, the use of nutritional support as adjunctive therapy early in the course of disease becomes an issue. Although improving nutrition has not been shown to reverse any of the cellular immunodeficiency caused by HIV infection, quality of life may be improved. In specific cases, nutritional support, whether through diet counseling, food programs, or intervention with enteral or parenteral nutrition, appears to improve strength and endurance, thus enhancing quality of life.

Nutrition education in schools of nursing in the United States. Part 2: The status of nutrition education in schools of nursing.

To explore whether nurses in academic institutions are being adequately educated to care for patients' nutritional needs, we conducted a survey of National League for Nursing accredited baccalaureate programs in the United States and their associated graduate programs. Data indicate that nutrition content is an integral part of baccalaureate nursing programs. Less emphasis is reported on nutrition content at the graduate level. Recommendations include revision of the substantive nutritive content and increased clinical experience in nutrition in both undergraduate and graduate nursing education.

Microbial growth in clinically used enteral delivery systems.

Potential contamination of enteral formulas has led to the development of policies limiting formula hangtimes. However, enteral administration bags can easily become contaminated during formula refilling. We prospectively studied enteral formula contamination when the hangtime of a prefilled 1000 ml pouch was compared with the standard 4-hour hangtime of a refilled enteral administration bag. Samples of formula collected from different locations along the enteral delivery system were cultured during 57 days of enteral hyperalimentation in 19 patients. The overall enteral formula contamination rate was 61%, where the greatest microbial growth occurred in reconstituted enteral formulas. The presence of microbial growth did not differ between canned formulas administered according to a 4-hour hangtime and the prefilled pouch. Greatest growth in all cases was at the distal tubing hub, where contamination during system manipulation or from the patient probably occurred. Use of prefilled enteral administration bags may delay formula contamination in the administration reservoir. A change in equipment design that would decrease the need to manipulate feeding sets or feeding tube connections should be further investigated.

Nutrition education in schools of nursing in the United States. Part 1. The evolution of nutrition education in schools of nursing.

In 1981 the Nurses' Committee of the American Society for Parenteral and Enteral Nutrition appointed an Ad Hoc Committee to investigate the evolution of and the current status of nutrition education curriculum in schools of nursing accredited by the National League for Nursing. This investigation identified current trends in the teaching of nutrition content in baccalaureate and graduate schools of nursing. Part one explores the evolution of nutrition content in school of nursing curriculum; while part two (to be published in a later journal) presents the results of a descriptive survey of accredited schools of nursing in the United States.

Microbial growth comparisons of five commercial parenteral lipid emulsions.

The ability of parenteral lipid emulsions to support microbial growth was compared using commercially available brands of lipid emulsion. Both 10 and 20% concentrations of soybean and safflower oil emulsions were used. Washed cultures of six gram-negative, three gram-positive, and one yeast, in concentrations of 1 x 10(4) to 2 x 10(4) colony-forming units/ml, were inoculated into lipid emulsion aliquots and stored at room temperature. There were than subcultured at 0, 6, 12, 24 and 48 hr. After 48 hr at 37 degrees C, growth was recorded as colony-forming units/ml. Normalized growth curves were expressed as mean +/- SEM. ANOVA demonstrated no difference in growth patterns due to the nature of the oil or its concentration. Gram-negative organisms multiplied faster when compared to gram-positive (p less than 0.05 at 12 hr, p less than 0.01 at 24 hr, and p less than 0.005 at 48 hr). Yeast grew as well as bacteria. The Center for Disease Control's recommendation of a 12-hr hang time for parenteral lipid emulsions should be observed until correlation of laboratory microbial growth patterns and clinical use are studied further.

Selenium deficiency with total parenteral nutrition: reversal of biochemical and functional abnormalities by selenium supplementation: a case report.

A patient with multiple intestinal fistulae maintained on total parenteral nutrition for 18 months developed low serum selenium. Erythrocyte glutathione peroxidase activity was 6% of normal. Erythrocytes were not able to metabolize H2O2 as well as those from controls, although the hexose monophosphate shunt itself was intact. Granulocytes from this patient had 15% of the erythrocyte glutathione peroxidase activity found in normals. Patient granulocytes were not able to metabolize H2O2 as well as controls, although the hexose monophosphate shunt was intact. Erythrocyte glutathione peroxidase-deficient granulocytes incubated with a respiratory burst stimulant, phorbol myristate acetate, had only 60% of the hexose monophosphate shunt activity present in control granulocytes. These abnormalities were reversed with selenium supplementation. Bacterial killing of Staphylococcus aureus 502A and cardiac function were not affected by selenium deficiency. Thus, selenium deficiency resulted in biochemical and functional abnormalities of erythrocytes and granulocytes. These abnormalities were reversed with selenium supplementation.

Performance evaluation of a new nasogastric feeding tube.

A performance evaluation of a new polyurethane nasogastric feeding tube and stainless steel stylette (Nutriflex, No 8 French) was conducted at University Hospital. Thirty-eight tubes were successfully placed in 18 patients. Tubes remained in place less than 1-29 days and feedings were administered for a total of 196 patient days. Enteral formulas commonly available were administered via continuous drip. The tube use was surveyed for ease of insertion primarily; however, patency and comfort to the patient were felt to be positive with the use of this tube. With slight modifications the new feeding tube is a welcome addition to the expanding technology associated with enteral feedings.