The real dangers of first dosing in the home
Is it really more dangerous than subsequent doses?
Penny Offer, CRNI, the infusion program coordinator for TGC Home Health Care in Tampa, FL, had just completed the start of a four-hour infusion of amphotericin B on one of her patients. This was the fourth dose of the medicine for this patient, who had demonstrated adequate knowledge on signs and symptoms of reaction and infiltration.
"She was able to monitor her infusion, and the responsibility of home care was to flush the access device and start the pump," Offer says. "Following the four-hour duration, the home care nurse would return and flush the device again."
Offer started the infusion and left, almost immediately returning when she realized she had left her scissors in the patient's house. "When I came back, the patient had had a severe reaction and was on the floor," recalls Offer. "She responded well to the epinephrine and fluids, but what if I had not forgotten my scissors?"
Every home infusion nurse has heard time and again the potential dangers of providing a patient with their first dose of a medication. But how dangerous is it really? And how much can you relax on subsequent doses following an uneventful first dose? Offerexample goes to show you're really never safe.
Experienced home infusion providers agree that if you treat future infusions with any less care or caution than the first, you're making a big mistake.
"I have no problem with extensive preparation for a first dose," notes Jim Herbert, RN, CRNI, an IHS Homecare clinical manager for Florida. "My concern is that the same preparation is not carried over to subsequent doses or non-first doses. There is no reason to prepare more for a first dose."
In fact, Herbert says the first dose "myth" often gives patients, caregivers, and nurses a false and potentially dangerous sense of security.
"It puts you and the patient at greater risk when you think 'The first dose is done, so now we're OK,' which is absolutely not true," he adds. "My recommendation is that if you are giving a medication in the home, you should be prepared to treat an allergic anaphylactic reaction."
Offer agrees. "This first dose business is relative in the sense that it's not just the first dose that will harm somebody," she says. "The literature bears this out that you also have to be concerned with the second and third dose. So you don't want to get lax in your judgment and say, 'I'm past that first dose, so it's fine.'"
Some providers, such as Fairlane Home Infusion in Southfield, MI, play it safe and don't administer first doses in the home.
"A reaction can happen later, but the later reactions have a tendency to come on more slowly," notes Julie Greening, BSN, MSA, CRNI, administrator at Fairlane Home Infusion, part of Henry Ford Health System. "You develop a rash or the person may complain of nausea or another sign of allergic reaction before you get into a severe reaction. So we do not do first dosing in the home. We don't want to put our nurses in that situation."
Greening notes that because Fairlane Home Infusion is part of a much larger health system, it has the option to give the first dose in a setting where physicians and other nurses are available.
Even though a patient may react to a drug on later infusions, you still must pay close attention to the first dose. "You have to go by the standards," says Offer. "But nurses need to be aware that a reaction doesn't always occur on the first dose."
Along those lines, IHS and TGC treat first doses with utmost care, even if a reaction can occur later. Herbert and Offer are largely responsible for deciding which patients are cleared to receive a first dose in the home. "IHS has an infusion resource team, which I'm a member of," notes Herbert. "Any time a patient is going to receive a first dose in the home, it has to be cleared by an infusion resource team member, and there are about five of us across the country. This helps us screen out the high-risk candidates."
Screening process for at-risk patients
TGC also has an upfront policy in place to screen out candidates who are at-risk for an anaphylactic reaction. "We distinguish from first dose in the home and initial dose," says Offer. "If the patient has received a medicine in the same family or group within the past six months, then we can administer the drug in the home, and we call that an initial dose."
An infusion is considered a first dose if the patient has not received a medicine in the same family or group of the prescribed medicine in the previous six months, in any setting.
Herbert and Offer evaluate patients on a case-by-case basis. (For more information on evaluating patients, see story, above left.) If there's a slight doubt but not enough to turn down the first dose, you might want to consider sending additional staff on the first visit. "Our policy states that if there is some question, we send two nurses out," notes Offer. "In the new climate of reimbursement issues, often the second nurse may not be covered, but this is an agency issue."
Greening points out that one of the dangers of first dosing is leaving a nurse by herself to handle a patient who reacts.
"It would be extremely difficult to handle it alone," she says. "I wouldn't want to be the CRNI doing it, and a nurse handling that in the home alone without assistance is at risk."
If a second nurse is not available and you have no choice but to give the first dose, Greening recommends you have:
· an anaphylaxis kit on hand (Herbert says there should always be a kit on hand. "If you are giving an intravenous medication in the home, you should be prepared to treat an allergic anaphylactic reaction.");
· an ambulance company standing by;
· the doctor readily available by phone;
· an extra pair of hands available.
"Insist there be another capable person in the home in addition to the nurse," says Greening. "You have to assess the situation. It could be a husband, wife, or daughter who can make a phone call for you or relay information back and forth because if the patient is in severe trouble, you can't pick up the phone and make a phone call and talk to the 911 operator."
But if there's doubt as to whether the patient is a safe candidate, Offer says to play it safe. "Always err on the side of caution," she says. "Have the physician give the first dose, or do it in the emergency room or in an outpatient clinic."
In making the choice, it's always wise to put patient safety above the potential gain of patient revenue.
"This is a tough call, but you have a responsibility for patient advocacy," says Offer.
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