Rectal Hydration and Medication Administration: Cost effective Strategies Robert Parker, DNP, RN, CENP, CHPN, CHP Chief Compliance Officer, VP of Clinical Excellence and Integrity Intrepid USA Disclosure Statement No conflict of interest exists for any individual in a position to control the content of this educational activity 1
Desired Learning Outcomes At the conclusion, participants will be able to: Incorporate new ideas that can help improve patient outcomes Incorporate new understanding that can drive nursing efficiency Leverage existing resources to reduce costs 2
Study Aim Palliative program QI project to look at the feasibility of using a rectal administration catheter to facilitate safe, easy, comfortable and effective hydration and medication delivery via the rectal route, and the ability to treat changes in patient s condition while decreasing the need for parenteral therapy and ED/hospital utilization including general inpatient level of care. Parenteral Dosing Definitions Injection or infusion (IV, SQ, IM) Hypodermoclysis Administration of fluids subcutaneous Proctoclysis Administration of fluids via the rectum 3
Cost Challenges Increased utilization of general inpatient Delays causing ED/hospital utilization Supplies Parenteral dosages are costly Staff time Contract services Safety Challenges Patient Insertion of an IV can be difficult or contraindicated Pain Infection Infiltration Combative patients Nursing Proper skills training to insert an IV Difficult venous access patients Needle stick Other injury 4
Anatomy and Physiology of Microenema delivered Medication Mucosa is highly vascularized High % absorptive cells Liquid medications absorbed more quickly than suppositories Rapidly enters the circulation Anatomy and Physiology Proctoclysis Descending colon primary function to reabsorb fluids Fluid absorbed by diffusion into bloodstream Fluids should be hypotonic H20, Pedialyte Fluid flow of 250 ml/hr. tolerated well Based on literature Recommend break of 2+ hours between 250ml infusions Recommend volumes around 1000ml 1500ml/24hr 5
Versatile Route of Delivery Medication Versatility Rectal SQ IV SL Opioids NSAIDS Limited Benzodiazepines Limited Antiemetics Anticonvulsants Sedatives Antidepressants Neuroleptics Anticholinergics Steroids Antibiotics Study Results Ten of 10 (100%) participants from SNF, and 10 of 10 (100%) participants from hospice completed the study with 23 total use cases Hydration was effective in all 23 use cases, with all participants tolerating the intervention without signs of discomfort or expulsion of fluids The APN and attending physician who performed the prospective chart reviews deemed the patient s change in condition serious enough in 17 of the 23 use cases to warrant ED/hospital utilization or general inpatient level of care had the intervention not been successfully performed 6
Sample Study Order Sets Study Results Of the 17 use cases deemed serious enough to warrant ED/hospital utilization, 15 (88%) avoided a transfer to an acute setting after successful intervention with the catheter Each of these patients* returned to their previous oral medication and hydration regimen For the two patients transferred to the hospital it was necessary for acute care services mandating a transfer and not the failure of the intervention 7
Hospitalizations 66yr old male admitted to the SNF for ESRD and cardiac conditions after recent hospitalization. He was admitted to our community based palliative care program at the same time. Several days later, patient became hypotensive, and lethargic. The palliative APN gave orders to initiate the rectal catheter, and obtain a portable EKG. The EKG reading showed he was in Afib and he was sent to the ED and subsequently admitted to the hospital. Hospitalizations 44yr old male admitted to the SNF for acute kidney failure after recent hospitalization, he was also admitted to our community based palliative care program at the same time. Patient developed severe N/V and quickly became dehydrated. The palliative APN gave orders to initiate the rectal catheter. Symptoms resolved within 1 hour; however the patient s family requested that he be sent to the ED. Patient was not admitted to the hospital, and was quickly returned to SNF without further treatment. 8
Study Findings The catheter provided a safe, easy, comfortable and effective alternative to parenteral delivery options The intervention appeared to provide an effective and efficient way to treat patient s changes in condition leading to improved quality metrics and reduced ED/hospital utilization and use of general inpatient level of care Satisfaction Patient satisfaction with comfort and ease of use was high 12 patients who were able to verbally respond, reported comfort as 5 The remaining patients, the nurses performing the procedure reported the patients tolerated the intervention with no signs of discomfort All staff reported a 5 for both ease of use and perceived patient comfort 9
Analysis The intervention allowed us to quickly respond to patient s changes in condition when oral route failed Eliminated the need for IV infusions Catheter was initiated within 5 min. of order in SNF Patient s symptoms resolved within 30 60 min. from initiation High satisfaction with patients and families 10
Questions? Robert Parker, DNP, RN, CENP, CHPN, CHP Chief Compliance Officer, VP of Clinical Excellence and Integrity Intrepid USA bobparker_43@hotmail.com References Lyons N, Nejak D, Lomotan N, et al. An alternative for rapid administration of medication and fluids in the emergency setting using a novel device. Am J Emerg Med 2015;33:1113.e5 1113.e6 Honasoge A, Parker B, Wesselhoff K, Lyons N, Kulstad E. First use of a new device for administration of buspirone and acetaminophen to suppress shivering during therapeutic hypothermia. Ther Hypother Temp Manag. 2016;6(1):48 51 Dychter S, Gold D, Carson D, Haller M. Intravenous Therapy: A Review of Complications and Economic Considerations of Peripheral Access. J Infus Nurs 2012;35:84 91 B Bruera E, Pruvost M, Schoeller T, et al. Proctoclysis for Hydration of Terminally Ill Cancer Patients. J Pain Symptom Manage 1998;15:216 219 Paez K, Gregg M, Massion C, Macy B. Promoting Excellence in Symptom Management Case Series: Case Study: A New Intervention for Rapid End of Life Symptom Control in the Home Setting. J Hos Palliat Nurs 2016;18:498 504. 11