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Caregiver Teaching

Discharge Criteria for new HPN referral

Patient selection: 2 weeks before discharge

HPN Team consulted by primary service. Primary GI, inpatient nutrition attending and inpatient dietitian agrees to referral.

Defined indication for HPN (e.g., SBS, severe malabsorption, fistula, GI obstruction, IBD, motility disorder, swallowing disorders)

Enteral feeds tried and failed, or enteral feeds contraindicated

Anticipated PN duration ≥ 4 weeks

Underlying disease is stable. HPN is contraindicated for severe cardiopulmonary disease, unstable endocrinopathy, severe immunodeficiency, life-expectancy

Caregivers/patient provides verbal consent for HPN

Medical clearance: 1-2 weeks before discharge

Weight ≥ 5 kg

Central venous catheter tip in SVC/IVC or cavoatrial junction as documented on X-ray at BCH within 1 year if 2 years-old.

Afebrile (

IV medications other than PN ≤ 2 times/day.

Attention to medication-PN compatibility. IV lipids may need to be held.

Social work and case management clearance

Caregiver with appropriate domicile (Clean space, storage for supplies, working refrigeration (separate from community, phone, running warm water, electricity)

Health insurance in place for HPN and outpatient follow-up.

Caregiver/patient able to follow up in HPN program within 1 month, or X1/weekly if OM + direct bilirubin ≥ 2. (Distance, transportation, work/school schedule, means, collaborating other providers.)

Home services established (Home infusion company, nursing).

Parenteral nutrition regimen optimal at discharge:

PN cycled to ≤ 20 hours.

SMOFlipids for long-term PN considered, soybean-based IV lipids ≤ 1 gram/kg/day) and Compassionate-Use Omegaven considered for PNALD.

PN regimen unchanged for ≥ 3 days

Labs within expected range

Infusion rates of Intralipids and potassium in acceptable range (IL

If iron deficient and needing home IV iron, test dose has been tolerated inpatient

Meeting hydration, macro and micronutrient goals with present PN regimen

Weight trend in acceptable range.

HPN teaching complete

Patient/caregiver demonstrates competent central venous catheter care (Washing hands, putting on mask, wearing sterile gloves, scrubbing hub, flushing catheter, changing central line cap, changing dressing).

There are 2 adults trained for central line care (not including VNA).

Outpatient coordination in place

Outpatient labs plan agreed upon by patient/caregiver and inpatient team (location, timing, frequency). Maximum frequency ≥ 1 time/week, goal to space out over time (typically once per month).

Outpatient HPN appointment booked.

If long-distance, local provider identified PMD, local GI, surgeon to facilitate tests, home care orders.

 

New Patient Discharge Timeline

2 weeks prior to discharge

HPN consult (MD & NP)

1-2 weeks prior to discharge

HPN teaching (RN)

1-5 days prior to discharge

SimLab (RN, SimLab staff)

1-3 days prior to discharge

Pre-discharge briefing (HPN team, case management, nursing and primary team)

Discharge day

Wrap up session (HPN team)

Post-discharge day 1-3

Telemedicine visit (HPN team)

1-2 weeks post-discharge

HPN visit (HPN RN emphasis)

1 month post-discharge

HPN visit

 

 

Social Media

From Home Parenteral Nutrition at Boston Children's Hospital Facebook Program Group June 14, 2017
 
"Can we draw you a picture to help? 
- Picture's worth 1,000 words.
- HPN families can use pictures to learn & remember all sorts of concepts.
- Speak up if you think an illustration might help to explain something -- e.g. central line flushing, liver anatomy, IV lipid types, PN tubing hook-up (below)."

pn setup

 

 

Social Media

From Home Parenteral Nutrition at Boston Children's Hospital Facebook Program Group  October 2, 2017
 
"Family members can actively participate in discharge process to improve safety.
- Personally obtain copies of discharge summary.
- Review information for accuracy, especially prescriptions!
- Forward summary directly to your HPN team.
- Request attending physician-to-physician sign-out."

102

 

Five-session teach developed by Mary Gallotto: Prior to hospital discharge, the home parenteral nutrition nurse leads caregiver through standardized HPN curriculum over five sessions with increasingly complex tasks using low-fidelity simulation mannequin, including central venous catheter (CVC), CVC supplies as well as infusion pump equipment

5 session Teach

Click here for related Clinical Vignette

 

Special discharges:

Discharging HPN patient who is NPO:

  • Make sure definite medical indication for NPO status.
  • Ensure patient maintains blood sugar and hydration while inpatient cycling.
  • Prescribe and teach caregiver to use glucometer.
  • Consider prescribing glucagon.

 

ESPEN guidelines for Adults with Intestinal Failure

 

Discharging HPN patient who is receiving IV antibiotics:

  • Antibiotic frequency (maximum frequency every 8 hours).
  • Pre-medications needed (orally versus IV).
  • PN and IV lipid compatibility of antibiotics.
  • Administration device (syringe pump, ball).
  • Tubing (bifuse).
  • Laboratory coordination (electrolytes, repeat blood cultures).
  • Counseling parents to monitor for side-effects on IV antibiotics.
     
HPN Post-discharge Debriefing
  1. What happened?
  2. Was communication clear?
  3. Were roles and responsibilities understood?
  4. Was situation awareness maintained?
  5. Was workload distribution equitable?
  6. Was task assistance requested or offered?
  7. Were errors made or avoided?
  8. Were resources available?
  9. What should improve?
 

Challenge Point Framework of Teaching:

HPNHPN2

 

Guadagnoli MA, Lee TD. Challenge point: a framework for conceptualizing the
effects of various practice conditions in motor learning. J Mot Behav. 2004
Jun;36(2):212-24. PubMed PMID: 15130871.