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Canadian Paediatric Society

Position statement

Home intravenous therapy: Accessibility for Canadian children and youth

Posted: Feb 1 2011 | Reaffirmed: Feb 1 2016


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Principal author(s)

DL Moore, R Bortolussi; Canadian Paediatric Society, Infectious Diseases and Immunization Committee

Paediatr Child Health 2011;16(2):105-109

Abstract

The administration of intravenous (IV) therapy at home is an alternative to hospitalization for treatment of infection and a number of other conditions, and has been demonstrated to be effective and safe, to reduce cost and to improve quality of life. While home IV therapy has many advantages for children, it is not uniformly available and access may be limited by age, geographical location and ability to pay. Physicians caring for children need to be aware of the indications for home IV therapy, its requirements and limitations, as well as whether this option is available for children in their care. Where access is limited, physicians should advocate for home IV therapy for children when it is medically indicated.

Key Words: Antibiotic; Home intravenous therapy; Paediatric; Parenteral nutrition

Introduction and objectives

Home intravenous (IV) therapy spares children the psychological impact of prolonged hospitalization and disruption of school, work and family activities. Its use has been advocated since the 1970s when successful home IV therapy for children with cystic fibrosis was first reported [1]. However, home IV therapy programs for children have developed more slowly than those for adults, and access is not uniform across Canada. The objective of the present document is to inform physicians who care for children about the indications for home IV therapy for children and to advocate for better access across Canada. We do not intend the document to be a guide for management of home IV therapy programs because published guidelines are available for that purpose [2]-[6].

Background

Home IV therapy for children with infections, those needing long-term parenteral nutrition (PN) and for selected other conditions is at least as effective and as safe as IV therapy in hospital [2][3][7]-[19]. Home IV therapy for children provides improved quality of life, and patients and families show a preference for treatment at home [10][17]-[20].

Home IV therapy programs have been stimulated by the need for hospitals to control costs. With rising health care costs, children who need IV therapy alone, in the absence of other technology-­dependent therapies, can be treated more economically at home [13][17]-[19]. Other options for outpatient IV therapy exist, such as treatment at hospital-based or free-standing clinics. These require frequent visits (at least once daily) and, for long-term therapy, are impractical, inconvenient and extremely burdensome for children and family members.

Many home IV therapy programs rely on the patient or caregiver to administer the infusion [8][11]. In some instances, visiting nurses may provide all or part of the care, which increases the cost. Programs are often hospital based, but may be run by free-standing clinics or regional health authorities. Home IV therapy requires a team approach, with the primary care physician being an important member of the treatment team.

Indications

Infection is, by far, the most common indication for home IV therapy [2][11]. Infections accounted for 95% of home infusion therapy provided to adults in Calgary [21] and one in 1000 Americans have received home IV antibiotic therapy [2]. Home IV treatment of acute and chronic infections has increased in recent years, aided by the availability of newer antibiotics with longer half-lives and technical advances in vascular access devices (VADs) and infusion pumps. The most frequent indications for home antibiotic therapy are soft tissue and bone and joint infections [2][11][21]. It may be indicated for pneumonia if oral therapy is not an option and the patient does not require other supportive care. Although many studies have shown home IV therapy to be beneficial for treatment of cystic fibrosis, a few have shown better or faster improvement in pulmonary function with treatment in hospital [22]. For meningitis, endocarditis or sepsis syndrome, home IV therapy may be indicated after a period of hospitalization, once the condition has stabilized and sudden deterioration is not expected. Neonates may be candidates for home IV therapy if expertise in maintaining IV access in newborns is available [23][24]. Home IV treatment of opportunistic infections such as cytomegalovirus and fungal infections is appropriate for immunocompromised patients in stable condition. An international registry of patients receiving outpatient parenteral antimicrobial therapy was created in 1997 [8][25]. In a 2004 publication [11], fewer than 5% of the patients in this registry were children.

Home IV therapy programs are also increasingly used to provide long-term home PN. Children – mainly those with intestinal dysfunction due to congenital anomalies or perinatal events [13]-[16][26] – make up 15% to 20% of patients receiving home PN [13].

Other home IV therapy programs involve administration of clotting factors for hemophilia, chemotherapy, therapy for immunodeficiencies, medications for palliative care and anti-­inflammatory mediators [10][17]-[21]. New therapies, such as monoclonal antibodies and other biologics, will increase the need for home IV therapy in the future.

Home IV therapy has been shown to be cost saving to the health care system [14][17]-[19]. It is, therefore, important to ensure that it is not used inappropriately simply to achieve this end, if the patient’s health could be compromised by treatment at home.

Complications

The most common complications of home IV therapy are mechanical, which may occur during IV insertion (eg, correct catheter tip placement or vessel puncture) or later (eg, thrombosis, dislodgement, occlusion or leakage). Infectious complications are less frequent. In one report, the rate of mechanical complications was 0.83 per 1000 catheter days, while catheter site infections and bloodstream infections were 0.26 and 0.19 per 1000 catheter days, respectively [12]. Thrombotic catheter occlusion occurred at a rate of 0.23 per 1000 central venous catheter (CVC) days. Patients receiving PN at home had lower infection rates and longer catheter survival than those treated in hospital [14]-[16].

Other complications are related to the treatment administered. Adverse reactions to antibiotics are common but usually mild [27], resulting in discontinuation or a change in treatment in 3% to 10% of cases [2]. Metabolic complications (eg, electrolyte abnormalities and hypoglycemia) and hepatic complications occur with long-term PN whether delivered at home or in hospital [16][26].

Access to home IV therapy

Home IV therapy programs are still evolving and it is likely that many children who could benefit from home IV therapy do not yet have access to it. Programs may be limited to adults and adolescents in places where personnel experienced with providing and supervising home infusion for infants and young children are lacking. Access may be limited by financial concerns in provinces where the costs are not covered or only partially covered by government or insurance programs and the family cannot afford to pay.

A 2006 report [28] by the Health Council of Canada indicated limitations to the availability of home IV care across Canada and recommended expansion of services as well as standardized public payment for the medications required. Access to home IV care varied in different provinces and territories, as did funding for different types of services.

Results of a questionnaire distributed to infusion nurse specialists and members of the Canadian Paediatric Society Infectious Diseases and Immunization Committee in 2008 showed that there were discrepancies in access to home IV therapy in Canada. We received responses from 13 individuals in six provinces. All stated that home IV antibiotic therapy was available, but PN, palliative care medications and chemotherapy were less frequently available at home. Six replied that home IV therapy was available only after a period of hospitalization. The delay from request to institution of home IV therapy ranged from one to more than three days. In four instances, therapy had to be administered by parents. When administered by nurses, treatment was available 24 h/day in only two instances. Six replied that home IV therapy was not available if parents could not master the required skills. In four instances, it was not available for young infants. Five stated that therapy was available only in urban and selected rural areas. Programs were usually funded by provincial governments or hospitals, but did not necessarily cover medication costs, which in six instances were paid in part or in total by insurance and parents. These results suggest that home IV therapy is not available for all children for whom it is medically indicated, and that options may be limited by type of treatment required, age, cost, distance from a major centre and parental ability (D Moore, unpublished data).

Infrastructure requirements

Successful implementation of home IV therapy requires the establishment of a home IV therapy team with appropriately trained personnel, facilities for insertion of VADs, and availability of infusion pumps and other devices. Home IV therapy programs should have written protocols for assessment and selection of patients, VAD insertion and care, patient education and monitoring, outcome assessment and documentation [2]-[5].

The home IV therapy team

  • A physician with expertise in the care of children and youth, and who is knowledgeable about home IV therapy and the condition to be treated; for antibiotic therapy, a physician knowledgeable about infectious diseases of children and youth. Some programs require consultation with an infectious diseases specialist when home IV antibiotic therapy is being considered [29].
  • The patient’s primary care physician, and the referring physician if not the same.
  • An infusion nurse specialist who is knowledgeable about home IV therapy and care of children.
  • Representation from the community home care service, if applicable.
  • Collaboration with surgeons, interventional radiologists, vascular access nurses or other personnel skilled in the insertion of VADs in children.
  • A pharmacist who is knowledgeable about home IV therapy.
  • Access to other specialists, as appropriate, for the underlying condition (eg, for home PN, a gastroenterologist and dietician).
  • A social worker if indicated (eg, to assess family resources, explore sources of funding, etc).
  • A case manager if this role is not performed by the home IV therapy team physician or infusion nurse.

An IV therapy team physician and nurse should be available 24 h/day. There should be a system in place 24 h/day for rapid communication between the family and the IV therapy team [2][3].

What the primary physician should be aware of about home IV therapy for children

Factors to consider in the selection of patients for home IV therapy

Clinical factors

  • Is IV therapy necessary (eg, if antibiotic therapy, is there an acceptable oral alternative)?
  • Does the child need hospitalization at this time for any other purpose, whether related to the disease under treatment or other comorbidity?
  • Is the condition stable and the risk of a sudden or life-threatening event rare (unless the goal is to provide palliative care at home for a terminal illness)?
  • Is the IV medication used an accepted standard of treatment and of comparable efficacy to alternative therapy that would have to be given in hospital?
  • Is the child at higher risk of central catheter-related complications (eg, vascular thrombosis and bleeding) because of underlying coagulopathy or other disease?

Patient and family factors

  • Are the patient and primary caregiver willing to participate in home IV treatment?
  • Do the caregiver, and the patient if old enough, fully understand the importance of compliance with therapy?
  • Do the caregiver, and the patient if old enough, fully understand the potential adjustments to routine schedules and the limitations on sports and other activities that may be required until the therapy has been completed?
  • Is the caregiver able to understand the benefits and risks of home treatment, to anticipate and solve problems related to the medication, infusion or access device, and to know when to call for help?
  • Is the caregiver able to learn and perform the necessary skills reliably (eg, administration of medication, care of the IV access site, catheter and pump, and appropriate disposal of needles)? Are there physical factors (poor eyesight or lack of dexterity), or cognitive or psychological factors that could impede care?
  • Does the family understand the economic implications of the therapy (will the cost of the service be fully or partially reimbursed, are initial out-of-pocket expenses required, what can they afford to pay, what is the impact of taking time off work, etc)?
  • Does at least one caregiver have the time and flexibility of schedule required to provide the therapy (eg, a single parent with other young children to care for may not be able to cope alone)? For prolonged PN therapy, is skilled home help available to permit parents some respite time?
  • If problems occur, is rapid communication with the home IV therapy team possible (eg, telephone, and means of transport to clinic or hospital)?
  • Does the home have adequate conditions for provision of IV therapy (eg, space, cleanliness, water supply and refrigerator for drug storage)?
  • Is the home environment safe for provision of IV therapy (eg, factors such as alcohol or drug abuse may impede care)?

Factors specific to antimicrobial therapy

It is important to recognize that not all antibiotics are suitable for home IV therapy. Efficacy and safety are the primary criteria for the choice of antibiotic. For home IV therapy, pharmacokinetic and pharmacodynamic properties must also be considered. A long half-life permitting once or twice daily dosing is an advantage. Administration more frequently than every 8 h may not be practical.

Treatment that involves more than one IV drug may present difficulties in scheduling and drug compatibilities. Drug stability is also a concern. For use with a programmable electronic pump, the diluted antibiotic preparation must be stable at room temperature for at least 24 h. If prepared in unit doses by the pharmacy, it must be stable in the refrigerator for at least one week. If the drug is not stable, each dose must be prepared separately for use, requiring more work and expertise on the part of the caregiver. Phlebitis risk must be considered, especially when antibiotics are administered through a peripheral IV catheter. Aminoglycosides, vancomycin and other drugs that need a controlled rate of delivery require special infusion pumps [2].

VADs

The preferable type of device will vary with age, clinical status, condition of veins, type of medication to be given, dose frequency and duration of treatment [2][3][30][31]. Security of the access site is especially important in young children and others who are very active, and who may not be able to understand or comply with measures needed to reduce the risk of VAD dislodgement (Table 1).

TABLE 1
Types of vascular access devices
   

Central venous catheters

 

Peripheral IV catheter

Midline catheter

PIC catheter

Tunnelled
(eg, Broviac or Hickman)

Implanted port

Anticipated duration of use

1-2 weeks

2-4 weeks

Weeks to months

Months to years

Months to years

Advantages

  • Easily inserted
  • Many potential insertion sites
  • Easily inserted
  • More stable than a peripheral IV catheter
  • Insertion less invasive than other central catheters
  • General anesthetic usually not required
  • Multiple lumens allow multipurpose use
  • Convenient for blood withdrawal
  • More stable than a PIC catheter
  • Vascular system not exposed until catheter is accessed
  • Lowest infection risk
  • Minimal effect on patient activities
  • Useful for intermittent treatment at intervals of days to weeks

Disadvantages

  • Easily dislodged
  • Infiltration and blockage common
  • Phlebitis common
  • Medication extravasation may cause tissue breakdown
  • Not widely used in children
  • Limited number of insertion sites
  • May be confused with a PIC catheter
  • Accidental dislodgement common with younger children
  • Blood withdrawal may be contraindicated or difficult to achieve
  • May require continuous access to maintain potency
  • Insertion procedure invasive, often requiring general anesthesia
  • Requires ongoing catheter site care, weekly heparin infusion and dressing changes
  • Insertion procedure invasive, often requiring general anesthesia
  • Not useful for continuous or daily access (skin breakdown over device)

IV Intravenous; PIC Peripherally inserted centre

  • A peripheral IV catheter may suffice for short-term treatment (less than one week in a young child, or less than two weeks in an older child or adolescent), provided that the drug administered is not prone to cause phlebitis or soft tissue damage if infiltration occurs.
  • A midline catheter is a longer type of peripheral IV catheter used in some centres. It is inserted via the antecubital fossa and should not be confused with a peripherally inserted CVC because the management is different. There are little data on duration of use, but six to 28 days has been suggested for adults [32].
  • Children requiring therapy for more than two weeks will usually require a CVC [30].
    • Peripherally inserted central catheters are used most frequently for antibiotic therapy. Insertion is less invasive than insertion of a tunnelled CVC and may often be accomplished without general anesthesia. The disadvantage is accidental dislodgement if the child is very young or very active.
    • A tunnelled central line (eg, Broviac or Hickman catheter) is preferred for prolonged therapy if multiple lumens or frequent blood tests are required. It is more stable and may be more appropriate for a very active child.
    • Totally implanted ports are used for very long-term access for which treatment is intermittent. Once the port insertion site has healed, the device does not impede patient activities. Ports are less appropriate for long-term daily access because there is a risk of skin breakdown over the port.

Infusion pumps

Although infusion administration by gravity is sometimes used in adults and older adolescents when a controlled flow rate is not necessary, a pump is usually required. Gravity infusion may result in rapid boluses of drug if flow is too fast, or clotting if flow is too slow. Varieties of mechanical pumps with controlled flow are available but may be cumbersome to use. Portable electronic pumps, which are light enough to be worn throughout the day and may be programmed to deliver medication doses at fixed intervals, are most often used for children. These make treatment relatively easy for the caregiver, who needs only to insert a medication cassette once a day [2][3][31].

Patient monitoring

The patient should be seen by a physician and nurse at least once a week, and may initially require more frequent visits. Once clinical and laboratory parameters have stabilized, physician visits may be scheduled at less frequent intervals at the discretion of the home IV therapy team. Patients living close to the home IV centre will usually be evaluated there. Patients remote from the home IV centre will usually be monitored by their primary physician, who should be in weekly communication with the home IV therapy team physician. Patient monitoring includes the following [2][25][33]:

  • Ongoing clinical and laboratory evaluation of the illness being treated including potential for change to oral therapy.
  • Evaluation of the IV site and functioning of the VAD – edema, induration, pain at infusion site, erythema, drainage or other evidence of thrombosis, extravasation or infection at the site or over the catheter tract.
  • Compliance with therapy and IV site care.
  • Clinical and laboratory evaluation for adverse drug effects and, where appropriate, drug levels.

Outcome monitoring by the home IV centre includes clinical outcome, whether treatment was completed as planned, adverse medication events, complications associated with the VAD, patient satisfaction and cost [2][8].

Recommendations [34]

  • Paediatricians and others providing primary care to children and youth should ensure the following (BIII):
    • Be aware of indications for and contraindications to home IV therapy.
    • Be aware of programs available to their patients and how to access them.
    • Advocate for the development of home IV therapy programs for children and youth, including appropriately trained personnel and equipment, where these are not currently available.
    • Advocate for adequate funding, by provincial health care programs or alternative sources, of all aspects of home IV programs and appropriate reimbursement mechanisms to ensure that children and youth are not denied home IV therapy because their families cannot afford the cost.
    • Advocate for skilled home help to provide respite for parents providing home PN and other therapies that require IV infusion 24 h/day for prolonged periods.
  • Children and youth should have access to appropriate home IV therapy in situations where it is indicated, given the following:
  • Home IV therapy for children and youth with infections, those needing long-term PN, and for selected other conditions is at least as effective and as safe as IV therapy in hospital [9][10][12]-[19] (AII).
  • Home IV therapy for children is cost effective [14][17]-[19] (AI).
  • Home IV therapy for children provides improved quality of life and greater satisfaction to patients and families [10][14][17]-[20] (AI).
  • Those responsible for providing home IV therapy to children and youth should have expertise in the treatment of children and youth, should receive appropriate training and should be knowledgeable about relevant paediatric issues (BIII).
  • Appropriate training should be provided to patients and their families (BIII).
  • Home IV programs should have written protocols for assessment and selection of patients, VAD insertion and care, patient education and monitoring, outcome assessment and documentation [2][3][25] (BIII).
  • Specialists responsible for home IV programs should liaise with paediatricians and other physicians providing primary care to children and youth, and should promote the involvement of these primary caregivers in the follow-up of their patients (BIII).

Additional Resources

INFECTIOUS DISEASES AND IMMUNIZATION COMMITTEE 

Members: Robert Bortolussi MD (Chair); Jane Finlay MD; Jane C McDonald MD; Heather Onyett MD; Joan L Robinson MD; Élisabeth Rousseau-Harsany MD (Board Representative)
Liaisons: Upton D Allen MD, Canadian Pediatric AIDS Research Group; Charles PS Hui MD, CPS Liaison to Health Canada, Committee to Advise on Tropical Medicine and Travel; Nicole Le Saux MD, Immunization Program, ACTive; Larry Pickering MD, American Academy of Pediatrics; Marina I Salvadori MD, CPS Liaison to Health Canada, National Advisory Committee on Immunization
Consultants: James Kellner MD; Noni E MacDonald MD; Dorothy L Moore MD
Principal authors: Dorothy L Moore MD; Robert Bortolussi MD

 


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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.

Last updated: Apr 4 2016