Home Health Nursing Initiative: Symptom Response Kit - Essay Example

Home Health Nursing Initiative: Symptom Response Kit Introduction There are various home health nursing projects which are being applied in home health nursing. These projects work not just for the benefit of the nurse, but, more importantly for the delivery of quality home and community health care for the patient. In some home health care settings, the Symptom Response Kit (SRK) is being implemented as a project. In order to further understand this kit and its application to the home health nursing setting, this paper shall describe in detail the application and the usage of this kit. Through this assessment, a deeper and more thorough understanding of the home health nursing process can be achieved. This paper is also being undertaken in order to assess the appropriateness of the application of this kit using the current literature on this kit. This assessment of literature will hopefully shed light to the evidence-based application of this kit and hopefully make a credible evaluation of the actual application of the Symptom Response Kit. Description The Symptom Response Kit is described by the South West Community Care Access Centre (CCAC, 2009, p. 1) as “a kit of medications that can be ordered by a physician, to be available in a client’s home to relieve potential symptoms for clients requiring hospice palliative care services or who are at the end of life stage in their disease management”. In the most basic sense, this kit is a reserve kit which can be used in case unanticipated symptoms of a long-term care patient would surface. The kit contains emergency medical supplies previously approved or prescribed by the patient’s doctor in anticipation of probable symptoms of the patient’s illness. It contains limited amounts of a few medications which have been deemed effective in addressing the usual symptoms of distress in clients who are at the end of their lives (Matzon & Sherman, 2006). The kit is “solely for the purpose of alleviating unanticipated symptoms, to avoid unnecessary hospital/ER admission or until a regular prescription can be obtained” (CACC, 2009, p. 1). This kit acts as an interim remedy for the patient in order to prevent further deterioration while a more comprehensive consultation with the doctor is being scheduled. Symptom relief kits or emergency kits are set-up in order to address the “need to have appropriate medications readily available in the home, extended care facility, or hospital” (Matzon & Sherman, 2006, p. 322). Among palliative health care givers, there is no specific timing where the dying process can be predicted, and in order to address these inconsistencies, the symptom relief kit has been conjured by health care workers. A Symptom Response Kit is often prepared for a patient with a Palliative Performance Scale (PPS) of 50% of less; for a patient who may require unanticipated symptom management; and for a patient whose illness is nearing its end stage and where an End-of-life plan is already in place (CCAC, 2009, p. 1). The South West CCAC has the responsibility of preparing the Symptom Response Kits and of making them available in the home of the patient in order to relieve symptoms of the patient under palliative care. The CCAC would place the SRKs in the patient’s home in order to enable quick response to rapidly escalating or changing symptoms; unanticipated symptoms; comfort measures at the end stages of life (2009, p. 1). The patients included above are the most likely candidates for home health nursing and they are also the ones who are likely to manifest a variety of symptoms while they are in the care of the home health nurses. There is also a high probability that these patients would not be mobile and would require assistance in their daily activities. The Symptom Response Kit would work well for their benefit because it would increase response time for their symptoms and would reduce their anxiety. It is however important to note that in the following instances the SRK cannot be prescribed to the patient: when there is no caregiver in the home who can be responsible for safekeeping the kit; when there is evidence of substance abuse on the part of the client or any of his family members and there is no plan to prevent drug abuse; and when there is evidence to suggest that the medications in the kit may be used for other purposes (CCAC, 2009). Since, many of the drugs which may be stored in the kit are prohibitive and addictive drugs, care must be undertaken in order to prevent drug abuse and addiction not only for the patient, but also for his family members and potential caregivers. Drugs which were commonly prepared and prescribed as part of the kit includes the following medications: Atropine Ophthalmic Drops 1% 5 ml bottle x1; Dexamethasone (Decadron) 4 mg/1 ml – 5 ml amp x 2; Haloperidol (Haldol) 5 mg/1 ml amp x 5; Hydromorphone (Dilaudid) 2 mg/1 ml amp x 10; Hydromorphone (Dilaudid) 10 mg/1 ml amp x 5; Lorazepam (Ativan) 1 mg tabs x 24 tabs; Methotrimeprazine (Nozinan) 25 mg/1 ml amp x 5; Morphine 15 mg/1 ml amp x 10; Prochlorperazine 5 mg/1 ml – 2 ml amp x 2; and Olanzapine (Zyprexa Zydis) 5 mg tabs x 3 tabs (CCAC, 2008, pp. 1-2). This kit also contains the following medical supplies: 4 Tegaderm Transparent; 1 Micropore Paper Tape; 10 Alcohol Swabs, 70%; 5 Safety needled syringe, 25g x 5/8”, 1cc; 5 Safety needled syringe, 22g x 1 ½”, 3 cc; 1 Sub Q Access Device (Saf-T-Intima); 5 5/8” needles; 5 1 1/2” needles; 1 Needleless Access/Positive Pressure Device; Sharps Container (CCAC, 2009, p. 1). The contents of the kit help prepare the patient for more aggressive or more specific health care needs. When more specific treatment is henceforth instructed by the doctor, the succeeding interventions would bypass the initial patient preparation since the patient is already prepared before his admission to the emergency rooms. The South West Community Care Access Centre (2009) further describes the physician/medical doctor accountability in the use of the Symptom Response Kit. Their accountability is in authorizing the use of the kit for the patient; also in completing the order (verbal/written) to the community visiting nurse before medications are administered out of the kit; and he must also complete a separate ongoing order if the medication is anticipated for continuous use based on limited supply in the kit (CCAC, 2009). In other words, it is the doctor’s responsibility to prescribe the use of the kit. Therefore, these doctors must thoroughly assess the patient who should rightly be prescribed the kit. It is also their responsibility to verify the verbal orders they may relay to the visiting nurses who would otherwise administer the contents of the kit to the patient. This would help ensure that orders are verified and medical errors in the administration of drugs are reduced. The nurse is also accountable for her actions in the dispensation of medication via the Symptom Response Kit. The visiting nurse has to obtain the order for the kit from the doctor at such time when a patient might actually be a viable candidate for the kit; she will also inform the CCAC who will coordinate the dispensing through a CCAA provider pharmacy; and the nurse must also obtain the specific order from the doctor for any medication in the kit before she administers it (CCAC, 2009, p. 1). It is also important to note that only the visiting nurse who is assigned by the CCAC and the patient’s attending physician has the authority to use the SRK. Even if the drugs are already within the kit, there is still a need for doctor’s orders before any of these medications can be given to the patient (CCAC, 2009). The nurse would be responsible for administering the drugs in the kit based on the doctor’s orders. When the strength or the concentration of a medication is changed, an order process must be followed by both the doctor and the nurse. The kit and its contents are considered the property of the patient and when the kit is no longer needed, the kit plus its contents are supposed to be returned to the local pharmacy for disposal (CCAC, 2009). The nurse has to fill up the Symptom Response Kit Evaluation Form when the kit is to be returned to the provider. The nurse, along with the patient’s caregiver has also to be reminded that the SRK: has to be kept in a cool and dry place, out of the reach of children and is stored in a place which is convenient and accessible to the nurse (CCAC, 2009, p. 1). This project was chosen because it is important for patients under palliative care to have immediate relief of their symptoms. And it is important for them to be in the comfort of their homes while they are being treated. As was emphasized by the South West CCAC, it supports the principles of Client-Driven Care. And for those who are already at or near the end of their life, it is important to give them every comfort possible. The kit “enables the client to manage effectively symptoms at home, when that is their chosen location of death...[allowing] the CCAC to be a good steward of resources through timely, effective and efficient use of health providers, medications, and supplies” (CCAC, 2009, p. 1). Many of the patients under palliative care would be under pain and symptom management (CCAC, 2008, pp. 1-2). They are likely to be experiencing chronic pain and all manners of discomfort almost every minute. Other symptoms may include: terminal secretions in their air passages, seizures, delirium, agitation, nausea, and severe dyspnoea (CCAC, 2008, pp. 1-2). There is therefore a need to be prepared to meet all eventualities in palliative care. Literature: Implementation The following are the different steps which must be followed before a SRK can be prescribed for a patient. Firstly, the nurse has to contact the physician in order to express the need for the SRK. Second, the physician, after due assessment of the patient and of the conditions upon which the patient is living, would give the order for the SRK (CCAC, 2009, p. 1). Third, the nurse then contacts the Case manager in order to relay the physician’s approval of the SRK. Fourth, the Case Manager would contact the pharmacy, and then complete and fax the Symptom Response Form to the pharmacy (CCAC, 2009, p. 1). Fifth, the pharmacy would then fax the completed SRK request form to the physician approving or prescribing the kit. Sixth, the attending physician then signs the order and faxes it back to the pharmacy which would authorize the filling and the delivery of the kit to the patient. The physician must sign off on the order after due inspection of the kit before it can be dispensed to the client (CCAC, 2009, p. 1). Seventh, the pharmacy would now deliver the kit to the client’s home within 24 hours after receiving the signed order from the physician. The CCAC also recommends that a lead-time of 72 hours be set aside in order to enable assistance in the delivery turnaround time (CCAC, 2009, p. 1). The implementation of the SRK is noted for symptoms which may include terminal secretions. In this case, Atropine is administered to the patient. The nurse is also responsible for keeping the mouth clean. In cases where there are secretions in the airways, the nurse should strategically position the client in order to allow drainage of secretions (CCAC, 2008, p. 1). In cases of seizures, Lorazepam (2 mg S/L & 2 mg every 30 minutes S/L until seizure is controlled) is available in the SRK. The nurse should crush and dissolve the medicine in 1 ml of water and put the medication under the patient’s tongue; the nurse is also obliged to keep the patient and his family calm in order to allow for the effective control of the seizure; however, in case the management is still ineffective, then the patient should be transferred to the hospital (CCAC, 2008, p. 1). In case the patient would be delirious or agitated, the nurse is obligated to first identify the cause of such agitation which may possibly include: rectal impaction, urinary retention, increase in pain, medications metabolic derangements, dehydration, hypoxia, and brain metastases (CCAC, 2008, p. 1). The cause of the agitation would be the basis of the intervention or treatment which shall be administered to the patient. In the SRK, the following medications may be administered based on doctor’s orders: Haldol (to clear sensorium with minimal sedation) 0.5 – 5 mg subcutaneously administered every 4 – 6 hours (prn) as interim; or Methotrimeprazine 5 – 50 mg subcutaneously administered every 4 hours (prn); or Olanzapine 5 mg tab (stat) daily for agitation (CCAC, 2008, p. 1). In case the patient is in pain, the nurse should notify the physician of the patient’s pain status, his current opioid usage, and the number of breakthrough doses the patient has had in the past 24 hours. Answers to these questions would help determine the subsequent orders of the physician (CCAC, 2008, p. 2). It is important for the nurse to know that Dilaudid is about 5 times more potent than morphine and that Decadron may be used as an adjuvant in managing increasing somatic, visceral or raised intracranial pain; and the nurse should remember that an IV or an SC dose is half the oral dose (CCAC, 2008, p. 2). It is therefore important for the nurse to consult first with the physician before administering any pain medication to the patient. In instances of patient nausea, again, it is important for the nurse to establish the cause of the nausea. If it is an opioid-induced nausea, then Haloperidol (Haldol) 0.5 – 2.5 mg SC 2 to 3 times a day can be administered to the patient; if the cause of the nausea cannot be determined, broad spectrum drugs may be administered (CCAC, 2008, p. 2). These broad spectrum drugs like Methotrimeprazine (Nozinan) 2.5 – 12.5 mg SC every 6 hours (prn) or Prochlorperazine (Stemetil) 5 – 10 mg IM/IV/PR (not to be given SC) every 4 hours (prn) may be administered (CCAC, 2008, p. 2). In case of severe nausea, the nurse can apply some independent nursing interventions in order to relieve the patient’s symptoms. She may open a window, plug an electric fan, ensure a quiet and calm environment, and consider oxygen therapy at minimal flow rates (CCAC, p. 2). In case there is dyspnoea and the patient is on a long-acting opioid for pain, the medication may then be increased by 30%; if patient is not on opioids for pain, a low dose and short-acting opioid every 4 hours may be started for the patient (Morphine 2.5 – 5 mg per orem) (CCAC, 2008, p. 2). For anxiety/dyspnoea, Lorazepam (Ativan) 1 – 2 mg sublingual every 1 hour (prn) may be administered to the patient; it should be dissolved in 1 ml of water and put under the patient’s tongue. Dexamethasone may also be administered to the patient at 4-8 mg SC once daily with dosage adjusted based on patient response (CCAC, 2008, p. 2). As can be noted from the above medications and their indications, there are things that the nurse has to take note of before she can administer any of the drugs in the SRK. Hence, it is very much important for the nurse to be present before any drug in the SRK can be administered or even recommended for a patient. The SRK is not a simple medicine supply kit which can be administered immediately to the patient once he manifests symptoms which are covered under palliative care. There is a need for a thorough assessment of patient’s symptoms to determine aetiology of symptoms before any drug can be administered to him. Based on a report by the South West End-of-Life Network (2008, p. 5) the implementation of the SRKs in Huron and Perth were started in the fall of 2008 and evaluation was conducted shortly thereafter. Other kits used in the South West region were modified in order to fit the Huron-Perth kit and the kit was able to combine the best practices across the region (South West End-of-Life Network, 2008, p. 5). Medications contained in the kits set them apart from each other. The report also revealed that local doctors and pharmacists have a vital role in the determination of kit contents. In Oxford and Elgin, prescription forms were revised to make way for the mandate of the College of Pharmacies requiring individualized prescriptions (South West End-of-Life Network, 2008, p. 5). There was however an unsuccessful effort in Grey Bruce to transfer a kit with a client when she was about to be admitted to a long-term care institution. “Although long-term care policies may not allow them to accept symptom response kits when a person is admitted, a solution many need to be developed to ensure appropriate medications are available for symptom management” (South West End-of-Life Network, 2008, p. 5). In a study by Petrin (2006), he sought to offer an update on the use of the Hospice Symptom Relief Kit. He explained that the condition of patients can change quickly because of the unpredictability and the sudden changes in an end-of-life patient’s pain and other symptoms. It is therefore important to plan ahead in order to prevent needless suffering on the part of the patient. The development or the introduction of the Hospice Emergency Kit which has been renamed as the Symptom Relief Kit has been engaged in order to provide immediate relief to long-term care patients (Petrin, 2006). The main idea behind this kit is to anticipate the needs of the patient, to make the interventions ready even before he actually needs them. The author’s update mentions that the kit has made it possible for hospice care providers to treat their patients with the dignity and care they deserve (Petrin, 2006). An article about palliative and end-of-life care written by Judy Steed (2009) set forth some important truths about dying patients. The most important detail for caregivers and health professionals to remember about these patients is that they are still alive and while they are alive, health care givers should treat them like they are alive and not as if they were not even in the room. It is also important to reassure the patients that their pain is manageable and that everything would be done in order to manage their pain and other symptoms. In the process, it is also important to engage the patient in conversation, to allow him to express his grief which he may not be able to express with his family members (Steed, 2009). Steed (2009) also mentions that the symptom relief kit is one of the interventions which are being used by health professionals in order to ensure the immediate relief of pain. Pain is one of the most common palliative and end-of-life symptoms which can be a great cause of anxiety for patients. In order to improve the quality of life of these patients, remedies are now available within the confines of the patient’s home. The symptom response kit is one of these remedies. In a study by Bishop, et.al., (2009, pp. 37-44) they sought to assess the prescribing, dispensing, and utilization of medication kits for managing symptomatic emergencies in the home of patients under hospice care. Their study was conducted through a phone survey covering 22 agencies in New Hampshire which were providing hospice care. The study sought to establish the timing of medication kits ordering and the availability, characteristics of prescribers and pharmacies, the kit contents, costs, frequency of use, and perceived impact of kits (Bishop, et.al., 2009, p. 37). The study revealed all medication kits contained medications for pain and dyspnoea, with 81% for nausea and vomiting and 76% for seizures. About 86% of these agencies report that the kits were used in about 50% of the cases prescribed with such kits (Bishop, et.al., 2009, p. 37). Authors concluded that hospice programs which often utilized these kits contained prescription medications for uncontrolled symptoms in the patient’s home. They also believed that these medications minimized visits in the emergency departments and even hospital admissions. The authors also recommended more studies to be conducted in order to fully assess the outcomes of the medication kit practice (Bishop, et.al., 2009, p. 37). In an interview with Clark (2003), a nurse spearheading the FOCUS program in the home setting in North Carolina (USA), she speaks about the program being implemented specifically to care for the needs of patients with COPD and CHF. In this program, once a patient is enrolled, a scheduled visit with the physician is held. After assessment by the physician, the patient is given a medication kit. This medication kit gives the physicians and the other health care givers the chance to control the patient’s symptoms quickly and while in the home setting. Further reports after administration of the medication is reported to the physician in charge (Clark, 2003). In this program, the nurse regularly updates the physician on the patient’s condition and makes appropriate recommendations based on her observations and personal assessment of the patient. Strengths and Weaknesses The medication kit practice which is practiced in some states in America is advantageous in the sense that it minimizes emergency room visits and hospital admissions for patients under hospice care. It also gives these patients a chance to be cared for within the comfort of their own home. The medication kit practice however does not contain other medications which may be essential to palliative care. The medication kit practice essentially carries benefits similar to the SRK; however the SRK brings more specific relief to palliative care patients – including relief of nausea, dyspnoea, terminal secretions, anxiety, delirium, and chronic pain. The FOCUS program as discussed by Clark is very much similar to the medication kit and the symptom response kit. They all have similar goals. More importantly, the FOCUS program also recognizes the fact that delay in treatment of a long-term care patient may cause him further distress (Clark, 2003). And this distress may then lead to emergency care for the patient. For these reasons, the FOCUS program carries important benefits for the patient which is very much in keeping with the aims of the symptom response kit. The FOCUS program is however more limited in its coverage as it covers only patients with COPD and CHF. On the other hand the symptom response kit is more comprehensive as it covers patients under palliative care, and this may actually already include COPD and CHF patients. In the current home health nursing initiatives offered for long-term or palliative care patients, there are limited nurses or health care givers practicing. This is directly attributable to the limited number of nurses the world over. The situation among palliative care nurses is exacerbated by the fact that those engaging in this field have limited training and limited skills to adequately deliver quality health services (Lloyd-Williams, 2002, p. 589). Moreover, the shortage is affecting the implementation of the SRK home health initiative because as was previously mentioned, a nurse qualified by the CCAC is needed before the kit can be issued or prescribed to a patient. There is a need therefore to resolve the nursing shortage issue and to implement adequate training measures for nurses in order to adequately implement the Symptom Response Kit program. Conclusion The Symptom Response Kit (SRK) is a home health initiative which is primarily being implemented for palliative or long-term care patients. It is basically a medicine kit which contains essential meds which may be used by a palliative care patient based on manifested symptoms. It is meant to relieve the patient’s symptoms within the confines of his home in order to prevent or minimize hospital admission, to reduce anxiety or distress, and to ensure the patient’s comfort in the last days of his life. The kit is prescribed by the attending physician upon assessment and recommendation of the nurse contracted by the CCAC. The pharmacist receives the request from the physician and then personally delivers the kit to the patient’s home. The administration of medications in the SRK is done by the nurse based on patient symptoms. Close coordination with the doctor is required when medications are administered. Similar kits or programs are being implemented under similar goals, but the goals of the SRK program are more specific and focused on palliative care. Works Cited Bishop, M., Stephens, L., Goodrich, M., & Byock, I. (January 2009) Medication Kits for Managing Symptomatic Emergencies in the Home: A Survey of Common Hospice Practice. Journal of Palliative Medicine. Volume 12, number 1, pp. 37-44 CCAC Procedure (25 April 2009) South West Community Care Access Centre. Procedure Number 1.1.14, pp. 1-2 Clark, B. (July 2003) Providing Home-based Palliative Care for People with Congestive Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD): An Interview with Betsy Clark, RN, CHPN. Innovations in End-of-Life Care an international journal of leaders in end-of-life care. Retrieved 17 January 2010 from http://www2.edc.org/lastacts/archives/archivesJuly03/fipart1.asp Clinical Guidelines: Clinical Guidelines Created in collaboration with Care Partners, Clark’s Pharmasave, Saint Elizabeth Health Care and Pain & Symptom Consultant. (15 December 2008) South West End-0f-Life Care Network. Retrieved 17 January 2010 from http://thehealthline.ca/docs/WorkPlan2008-12-03.pdf Lloyd-Williams, M. (October 2002) Are undergraduate nurses taught palliative care during their training? Nurse Education Today. Volume 22, Issue 7, pp. 589-592 Matzo, M. & Sherman, D. (2006) Palliative care nursing: quality care to the end of life. New York: Springer Publishers Ronald, P. (July/August 2006) Hospice Symptom Relief Kit: An Update. International Journal of Pharmaceutical Compounding. Retrieved 17 January 2010 from http://www.ijpc.com/Abstracts/Abstract.cfm?ABS=2415 Steed, J. (3 October 2009) Palliative care is about easing final transition. Health Zone.Retrieved 17 January 2010 from http://www.healthzone.ca/health/yourhealth/article/702922--palliative-care-is-about-easing-final-transition Symptom Response Kit (25 April 2009) South West Community Care Access Centre. Policy number 1.1.14. pp. 1-2 Symptom Response Kit Frequently Asked Questions (27 October 2009) South West Community Care Access Centre. Retrieved 17 January 2010 from http://www.ccac-ont.ca/Upload/sw/General/SymptomResponseKitForms/SWCCACSRKFAQ.pdf Symptom Response Kit (SRK) Request Form (27 October 2009) South West Community Care Access Centre. TOO.0064 11/07 Read More