Educational Webinar: Preferred Demonstrated Practice – IV Management in the Home Setting

20250910_Clinical_1730284_MMS_HomeInfusion 0:01 Hello and thank you for joining us today. 0:03 My name is Brandon Martin here at McKesson Medical Surgical and I'm so excited to welcome you to today's clinical connections. 0:10 Presentation preferred demonstrated practice IV management in the home setting. 0:18 Before we get started, I'd like to direct your attention to our disclaimers. 0:23 While you're reviewing that information, I will remind you that this presentation is being recorded within a day or two. 0:31 You can expect to receive a link to rewatch the presentation. 0:34 And if you have a question, feel free to enter it into the Q&A panel to the left of your webinar window at any time and we will do our best to answer at the end of the presentation. 0:46 Our speaker today is representing McKesson Medical Surgical's newly formed Clinical Center of Excellence. 0:54 Shantelee Jackson is a dedicated and compassionate registered nurse with 20 years of nursing experience. 1:02 A graduate of Northeastern University in 2004, Shantelee spent her nursing career in various healthcare settings such as acute care, home health, community health, and in home infusion. 1:16 As a clinical service Liaison, Shantelee is actively involved in professional development activities to stay abreast of the latest advancements in the nursing profession and as a result, she holds a Master of Science and Nursing degree for Leadership in Nursing from Kennesaw State University and has two nursing certifications, certified Medical Surgical nurse and Certified Registered Nurse infusion. 1:44 Shanti, thank you so much for joining us today. 1:49 Thank you so much for the introduction and hello everyone again. 1:53 My name is Shantelee Jackson, and I am the IV Therapy Clinical Program Manager at McKesson with a focus on the home infusion therapy division within our organization. 2:04 I'm super excited to present for you all today to discuss some of the best demonstrated practices and nursing considerations as it relates to IV therapy management in the home setting. 2:18 Our agenda for today includes A brief discussion on background and a little vessel anatomy as well as a discussion on IV line types, followed by a little information on therapies, particularly core therapies. 2:31 So we'll just review a few there and lastly, a small review on methods of administration. 2:40 So what is an infusion? 2:41 Infusion therapy is the administration of solutions, medications, nutritional products, and blood or blood components directly into a vein, which is also known as the parenteral root. 2:55 IV therapy is used in over 90% of hospitalized patients and so because of its wide use, advancement and evolution over the years we are seeing it more and more in various non acute care settings. 3:07 So definitely in skilled nursing facilities and in sub acute rehabs. 3:12 It's also often seen in specialty clinics such as oncology offices or health systems that have designated infusion clinics for their patients. 3:23 We'll also find large and home infusion pharmacies will have an ambulatory infusion suite or an AIS for patients to receive their treatments that require more nurse monitoring. 3:34 So perhaps for those specialty infusions. 3:37 And then of course, in our favorite setting as home care clinicians to home, there are several reasons for a patient to receive IV therapy in the acute setting to home. 3:48 So I'm sure you're all aware of these indications, but let's just review them quickly. 3:52 First, to maintain or hydrate the body and replete electrolytes. 3:57 Secondly, to restore hemodynamic function right to to maintain that hemostasis for patients. 4:05 Also to treat pain, give blood or diagnostic agents such as IB dye maybe for CAT scans or MRIs. 4:11 And then of course for medication administration and all levels of care. 4:16 And lastly, we just know that IV administration is the fastest route of of medication administration, thereby making it the most useful and emergent situations. 4:31 There are a few type of infusions ordered for the home setting. 4:35 Continuous infusions are usually larger volumes of medications ordered to be infused daily over like a 24 hour period of time to maybe several days to a few weeks. 4:47 These medications may be more potent where accuracy during administration is a must and therefore you will typically find most continuous infusions are administered by some type of pump, ambulatory pump, which usually has like a ± 5% variant. 5:05 So it's pretty accurate method of administration. 5:09 Intermittent infusions are given at time intervals or as a frequency with a set volume to be infused. 5:17 So these are like our gravity infusions. 5:20 In the hospital, we may piggyback them. 5:22 But of course in the home setting, these are typically just our primary infusions and depending upon the frequency are definitely a bit more convenient for the patient. 5:36 Patient controlled analgesia or PCA, of course is used for pain management in the home, typically seen in maybe a palliative setting or for Hospice patients. 5:48 We may not see as much of these types of Ivy's use in home because most pharmacies are a little bit more leery with the regulations for the use of narcotics in the home. 5:58 But definitely, again, you could see them. 6:00 And so definitely something to keep in mind. 6:03 And then lastly, the subcutaneous route, which is widely used for infusions at home where we use smaller gauge needles with shorter lengths, maybe around 5/8 of an inch or a little longer, a little shorter depending on the patient's anatomy. 6:17 And this is a good route and a good alternative to IV intravenous catheterization in specific situations, perhaps for rehydration during hypoderma crisis or for palliative support in Hospice patients. 6:32 And then sometimes you'll find it in administration of generic drugs like antiemetics. 6:38 They those come to mind. 6:39 So maybe for Zofran pumps, maybe for expecting mothers who may be experiencing hyper emesis, gravidum, something like that. 6:48 So subcutaneous is another roots you may find as well. 6:54 Before we go on, it's important to discuss a little anatomy and Physiology. 6:58 And I know, I know, I understand taking us back to our nursing school days, right, with a little A&P can make us all cringe just a little bit. 7:07 But it's good to review and it can be helpful and a good reminder when putting things into context. 7:15 So just a little vein anatomy here. 7:18 The tunica adventure or the Tunica externa, it's the outer layer of the vein. 7:23 It's made-up of mostly connected tissue. 7:26 This layer supports and protects the vessel. 7:30 So that's the outer layer of the vein and then the middle. 7:35 The tunica media is the middle layer of the vein. 7:38 It consists of muscular and elastic tissue. 7:41 The nerve fibers, veins are in this layer and it therefore effects vasoconstriction as well as vasodilation. 7:49 It's also the area that senses pain during cannula cannalization of the vessel. 7:55 The tonica entema is the inner layer of our vessels. 7:59 It mostly consists of smooth layers and flat endothelial cells, so there's no nerves here, there's no sensing of pain. 8:06 Once you're at this part of the vessel. 8:09 It's the innermost layer of the vein, but it is the area of the vessel where thrombosis occurs after venom puncture. 8:16 So it's good to keep that in mind. 8:21 Veins are broken up into three main categories. 8:24 OK, so we have deep veins, superficial veins and perforating veins. 8:29 Deep veins are made deep, usually in a company in artery. 8:36 These are the veins that require ultrasound guided technology to cannulate UMM, so they may not necessarily be the veins that we can await as home health nurses. 8:47 But good to know about deep veins. 8:50 Superficial veins are what we use for venipuncture and IV therapy. 8:54 These veins lie directly under the skin and are usually palpable. 8:59 They're the wriggly veins, right? 9:00 So they're the ones that will roll on us a lot when we attempt to place the IV catheter and therefore require anchoring or some sort of skin traction to advance the catheter when accessing the vein. 9:15 And then perforating veins connect deep veins to superficial veins. 9:19 So they're sort of, I like to think of them sort of in the middle. 9:27 We will not belabor all of these veins in detail, but I just wanted to highlight the ones that are most widely accessed for peripheral IV use or or intravenous use. 9:37 So you can see here the bacillic, the cephalic and the anti cubital veins. 9:41 And with their locations listed here on the screen and also listed here as one of the most widely used vessels for IV insertion, the subclavian, that's the vessel that's most likely accessed by vascular access nurses and interventional radiologists. 9:57 So it's, it's a good vessel to review and definitely one of the most popular veins for use for IV infusion. 10:08 OK, let's switch gears here and talk a little bit about intravenous Lyme type. 10:12 So peripheral Ivs are categorized in three main types, which we will discuss in just a moment. 10:20 But I do want to make note that there are approximately 330 million peripheral IV catheters sold each year. 10:28 That's a lot of IV catheters and about 3.2 million likely more using the home setting, making peripheral IV insertion a significant skill for healthcare professionals to acquire and maintain. 10:43 The decision though for which peripheral IV catheter chosen for use, it's dependent upon a couple of things and that would be the type of therapy needed or the length of need for the treatment as well. 10:58 Oftentimes to to help with successful insertion of an intravenous catheter, we'll find the use of vein lights that's becoming more popular for use in the home setting. 11:11 And then of course in more advanced or inpatient alternative sites of care, you may find ultrasound guided technology has helped to enhance that successful placement of peripheral IV devices. 11:30 So we all know what a peripheral IV catheter or short peripheral catheter is. 11:34 It's typically an IV catheter, it's around an inch or so in length and use your therapies that are only short term needs, so likely less than a week. 11:45 There are several kinds to choose from. 11:47 Some can be winged or straight, have passive or active needle safety technology for the retraction. 11:54 So those are just a few we may find and are very popular used in the home setting. 11:59 Long peripheral IV catheters are around 2 1/2, two to five inches in length and are placed in superficial or deep veins. 12:09 We don't usually access these types of Ivs in a home. 12:12 They require vascular visuals visualization technology. 12:16 So usually these IV catheters are placed by vascular access nurses. 12:24 This is a good segue to the next type of IV line, the midline catheter, also placed by that nurses. 12:29 Using ultrasound guided technology, these Ivs are placed typically accessing the brazilic or cephalic or even the brachial veins. 12:39 The catheter lengths are around 7 to 8 inches and the tip of the midline catheter usually terminates at the level of the axilla. 12:49 Usually the length of therapy is at least two weeks, although it's common to see therapies order for a bit longer with the use of a midline as dwell times for a midline can be about 28 days or so. 13:09 As it relates to best demonstrated practices for placement of short peripheral catheters. 13:13 When choosing an IV kit, just a gentle reminder that your kit will likely include two pleasing agents, so either a 70% alcohol and an antimicrobial agent, so likely chloroprep or maybe even PvP. 13:30 And then of course your additional commodity items such as transparent dressings, skin prep and extension set in a tourniquet, preferably latex free, keeping in mind our patients with latex allergies. 13:43 It's also good practice to have a dressing label to document the date and time of placement for your IV catheter. 13:50 And then additional items needed for successful insertion are needleless connectors and a saline flush. 13:58 When we choose a vein to access, we want the veins that are bouncy. 14:01 We want the veins that are soft, preferably visible, and definitely easily palpable. 14:07 They can all be that simple and that easy. 14:10 Everything will be OK. 14:11 We know it's not always we want to choose veins that are likely to last the duration of the therapy. 14:19 So distal site selection is important, right? 14:23 Choosing sites at a distal spot and moving up the arm as needed. 14:27 We don't want to poke veins all over the place. 14:30 Definitely we want to keep in mind to avoid areas of flexion. 14:35 We want to avoid Bony prominences or inside the wrist is those areas can be painful and they're prone to complications. 14:46 And we want to stay away from areas that are bruised or have recently been infiltrated as well. 14:53 Refraining from sticking vessels on the side of a mastectomy or AB fistula or even for those patients who have an upcoming planned procedure, those are good to avoid as well. 15:08 Again, I'm sure we all know the basics behind short peripheral catheter insertion, but let's highlight again starting with which size catheter to choose. 15:19 We, we know well the universal coding system, the color coding system to make selecting the appropriate peripheral ID easy. 15:28 It's a standard across the healthcare spectrum. 15:31 So even though those colors are meant to guide us, it's still important to check the outer packaging for proper gauge selection, right? 15:38 So that you know, when you grab a pink, there's actually a 20 gauge needle in there or, or a yellow that you know there's a 24 gauge. 15:46 And when opening the package, we want to take into careful consideration the needle bevel that it's, it's it's up and that the catheter overlay are intact and definitely taking care not to touch those parts prior to insertion. 16:04 That brings me to the aseptic non touch technique, which is just a theoretical framework of practice incorporating standard precautions with a sterile technique and the aseptic field management across all levels. 16:21 That way we protect the key sites and key part areas of the insertion and infusion, so making sure we decrease the risk of extrinsic contamination and that is something that is widely encouraged by the Infusion Nurses Association. 16:39 When choosing a site to access, planting the area you plan to access with CHG, which is usually the antimicrobial choice, back and forth motion allowing the skin to dry for 30 seconds. 16:53 We don't wave, no blowing, no fanning. 16:55 You know, back in the day we might have even popped the finger tip of the glove to retouch the area after it was cleansed. 17:03 We don't want to do that. 17:05 We, we, we've learned that you would have to redone your gloves and re cleanse the area each time you touch it. 17:12 And then of course, considering your catheter to vein ratio, we do not want to choose peripheral IV catheters that are too large for the vessel in which we are accessing right. 17:22 Again, putting the patient at risk for complications during use. 17:27 You know, hemodilution is, is an important facet to to keep in mind. 17:34 Then again, remembering we want to refrain from multiple tourniquet use and limit the vein popping or vein tapping, which just really further makes an already uncomfortable situation for the patient more uncomfortable. 17:53 So this slide outlines a few of the key complications associated with peripheral IV lines. 17:59 So from phlebitis or inflammation of the vein wall to infiltration which occurs when IV fluids or medications are inadvertently enter the surrounding tissue instead of the vein. 18:12 I would be remiss if I did not mention extravasation as well. 18:17 It's not listed here, but it's a bit worse is it's the inadvertent administration of a vesicant solution into the surrounding tissues, which without proper identification, without correct assessments and action can cause blistering or worse yet tissue necrosis. 18:41 OK, so moving on to central lines, What makes these line type central is where the tip of the catheter terminates. 18:49 So either in a central vein like the superior vena cava or inferior vena cava, there are several indications for use for inadequate vein access to the need for long term therapy. 19:03 So those are some of the most common reasons we find the use of a central line in the home setting. 19:11 But it's this is foundational understanding and it just supports the clinical decision making around the appropriate IV therapy modalities. 19:23 For central venous catheter types, there are tunneled and non tunneled, which helps to clarify selection for the insertionist based on therapy duration, insertion criteria and of course the patient needs. 19:34 So I've just listed a few things here and then of course pick lines and ports. 19:43 We commonly see these Ivs used in the home arena for infusion needs. 19:49 PICC lines definitely invasive, placed peripherally and suited for wide range of therapies and long term use. 19:59 Ports are surgically implanted under the skin and are accessed intermittently with a Huber needle, so they require minimal daily maintenance and are ideal for patients requiring infrequent but extended therapy. 20:14 Of course, obtaining permission for the provider prior to using a port is super important, but again here just showing the details to support choosing the appropriate device, again based on therapy frequency, patient condition, and even the care setting as it relates to best demonstrated practices for central line management. 20:39 Choosing a standard kit with commodity items as listed in the slide here is really important. 20:45 We know that the Infusion Nursing Society encourages the use of additional sort of advanced items. 20:52 So the use of a stabilization device to decrease the risk of micro pistoning of our central lines is important. 21:00 So that's something to consider. 21:01 Well, also the use of an antimicrobial disc such as the CHD patch has the evidence based practice to support the reduction of classy rates when used. 21:14 So it's important to consider this, especially if it is per your organization's policies. 21:23 And then site assessment is vital in the home setting, especially as we educate patients and families on what to watch out for. 21:31 So focusing on identifying signs of infection, redness, drainage, tenderness, swelling, all of those things are important. 21:42 Monitoring for adhesive reaction is again an important consideration, especially for our at risk populations like the elderly or maybe Pediatrics. 21:52 Marcy is is very common. 21:54 So doing what we need to do to mitigate these complications, perhaps using skin prep or an adhesive removal is definitely something to keep in mind. 22:05 But all the things we do related to assessment and education of the insertion site are critical for maintaining catheter integrity and ensuring that patient safety during long term IV use is upheld. 22:25 This site emphasizes the importance of maintaining, you know, sterile technique during central line dressing changes. 22:31 You can see what I have listed here. 22:35 I want to just highlight our role as home health nurses and ensuring safety prior to use. 22:42 Assessing and documentation of the central line, particularly our PIC lines is key. 22:50 What does that site look like prior to use? 22:53 Are we able to measure the arm circumference and length of the pigtail right that these things are necessary when we are working with central lines, particularly pick lines, we definitely want to look for documentation of the PIC line tip to confirm whether it's been placed in the correct vessel. 23:14 So usually we're looking for a chest X-ray or a three CG waveform prior to use. 23:21 That way we know the tip resides in the SVC or the Cabo arterial junction and it's nurses. 23:28 It's pretty important as well to monitor the dressing needs for our patients. 23:34 So seven day wear time for most TSMS, most transparent semi permeable membranes, but watching for drainage at the insertion site and notifying the provider for anything that is concerning. 23:47 And remember, if for some reason we need to use gauze and change the dressing to a gauze dressing, then that will require an assessment and changing more frequently. 24:00 So that moves to every 48 hours versus the weekly dressing change. 24:05 And of course, as home health nurses, we know the importance of caregiver involvement and patient education for ongoing care responsibilities in this area. 24:20 And lastly, we definitely want to highlight and understand the care and maintenance of the implanted port. 24:27 So choosing a Huber needle length and gauge that are appropriate size for your patient. 24:33 You can see here the management of ports mirror central line dressing protocols. 24:37 You know they still require sterile technique for site preparation prior to access. 24:43 Some of the key considerations include identifying what can make maybe the patient comfortable prior to insertions or perhaps identifying or pertaining and obtaining an order for a topical anesthetic before careful needle insertion could really help make your patients feel comfortable. 25:01 But All in all, again, minimizing the risk of infection and enhancing the patient experiences is what we want to do here. 25:12 All right, moving on to infusion therapies, as it relates to therapies commonly seen in the home setting, mostly what we coin as core therapy. 25:23 So these would be your anti infectives, your antibiotics, TPN, of course, anatropes or chelation therapy in home infusion. 25:33 There's definitely been a rise in the use of specialty drugs in the home setting. 25:37 So therapies like biologics or IVIG and chemotherapies are seen more and more in home as well. 25:46 And then of course not the perennial route, but definitely part of the home infusion space, enteral therapies and we'll find those in the home as well and they support those patients needing PEG tooth feeding, some things like that. 26:06 So let's chat just a little bit about just a few of the core therapies. 26:11 We will start with any effective agents, which is the intravenous infusion of antibiotics, antifungals, or antimicrobials. 26:21 We know these therapies to be critical interventions for managing complex or resisting infections. 26:27 These medications are typically reserved for cases where oral treatments are ineffective or maybe when a patient's immune response is insufficient and it hasn't been able to control the infection. 26:42 Any infectives make up the largest segment of IV administered drugs and function through either inhibiting microbial growth, we call that bacterial static or directly eliminating pathogens, we call that bacterial cycle. 26:59 Their uses require careful consideration of the individual drug properties by the provider, and that includes how they're absorbed or metabolized and even excreted. 27:14 And as clinicians, we must assess the potential for allergic reactions when we're infusing our antieffectives and definitely remain vigilant regarding that, especially while we know that antimicrobial resistant is on the rise can definitely you know influence treatment decisions. 27:46 I have listed a few of the top and infected drug classes infused in the home. 27:50 So penicillins also you may find these drugs infused as a continuous infusion for your patients. 27:57 We'll see carbapenems another broad spectrum IV category. 28:01 So in Vance or marim are are often found as grabbing infusions and then commonly seen cyclosporins. 28:10 So you can see listen here Rosefin and Seth Fortez, Maxapine, all those drugs you will find likely infused in the home setting and we typically cephalosporins can be given simply by IV push. 28:32 One of the antibiotics I would like to pay special attention to is vancomycin. 28:38 As home care clinicians, we have a critical role when managing glyco peptides and this type of high risk medication, particularly due to the risk of serious adverse effects and the need for very precise dosing. 28:54 Vanco is often used for resistant bacterial infections or maybe even for patients that have penicillin allergies. 29:04 So we have to be mindful of the need for close monitoring with vancomycin. 29:10 It's got a narrow therapeutic window and with that, watching for signs of nephrotoxicity or auto toxicity and ensuring lab values such as the peak and through levels are obtained and communicated properly and promptly is is it's of the utmost importance. 29:32 Hypersensitivity to vancomycin infusions may or may not appear immediately as well. 29:38 So there is a continual need for ongoing assessment. 29:44 And for us as home health nurses, this means having that multidisciplinary approach to clear communication with the prescribing provider and the pharmacy teams, right? 29:55 Educating the patients and caregivers to ensure visits are kept for those timely lab draws and to assess symptoms and to report them, but also to help prevent complications and support the safe and effective treatment while a patient is receiving this drug. 30:21 Another course therapy that I'd like to touch on and very briefly is anatropic therapy. 30:28 One of my favorite therapies to educate on. 30:31 It's used to support the contractility of the heart in patients with advanced stage D class 4 heart failure. 30:39 Most of these patients you will find, are symptomatic without their infusion and their symptoms improve once the infusion begins. 30:49 Most of the patients have tried all the guidelines directed medical treatment and it's failed. 30:56 So inatural use is usually one of the final options to determine whether it's used for palliation versus a bridge to an LVAD and then maybe a heart transplant. 31:14 So briefly little known and dobutamine are the most commonly found. 31:18 They're dosed in micrograms per kilograms per minute. 31:21 Both are infused by pump. 31:25 You will find that these patients will likely have a double lumen central venous catheter. 31:31 They have to in case one side gets occluded. 31:36 Usually you'll also find that these patients will be sent home with two pumps in case there's a malfunction of 1. 31:43 So encouraging the either switching between both pumps or periodically monitoring the pump that's not in use for errors and and battery needs is very important for us as home care clinicians. 31:59 And just a reminder that with between the two, dobutamine has the shorter half life. 32:07 So minimizing interruptions really for both, but but, but particularly for dobutamines has to be emphasized for these patients or you will find they will likely become symptomatic. 32:25 OK. 32:26 Let's lastly here discuss methods of administration. 32:30 Common infusion methods in the home infusion range from Ivy push, which is one of the simplest, most cost effective but safest way to infuse, particularly when educated properly. 32:44 In the home we have gravity infusions as well, mostly using a dollar flow or perhaps a rate of ray flow device and of course pumps for continuous infusions. 32:59 Elastomerics are pretty popular method of administration in the home setting. 33:05 For those who may not be familiar with an elastomeric device, it's simply a balloon like reservoir housed in a rigid container and it uses mechanical pressure to infuse the solution at a predetermined rate. 33:17 Patients love the simplicity and the ease of use when using an elastomeric device. 33:23 It's it's easy during ambulation. 33:25 You know the patient can put it in a carry pouch or in a pocket when moving about the home. 33:31 And providers love it for their patients, right? 33:35 Most patients are able to safely comply with the treatment. 33:40 You don't often find a lot of missed doses or wasted medication. 33:50 Ambulatory pumps are what is identified as compact portable devices used to deliver the perennial medications with precision. 34:01 We talked about that a little before. 34:03 They're usually battery operated or they can be electronically powered and are designed to support a wide range of drug therapies, making them super versatile in the home and in alternate settings. 34:21 So we also call them electronic infusion devices or EIDS. 34:26 They are key in their ability to regulate the infusion accurately, which is especially important for medications requiring tighter control overdosing. 34:35 So we just talked about inotopes, that will be one of them. 34:38 TPN we did not talk about that would be one of them. 34:43 The pharmacist will typically program the pump with the specific parameters such as the dose, the rate, the volume based on the prescribed therapy. 34:51 And so if any adjustments are needed, nurses have to follow the pharmacy protocols or maybe your organization's protocols to ensure safety and compliance. 35:00 Most times it's done over the phone with the pharmacist and and you are double checking and triple checking together. 35:11 From the nursing perspective, there are several practical considerations to take into account. 35:17 So just making certain patients know to prime their line correctly before starting the infusion with the Eid. 35:25 Additionally, we want to encourage our patients to use any appropriate accessories like carry pouches or if they have been supplied with a pole holster in a pole. 35:36 So just to maintain comfort and safe mobility. 35:41 You know, that helps to decrease falls in the home. 35:43 And we know that is a goal that is super important for us as home care clinicians. 35:50 We want to make sure patients leave home with the appropriate needs to maintain the infusion while they're away. 35:56 So encouraging them to bring their extra batteries and all the things that will support safe infusion while away from the home is key. 36:06 And lastly, troubleshooting skills are important as well. 36:10 So properly addressing alarms, checking battery levels prior to the infusion and resolving quick flow interruptions is is is definitely something we want to encourage our patients to do. 36:26 You know, at the end of the day, pumps not only support clinical accuracy, but they promote independence and a quality of life for patients receiving IV therapy outside of traditional settings. 36:41 So definitely want to make sure we're constantly educating patients on what to do here. 36:51 And then lastly, this slide brings it all together despite whatever method of administration with the essential administration steps and for what's needed to maintain central line patency. 37:04 So in home, we encourage the SASH technique which stands for saline administer the medication followed by saline flush and then heparin. 37:14 Depending on the line type could just be SASS saline administer saline may not need to happen, but this is a widely accepted protocol for flushing IV catheters. 37:26 We encourage it in the home setting from the home infusion pharmacy just because it helps to prevent occlusions and to maintain that line and prevent infections. 37:37 Again, a few best demonstrated practices and critical reminders. 37:43 We want to encourage the use of A10CC syringe to avoid the excessive pressure buildup that could damage the tips of catheters when we are flushing or giving something IV push. 37:58 We also want to make sure to encourage the scrubbing of the hub right for full 10 to 15 seconds before accessing the line. 38:06 We know this is an evidence based non negotiable for infection prevention. 38:11 So encouraging patients to do it as well as making sure we're scrubbing that hub ourselves as the home health nurse. 38:21 And also just being mindful of solution compatibility when flushing between medications. 38:28 It's very important and following any specific guidance on the not just the the heparin concentration, but the volume and all of that could vary between provider or institution and even drunk what therapy the patient is getting. 38:50 So I believe that brings us to the end of our journey through IV therapy management and best demonstrated practices in the home setting. 39:02 I appreciate you all for tuning in and engaging. 39:06 We've covered a lot of ground here, so I'll open it up to questions and pass it back off to you all. 39:12 Thank you. 39:14 Thank you so much, Shanti. 39:16 We can have a couple of questions that have come in the chat here. 39:20 And just a reminder to everyone on the call, if you do have some questions, you can go ahead and submit those in the Q&A box to the left of your screen. 39:32 So to start, could you provide us a little bit more guidance on determining the most appropriate IV Lyme type for a patient receiving long term therapy in the home? 39:47 Sure, absolutely. 39:48 Good question. 39:50 A lot of that is determinant upon the type of therapy that has been ordered and how long the patient will need that therapy. 40:01 And thankfully the providers will identify which type of line is appropriate based upon those two factors. 40:13 Excellent. 40:14 So going back towards the beginning there and talking about a little some of the anatomical considerations, could you explain a little bit more about those key considerations when selecting A vein or peripheral IV insertion? 40:35 Absolutely. 40:37 Well, it's really important. 40:39 We want to, of course, try to make something that is already, you know, uncomfortable for patients where there may be, you know, fear of needle or you know, discomfort. 40:54 So choosing areas that are don't, do not have a lot of flexion. 40:59 So avoiding the wrists areas, you know, where there's lots of nerves, things like that. 41:04 And we definitely want to avoid areas where there are Bony prominences. 41:10 Those can create some discomfort as well if the patient is moving. 41:14 So again, avoiding Bony prominences, areas of flexion in areas where there are a considerable amount of nerves such as in on the inside of the wrist. 41:28 Sure. 41:29 And then we have a ask here about like some of the best practices as far as like preventing some of those complications. 41:40 Sure, that's a really good question. 41:43 I think a lot of it is, you know, making sure we adhere to the proper skin prep prior to insertion or when changing or dressing so that there is no, I mean extrinsic or external factors that affect that could affect long term complications such as electrolytes or something like that. 42:04 Also, I think making sure we anchor our vascular access devices. 42:08 So whether or not you use, you know, a, a, a manufactured item that is a branded item that is meant to secure those IV line types, I think is important. 42:23 And then, you know, as home care clinicians, we the foundational principle of our work is education for patients and family members. 42:32 So of course, educating them on what to watch out for, early signs and when to notify their healthcare providers I think are key factors here as well. 42:46 Thank you so much. 42:47 And Speaking of education, I'm just going to click through here and give folks a chance to review the references. 42:57 So I thank you for including that. 43:07 And one more time, I just want to show everyone our disclaimers for this presentation. 43:22 And finally, for a full list of our upcoming events, I invite you all to visit us at mms.mckesson.com/learning-webinars. 43:34 You can register for a future webinar, share events with your colleagues, or sign up to receive regular updates on our webinar schedule. 43:44 Once again, Shanti, thank you so much for sharing your time and expertise with us today. 43:49 This was a fascinating topic and I do hope that we can have you back again soon. 43:58 Thank you again, thank you, thank you. 44:02 Sorry to cut you off there. 44:03 But also thank you again to our audience for taking the time to join this presentation and I do hope everyone has a great day.