Home PN Discharge Planning & Management

Pediatrics Home PN Referral and Discharge Process (algorithm)

How to order Home PN for discharge

Discharge Checklist for New Pediatric Home PN Patients

• Order PN labs before discharge: correct imbalances and give infusions/ transfusions as needed. (Hgb, Pltlt, WBC, Glucose)
• Discontinue therapies several days before discharge to home if that therapy will not be continued at home i.e: narcotics/meds, suctioning, chest PT, O2, GT to low wall suction.
• If a patient is to be discharged home on PN, please order a Home PN consult.  Give PN RN and Case manager at least 1 day advance notice for established PN patients and
  7 days for new PN patients.
• On the day prior to discharge, write anticipatory discharge orders, Home PN program, Enteral feeding, Oupatient medication prescription (that includes: resumption of Home Health nursing, monthly PN labs,  IV abx/ hydration). (These will be faxed to the Infusion Pharmacy and Nursing agencies so delivery of PN/VAD and enteral supplies are arranged the day of discharge. This will also prevent delay of discharge)  
• CCS patients will need orders signed by CCS paneled attending.  On the day of discharge, final discharge orders should be in the chart if possible by noon time.  New patients should not be discharged on weekends or holidays. If an established PN pt is going home on IV abx or IV fluids besides PN, please notify us as early as possible before day of discharge so training can be arranged.

CENTRAL VASCULAR ACCESS DEVICE (CVAD)

Once a triple lumen (CVP), Broviac/Hickman or PICC line is placed a CXR must be taken to check for proper placement of the catheter tip. Central Venous access device should terminate in the lower one third of the superior vena cava or in the upper one third of the inferior vena cava. Ideal catheter tip position is at the junction of the superior vena cava and the right atrium.

 (Click to enlarge)

• Incorrect placement into the right atrium places the patient at high risk for cardiac tamponade and embolism.
• Placement higher than 1/3 of SVC is not considered a central placement and the patient is at risk of thrombosis and damage to epithelial cells of the subclavian vein. Policy R 15
• For Home PN patients we recommend a single lumen central line.
  (Multiple lumens=higher incidence of infection)
• “Pinch off syndrome”Definition- Catheter positioned between clavicle and first rib characterized by intermittent catheter malfunction in conjunction with radiologic evidence of catheter compression.
  Warning Signs- RN will report difficulty flushing or withdrawing blood from CVAD and resistance to infusion of IV fluids, Recommend cathetergram with abduction and adduction of extremity correlating with the side where CVAD is placed. If diagnosis confirmed, recommend placement of new CVL.

Potential complications if left untreated- Catheter fracture characterized by migration of the distal catheter fragment through the heart and, often, into the pulmonary artery; it may be accompanied by the sudden onset of chest pain, palpitations, and arrhythmias.