Nurses Exchange Best Strategies in Improving Delivery of Hepatic Artery Infusion Pump Education

A multidisciplinary approach is ideal in training nurses to use hepatic artery infusion pumps (HAIP) for chemotherapy delivery, according to Kathleen Gander DNP, APRN, CNS.¹

Kathleen Gander DNP, APRN, CNS

“A multifaceted approach for staff education was beneficial,” she said, during a presentation at the 48th Annual Oncology Nursing Society Congress. “[Using] a core group of chemotherapy-trained nurses to complete the HAIP access procedure was advantageous to ensure proficiency for this relatively low-volume, highly technical skill before expanding it to additional nursing staff.”

Sarah Middlekauff, MSN, RN, OCN, presented findings supporting a standardized approach to HAIP education is the best way to ensure oncology nursing confidence. Both institution-wide HAIP education initiatives were shared in poster presentations during the Congress.²

“Standardized HAIP education in the ambulatory oncology setting has enhanced the infusion nurses’ confidence in caring for these patients and provided a standardization of care, thus improving patient safety,” Middlekauff said.

HAIPs represent a novel way to deliver chemotherapy in a higher concentration to a specific area in the body. Some patient populations that may receive their treatment through HAIP include patients with unresectable colorectal cancer or cholangiocarcinoma that has metastasized to the liver.³

Because HAIPs are surgically implanted, it offers higher, localized concentrations of chemotherapy and minimizes systemic toxicities.³ Use of HAIPS, however, requires specialized training, and support from several specialties, such as surgery, radiology, and medical oncology.¹ Oncology nurses play a large role in helping patients with HAIPS by routinely accessing the HAIPS to administer treatment, teaching patients what to expect from treatment, and assessing patient symptoms throughout the treatment course. Proper nurse education, therefore, is critical.^1,2

Offering an Additional Treatment Option for Chemotherapy Delivery

Gander’s team, based out of Mayo Clinic in Rochester Minnesota, established an intervention to lead HAIP implementation efforts for their institution. The intervention included the following processes: first a procedural guideline outlined pump access procedures and documentation.¹ This included information for complications and troubleshooting. They then turned to an electronic education module, which provided an overview of HAIPs and patient education points.

Next steps included staff education sessions, in which pharmacology principles and toxicity assessments were discussed, and nurses were provided with patient education resources. Hands-on training followed, during which time nurses observed access procedures using samples pumps and needle kits and reviewed the company provided resources.

Nurses then demonstrated access procedure competency in real time with patients. This was observed by nursing leadership teams. Ultimately, a group of unit champions were selected—this was a core group of chemotherapy nurses who served as the unit leaders for training additional nurses.

Ultimately, the cohort of trained nurses successful demonstrated competence with this chemotherapy delivery method. Between February 2022 and March 2023, 13 patients have had HAIPs implanted at the institution, and specially trained oncology nurses have successfully accessed the HAIPS for 163 treatment sessions.

“A multidisciplinary approach was instrumental to the success of this project,” Gander wrote. She added, “Nursing involvement was fundamental for the development of process and integration of this treatment modality as a new clinical practice within the institution.”

Standardizing Care for Patients with Hepatic Arterial Infusion Pumps

Middlekauff works at the Ruttenberg Treatment Center with the Mount Sinai Hospital System.² The Mount Sinai Hospital had to change which HAIP product their institution uses multiple times in recent years, because of supply chain and manufacturer difficulties. The consequence was that infusion nurses expressed a lack of confidence in assessing the different HAIPs. When the newest HAIP was introduced in 2022, Middlekauff’s team implemented an education plan to standardize the care of patients receiving their chemotherapy this way.

To do so, her team reviewed the existing HAIP procedures for Medtronic Syndromed 2 against the procedure for the new product Intera 3000. A team from Intera 3000 partnered with nurse educators and together they conducted didactic lectures and hands-on practice. They created an electronic resource page for the nurses, which included information on the HAIPs, including assessment access, pump rate, and troubleshooting. Standardized smart phrases for electronic medical record (EMR) documentation were developed.

Next, the nurse educators developed a reference table which outlined the expected volume remaining based on the programmed flow rate and the number of days since refill. Together, the nurse educators collaborated with the EPIC team to develop a HAIP assessment checklist which could be implemented in the EMR. These same nurse educators were consulted on changes to the system-wide policy overseeing the incorporation of the new HAIP.

Overall, more than forty nurses were trained prior to the first patient receiving their treatment with the newest HAIP model. Training on both the Metronic and Intera 3000 HIAPS were incorporated into the annual nursing infusion competency. Over 6 months, 75 RNs were trained on the maintenance and access of HAIPS.

“The access and maintenance of the HAIP for the administration of floxuridine continues to be an annual competency and orientation requirement for all infusion RNs,” Middlekauff shared. “Infusion RNS reported an increased level of confidence regarding the access and maintenance of the HAIP as a result of the standardized education program.”

References

1. Gander K, Peterson L, Eastman J, et al. Offering an additional treatment option for patients: hepatic infusion pumps for chemotherapy delivery. Presented at: 48th Annual Oncology Nursing Society Annual Congress; April 27-May 1, 2022; San Antonio, TX. Accessed April 21, 2023. https://ons.confex.com/ons/2023/meetingapp.cgi/Paper/13051
2. Middlekauff S, Simon T, Boyde T. Standardizing care for patients with hepatic arterial infusion pumps (HAIP) through education. Presented at: 48th Annual Oncology Nursing Society Annual Congress; April 27-May 1, 2022; San Antonio, TX. https://ons.confex.com/ons/2023/meetingapp.cgi/Paper/13222
3. Song MJ. Hepatic artery infusion chemotherapy for advanced hepatocellular carcinoma. World J Gastroenterol. 2015;21(13):3843-9. doi:10.3748/wjg.v21.i13.3843