What are the different types of infusion therapies used in Skilled Nursing Facility (SNF) rehabilitation?

Types of Infusion Therapies Used in Skilled Nursing Facility (SNF) Rehabilitation

Skilled Nursing Facilities (SNFs) commonly provide various infusion therapies as part of their rehabilitation services, with parenteral antimicrobial therapy being the most established and well-documented type of infusion in this setting. 1

Antimicrobial Infusion Therapy

Antimicrobial infusion therapy in SNFs offers several advantages:

• Nursing staff is available on-site for medication administration and monitoring
• Other skilled nursing needs (physical therapy, wound care) can be met simultaneously
• Usually covered by Medicare and other payers
• Allows for completion of antibiotic courses without prolonged hospitalization 1

Common antimicrobial agents administered in SNFs include:

• Vancomycin: Requires 60-120 minute infusion time depending on dose, with weekly monitoring of trough levels. Must be administered over at least 60 minutes to avoid infusion reactions including hypotension and cardiac arrest. 2
• Aminoglycosides (e.g., tobramycin): Require 30-120 minute infusion time with careful monitoring for nephrotoxicity and ototoxicity
• Trimethoprim/sulfamethoxazole: 60-90 minute infusion with monitoring for hyperkalemia, rash, and nephrotoxicity
• Other antibiotics: Including telavancin, tigecycline, and various beta-lactams 1

Anticoagulation Therapy

Anticoagulation therapy in SNFs includes:

• Subcutaneous heparin: Administered as deep subcutaneous injections (above iliac crest or abdominal fat layer) every 8-12 hours, with dosing typically 5,000-20,000 units depending on indication 3
• Intravenous heparin: Can be given as intermittent injections every 4-6 hours or as continuous infusion (20,000-40,000 units/24 hours) 3
• Low-dose prophylactic heparin: 5,000 units subcutaneously every 8-12 hours for prevention of postoperative thromboembolism 3

Cardiac and Heart Failure Management

SNFs provide infusion therapies for heart failure management, which may include:

• Intravenous diuretics: For management of volume overload in heart failure patients
• Inotropic agents: In select cases for patients with advanced heart failure 1

Heart failure management in SNFs should focus on:

• Monitoring for symptoms of volume overload
• Initial management of decompensation with oral or intravenous diuretics
• Decisions about hospitalization based on goals of care and functional status 1

Anemia Management

For anemia management in SNFs:

• Intravenous iron: Considered when oral supplementation is not tolerated or ineffective 4
• Blood transfusions: Reserved for symptomatic patients with hemoglobin <7-8 g/dL 4

Pain Management

Infusion therapy for pain management in SNFs may include:

• Intravenous analgesics: For patients with severe pain not manageable with oral medications
• Neuropathic pain infusions: Various agents for short-term relief of neuropathic pain from conditions like diabetic neuropathy and post-herpetic neuralgia 5

Palliative Care Infusions

SNFs increasingly provide palliative care infusions for:

• Symptom management: Including pain, nausea, and dyspnea
• Hydration: When oral intake is insufficient 6

Implementation Considerations and Challenges

When implementing infusion therapies in SNFs:

1. Vascular access management: Proper care of central vascular access devices is essential to prevent complications like infection, occlusion, and dislodgement 7

2. Staff training: SNF staff must be trained in:

   • Proper administration techniques
   • Recognition of infusion-related complications
   • Monitoring parameters for specific medications 1

3. Monitoring requirements: Regular laboratory monitoring is essential:

   • Weekly monitoring for many antimicrobials
   • More frequent monitoring for anticoagulants
   • Electrolyte monitoring with diuretic therapy 1, 4

4. Rehabilitation coordination: Infusion therapies must be coordinated with rehabilitation activities to maximize functional outcomes 8

Pitfalls to Avoid

• Inadequate monitoring: Failing to monitor drug levels, renal function, or other parameters can lead to toxicity
• Infusion reactions: Especially with vancomycin if administered too rapidly 2
• Vascular access complications: Including infection, thrombosis, and mechanical problems 7
• Medication interactions: Particularly with multiple medications common in SNF patients

By providing these specialized infusion therapies, SNFs can help patients complete necessary treatments while simultaneously addressing rehabilitation needs, potentially reducing hospital readmissions and improving overall outcomes.