The Infusion Center: Where everybody knows your name
Nurses at the Brigham and Women's Hospital Ambulatory Infusion Center are working with world-renowned physicians to provide high-power medication treatments with superior skill, style, and a smile
When she talks about her visits to the infusion center at Brigham and Women's Hospital in Boston, Ella, who is 77, says, "I felt like I was attending old-home week." Ella has rheumatoid arthritis, and over a recent two-week period, went to the center twice for two six-hour-long infusions of Rituxan. Each time, she says, the infusion nurses were hugging patients as they arrived and exchanging stories with them about each others' kids and grandkids. The second time, Ella took books to read. "But I forgot my glasses," she says. "I had my bag, and my nurse, Karen, asked what was in it. I told her the problem and she reached in a drawer, took out a pair of reading glasses, and said, ‘Try these.' They worked perfectly. The nurses took really good care of me all day."
The nurses that work in the Ambulatory Infusion Center at Brigham and Women's infuse between 20 and 25 different medications to patients with a wide variety of conditions. A course of treatment, depending on the needs of the individual patient, may extend over months or even years. The nurse with a drawer full of glasses is Karen Hegarty, RN, and she's been at the center for nine years. "We see a lot of different people with a lot of different issues," she says. "And most of our patients are repeat patients. They come anywhere from every two to four weeks to every six months to every year."
Hegarty says the nurses at the center establish ongoing relationships with the patients they see because their medical needs are persistent. "Some patients are on their medications for several years," she says. "And some of them will leave us and go on to something else, a different medication that may not require us." Despite a constant turnover, she is still seeing some patients she first treated nine years ago. "It's enjoyable," she says. "Patients will say they remember starting at such and such time, and then talk about the old days and how things have evolved."
Evolving treatments for a growing patient population
Jayne Daly, RN, has been at Brigham and Women's for 32 years. She worked in orthopedics and rheumatology, as well as IV nursing, before she joined the infusion team. She estimates that between 17 and 23 patients are seen daily at the center, with Fridays being the slowest days. The majority of their clients are rheumatology patients. But they also work with patients who have gastrointestinal diseases such as colitis and Crohn's disease, as well as patients with neurology, pulmonary, or renal conditions. "We'd like to serve all different areas in the hospital," Daly says. "We are here to help all patients."
The patient population has grown steadily over the years, according to Daly. "There has been a big increase in our patient population ever since we first started," she says. "If I had to make a quick guess, I'd say we've increased 70 percent since five or six years ago." Daly says the staff-to-patient ratio is quite good. "There are usually four nurses on during the day," she says. "And one day [each week], we work with five."
Over the past three decades, Daly says, she has seen the treatment of arthritis evolve from nurses and providers working conservatively with disabled, hospitalized patients to administering aggressive outpatient treatment at the infusion center. "The current treatment for arthritis is to hit [patients] with all the drugs that can stop the progression of the disease," she says. "It's not going to cure the damage that's been done to the joints. But the new medications hopefully will stop the progression, so the joint replacements don't have to be done right away."
There are, of course, risks associated with the treatment. Nevertheless, Daly says, patients are usually happy to come in for infusions. And that fosters strong patient/provider relationships. "The infusions make them feel better and we really get to know our patients very well," Daly explains. "And you can get involved in referring them to other doctors they need to see if they are having problems. Or sometimes, they think their problem is nothing and you can say, ‘Oh no, no, no. This is something and you need to look into this. You should be calling your primary.' So we are a first-line defense in their care."
Upbeat caring mixed with demonstrated expertise
Mae Hansen, RN, BSN, MSN, is the nurse program manager. She oversees the nurses at the ambulatory infusion center, as well as other departments at Brigham and Women's. She says qualifications for infusion nursing include not only experience but also a certain mindset. "First and foremost, [the nurses] need to be positive, caring individuals who demonstrate expertise in whatever field they are coming from," Hansen says. "These nurses are genuine in that aspect. They have a lot of respect and empathy for their patients."
Hansen says a lot of the nurses working in the infusion center come from the IV team in the hospital. "I think from a patient's perspective, that's one of the most important things, the ability to get the IV in." Hansen adds, "The nurses at our outpatient infusion center also have a lot of experience dealing with patients who have adverse reactions to the infusions that they are receiving."
- First and foremost, the nurses need to be positive, caring individuals who demonstrate expertise in whatever field they are coming from.
- – Mae Hansen, RN, BSN, MSN
In addition to establishing relationships with patients, nurses in the infusion center have to maintain relationships with nurses and managers of various referring departments, such as the staff in rheumatology and pulmonary. "The staff relationship is very important," Hansen says, "when we are clarifying orders with physicians or talking to the PA or someone covering a patient's condition."
A team effort
Mary Verni, RN, is another infusion nurse at the center who has seen the evolution of treatments for arthritis. The medications being infused keep the disease in check, she says. That means that over the years she's seen more people walking who would have been in wheelchairs had they gone untreated. She's also seen a lot less finger distortions.
Verni's experience includes ER, CCU, ICU, IV nursing, and homecare. She's also worked in orthopedics and rheumatology. She came to Brigham and Women's in 1981. "Back then, the rheumatologists used to admit their patients," she says. "They would be so crippled up in the bed, their joints were all frozen and distorted. They had to have a lot of occupational therapy, building up to using forks and knives and spoons so they could feed themselves. They had to learn to use all kinds of assistive devices so they could care for themselves. And then, eventually, they couldn't because they were so debilitated."
Patients and nurses, according to Verni, are on a first-name basis. That keeps the atmosphere, which can often be very tense, a bit less formal. "We don't get into Ms., or Miss, or Mrs.," Daly adds. "They call us by our names. And that's okay because we don't want it to be an uptight situation. If someone is chronically ill, I think the worst thing you can do is make them feel like they are in this stiff, sterile environment. They want to feel comfortable. They want to feel confident that the people here know what they are doing—and [that] if there is an emergency, they know what to do to handle the emergency, which we do."
Daly says they also give patients food if they are there during lunch hours. "We try to make them comfortable with warm blankets and pillows. We have infusion chairs that recline and TV sets." Some of the patients, she says, can be in the center for an infusion that may last four hours or more. "The shortest visit will be the Xolair shot [for allergic asthma]. But some people can be here eight hours."
Because the center is entirely staffed with nurses and one secretary, volunteers are "a wonderful asset" to patient care, according to Verni, who instituted the volunteer program three years ago. "We don't have any nurse's aides or PCAs," she says. "And the pharmacy is in the main hospital. So if we have to pick up anything, we have to walk one-quarter mile to the pharmacy to get it. And that can take 10 minutes each way."
She says volunteers are the ones who do all the running for them. "And," she says, "we have to teach them that when you walk with these drugs, you can't power walk and shake them. You have to be gentle, because there are molecules that can burst and potentially cause reactions."
Many of the volunteers are college graduates who are looking to go into medicine or some field of healthcare. Volunteers must be patient-focused and undergo training to work on the infusion unit. That training includes infection control as well as proper handling of medications. Other volunteer duties include picking up and bringing patients to the unit, delivering labs, assisting the secretary in putting away supplies, and delivering lunches and snacks. The charge nurse for the day oversees these activities, whether it's a volunteer, the secretary, or another nurse who completes them.
"You can't leave patients," Verni says. "You have to have at least two nurses on the floor when a patient is being infused. So if you've got four patients going, that means you have to have all the nurses here. This is where the volunteers truly are worth their weight in gold. I can't say enough. They are doing it for nothing. There is no fame and glory here, so we love them."
Most nurses who work on the unit agree that infusion nursing is one of the best jobs they've had. Verni says, "It is rewarding to see people staying well, [and] at least managing their chronic illness. When they go into the hospital, we go visit them if they are here. It's rewarding to know we are contributing in some way to these people being able to manage their lives with an illness. I drive a very long distance [63 miles] to get here and do what I am doing. To get up and be able to come in knowing the drive ahead of me — it makes me feel very good. I just love this job."