Supporting Safety for Infusion Therapy Through Standards and Capital Equipment with NICA’s Kaitey Morgan

Kaitey Morgan

 
Welcome to Champions of Care, a Champion Chair podcast, and your go-to resource for industry-leading insights regarding medical seating and their applications. Hello, everyone. Welcome to another episode of Champions of Care, a Champion Chair podcast. I'm your host Daniel Litwin, the voice of B2B, and thank you so much for joining us on this episode of the podcast. Make sure that you're subscribing wherever you're listening to your podcast content. Could be Apple podcast, Spotify, we're on there. Make sure you're also heading to our website and checking out more services from Champion Chair as well as more content like podcasts, videos, and articles.
For today's episode of the podcast, we're exploring the quality and standards of care in infusion therapy centers and in the practice of infusion nursing. Until very recently, these centers, critical for chronic diseases that require intravenous medications, had no standards. This lack of cohesive oversight was observed day in and day out by our guest on the podcast today as she traveled the country for a national infusion management company, and that experience and those many visits led her and her current organization to craft the first set of standards for infusion centers.
With our podcast today we're taking a look at infusion centers before and after industry-wide standards were put in place. We're going to break down why these standards are important for quality care and how capital equipment plays a large part in meeting and maintaining those standards. For insight and perspective, I'd like to welcome Kaitey Morgan, director of quality and standards at the National Infusion Center Association. Kaitey, thanks for joining us on the podcast today. How are you doing?
I'm doing great. Thanks so much for having me.
Absolutely. How are you holding up during this pandemic? It's always a little crazy. You got to ask all our guests that.
Yeah, I know it's unavoidable, right? Well, I am lucky enough to work from home normally, pre-pandemic, so it hasn't been a huge adjustment for me except that now I have my two and six-year-old children as officemates, so that can make it a little bit challenging sometimes.
Yeah, I feel that. There's only one roommate here with me and he's holed up in his office as well. Things are actually quieter at home for me than they were in the office, which is I think the unique situation, so I'm counting my blessings on that one. All right. Let's jump into the main topic here.
You've experienced almost every side of infusion care. Before your work at NICA, is there a shorthand way to say that? NICA?
We usually say NICA.
NICA. Perfect. All right. Before your work at NICA, I know you oversaw clinical operations for a national infusion center management organization, and while you were a registered nurse before that, you spent the majority of your career involved with infusion therapy. You've really gotten the whole gamut of infusion care. What was your experience like as a nurse in infusion therapy when there were no industry-wide quality standards? Did that affect your work ever? Was that something that was front of mind for medical professionals administering this care? What are your thoughts on that?
It was always front of mind for me. Anyone who knows me or has worked with me will tell you I'm big on rules. I like rules, policies, standards. I think they're really important. And in the acute care settings in hospitals, that's where I started my nursing career, there are rules everywhere. There's a procedure for everything. There are policies about policies, there's no shortage of regulation, compliance, audits. So when I transitioned from working in the hospital setting to non-hospital settings and then actually opening and taking over management of existing infusion suites, when I went to the infusion management company, I wanted to see the rules. Show me the rule book, point me to the standards checklist. If we're going to do this, we're going to do it right.
And I was really surprised and shocked that these standards just didn't exist. It was actually that search that led me to my first conversations with Brian Nyquist, who's now my boss, the executive director of NICA. And, I was really just Googling, looking for these rules that didn't exist. And when I got in touch with Brian, he confirmed for me that, no, there are not standards in our industry yet. But he said he agreed that we need them, and they were really working hard to develop them, and "Hey, do you want to help?" So that's sort of how I got involved.
Yeah. How did that affect your work both as a nurse and then also once your perspective evolved and you entered the management side of infusion care? I guess how does a lack of standards actually impact day-to-day procedures for medical professionals?
When I was a nurse and I'm still a nurse, but I'm not providing direct patient care anymore, so when I was a nurse providing direct patient care, I wanted the standards to tell me how to do my job perfectly and provide the very best care possible to my patients. When I moved to a more administrative role, this purpose of standards, that same purpose is still important but there's another purpose. It doesn't only guide the practice of caring for patients, but standards also protect our industry and our ability to provide care to any patients. If there are no standards, then it's much harder to identify substandard care and separate that from the excellent care that most infusion providers try to deliver and do deliver by meeting or even exceeding those standards. Right? So if there's no clearly defined criteria for what is okay and what is not okay, then it's much harder to really definitively know when care that was provided has deviated and failed to meet that mark.
So it's harder to protect the integrity of the industry and say, these are valid high-quality care settings because they followed these rules, and anyone who is not following these rules is not meeting the standards, not delivering the care that they need to be.
So it sounds like when you made your way to NICA, folks knew that these standards needed to be put in place, but they were still being crafted and they weren't there and it was really more up to individuals to maintain that personal level of quality and I guess personal standards, but there wasn't really anything industry-wide that you could reference. Why do you think it took so long to conceive of these standards and to get them in place in the first place?
Yeah. It's a great question because that's what I wondered too when I looked for them and they weren't there and I wanted to know why not?
Why don't they exist? Yeah.
I know. There are standards for everything. And if you look back, especially at healthcare standards, their implementation usually or often follows a particular incident. Often it's an unfortunate incident, a tragedy, and then regulators step in and say, "Okay, this can't ever happen again. We're going to put these standards into place." So I feel fortunate that we're able to put these standards into place proactively. And I think the fact that the infusion industry has continued to grow despite not having standards in place is really a testament to the fact that the overwhelming majority of clinicians want to do the right thing and they've taken it upon themselves to follow best practices for their own sake because there just hadn't been external pressure from regulatory bodies to tell them what to do. Like you said, it's really just their own personal standards of care that prevented tragedies and unfortunate incidents from triggering outside agencies to step in and say they're going to set the rules for us.
Right. Does this lack of standards extend beyond maybe a reduction in quality of care and does it affect healthcare professionals and their retention as well or any part of the patient experience besides care? Because I can imagine it might be frustrating for professionals in this space to want to do a job that meets a set of standards or best practices, not have that, feel frustrated by that, and maybe that plays into some of the broader issues of a healthcare professional retention that we see throughout the industry. So yeah. What are your thoughts on that kind of domino effect, I guess, of not having those standards?
I think you're absolutely right. I think that's a huge contributor to burnout. You hear a lot about healthcare, professional burnout, especially nursing burnout. Substandard care, I don't think it's usually intentional. I've never worked, in 12 years, worked with a nurse, doctor, any clinician that I think got out of bed that morning and said, "You know what? I think I'm just going to give my patients sort of halfhearted care today." Every healthcare worker wants to give their patient the very best care. But if where they work, their practice setting isn't focused on quality, and doesn't provide the training and support and resources to do that and isn't making an effort and giving a lot of attention to that constant engagement in quality assessment and quality improvement efforts, then I think you're right, I think healthcare workers will leave and go find a place to work that aligns with their goal, which is just to take excellent care of patients.
And also, I'll add that patients pay attention. They're not passive members of this healthcare journey they're on. Patients, they pay attention. They're really actively involved in their care and they can tell when their care setting or their infusion center is focused on quality or when they're not and maybe they're just doing the bare minimum to get patients in and out the door. Infusion therapy is not pass/fail. Patients are more empowered and engaged as their own advocates today than they ever have been and especially patients like those treated with infusion therapy, with these complex chronic diseases. They need to have confidence in the care they receive from their infusion providers. So I think the level of quality does affect more than just the actual technical clinical care they receive with the whole experience.
All right. That's enough time spent on the pre-standards world because luckily we now are in the post-standards world. They exist and they are now influencing infusion care. And in the last year, NICA was the org that developed the industry's first set of standards of care specifically for infusion therapy and for outpatient infusion sites. Were you involved in the standards creation process, and if so, break down what that process looked like, how you began to hone what that standardization would look like, and why did NICA decide to take on this task of being the ones to set up the standards for the whole industry?
I was involved in the development of the standards. Like I had mentioned, my first conversations with Brian where they had started working on the standards before I was aware of NICA or joined their advisory committee. So despite Brian's best efforts and NICA's best efforts, the development of the standards wasn't gaining momentum quickly. There was a lot of other stuff going on, I'll say in the infusion world, it's growing, it's expanding. There are so many infusion medications coming out all the time and it just was sort of getting pushed to the side. So when I joined the advisory committee, I was one of a few additions to the group at the time that brought on more clinical members. There were a lot of and still are a lot of C-suite executives in that advisory committee and some are clinical and some are not.
So when I joined the advisory committee, several other clinical members joined at the same time to really help drive the standards development process and prioritize that. So that has been our priority since that time. Our first meeting was in Austin, Texas, a whole bunch of people sitting around at a really big table all day long. And we really started this iterative process of discussion, research, review. We started in-person and then this carried on remotely for months and months until we'd reached a point where we felt the standards were ready for our release, which was last year just prior to our first annual meeting last June.
Well, NICA's mission, to maybe oversimplified a bit, is to increase patient access to affordable, high-quality infusion care when and where they need it. In that pursuit, it was really important to us that the quality of care didn't vary across care settings. We weren't looking to preserve, protect, and expand access to just some form of infusion care. We wanted to increase access to excellent infusion care and continue to raise that bar. Patients should be able to expect to receive the same high-quality care regardless of where they receive the care. If it's a hospital, outpatient infusion department, or their rheumatologist office, the standard is the standard, and NICA saw that and knew it was important.
I'm sure an important part to crafting the set of quality and standards for the industry was getting feedback from professionals in the industry and understanding what are some of the standards that would make your life easier and would make patient care more effective and just better all around. Was that part of your approach to defining quality and standardization as a whole for infusion therapy and infusion centers and how did that play into your broader approach to starting to craft those standards and feeling like you could really feel proud and confident of the ones you came up with?
The advisory committee worked to develop the standards by first looking at the validated resources and existing standards that are out there maybe in similar fields and look at how well that applied to our care setting, and that helped us to identify where the gaps were. If there were existing standards or guidelines, maybe a commonly known example is the safe injection guidance put out by the CDC several years ago, we didn't need to recreate the wheel. We referenced an incorporated those because they applied to our care settings. But infusion is a really unique vertical in healthcare, and so there are many areas where there was just no consensus or not even controversy, there's just no information available. So that's where we went through that iterative process I described earlier to look at the standards of practice, so not necessarily how it should be done, but just the beginning step of how is it being done out there in the world.
And then we would go to the research, the literature, why do we do it this way? Does the data support it? What evidence do we have to say that doing it this way makes sense? Or on the other hand, what evidence do we have to say there's a better, safer way? Because the standards of practice are not the same as the standards of care. Standards of practice or the way people commonly do things, and the standard of care is the way it should be done. So if you're examining a process and asking why it's done a certain way and the answer you come up with is, that's the way we've always done it, then you need to go back to the drawing board and do some research. Because true evidence-based care is grounded in the data, not in historical patterns of practice.
So then for those individual sites, do the different quality assurance department members establish their own guidelines for safety and cleaning once there has been the state-level audit on let's say a specific piece of equipment or just general facility compliance, or is that power I guess granted to each facility where they get to tweak individual things to meet their care best? What does that dynamic look like in practice?
Overall, the answer really depends I think on the location. So like I said, in those large hospital or large health systems, there are plenty of regulations. In the private physician offices and freestanding centers, there really isn't a national unifying set of standards aside from the NICA standards of care. There are state departments of health, maybe state boards of pharmacy, or departments of professional licensure, it really varies by location, that set some standards and might have some requirements for types of equipment or cleaning, or do an audit to identify issues, things like that. But for the most part, I think it really is left up to each group in each state as to what they're going to do.
Another important part of an effective and sanitary care environment that we haven't quite touched on yet, but it's where I want to take the rest of the conversation is focused more on proper gear and that being an essential part of maintaining those standards. Are there standards set by health systems for capital equipment such as beds, wheelchairs, and patient seatings, specifically for infusion care centers? And if so, are the standards specified and required to be met for gear, or do they serve more as a guideline? And go ahead and break those standards down for me.
Sure. The state departments of health, boards of pharmacy, those regulators I mentioned earlier, their rules, regulations are not optional, they're required for licensure. So for some capital equipment like infusion pumps, vital signs monitors, those class two and three medical devices, they're subject to strict FDA regulations. But for things like infusion chairs, there are best practices that can be called from different professional associations. One that comes to mind is APIC, the Association for Professionals in Infection Control, and they have some guidelines but they're not an enforcement body, so they just put out best practices. Best practices would say you shouldn't place patients in plush open-weave fabric chairs that can't be disinfected. But in reality, there most often isn't some watchdog preventing a practice from deciding to see their infusion patients in plush, woven-chairs or beanbag chairs or whatever they feel like doing that day. Actually, in my own primary care provider's office, the waiting room looks like it could be someone's living room. There's a fabric sofa and upholstered rocking chairs and it's very cozy, but it's not great for infection prevention purposes.
Why are the standards set up that way for capital equipment versus the rest of the industry and the standards for just general infusion care?
I think the lack of standards and enforcement and infusion care sort of goes back to what I alluded to earlier, which was that we haven't had that big impetus for changes. There was several years ago, a compounding facility in Massachusetts that had some contamination issues with a batch of injectable steroids that they created, produced and many patients got sick and died. And so that tragedy resulted in all these regulations and increased enforcement efforts for compounding of IV products. That's an example of the type of situation that usually triggers these regulations to come into play. So the fact that the infusion world, knock on wood, hasn't had something like that I think is one of the main reasons that we aren't seeing those outside regulators coming in and dictating what types of furniture and infusion pumps and things we can have.
So then how important is the sourcing of equipment that meets even just the general required and specific needs of an acute facility? How does that impact care? And how has that sourcing search evolved now that there are at least a basic level of quality and standard assurances for infusion care therapy?
Now that we have some standards in place, I think it gives those, maybe the smaller groups that don't have a centralized purchasing department, it gives them sort of a list of things to look at when they're evaluating a product or something they're looking to bring into their practice to see how this product or device or whatever stacks up against those standards. They know the questions to ask. They know what to look for. Because a lot of times it's not something you would think of. Like the example of chairs, you want them to be comfortable, but you also have to be able to clean them and they have to be safe.
Definitely. And of course, we can't go the whole podcast without mentioning it, I know several infusion centers now choose Champion Chairs for their infusion suites. What are some of the main reasons that you've seen why Champion Chairs have been the ones to better meet these set of standards and quality assurances for this industry?
Yeah. We definitely do see Champion Chairs in many infusion suites and it's not just because they look nice.
Yes. That's an added benefit.
They do, they look great, but that's really not what's most important as you can imagine. First, I'll say if you've ever had a seat in one, you'll know why infusion centers like them, they're really comfortable, and comfort isn't the only consideration, but it is really important. Some infusion appointments will require a patient to be seated in that chair for a full day, six to eight hours. They have to be comfortable. I actually had a personal experience in a former role where the comfy infusion recliner at one of the suites was replaced with a combination exam table that could be lowered down into a chair, but it was very firm. It didn't recline. The patients couldn't put their feet up and there were patients who receive really long infusions frequently and they were prepared to reschedule their infusions or get their care elsewhere instead of sit in that exam table chair for hours. So, it's not just a luxury to have a comfortable chair. It was really a requirement for a lot of patients. And I'm happy to say that story had a happy ending. We got the comfy chairs back.
I think another reason that infusion centers choose Champion Chairs is that they hold up really well to the type of cleaning and disinfection that has to take place in infusion centers. Large, busy infusion centers have been pleased with the life that they're able to get out of that investment into a quality chair. And I believe, you can correct me if I'm wrong, but I believe that the individual parts of the chair can be replaced instead of the whole chair. So if a particular piece has a unfortunate early demise, then they can just replace the arm instead of the whole chair. It makes it much more cost-effective for them.
And I think another reason practices might choose Champion Chairs is there are a lot of infusion practices that have a significant population of patients with mobility issues. Whether that's a rheumatology practice with patients with rheumatoid arthritis or a neurology practice, patients arriving in wheelchairs, those practices and their patients really benefit from the style of chair that Champion has, where the side of the chair, the arm can be removed. It sort of swings open like a car door and it swings out of the way to facilitate the proper patient transfer from a wheelchair into a recliner. Speaking as a nurse who's used really poor body mechanics to lift patients out of one chair and transfer them to another on multiple occasions, I can personally attest to, number one, how foolish it is to do that and how much safer it is for the nurse and the patient to have the ability to do that proper transfer. So having the side of the chair, the arms sort of swing out other way really facilitates that.
So that longevity, that ease of use for caregivers, how does that help meet these newly established quality and standards set by NICA? Has Champion reached out or collaborated with NICA at all to make sure that their gear fits into these standards and how does that impact day-to-day helping the professionals in infusion care and infusion therapy meet those standards as well?
The Champion Chairs stack up really well with this infection prevention and control checklist. They're upholstered with a vinyl or nonporous material so it can be disinfected with hospital-grade products and it's able to withstand how harsh those cleaners can be. For other chairs which are marketed to be used in the home, they're not meant to be wiped down with a CaviCide wipe every hour, five days a week. Also, the chairs open up, recline really far and this way the sides swings away, all the surfaces that come in contact with a patient are able to be cleaned and disinfected, which is really hard in a chair, especially a recliner chair. But that's something that Champion has in place already, separate from the development of any standards that's more in line with hospital standards that were already in existence. I think that's why you see Champion Chairs in so many hospital infusion centers and dialysis centers.
And then the other thing, Champion Chairs have the ability, there's a little handle on the back that you could use to quickly lay a patient down flat, what we call the Trendelenburg position, if we find ourselves in a situation where we need to do that. So there are different scenarios, like if a patient's blood pressure maybe gets a little too low or they get lightheaded, it's important to get them into that flat position really quickly to optimize circulation and help get blood to vital organs like the brain. But not all infusion chairs have that feature. So it's one you hope you don't have to use it that often, but if you're in a situation like that, then you'll be really glad that you have a chair that can go into Trendelenburg really quickly. Because the alternative is you have to get that patient onto the floor as quickly and gracefully as possible. So pulling a little lever to flatten them out as much safer for everyone involved.
So let's go ahead and wrap this up with some timely news. It's hard to avoid talking about this. We brought it up at the beginning, but we're in a pandemic and I think it's essential to contextualize this, especially on a healthcare podcast. So as the COVID-19 pandemic surges in the United States, what has NICA's response been to support infusion centers and patients? Do your standards help make that care safer during something like this? And have there been any last-minute tweaks or adjustments in messaging or in the actual standards themselves?
NICA has really been all hands on deck, fully engaged in supporting infusion patients and providers through this crisis from day one. We represent a really unique group of patients, a lot of infusion patients treatments altered their immune system and put them in that high-risk category for having a more severe or a more complicated COVID-19 disease course if they were to get it. But at the same time, the treatments that these patients are receiving are not optional. They're not elective procedures that the patient could just say, "I think I'm just going to stop my infusions for now. I'll just stay home and stay safe." If they stop their treatments then their disease can and usually will become more active and progress and those consequences are usually irreversible with huge impacts on their health and quality of life, and not to mention the financial impacts.
And then worst of all, in the setting of this public health emergency, these patients, if their disease flares, then it's going to cause them to require more healthcare services and potentially put them in exactly the place we don't want them to be. Not only are they now out in public, but they're in settings with a high-risk for being exposed to COVID-19 should they need to go to the emergency department or something like that. So they're at higher risk for being exposed. And then they're also adding to the patient volume and the associated burden that's already on the healthcare system that's kind of maxed out.
So it was really clear to us right away that we needed to issue some guidance to make patients feel safe and then also to help the infusion community sort of navigate the million guidelines that are out there quickly to continue to providing care while keeping patients safe, and then also to the broader healthcare community to say, hey, there are going to be a lot of patients who would normally be in the hospital or maybe a post-acute care setting like a long-term care facility that are now going to be discharged earlier than they might have otherwise and those patients will need services that they weren't getting either in the hospital or in long-term care, which oftentimes, is infusion therapy, maybe an extended course of IV antibiotics or something like that.
So not only did we have to issue guidance on how to keep patients safe in the infusion centers, but also how to sort of expand and facilitate access to account for all those patients that are going to be diverted into these centers and help to proactively offload the burden that's placed on hospital systems right now. We sort of see that as our way to help in the crisis associated with, you keep hearing the phrase surge capacity, medical surge capacity when a healthcare system as a whole has too many patients and not enough resources. So NICA can't build hospitals, but we can preserve the infusion delivery channel so that other healthcare sectors can focus their resources on this wave of patients that need really high levels of care right now.
And just to end back on the note of NICA's standards, how have those quality standards that have been put in place, how have they helped with the response to COVID-19? And what kind of case does it make for having a unified set of standards for each subsection of healthcare?
The standards have been very helpful and handy to have to say the least. As hospitals are trying to expand their capacity to care for these unprecedented numbers of critically ill patients, outpatient infusion departments are often one of the groups getting moved to alternate sites. And that's to both protect immunocompromised patients because these are sometimes oncology infusion patients as well, and also to open up that space to be able to use it to treat patients with COVID-19. So having the standards along with our COVID-19 specific guidance have provided sort of a cursory checklist of sorts to help determine what space would and would not make an acceptable temporary location for an infusion center. Things that even the most well-intentioned healthcare providers might not think of when looking at a space, like, no, you can't prepare infusion medications for administration next to a sink or near an open window.
Some of the people making the decisions on when and where and how to relocate infusion centers are not necessarily involved with infusion therapy on a daily basis. So they can look to these standards to guide their planning. And I actually had an interesting conversation the other day with an infusion center operator who's in the eye of the storm right now, I guess in New York City, and he had been approached by a hospital asking him for guidance on how that hospital could put up sort of a popup infusion suite so they could clear out their infusion center to care for other patients. So knowing that he was a successful infusion center operator, they looked to him. And so this gentleman had indicated to us that he was looking to NICA standards to help that hospital facilitate moving this infusion suite temporarily in a way that that is still safe.
All right. Thank you so much for your thoughts on today's podcast. Again, we've been chatting with Kaitey Morgan, director of quality and standards at the National Infusion Center Association. Kaitey, I really appreciate it. Thank you so much for joining us on Champions of Care. Any final thoughts before we sign off?
No, Daniel, really, I appreciate you having me on. I always like an opportunity to sort of geek out about infusion center standards of care, so thank you so much.
Absolutely. And thank you, everyone, for listening to this episode of Champions of Care. And if you like what you heard and want to listen to previous episodes, you can make sure to check out our podcast on Apple Podcasts and Spotify, and make sure you're also heading to Champion Chair's podcast for a full gamut of our products, our services, and also more content, including podcasts, videos, and articles. I'm your host, Daniel Litwin, the voice of B2B. Till next time.