A Multi-Center Time Study of Home Infusion Nurse Services During Therapy Initiation
Danell Haines, PhD — Research Consultant
Michelle C. Simpson, PharmD, BCSCP, MWC — National Home Infusion Association
michelle.simpson@nhia.org
Jennifer Charron, RN, MSN, MBA — National Home Infusion Association
Abstract
Introduction
Home infusion therapy is an established and growing model of care that allows patients to receive complex infusion treatments in the home setting. Successful initiation of home infusion therapy requires coordinated nurse, pharmacy, and prescriber involvement, particularly during the transition from referral to the first home visits. Although home infusion nurses perform a wide range of clinical and coordination activities, limited published data describe the time required to deliver these services or how nurse workload varies by therapy type. This multicenter descriptive observational time study quantified home infusion nurse time and task distribution during therapy initiation for anti-infective and intravenous monoclonal antibody therapies.
Methods
Data was collected from November 2024 through May 2025 by nurses employed by participating home infusion providers. Nurses self-reported time spent on patient-specific tasks using standardized tracking forms. Data collection began at referral and continued through the first required visits, including pre-visit activities designated as Visit 0 and the first 2 home visits when applicable. Nurse tasks were categorized as patient assessment and documentation, care plan development, vascular access device care and laboratory monitoring, education, care coordination and telephonic communication, drug administration, travel, and other work-related tasks. Travel time and drug administration time were analyzed separately to avoid duplication when nurses performed concurrent activities.
Results
The study included 44 patients served by 7 providers from the 5 U.S. regions: 28 receiving anti-infective therapy and 16 receiving intravenous monoclonal antibody therapy. Across the study period, nurses documented 309 tasks for anti-infective patients and 115 tasks for monoclonal antibody patients. A greater proportion of anti-infective tasks occurred before the first home visit, with Visit 0 accounting for 22.0% of all anti-infective nurse tasks compared with 5.2% of monoclonal antibody tasks. During Visit 0, care coordination and telephonic communication were the predominant activities, underscoring the importance of pre-visit nurse involvement in safe therapy initiation. Mean total nurse visit time, including travel and excluding drug administration, was 3.93 hours for anti-infective Visit 1, and 2.87 hours for Visit 2. For monoclonal antibody therapy, mean total nurse visit time was 1.27, 4.06, and 3.21 hours for Visits 0, 1, and 2, respectively. Mean round-trip travel time was 1.23 hours. Approximately 40% of nurse patient care time occurred outside the patient’s home for both therapy groups, reflecting care coordination, documentation, telephonic communication, and other non–face-to-face activities.
Conclusion
These findings demonstrate that home infusion nurse workload extends well beyond in-home infusion administration. Although anti-infective and monoclonal antibody therapies differed in task intensity and visit structure, both required substantial nurse time during therapy initiation. Objective measurement of these activities is essential to inform staffing models, productivity expectations, reimbursement policy, and resource allocation for sustainable, high-quality home infusion care.
Keywords: Home infusion, nurse visit, time study, OPAT, Monoclonal antibody, specialty
Introduction
Drug utilization review (DUR) is a systematic process used to evaluate the prescribing, dispensing, and use of medications to ensure safe and effective therapy. DUR involves a comprehensive review of a patient’s drug therapy and medical history against predetermined criteria for appropriate drug therapy.¹ Pharmacists can engage with DUR systems as part of medication therapy management and clinical decision support system. DUR systems can help pharmacists identify Drug-Drug interactions, drug-patient precautions, and drug-disease contraindications to better inform clinical decision-making. Alerts triggered from DUR systems thus serve as valuable tools for improving patient care, enhancing patient outcomes, and reducing overall health care costs.²
These clinical decision support systems, however, have some drawbacks. For example, there are discrepancies between the evidence provided for various alerts and the clinical significance of the evidence. As the number and frequency of DUR alerts—especially those that are redundant, clinically irrelevant, or erroneous—appear when reviewing patient medications, alert fatigue can occur.³ Alert fatigue can be dangerous, especially when a clinician overrides a number of alerts but misses one that can jeopardize patient care and safety. Thus, it is imperative that DUR alerts are clinically relevant and accurate to minimize alert fatigue and optimize patient care.
There are published studies examining pharmacists’ perceptions of DUR alerts, but a limited number of those studies consider how these alerts should be improved upon.⁴⁻⁶ This lack of information is suboptimal, especially since one of the best practices outlined in the 2017 Institute for Safe Medication Practices (ISMP) Medication Safety Self-Assessment for Community/Ambulatory Pharmacy is the periodic evaluation of pharmacy computer systems for “clinically insignificant and false positive alerts,” as well as “action taken to minimize alert fatigue.”⁷ The publication of specific analyses that pharmacies have performed to improve their alert system would be helpful to inform other pharmacies on best practices they may want to consider adopting.
This study aims to address this gap by analyzing DUR alerts overridden in the outpatient pharmacy medication dispensing system within our health system. We selected the system used in our outpatient pharmacies because it is the most robust platform available to us for capturing a large data set. Although infusion medications are dispensed through other systems in our organization, medication profiles for our infusion patients can still be found in our outpatient pharmacy medication dispensing system. By examining pharmacist responses and documentation within this primary system, we aim to provide actionable recommendations to optimize alert frequency, type, and presentation. These recommendations are intended to be applicable to all pharmacy dispensing systems, including those used in infusion practice settings, though we acknowledge that alert logic and workflows can vary across vendors. Ultimately, this will support improved clinical review processes and lay the foundation for future studies comparing DUR alert performance across other systems to enhance medication safety, regardless of specific pharmacy dispensing system.
Pharmacist Responses to DUR Alerts
Of the 4 radial buttons available for pharmacists to click to override the alerts, the most common response was Clinician Reviewed (89.4%). The full breakdown of pharmacist responses and frequency can be found in Table 3.
Pharmacist free-text responses to Drug-Drug alerts were also reviewed, since one of the primary responsibilities of pharmacists is to ensure that concomitant medications are taken safely. The pharmacy dispensing system only requires review and override of High and Very High importance Drug-Drug alerts, which comprise severe and contraindicated Drug-Drug interactions, respectively. A key finding was that of the 6,923 total Drug-Drug alerts overridden in the system, only 78 (1.2%) of these had comments that further explained why reviewing pharmacists overrode the alerts. The full breakdown of Drug-Drug alert response by importance severity can be found in Table 4.
A summary of the major themes gathered from review of the free-text comments provided by pharmacists overriding severe or contraindicated Drug-Drug interactions can be found in Table 5.
Discussion
High Volumes of Overridden DUR Alerts
The results of this study demonstrate that a large number of alerts were overridden in the pharmacy dispensing system and reviewed by outpatient pharmacists. An average of approximately 1,011 DUR alerts were reviewed in the pharmacy dispensing system each day. In addition, 2 DUR alert categories (Duplicate Therapy and Drug-Food) accounted for most alerts (65.2%) versus Drug-Drug alerts comprising only 7.4% of alerts.
These findings raise some important questions: How valuable are all these alerts when clinically reviewing prescriptions? Do they contribute to alert fatigue and potentially obscure more serious alerts (e.g., Drug-Drug alerts)? Targeting these high-volume categories for refinement could significantly reduce alert burden and improve pharmacist focus on clinically relevant issues.
References
- Academy of Managed Care Pharmacy. Drug Utilization Review. Accessed August 14, 2024. https://www.amcp.org/concepts-managed-care-pharmacy/drug-utilization-review
- Carver N, Jamal Z, Dering Anderson AM. Drug Utilization Review. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2024.
- Reynolds JL, Rupp MT. Improving Clinical Decision Support in Pharmacy: Toward the Perfect DUR Alert. Journal of Managed Care & Specialty Pharmacy. 2017;23(1):38-43. doi: 10.18553/jmcp.2017.23.1.38.
- Alshehri N, Alanazi A. Pharmacists’ Perceptions on Safety Alerts of the Drug Utilization Review (DUR) in Electronic Health Records in a Tertiary Healthcare Hospital. Pharmacy. 2023;11(4). doi: 10.3390/pharmacy1104011.
- Lee S-M, Lee S-O, Kim D-S. Physicians’ and pharmacists’ perceptions on real-time drug utilization review system: a nationwide survey. International Journal for Quality in Health Care. 2017;29(5):634-41. doi: 10.1093/intqhc/mzx085.
- Moon J, Chladek JS, Wilson P, Chui MA. Clinical decision support systems in community pharmacies: a scoping review. Journal of the American Medical Informatics Association. 2024;31(1):231-9. doi: 10.1093/jamia/ocad208.
- Institute for Safe Medication Practices. 2017 ISMP Medication Safety Self Assessment for Community/Ambulatory Pharmacy. Accessed August 14, 2024. https://www.ismp.org/sites/default/files/attachments/2017-11/2017_ISMP_CommunityAmbulatory_Pharmacy_Self_Assessment.pdf
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