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
Preface: This article is part of Infusion Journal’s nurse-time-themed issue. Because the methodology is thoroughly detailed in the issue’s lead article, “A Multi-Center Time Study of Home Infusion Nurse Services During Therapy Initiation” by D. Haines, M. Simpson, and J. Charron, it is not repeated here. For the full methodological framework, please refer to the primary article.
Introduction
Home administered intravenous immune globulin (IVIG) is well established as a patient-centered alternative to facility-based infusion. Safe delivery of home based IVIG relies on appropriate infusion support, which may include an infusion nurse to prepare and administer therapy, monitor the patient’s response, perform vascular access care, provide patient education, coordinate care, and communicate with the interdisciplinary team.
This study quantified nurse time and task distribution associated with home infusion of IVIG during the early phase of therapy.
Methods
The National Home Infusion Foundation conducted a descriptive, observational, multicenter nurse time study among home and specialty infusion providers. Nurses used standardized data collection tools to retrospectively record time spent on IVIG-related nurse tasks performed in and outside the patient’s home. Data was analyzed for patients meeting inclusion criteria for IVIG initiated in the home. Nurse tasks were quantified and grouped into 8 categories while nurses’ time was summarized by visit. Just as important, nurses’ travel time and patient drug administration times were also calculated. The IVIG-related nurse tasks and times were compared to anti-infective and monoclonal antibody data.
Results
Nineteen IVIG patient cases met inclusion criteria and were submitted by 7 providers. The mean patient age was 53 years. Across 3 nursing visits, 198 nurse tasks were documented. More than half of all tasks occurred during Visit 1, and the most frequently reported task categories included drug administration, vascular access device care, laboratory monitoring, and patient assessment and documentation. Mean drug administration time was 3 hours and 58 minutes, with substantial variability across patients. Compared with anti-infective and monoclonal antibody administration times, IVIG takes considerably longer, increasing overall nurse time. Mean round-trip nurse travel time was 1 hour and 16 minutes. Nurse tasks performed outside of the home which included care coordination, documentation, and telephonic communication, contributed to additional time that was not captured during the patient-facing infusion time.
Conclusion
While it is well known that IG requires more nurse time, it has not been measured. The study determined that IVIG requires more nurse time than anti-infective and monoclonal antibody therapies. These findings highlight that the nursing workload associated with home-based IVIG extends beyond direct in-home infusion administration.
Keywords: Home infusion, intravenous immune globulin, nurse, visit, time
Intravenous immune globulin (IVIG) is a first-line therapy for a wide range of immunologic and neurologic conditions, including primary immunodeficiency diseases, chronic inflammatory demyelinating polyneuropathy, and numerous off-label autoimmune and inflammatory disorders.1-5 The use of immune globulin has expanded steadily over time, driven by both new indications and growing recognition of its clinical utility across diverse patient populations.5-7 In the United States, immune globulin therapies are delivered through multiple routes and care settings, with increasing emphasis on the home setting as a safe, effective, and patient-preferred alternative to facility-based infusion.8
Home infusion of immune globulin has become an important component of the broader shift toward lower-cost, patient-centered care delivery. Recent analyses estimate that approximately 83,000 patients per year receive immune globulin therapy in the home setting, reflecting both strong clinical demand and favorable outcomes associated with home-based care.6 Compared to hospital outpatient departments or physician offices, home infusion offers advantages including reduced health care system costs, and decreased exposure to health care-associated infections.8 For many, the ability to receive treatment in a familiar environment is the determining factor in sustaining their quality of life.9 These benefits have contributed to increasing adoption among commercial payors, physicians, and patients.
Central to the safe and effective delivery of IVIG in the home is the role of the home infusion nurse. Compared with many facility-based infusion models, home infusion relies on highly skilled nurses who independently manage complex clinical care in patients’ homes. This includes vascular access management, infusion initiation and monitoring, recognition and management of adverse events, patient and caregiver education, and coordination with pharmacists, prescribers, and payors.10
The purpose of this study was to quantify nurse time and task distribution associated with IVIG home infusion care during the early phase of therapy, defined as the period from patient referral through the second dispensing cycle, which included all visits required to complete 2 drug administrations. The study objectives were to identify nurse task categories, both overall and by nurse visit, and to quantify the nurse time. It is surmised that nurse tasks and time are unique to the IVIG patient group when compared to anti-infective and monoclonal antibody patients due to differences in treatment complexity, interaction frequency, and patient management needs. Previous research shows that nurse workload, including both time and task distribution, differs across anti-infectives and monoclonal antibodies.11 By characterizing IVIG nurse activities during this defined phase of care, this study aims to provide data to support staffing models, reimbursement considerations, and enhance the delivery of home infusion services. This study includes a comparative analysis of IVIG nurse time compared to anti-infective and monoclonal antibody therapies using data presented in the lead article of this issue of Infusion Journal titled “A Multi-Center Time Study of Home Infusion Nurse Services During Therapy Initiation.”11
The National Home Infusion Foundation (NHIF) conducted a descriptive, observational nurse time study to analyze the tasks and time that nurses spend caring for home infusion patients. To account for the substantial time required for nurse travel, data was also collected on round-trip nurse travel time to and from patient’s home. The NHIF web page invited all home infusion providers to participate in a multi-center study that involved a variety of home infusion therapies including IVIG. The nurse time data was collected retrospectively in 2025, with nurses tracking the time dedicated to various tasks, performed both inside and outside of the patient’s home, for each IVIG patient serviced.11 The task categories and examples were provided by an expert nurse committee. The nurses at the participating provider locations received an orientation video, a data entry guide, and patient-tracking Excel® spreadsheets.
For additional information on the study methodology and Institutional Review Board (IRB) status, see the first article in this issue of Infusion Journal, “A Multi-Center Time Study of Home Infusion Nurse Services During Therapy Initiation.”
The data from 22 submitted IVIG nurse time forms were combined into a single Excel® file. This file included all nurse tasks for nurse Visits 0, 1, 2, and 3. Nurse Visit 0 included non-patient-facing tasks such as care coordination and telephonic communication. These nurse tasks occurred prior to the first patient-facing visit, (nurse visit 1). The data was imported to IBM SPSS (Statistical Product and Service Solutions) Version 31 for additional analysis. After the initial analysis, the data was reviewed by an expert panel to identify outliers and data entry errors. During this process, it was noted that 3 patient cases did not meet inclusion criteria and were deleted making the final patient case number 19. No outlier data was observed, and one obvious data entry error was replaced with the mean score for the task category.
Patient age was summarized using mean and standard deviation. Nurse tasks were analyzed using frequencies and percentages and determined for each nurse visit (Visit 0, 1, 2, 3). Due to the amount of variance in the nurse time needed to complete each type of task, the mean, standard deviation, median, and the minimum/maximum amount of time was calculated and reported. The patient times were totaled for each visit and divided by the number of patients served during the visit.
After data analysis, it was found that the IVIG administration time exceeded the calculated nurse visit time, as determined by the sum of the in-home and out-of-home nurse time. Unlike the initial nurse time study of anti-infective and monoclonal antibody patients, this study found that drug administration time exceeded the nurse visit time, as determined by the sum of the nursing tasks. Because anti-infective and monoclonal antibody patient nurses concurrently perform other tasks, that take longer than the drug administration time, drug administration times were excluded from the calculations. In this study, involving IVIG patients, drug administration time exceeded the time of the other tasks performed concurrently thus the drug administration time was added to the out-of-home tasks and round-trip travel time to determine estimated nurse time per patient, as shown in Figure 1.
To determine IVIG nurse time and to enable a direct comparison with anti-infective and monoclonal antibody nurse time, the following metrics were calculated:
Nineteen IVIG patient cases were submitted by 7 home and specialty infusion providers. The mean patient age was 53.53 years old (SD=17.16) with a range of 12 to 76. To ensure consistency in drug administration time data, the study inclusion criteria specified that the IVIG medication had to be pump administered and the initial patient dose started in the home.
Nurse task data was grouped into 8 categories. Data analysis shows that nurse Visits 1-3 focus heavily on 3 main tasks (Figure 1). These tasks yield slightly higher percentages than other tasks: drug administration, vascular access device care and lab monitoring, and performing patient assessments and documentation. Comparison of IVIG nurse tasks with anti-infective tasks shows distinct differences. For example, drug administration accounted for only 5.83% of the nurse tasks for anti-infective patients while it was 17.17% of the tasks for IVIG.
Additionally, there was a higher percentage of patient assessment, documentation, and education tasks for anti-infective patients, accounting for 23.62% and 19.42% of the overall nurse tasks, respectively.
When monoclonal antibody nurse tasks are compared to IVIG tasks, 2 tasks categories show reportable differences. Patient education accounted for 10.43% of the monoclonal antibody nurse tasks while it was 15.66% of the IVIG tasks. “Other work-related tasks” accounted for 14.78% of monoclonal antibody nurse tasks, compared to only 4.04% for IVIG tasks. This discrepancy suggests that monoclonal antibody patients may require more specialized or unique care than IVIG patients.11
Table 1 shows the breakdown and comparison of tasks by nurse visit. As expected, all 19 patients had a nurse Visit 1, while 12 had a second visit and 3 had a third visit. Overall, Visit 1 and 2 tasks are similar when the task percentage is compared. The highest percentage of tasks are in the patient assessment and documentation and drug administration time categories. Strong inferences cannot be made for patient Visit 3 due to only 3 patients requiring the nurse visit. Care coordination and telephonic communications accounted for the most tasks during Visit 3 while all 3 patients had their IVIG administered during the nurses’ visit.
The average amount of time spent on each of the 8 task categories is shown in Table 2. As expected, drug administration was the most time consuming with a mean time of 3 hours and 58 minutes (SD=1:35) and range of 1:50 to 6:50 followed by patient assessment and documentation which averaged 1 hour and 3 minutes (SD= 0:46). IVIG takes much longer to administer than anti-infective and monoclonal antibody therapies. Unlike standard, concentrated monoclonal antibodies or anti-infectives that can often be infused in under an hour, IVIG requires a slow, gradual rate increase to lessen side effects. As a result, anti-infective drug administration averaged 49 minutes (SD = 0:42 minutes) while monoclonal antibody infusions lasted an average of 1 hour and 55 minutes (SD = 1:07).11 The large standard deviation for the IVIG drug administration task time highlights considerable variation in the time required. This variance might stem from the unique clinical requirement of IVIG therapy and the highly individualized care each patient demands.
To meet the IVIG nurse time objective of this study, this analysis quantifies the amount of time that a home infusion nurse spends caring for a patient in and out of the patient’s home and considers travel time and drug administration time. Nurse travel time is an important operational component of home infusion delivery with the round-trip travel time for the 19 tracked patients being 1.27 hours (SD=0.78 hours) with a minimum of 0.25 hours and a maximum of 3.80 hours.
Four IVIG patients required pre-visit nursing support, designated as Visit 0, which primarily involved telephonic communication and care coordination prior to their initial in-person home nurse visit. These 4 patients averaged 1 hour of preparatory nurse time.
As shown in Table 3, nurses spend noticeably more time on out-of-home tasks, such as care coordination and phone calls, during Visit 1. These external duties average 0.55 hours in Visit 1, compared to 0.20 hours in Visit 2 and 0.49 hours in Visit 3. Visit 1 also involves the most time spent in the patient’s home conducting tasks other than drug administration with a mean of 2.71 hours compared to 2.06 hours for Visit 2 and 2.01 hours for Visit 3. It was reported that 3 of the 19 patients had a nurse Visit 3, which included drug administration.
IVIG nurse time is calculated by adding the drug administration time to the out of home nurse time and nurse’s round-trip travel time, as shown in Figure 1. This formula is used because the nurse is with the patient during the entire drug administration while conducting other in-home tasks concurrently. Additionally, the nurse completes tasks that are outside of the patient’s home, such as patient documentation, coordination of care, and telephonic communication with other health care providers including physicians and pharmacists. Based on IVIG nurse time formula, the estimated time by visit is the following:
Patient Visit 1 IVIG Patient Nurse Time = 5.90 hours
Patient Visit 2 IVIG Patient Nurse Time = 4.97 hours
Patient Visit 3 IVIG Patient Nurse Time = 6.61 hours
When comparing home infusion nurse time across therapies, using data from Visit 1 provides the most accurate baseline. During Visit 1, IVIG patients require considerably more nurse time than anti-infective or monoclonal antibody therapies. This difference is primarily driven by longer drug administration times, as Visit 1 nurse time averaged 3.93 hours for anti-infectives and 4.06 hours for monoclonal antibodies. Both times include 1.23 hours of round-trip travel, which is consistent with the 1.27-hour travel time for IVIG nurses. While Visit 3 recorded the longest times, the data lacks representation due to the limited sample size of three patients.
The key finding in this study is that nurse tasks and visit time were quantified and included analysis by nurse visit, drug administration time, and travel time. It was determined that IVIG is more nurse time-intensive than anti-infective and monoclonal antibody therapy with nurse Visit 1 requiring about 5.90 hours of nurse time. This time is primarily driven by drug administration time.
While IVIG is administered, the nurse will concurrently perform patient assessments and documentation, continue to develop and document the plan of care, monitor the vascular access device, review labs, provide patient education, coordinate care, and communicate with other health care providers, such as physicians and pharmacists. The distribution of nurse tasks underscores the complexity of IVIG therapy in the home. These activities are essential to ensuring safe and effective therapy, particularly in a population that often requires long-term, repeated infusions and close clinical monitoring. The findings align with prior studies in other home infusion populations, including anti-infective therapies, which similarly demonstrate that nursing care extends beyond the infusion encounter and includes substantial non-billable work.11-15
Comparison of IVIG nurse tasks with anti-infective tasks shows distinct differences. For example, drug administration accounted for only 5.83% of the nurse tasks for anti-infective patients while it was 17.17% of the tasks for IVIG. This is due to IVIG and monoclonal antibodies being exclusively nurse-administered to the patients in this study, while anti-infective patients are taught how to self-administer their drug. There was a higher percentage of patient assessment and documentation and education tasks for anti-infective patients with 23.62% and 19.42% of the overall nurse tasks respectively. As expected, drug administration was the most time consuming for IVIG patients with a mean time of 3 hours and 58 minutes (SD=1:35). The large standard deviation for the IVIG drug administration task time highlights the variation in the time required. This variance likely stems from the unique clinical challenges of IVIG therapy and the highly individualized care each patient demands.
Common for retrospective time studies, this study has limitations. The sample size was relatively small and limited to patients receiving IVIG via pump during the initial phases of therapy, which may not fully capture variation in long-term treatment patterns. Even though the task categories were defined and examples provided, there is the possibility of variability in nurse documentation of tasks and time. In addition, data were collected from a defined set of providers and may not be generalizable to all home infusion settings.
Retrospective recall has its own set of limitations which include recall bias and social desirability bias where participants alter their recollections to fit socially acceptable norms or to align with what they think researchers want to hear. Even so, the detailed time and task-level data provide valuable insight into the operational realities of home infusion nursing and address an important gap in the literature. If replicating this study, it is advised to split task category 1, “Performing patient assessments and documentation” into 2 distinct categories.
It was determined that IVIG is more nurse time-intensive than anti-infective and monoclonal antibody therapy with nurse Visit 1 requiring about 5.90 hours of nurse time. Based on the mean times for the nurse task categories, the overall nurse time is driven by drug administration. Also time-intensive is round-trip travel time to and from the patient’s home, which averages 1.27 hours. Home infusion of IVIG requires substantial nurse time primarily due to prolonged drug administration time. Travel time contributes to the overall operational workload of home infusion care but should be interpreted separately from therapy-specific administration time. These findings highlight that the nurses’ workload associated with home-based IVIG extends beyond direct in-home infusion administration. IVIG nurse time exceeds what was reported for anti-infectives and monoclonal antibodies due to drug administration time and the suspected complexity of the patient.
Disclosures: Study funded by contributions made to NHIF.
Commentary: When reviewing a manuscript submitted by one of Infusion Journal’s editors or staff, the author is deliberately excluded from all aspects of the review process. The Editor-in-Chief or alternate editor is responsible for handling the peer review process independently of the author. The author is not aware of the choice of peer reviewers and is not present when discussing the manuscript at editorial meetings.
Acknowledgment
We express our sincere appreciation to Laura Luckow, MSN, BSN, CRNI, for her valuable contributions to this study. Her clinical insight informed the research design and protocol development, and her thoughtful review of the final manuscript strengthened the article. We appreciate her insight and time invested in this project.
