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Parenteral Nutrition Safe Practices: Results of the 2003 American Society for Parenteral and Enteral Nutrition Survey

Parenteral Nutrition Safe Practices: Results of the 2003 American Society for Parenteral and Enteral Nutrition Survey

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Special Report 
Parenteral Nutrition Safe Practices: Results of the 2003 AmericanSociety for Parenteral and Enteral Nutrition Survey*
David Seres, MD, CNSP*; Gordon S. Sacks, PharmD, BCNSP†; Craig A. Pedersen, RPh, PhD, FAPhA‡;Todd W. Canada, PharmD, BCNSP§; Deborah Johnson, MS, RN
; Vanessa Kumpf, PharmD, BCNSP¶;Peggi Guenter, PhD, RN, CNSN#; Craig Petersen, RD, CNSD**; and Jay Mirtallo, MS, RPh, BCNSP††
 From the *Beth Israel Medical Center and Albert Einstein College of Medicine, New York, New York;
School of Pharmacy, University of Wisconsin, Madison, Wisconsin;
College of Pharmacy, Ohio State University, Columbus, Ohio;
The University of Texas MD Anderson Cancer Center, Houston,Texas;
 Meriter Hospital, Madison, Wisconsin;
 Nutrishare, Inc, Elk Grove, California;
 A.S.P.E.N., Silver Spring, Maryland;
University of  California Davis Medical Center, Sacramento, California; and the
The Ohio State University Medical Center, Columbus, Ohio
The American Society for Paren-teral and Enteral Nutrition (A.S.P.E.N.) recently published arevision of its “Safe Practices for Parenteral Nutrition” guide-lines. Because there is a paucity of published scientific evi-dence to support good practices related to ordering, com-pounding, and administering parenteral nutrition (PN), asurvey was performed in the process of the revision to gaininsight into the discrepancies between reported practices andprevious guidelines.
A web-based survey consistingof 45 questions was conducted (n
651) June 1–30, 2003.Respondents were queried about primary practice setting,professional background, processes for writing PN orders,computer order entry of PN orders, problems with PN orders,and adverse events related to PN.
There were 651survey responses, 90% of which were from hospital-basedpractitioners. Almost 75% of responders processed between0 and 20 PN orders per day. Overall, physicians (78%) wereresponsible for writing PN orders, but dietitians and phar-macists had significant involvement. PN base componentswere most often ordered as percentage final concentrationafter admixture (eg, 20% dextrose), which is inconsistentwith safe practice guidelines of ordering by total amount perday (eg, 200 g/day). There was no consistent method forordering PN electrolytes. Approximately 45% of respondersreported adverse events directly related to PN that requiredintervention. Of these events, 25% caused temporary or per-manent harm, and 4.8% resulted in a near-death event ordeath.
Although the survey found consistency inPN practices for many areas queried, significant variationexists in the manner by which PN is ordered and labeled.
Journal of Parenteral and Enteral Nutrition
259–265, 2006)
 As part of its mission to serve as the preeminent,interdisciplinary nutrition society dedicated to patient-centered, clinical practice worldwide through advo-cacy, education, and research in specialized nutritionsupport, the American Society for Parenteral andEnteral Nutrition (A.S.P.E.N.) published “Safe Prac-tices for Parenteral Nutrition.”
This document pro- vides guidelines with supporting evidence to fosterquality parenteral nutrition (PN) therapy. The intentis for the principles provided in the document tobecome incorporated into healthcare organizationpractice for the purpose of minimizing the risks of PNcomplications.“Safe Practices for Parenteral Nutrition” was exten-sively revised, adding a new section on the PN orderingprocess and significantly expanding the sectiondevoted to PN administration.
Unfortunately, there islittle, if any, published evidence to support good prac-tices in these areas. Although data from randomizedclinical trials of nutrition support are ideal for devel-oping clinical practice guidelines, this type of informa-tion is not widely available. Several factors inherentlylimit the use of prospective randomized clinical trialsin the evaluation of nutrition support.
Those mostlikely to benefit from the treatment (eg, severely mal-nourished patients) cannot be randomized to an unfedcontrol group due to ethical dilemmas. Other limita-tions include outcome results influenced by clinical variables independent of nutrition support and inabil-ity to recruit large numbers of eligible individuals from1 medical center, contributing to the enrollment of marginal candidates for nutrition support. Becauseclinical guidelines cannot be based solely on prospec-tive randomized trials, the A.S.P.E.N. Task Force forRevision of Safe Practices for Parenteral Nutrition con-ducted the 2003 Survey of PN Practices,
focusing onpolicies and procedures relating to ordering, com-pounding, and administering PN and quality oversightof this process. The final document published as “SafePractices for Parenteral Nutrition” was based primar-ily on the recommendations of experts in the field andwas evidence-based for as much as the literature pro-
Received for publication August 25, 2005. Accepted for publication February 6, 2006.Correspondence: Gordon S. Sacks, PharmD, BCNSP, 777 Highland Avenue, University of Wisconsin–Madison, Madison, WI 53705.Electronic mail may be sent to gssacks@pharmacy.wisc.edu.Results presented in part at Nutrition Week Meeting of the Ameri-can Society for Parenteral and Enteral Nutrition, Orlando, Florida,February, 2005.
0148-6071/06/3003-0259$03.00/0 Vol. 30, No. 3J
Printed in U.S.A.
Copyright © 2006 by the American Society for Parenteral and Enteral Nutrition
 vided evidence to support these recommendations. Theresults from this survey were used as a basis for therevised “Safe Practices for Parenteral Nutritiontoenhance the quality and efficacy of nutrition support.Following is a summary and analysis of the responsesto the survey.
 Development of the Survey Instrument 
One of the survey objectives was to identify commonpractices related to ordering and compounding, admin-istration of PN, and quality oversight of this process. Aquestionnaire based upon the existing A.S.P.E.N. “SafePractices for Parenteral Nutrition” was developed toobtain an overview of the variance and consistencywith current practices from a variety of healthcaresettings. It was designed to include both hospital- andnon–hospital-based PN practices. The survey instru-ment was not tested or validated before its distribu-tion, but it was reviewed by a multidisciplinary panelof nutrition support practitioners and revised beforebecoming available for participant responses. The sur- vey was administered electronically through the A.S.P.E.N. website and announced to the membership
society journals and A.S.P.E.N. list servers. Announcements inviting participation were also sentto selectedprofessionalgroups,including the AmericanCollege of Clinical Pharmacy, the American Society of Health-System Pharmacists, the National Home Infu-sion Association, and others. Participation in the sur- vey was completely voluntary.The survey instrument consisted of 45 questionswith multiple-choice and free-text responses. It wasorganized into 5 sections: demographics of the respon-dent, writing PN orders, computer order entry of PNorders, problems with PN orders, and adverse eventsrelated to PN. Questions in the demographic sectionfocused on information such as professional back-ground (ie, MD, RN, RD, RPh, other) and primarypractice setting (ie, hospital, homecare, etc). The order-writing section was designed to identify the disciplineresponsible for writing PN orders, whether or not stan-dard PN order forms were used, and the manner inwhich PN components were ordered (ie, dextrose inpercent final concentration
g/day, electrolytes inmEq/L
per day, etc). The computer order entry sec-tion was designed to quantitate the use of computer-ized order entry systems and automated compoundingdevices. The final 2 sections, problems and adverseevents related to PN, were developed to capture thetype and frequency of harm associated with the com-pounding and administration of PN formulations.
 Data Collection
The survey was announced on the A.S.P.E.N. web-site, in the society journals (eg,
Journal of Parenteraland Enteral Nutrition
Nutrition in Clinical Practice
),and list servers (eg, ASPENet) between June 1 and 30,2003. Messages were subsequently posted to informpotential respondents of the deadline for final submis-sion of survey responses. Participants were assuredthat their responses would be confidential and thatonly aggregate responses would be reported.
 Data Analysis
Descriptive statistics were used to characterize thefrequencies of surveyed practices. Questions with free-text responses were analyzed for content to determineif the responses were significant to the study. Datawere analyzed with the SPSS 11.5 (SPSS, Inc, Chicago,IL) statistical package. Frequency data were assessedwith
. The
a priori
level of significance was set at
The demographic characteristics of the respondents(n
651) are presented in Table I. The majority of respondents were registered dietitians (55%), followedby registered pharmacists (32%). Hospitals (teaching,nonteaching, and government) were the most commonprimary practice setting (90%). The remaining 10% of respondents worked in the home infusion setting.Twenty-six percent of respondents indicated the aver-age daily census for their organization was 400
patients, whereas 22% serviced only 100–199 patientsper day. Only 15% of respondents were preparing
20adult PN formulations or
5 pediatric PN formula-tions per day. A once-daily nutrient infusion systemwas preferred by the majority of organizations (76%). Approximately 54% (337 of 620) of those respondingto the question indicated that their organization used aperformance improvement (PI) process for variouscomponents of the PN system. Specific componentsidentified as part of the PI process are listed in TableII. The appropriate use of PN and accuracy of PNorders were the most frequently used markers for PI;costs of PN compounding and PN wastage rates weremonitored by
30% of respondents that used a PIprocess. Indicators reported in free-text answers but
 Professional background of respondents
Discipline Percent Response
Dietitian 55Nurse 5Pharmacist 32Physician 7Other 1T
Components of performance improvement process (n
 Appropriate use of PN 81 Accuracy of PN orders 56Catheter and infectious complications 56Metabolic complications 49Quality control for PN compounding 46PN costs 29PN wastage rate 25
Vol. 30, No. 3
not included as choices in the survey instrumentincluded (1) appropriate dose of nutrient, (2) appropri-ate monitoring of PN, (3) whether recommendationswere followed, and (4) efficacy of PN.
Writing Parenteral Nutrition Orders
The physician on the primary medical or surgicalteam responsible for the patients’ care was identi-fied most often as the party writing PN orders (78%).The specialty area of the physicians varied andincluded endocrinology, gastroenterology, pulmonary/ critical care, nephrology, pediatrics, and family medi-cine. The level of training also varied, ranging fromresidency to clinical nutrition fellowship. Respondentsindicated that dietitians and pharmacists were heavilyinvolved in the order-writing process, either as individ-uals or as members of a nutrition support service. Additional healthcare practitioners, such as advancedpractice nurses, as well as physician assistants, arealso involved in the order-writing process. Respon-dents were asked to comment on the professional groupinvolved with oversight of the PN order process, suchas development of standard PN order forms, productreview for inclusion/exclusion on the formulary, anddocumentation/reporting of PN-related adverse events.Pharmacy services, in collaboration with the nutritionsupport service or a medical staff committee, was mostoften responsible for this aspect of the process. Approximately 48% of organizations ordered the PNbase components in percentage of final concentrationafter admixture (eg, 20% dextrose) and 33% as the volume of percentage of original concentration (eg, 200mL of 50% dextrose). Several respondents reportedusing a combination of methods to order the individualmacronutrients, as listed in Table III. Of note, therewas no standardization between home infusion agen-cies and hospitals.No consistent method was identified for ordering of electrolyte components or quantities. Use of the elec-trolyte salts (eg, sodium chloride, potassium chloride)was favored over the use of the individual electrolytecations or anions (eg, sodium, potassium, chloride, ace-tate). However, the quantity of electrolyte ordered wasexpressed in a variety of ways. The number of mEq/L(or per 100 mL for neonates), mEq per day, and mEqper total volume were the 3 most common methods.Table IV includes a list of all the methods used. Phos-phorus was ordered in mmol of the salt (eg, potassiumphosphate or sodium phosphate) by 57% of respon-dents and in mEq of the cation by 26% of respondents. Approximately 17% used both methods of nomencla-ture. Some amino acid products are manufactured withelectrolytes as buffers (ie, chloride, acetate) or containelectrolytes as components (ie, sodium, phosphorus).When queried as to whether these electrolytes wereconsidered in the total electrolyte delivery, 71% did notinclude these in the total amount during the writing of PNorders.Thepharmacywasallowedtoadjustcertainelectrolyte additives such as acetate or chloride in 62%of respondent’s organizations.The overwhelming majority of organizations (90%)routinely ordered a standard volume of a commerciallyavailable multiple trace element product
each traceelement ordered separately. Approximately 1 of 5respondents (22%) adjusted the dose of trace elementsaccording to patient clinical condition (ie, gastrointes-tinal losses, liver failure). A total of 88% of respondents reported using a stan-dardized PN order form. Improved interpretation of PN orders and reduced errors were perceived by 83% tobe a result of using standardized PN order forms. Edu-cational information was frequently included either onor with PN order forms, as those writing PN orderswere felt to lack knowledge of PN preparation. Respon-dents from the home infusion setting reported that theprimary reason for not using a standardized PN orderform (32%) was the inability to standardize the order-ing process because orders were received from multipleorganizations. Only 54% of respondents reported usingstandard order forms for laboratory and patient careorders related to PN.There was a significant difference found between theuse of standard PN order forms and how often PNorders required clarification. PN orders written withthe use of standard order forms seldom required clar-ification, whereas PN orders required frequent clarifi-cation if standard order forms were not used (
.015).There was a trend (
.085) between the use of stan-
 Methods for ordering PN base components
Protein g/kg/d,* g/d, g/L of PN, volume of %original concentration, % finalconcentration, g/total volume of PNDextrose Infusion rate: mg/kg/min* or g/kg/h,g/L of PN, g/d, kcal/day, volume of % original concentration, % finalconcentration, nonprotein kcal*Intravenous fat emulsion g/kg/d,* g/d, g/L of PN, volume of %original concentration, % finalconcentration, g/total volume of PN, kcal/day, volume of %concentration to be added to PNor infused separate from PN (ie,200 mL of 20% lipid), ml/d*, ml/Lof PN, g per total PN volume,nonprotein kcal**Methods identified from free-text responses.T
 Methods by which PN electrolyte quantities are ordered 
Quantity ExpressionPercentResponse
mEq/L or 100 mL for neonates 43mEq/d 39mEq/Total volume 38mEq/kg 16mmol/Total volume N/A* Volume (mL) of multielectrolyte concentrateformulationN/A* Volume (mL) of original electrolyteconcentration (eg, 25 mL of 10% NaCl)N/A*mg/d (For calcium gluconate) N/A*mmol/L N/A**These methods were not included as a selection in the survey butwere provided by respondents when asked whether other methodswere used.
 May–June 2006 

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