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
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 firstname.lastname@example.org.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