Comparison of PN Usage Before and After the Implementation of a PN Usage Policy Ali Ballard, RD, LD, CNSC Clinical Dietitian, MUSC Background EN is preferred method of nutrition support whenever possible Better outcomes Less costly PN frequently prescribed unnecessarily by MUSC physicians (primarily GI surgery service) Background: PN Sticker Policy Stickers were created stating PN was “avoidable” or “no longer needed” PN Usage was documented and noted whether to meet ASPEN guidelines or to be “avoidable” PN Stickers Patient Name ____________________________________ MRN_____________________ The American Society of Parenteral and Enteral Nutrition (ASPEN) guidelines suggest that opportunities for discontinuing parenteral nutrition (PN) exist. Please document below an indication for continuing PN use. □ Intractable vomiting □ Intractable diarrhea □ Pancreatitis □ Stage 3-4 mucositis □ Unable to place feeding tube □ High residuals with gastric feedings and unable to obtain small bowel access □ Other _________________________________________________________________ Thank you, Nutrition Support Team Dr. DeLegge Pager ID 14373 Date / Time ________________ ____________________________________________________________ Patient Name ____________________________________ MRN_____________________ Please consider discontinuing parenteral nutrition based on the following: □ Patient is receiving >50% of needs via enteral nutrition and/or oral intake. □ Patient is a candidate for oral or enteral feedings. □ Other: _________________________________________________________________ Thank you, Nutrition Support Team Dr. DeLegge Pager ID 14373 Date / Time _________________ Background: PN Sticker Policy Data on “avoidable” PN usage presented to MEC New PN Usage Policy proposed and passed by MEC 1/2011 New PN Policy 2011 Identification of Appropriate PN Usage Adult Guidelines: The Nutrition Support Team (NST) will receive an automatic nutrition consult for adult PN orders. All consults must be ordered prior to the cut-off time indicated on the clinician order form. The NST member (RD or PharmD) will determine if the PN complies with A.S.P.E.N. guidelines (Appendix B). If the PN does not meet A.S.P.E.N. guidelines, the patient will not receive PN, and a sticker will be placed in the Progress Notes section of the patient’s chart documenting this. (Appendix C). In the event PN is believed to be necessary but does not meet A.S.P.E.N. guidelines, the requesting physician may contact the Director of Nutrition (or other designated physician) for a case review. PN will not be provided until approved by the reviewer. Adult Nutrition Guidelines Algorithm (Appendix B) Adult Nutrition Therapy Guidelines Aspiration risk factors: Documented previous episode of aspiration, delayed gastric emptying, neuromuscular disease or structural abnormalities of the digestive tract, persistently high gastric residual volumes, head of bed elevated < 30 degrees, vomiting Malnutrition is defined by: > 10 – 15 % documented weight loss OR < 90 % of Ideal Body Weight (IBW) START NO Does pt have functional GI tract? Start clears and advance to therapeutic diet as tolerated Non-functional GI tract YES NO Functional GI tract YES Begin EN YES Can patient take PO? Does patient have feeding tube? NO 1. Paralytic ileus (radiologic evidence AND NG output > 1000 ml) 2. Mesenteric ischemia 3. Small bowel obstruction 4. Short gut syndrome 5. GI fistula, except when enteral access can be placed distal to fistula or volume of fistula output is less than 200 ml/day 6. For GVHD stage 2 or above of GI tract AND malabsorptive diarrhea 7. Grade 3 or above mucositis AND platelet count < 40 K/CUMM 8. Enteral nutrition failed with small bowel feeding tube placement validated by RD/ PharmD evaluation Is patient high risk for aspiration* (see above) YES NO Place OG/NG Consider placing post-pyloric feeding tube (ex: Cortrak, dobhoff) Begin EN Complete EN Order Form Normal Renal Function References 1. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society of Parenteral and Enteral Nutrition (ASPEN). JPEN 2009;33:277-316. 2. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN 2002;26:1SA-138SA. 3. ASPEN Clinical Guidelines: Nutrition support therapy during anticancer treatment in hematopoietic cell transplantation. JPEN 2009;33:472-500. Begin Promote at 20 ml/hr and consult dietitian -NPO < 7d -NPO for procedure -No signs malnutrition* NPO > 7d Malnutrition* Cont NPO and start PO diet or EN when feasible Begin PN Consult RD/ PharmD Renal Failure Begin Novasource at 20 ml/hr and consult dietitian If after 1400 begin MIVF and consult RD/ PharmD New PN Sticker (Appendix C) Patient Name ___________________ MRN ________________ Based on the American Society of Parenteral and Enteral Nutrition (A.S.P.E.N) guidelines this patient is not an appropriate candidate for parenteral nutrition (PN). Indications for PN include: 1. Patient has failed enteral nutrition trial with appropriate tube placement (post pyloric). 2. Enteral nutrition is contraindicated. Examples include: • • • • • • • 3. Paralytic ileus (radiologic evidence AND NG output > 1000 mL) Mesenteric ischemia Small bowel obstruction Short gut syndrome GI fistula except when enteral access may be placed distal to the fistula or volume of fistula output is less than 200 mL/day GVHD stage 2 or above of GI tract AND malabsorptive diarrhea Grade 3 or above mucositis AND platelet count < 40 K/cumm Wound healing would be impaired if PN is not started within 5 to 10 days postoperatively for patients unable to eat or tolerate enteral feeding. PN for this patient will: □ not be initiated □ be discontinued Thank you, Nutrition Support Team ___________ Pager ID_______ Date Time_______ PN Usage Study Purpose of the study: to determine the effects of a PN usage policy on the ordering and usage of PN at our institution Data collection: from January to March of 2010 (prior to institution of the PN policy) and from January to March of 2011 (after institution of the PN policy) Results: PN Usage before Policy PN usage January 2010: 643 PN PN usage February 2010: 526 PN PN usage March 2010: 457 PN Total PN Jan-March: 1626 PN Results: PN Usage after Policy PN usage January 2011: 457 PN PN usage February 2011: 463 PN PN usage March 2011: 438 PN Total PN Jan-March: 1358 PN Results: PN Usage Decrease PN decrease January: 28% PN decrease February: 12% PN decrease March: 4.2% Overall PN decrease Jan-March: 16.5% Conclusion A nutrition-directed policy regarding PN usage was shown to decrease frequency of PN orders Further research into whether this affected other outcomes such as line infection rates and LOS would be beneficial Questions?? Thank you! Questions??