Comparison of PN Usage Before and After the Implementation

Report
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??


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