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Evaluation of the Appropriate Use of Parenteral Nutrition in an Acute Care Setting

1996; Elsevier BV; Volume: 96; Issue: 6 Linguagem: Inglês

10.1016/s0002-8223(96)00165-4

1878-3570

DIANE D HESTER, TARA M COGHLIN, NANCY L HSIEH,

Abdominal Surgery and Complications

Continuous quality improvement is conducted at Stanford University Hospital to provide ongoing monitoring and evaluation of clinical indicators in the pursuit of improved patient care ((1)Flanel D.F Fairchild M.M Continuous quality improvement in inpatient clinical nutrition services.J Am Diet Assoc. 1995; 95: 65-74Google Scholar). This program is focused on the mission of the Joint Commission on Accreditation of Healthcare Organizations, which is to improve the quality of care provided to the public ((2)Comprehensive Accreditation Manual for Hospitals. Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, Ill1994Google Scholar, (3)Krasker G.D Balogun L.B 1995 JCAHO Standards development and relevance to dietetics practice.J Am Diet Assoc. 1995; 95: 240-243Google Scholar). Within the Department of Nutrition and Food Services, the clinical nutrition manager is responsible for monitoring the evaluation of activities in the delivery of nutrition care. Action plans that have hospital-wide involvement are coordinated through the Multidisciplinary Nutrition and Total Parenteral Nutrition (TPN) committees. The clinical nutrition manager also reports results of the continuous quality improvement activities to the Stanford University Hospital Executive Quality of Care Committee. Data collection results for each indicator, action plans to improve performance on indicators, and progress toward problem resolution are reported. As many studies have been published to support the use of enteral feeding over parenteral nutrition support, the TPN Committee suggested that our continuous quality improvement program include an indicator on the appropriateness of parenteral nutrition (PN) use ((4)Kudsk K.A Clinical applications of enteral nutrition.Nutr Clin Pract. 1994; 9: 165-171Google Scholar, (5)Kudsk K.A Croce M.A Fabian T.C Minard G Tolley E.A Poret H.A Kuhl M.R Brown R.O Enteral versus parenteral feeding effects on septic morbidity after blunt and penetrating abdominal trauma.Ann Surg. 1992; 215: 503-513Google Scholar, (6)Moore F.A Moore E.E Jones T.N McCroskey B.L Peterson V.M TEN versus TPN following major abdominal trauma-reduced septic morbidity.J Trauma. 1989; 29: 916-922Google Scholar, (7)Moore F.A Feliciano D.V Andrassy R.J McArdle A.H Booth F.V Morgenstein-Wagner T.B Kellum Jr, JM Welling R.E Moore E.E Early enteral feeding, compared with parenteral, reduces post operative septic complications the results of a meta-analysis.Ann Surg. 1992; 216: 172-183Google Scholar, (8)Fink M.P Gastrointestinal mucosal injury in experimental models of shock, trauma, and sepsis.Grit Care Med. 1991; 19: 627-641Google Scholar, (9)Saito H Trocki O Alexander J.W Kopcha R Heyd T Joffe S The effect of route of nutrient administration on the nutritional state, catabolic hormone secretion, and gut mucosal integrity after burn injury.JPEN. 1987; 11: 1-7Google Scholar, (10)Lipman T.O Bacterial translocation and enteral nutrition in humans an outsider looks in.JPEN. 1995; 19: 156-165Google Scholar, (11)Lowry S.F The route of feeding influences injury responses.J Trauma. 1990; 30: S10-S15Google Scholar, (12)Poret HA I.I.I Kudsk K.A Croce M.A Fabian T.C Minard G Collier P.R Brown R.O Cicala R.S The effect of enteral feeding on catecholamine response following trauma.Surg Forum. 1991; 42: 11-13Google Scholar, (13)Mirtallo J.M Powell C.R Campbell S.M Schneider P.J Kudsk K.A Cost-effective nutrition support.Nutr Clin Pract. 1987; 2: 142-151Google Scholar). Clinical reports demonstrate a lower rate of septic complications in patients who receive enteral feedings than in those who receive parenteral feedings ((4)Kudsk K.A Clinical applications of enteral nutrition.Nutr Clin Pract. 1994; 9: 165-171Google Scholar, (5)Kudsk K.A Croce M.A Fabian T.C Minard G Tolley E.A Poret H.A Kuhl M.R Brown R.O Enteral versus parenteral feeding effects on septic morbidity after blunt and penetrating abdominal trauma.Ann Surg. 1992; 215: 503-513Google Scholar, (6)Moore F.A Moore E.E Jones T.N McCroskey B.L Peterson V.M TEN versus TPN following major abdominal trauma-reduced septic morbidity.J Trauma. 1989; 29: 916-922Google Scholar, (7)Moore F.A Feliciano D.V Andrassy R.J McArdle A.H Booth F.V Morgenstein-Wagner T.B Kellum Jr, JM Welling R.E Moore E.E Early enteral feeding, compared with parenteral, reduces post operative septic complications the results of a meta-analysis.Ann Surg. 1992; 216: 172-183Google Scholar). Studies have shown a decrease in gastrointestinal mucosal damage with early enteral feedings ((8)Fink M.P Gastrointestinal mucosal injury in experimental models of shock, trauma, and sepsis.Grit Care Med. 1991; 19: 627-641Google Scholar, (9)Saito H Trocki O Alexander J.W Kopcha R Heyd T Joffe S The effect of route of nutrient administration on the nutritional state, catabolic hormone secretion, and gut mucosal integrity after burn injury.JPEN. 1987; 11: 1-7Google Scholar). Maintenance of the intestinal barrier function may reduce the permeability to bacteria and toxins and, thus, prevent infection ((10)Lipman T.O Bacterial translocation and enteral nutrition in humans an outsider looks in.JPEN. 1995; 19: 156-165Google Scholar). In addition, enteral nutrition has been demonstrated to blunt the hypermetabolic response to injury ((9)Saito H Trocki O Alexander J.W Kopcha R Heyd T Joffe S The effect of route of nutrient administration on the nutritional state, catabolic hormone secretion, and gut mucosal integrity after burn injury.JPEN. 1987; 11: 1-7Google Scholar, (11)Lowry S.F The route of feeding influences injury responses.J Trauma. 1990; 30: S10-S15Google Scholar, (12)Poret HA I.I.I Kudsk K.A Croce M.A Fabian T.C Minard G Collier P.R Brown R.O Cicala R.S The effect of enteral feeding on catecholamine response following trauma.Surg Forum. 1991; 42: 11-13Google Scholar). Finally, if PN use could be reduced, the patients and hospital would gain an economic benefit ((13)Mirtallo J.M Powell C.R Campbell S.M Schneider P.J Kudsk K.A Cost-effective nutrition support.Nutr Clin Pract. 1987; 2: 142-151Google Scholar). Each registered dietitian is responsible for assessment and nutrition care planning for her or his patients who are receiving PN, so data collection on this patient population was feasible. A data collection form was developed for patients receiving TPN and/or peripheral parenteral nutrition. Criteria for the appropriateness and adequacy of the feedings were established by the clinical staff on the basis of published guidelines and are presented in Figure 1((14)ASPEN Board of Directors Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients.JPEN. 1993; 17: 1SA-52SAGoogle Scholar, (15)Powers T Deckard M Stark N Cowan Jr, G.S A nutrition support team quality assurance plan.Nutr Clin Prac. 1991; 6: 151-155Google Scholar). Data were initially collected 1 day per month by the clinical nutrition manager. After 6 months of data collection, the results from this trial study were presented to the TPN Committee. Of the 102 patient forms reviewed, only 80% met the threshold criteria of 100%. From this preliminary data collection, the following recommendations were made by the TPN Committee. The study should be expanded to include all patients receiving PN to provide the most accurate information. It was also suggested that we set our threshold criteria at 90%, because some patients begin enteral feedings unexpectedly due to changes in medical status, particularly in the critical care areas. In addition, the data collection sheet should include the name and service of the attending physician to facilitate the communication of inappropriate use of PN. When inappropriate use is identified, the dietitian should communicate this to the resident physician. TPN Committee recommendations were implemented. A revised form was developed to collect data for all patients receiving PN. Also, a monthly in-service session on nutrition support was provided for the resident physicians in the intensive care unit, where most of the PN orders originated. If inappropriate use of PN was found consistently, the clinical nutrition manager sent a letter to the attending physician reviewing the indications for PN support. The letter stated that PN use was being monitored and that the physician's usage was not in compliance with the guidelines established by the TPN Committee. As stated previously, the 6-month trial study only reviewed 102 patient forms, with 80% meeting the threshold criteria. After 6 months of data collection according to the revised procedure, data were collected on all patients (321) receiving PN support. Of the 321 patient forms reviewed, 92% met the threshold criteria. To validate these results, data were collected for an additional 6 months. Of the 342 additional patient forms reviewed, 94% of the patients received PN appropriately (Figure 2). Inappropriate use of PN was most common when family members refused tube feedings for aesthetic purposes. The patients would receive a consistency-modified diet in addition to PN to meet nutrition needs despite a functioning gut. Not only are there infection risks associated with PN ((16)The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group. Peri-operative total parenteral nutrition in surgical patients.N Engl J Med. 1991; 325 (32): 525Google Scholar), but PN is also the most expensive feeding method. Use of PN only when appropriate can result in substantial cost savings — an important factor given rapid changes in health care that require cost containment. After 18 months of data collection, the PN use indicator was discontinued because the data showed that PN was being used appropriately. This indicator will be rechecked once a year to monitor compliance in the pursuit of continuous quality improvement of patient care. Parenteral nutrition support has a unique role in medical nutrition therapy, but it must be reserved for those who have lost gastrointestinal function. The physiologic and immunologic benefits of enteral feedings continue to be demonstrated ((4)Kudsk K.A Clinical applications of enteral nutrition.Nutr Clin Pract. 1994; 9: 165-171Google Scholar, (5)Kudsk K.A Croce M.A Fabian T.C Minard G Tolley E.A Poret H.A Kuhl M.R Brown R.O Enteral versus parenteral feeding effects on septic morbidity after blunt and penetrating abdominal trauma.Ann Surg. 1992; 215: 503-513Google Scholar, (6)Moore F.A Moore E.E Jones T.N McCroskey B.L Peterson V.M TEN versus TPN following major abdominal trauma-reduced septic morbidity.J Trauma. 1989; 29: 916-922Google Scholar, (7)Moore F.A Feliciano D.V Andrassy R.J McArdle A.H Booth F.V Morgenstein-Wagner T.B Kellum Jr, JM Welling R.E Moore E.E Early enteral feeding, compared with parenteral, reduces post operative septic complications the results of a meta-analysis.Ann Surg. 1992; 216: 172-183Google Scholar, (8)Fink M.P Gastrointestinal mucosal injury in experimental models of shock, trauma, and sepsis.Grit Care Med. 1991; 19: 627-641Google Scholar, (9)Saito H Trocki O Alexander J.W Kopcha R Heyd T Joffe S The effect of route of nutrient administration on the nutritional state, catabolic hormone secretion, and gut mucosal integrity after burn injury.JPEN. 1987; 11: 1-7Google Scholar, (10)Lipman T.O Bacterial translocation and enteral nutrition in humans an outsider looks in.JPEN. 1995; 19: 156-165Google Scholar, (11)Lowry S.F The route of feeding influences injury responses.J Trauma. 1990; 30: S10-S15Google Scholar, (12)Poret HA I.I.I Kudsk K.A Croce M.A Fabian T.C Minard G Collier P.R Brown R.O Cicala R.S The effect of enteral feeding on catecholamine response following trauma.Surg Forum. 1991; 42: 11-13Google Scholar). The economic benefit of enteral feeding compared with PN support is remarkable ((13)Mirtallo J.M Powell C.R Campbell S.M Schneider P.J Kudsk K.A Cost-effective nutrition support.Nutr Clin Pract. 1987; 2: 142-151Google Scholar). At our institution, the cost of PN is 10 times greater than that of enteral nutrition support. Our study of the use of PN as a continuous quality improvement indicator offered an opportunity to educate the medical, nursing, and pharmacy staff through multidisciplinary committees and in-service sessions on the importance of choosing enteral feedings over parenteral feedings when appropriate.