Effectiveness of a clinical practice guideline for parenteral nutrition: a 5‐year follow‐up study in a pediatric teaching hospital

Duggan, Christopher; Rizzo, Camielle; Cooper, Andrew; Klavon, Susan; Fuchs, Vanessa Boanada; Gura, Kathleen M.; Richardson, Denise; Collier, Sharon; Lo, Clifford

doi:10.1177/0148607102026006377

Cited by 23 publications

(17 citation statements)

References 8 publications

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“…Many hospitals adopted policies to control the PN ordering process by integrating a “flagging” tool in the medical chart that would require physicians to indicate which A.S.P.E.N. guideline justifies their decision to order PN 16 , 29 . Nutrition training programs have been incorporated into medical school curricula, physician residency programs, physician fellowship curricula, and postgraduate physician education programs to bolster knowledge and practice of general nutrition and nutrition support 30 .…”

Section: Discussionmentioning

confidence: 99%

Assessing Appropriate Parenteral Nutrition Ordering Practices in Tertiary Care Medical Centers

Mack

DeLegge

Nichols

et al. 2010

J Parenter Enteral Nutr

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Background: Parenteral nutrition (PN) is an essential feeding route for specific patient populations. Despite its utility, PN is invasive, costly, and associated with clinical complications. In most U.S. hospitals, PN is overprescribed. This study measured rates of inappropriate PN use in hospitalized adults, as determined by the 2002 American Society for Parenteral and Enteral Nutrition guidelines, at 4 tertiary care South Carolina hospitals (facilities A–D). Secondary aims were to identify indicators of inappropriate use and estimated preventable costs. Methods: Over a 3‐month period, trained registered dietitians at each site collected data retrospectively and prospectively to determine PN appropriateness and indicators of use in 278 randomly selected PN cases. Results: PN therapy was inappropriately prescribed in 32% of cases, resulting in approximately 552 days and $138,000 in preventable hospital costs. Thirteen percent of patients who were prescribed inappropriate PN were discharged on home PN. Mean duration of PN therapy was higher in inappropriate cases vs appropriate cases (6 ± 7 days [range, 1–78 days] vs 10 ± 10.6 days [range, 1–51 days]; P < .004). Facility B had lower rates of inappropriately prescribed PN (23%) compared with facilities A (33%), C (35%), and D (38%). Dietitians recommended against PN in >70% of all inappropriate cases at facilities A and D compared with <45% at facilities B and D (P < .001). Facility B employed more certified nutrition support dietitians (68% of staff) and was among the 2 hospitals using a nutrition support team (NST). Conclusion: This study was novel by comparing PN practices in statewide hospitals. Results indicate that NSTs and certified nutrition support clinicians can curtail preventable spending from inappropriate PN use. Future studies should identify barriers in implementing evidence‐based practice.

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Section: Discussionmentioning

confidence: 99%

Assessing Appropriate Parenteral Nutrition Ordering Practices in Tertiary Care Medical Centers

Mack

DeLegge

Nichols

et al. 2010

J Parenter Enteral Nutr

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“…In particular, practice in relation to the BGL at which insulin infusion is commenced varies greatly. Adherence to practice guidelines can improve the effectiveness of practice, both by decreasing risk of complications and improving patients' outcomes as well as resulting in significant cost savings (Duggan et al, 2002).…”

Section: Discussionmentioning

confidence: 99%

“…Complications include catheterrelated sepsis, hyperglycaemia and hepatic steatosis. Regardless, PN is clearly indicated for use in particular patients, where a clinical benefit is anticipated, which would outweigh any harmful effects of restricting nutrition support (Wolfe and Mathiesen, 1997;Duggan et al, 2002).…”

Section: Introductionmentioning

confidence: 99%

“…Previous audits of PN administration within hospitals have indicated: a tendency to prescribe PN to malnourished patients regardless of severity of illness or gut function (Ioannides-Demos et al, 1995); provision of varied glucose loads (Ioannides-Demos et al, 1995) and increased shortterm PN use (less than 5 days) before introduction of practice guidelines (Duggan et al, 2002).…”

Section: Introductionmentioning

confidence: 99%

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Current practices in the delivery of parenteral nutrition in Australia

2006

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Objective: To determine current practice in the delivery of parenteral nutrition (PN) in Australian hospitals. Design: A cross-sectional mail survey. Setting: Acute-care adult hospitals with greater than 200 beds in Australia. Subjects: A total of 67 hospitals (65.7% response rate). Intervention: Surveys were posted to hospitals. A reminder letter with a second copy of the survey was posted 3 weeks later to non-respondents. Results: Twenty-seven (40.3%) of the hospitals have a PN team and 50 (74.6%) have a hospital protocol for PN delivery. An inaccessible or non-functional gastrointestinal tract is the most common indicator for commencing PN. Fat infusion is calculated by 24 (38.7%) respondents with a mean (s.d.) maximum amount of fat provided of 2.0 (0.7) g/kg/day. Over half (n ¼ 35) reported calculating carbohydrate infusion at a maximum amount of 5.4 (1.0) mg/kg/min. Two-thirds (n ¼ 41) reported commencing PN at a rate of 50% or less of goal rate. Blood glucose levels (BGL) were monitored at least once per day by the majority of respondents (n ¼ 56, 83.6%). Insulin infusion was commenced at varying BGL. Most respondents (n ¼ 40, 59.7%) reported ceasing PN when at least half of the patient's requirements are being met either orally or enterally. A number of practice guidelines were identified and the results of the survey were compared with these guidelines. Conclusions: Where there are clear practice guidelines, current practice appears to be in line with these recommendations, however, where evidence is lacking, practice is varied.

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“…A standardized multidisciplinary approach aimed at optimizing enteral nutrition with well defined thresholds for parenteral nutrition use is desirable. Parenteral nutrition may be initiated when enteral nutrition alone is anticipated to be insufficient to reach energy goal for 5 days or earlier in neonates and malnourished children [7,37]. Significant mortality reduction was achieved after implementing a nutrition support team that facilitated reduced parenteral nutrition utilization and increased use of enteral nutrition in a PICU [38].…”

Section: Parenteral Nutritionmentioning

confidence: 99%

Nutrition therapy in the critically ill child

Skillman

Mehta²

2012

Current Opinion in Critical Care

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Effectiveness of a clinical practice guideline for parenteral nutrition: a 5‐year follow‐up study in a pediatric teaching hospital

Abstract: In a large pediatric tertiary care hospital, a CPG was successfully deployed. CPGs can favorably affect the use rates and costs of parenteral nutrition.

Cited by 23 publications

References 8 publications

Assessing Appropriate Parenteral Nutrition Ordering Practices in Tertiary Care Medical Centers

Assessing Appropriate Parenteral Nutrition Ordering Practices in Tertiary Care Medical Centers

Current practices in the delivery of parenteral nutrition in Australia

Nutrition therapy in the critically ill child

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