The impact of computerization of the nutrition support process on the nutrition support program in a tertiary care hospital in the Philippines: report for the years 2000-2003

BACKGROUND & AIMS: To improve hospital health care delivery by identifying malnutrition in all admitted patients and following up those identified to be malnourished and "at risk of developing malnutrition" a hospital nutrition support program based on the JCAHO system was initiated in 1999. Two major problems were encountered: first, the inability to perform a nutrition surveillance process due to failure by the staff to implement existing nutrition screening tools and second, the lack of awareness and support from the medical staff in this initiative. Two solutions were implemented in 2000: computerization of the nutrition screening and nutrition support process and synchronizing this with the whole nutrition support program. METHODS: A computer program was developed which performs BMI-based nutrition screening, produces lists of all malnourished patients, and computes the different formulas for either nutritional requirement or parenteral and/or enteral formulation. It also generates patient status reports based on encoded data from the nutrition support team, which prioritized these patients for management based on the data output. RESULTS: From 2000 to 2003, improvement was seen in these areas: entry of height and weight in the patient record increased from 30% to 90%; nutrition surveillance shows nutritional status distribution to be: normal (58%), underweight (9%), overweight (25%), and obese (8%), referrals to the nutrition support team based on the screen notification increased from 37% to 100%, patient coverage by nutrition support services increased from 7374 (38.8%) in 2000 to 11,369 (83%) in 2003, and critical care patients seen increased from 10% in 2000 to 99% in 2003. More improvement is needed in physician response to nutrition support recommendations, which still remains low (11.2-24%). CONCLUSIONS: Computerization helps to improve nutrition support delivery in the hospital, but more cooperation and support from the medical staff is still needed for better results.     

Weight-based ordering: an evaluation of increased guideline use in hospital total parenteral nutrition dosing.

BACKGROUND: In the past, parenteral nutrition in the Calgary Health Region was ordered as volumes of standard solutions, which limited individualization. Ordering total parenteral nutrition (TPN) that falls within macronutrient dosing guidelines may minimize complications associated with TPN, such as hyperglycemia, azotemia, hepatic steatosis, or continued malnutrition and catabolism. The Foothills Medical Centre in Calgary changed to a weight-based ordering system for TPN in 1999. This study's purpose was to determine if this change increased adherence to TPN dosing guidelines. METHODS: Macronutrient doses in TPN solutions ordered as standard solutions were compared with those ordered by weight. Mean protein, dextrose, lipid, and kilocalorie doses and the number of orders deviating from guidelines were examined. RESULTS: Weight-based dosing showed a significant reduction in deviation from guidelines for kilocalorie dose compared with TPN ordered as standard solutions. There also was a significant increase in mean protein dose and reductions in mean dextrose load and mean kilocalorie dose in the weight-based TPN group only, suggesting these changes were caused by the change in ordering method. CONCLUSIONS: Overall, weight-based ordering increased adherence to TPN dosing guidelines. The study did not have the statistical power to show significant differences between weight-based or standard TPN dosing; however, several trends were shown.     

Stability of thiamin in parenteral nutrition solutions

Since the vitamin thiamin is sensitive to degradation in the presence of stoichiometric concentrations of sulfite ions, the stability of thiamin in parenteral nutrition solutions containing sulfite as an antioxidant and preservative has been questioned. The usual clinical practice of mixing amino acids, dextrose, and other solutions for administration in total parenteral nutrition significantly dilutes the concentration of sulfite. We have measured the thiamin concentration in total parenteral nutrition solutions sampled from containers after administration to patients. We have also determined the time course of thiamin degradation in solutions containing two concentrations of sulfite. Thiamin content exceeded labeled amounts in total parenteral nutrition bags containing amino acid, dextrose, and multivitamin solutions. However, when multivitamins were added directly to amino acid solutions containing 0.1% (9.6 mM) sulfite, significant degradation occurred by 5 hr. Thiamin was stable for at least 22 hr when added to total parenteral nutrition solutions containing less than 0.05% (4.8 mM) sulfite.     

Home parenteral nutrition with full-time home care nurses

A group of patients exists who cannot manage home parenteral nutrition (HPN) due to debilitating conditions and/or lack of family resources. They are limited to either nursing home placement or extended hospitalization unless home nursing care is provided. A 58-year-old single female with malabsorption secondary to scleroderma was sent home on cyclic HPN under the supervision of full-time home care nurses. A comprehensive patient-centered nurse training program was designed to teach nursing personnel from a private nursing service the theory and practice of HPN. Each nurse must achieve at least 80% in the theory posttest and demonstrate the competent performance of central venous catheter care, mixing of parenteral nutrition solutions, use of infusion pump, and application of the heparin lock. The results of the pre- and posttests have shown that the home care nurses have been able to learn the theory necessary for implementing HPN. The mean pretest value was 46% while the mean posttest value was 90% (n = 12, p = 0.01). The patient has been doing very well at home for 5 months in this psychologically, medically, and financially effective program covered by third party payers. To the best of our knowledge, this program has never before been accomplished.     

PARSAFE: computer program for safety assessment and optimization of parenteral nutrition formulations based on chemical speciation analysis.

Instability arising from the formation of precipitates and lipid emulsion aggregates is common in parenteral nutrition formulations due to the concentration- and pH-dependent incompatibility of some of the vital ingredients. Previously, the boundaries between stability and instability could only be established through the use of laborious and expensive empirical methods. The predictive technique with the concept of chemical speciation (based on the analysis of many competitive thermodynamic equilibriums) has been adapted for use with parenteral fluids so that these detrimental events may now be avoided. A comprehensive computer program, PARSAFE ((C) 1991. Sponsors interested in this program should contact D.R.W.) has been developed for this purpose. PARSAFE encompasses chemical-speciation techniques and contains a large data base of commonly used intravenous fluid constituents together with the appropriate thermodynamic equilibrium constants describing their interactions so that stability prediction may be readily achieved in hospital pharmacy laboratories. We review the relevant physical chemistry required for the successful implementation of PARSAFE and outline the audit trails involved in the development of the predictive model.     

Regulation of proteolysis and optimal protein accretion in extremely premature newborns

Growth outcomes for extremely premature infants remain poor, and improving growth in this population will require a better understanding of how to limit proteolysis and promote protein accretion. Extremely premature infants exhibit high rates of proteolysis that are unrestrained by physiologic increases in insulin, intravenous amino acids, and full parenteral nutrition. Imbalances in current amino acid solutions may be in part responsible for the inability of parenteral nutrition to reduce proteolysis in preterm infants. However, amino acids in parenteral nutrition are effective for increasing protein synthesis in extremely preterm infants, which leads to improved protein balance. Current evidence suggests that early administration of 3 g amino acids kg(-1)d(-1) to extremely premature infants is safe and effective. Enteral nutrition may be more effective than parenteral nutrition in limiting proteolysis and producing protein accretion in preterm infants, but the protein content of current preterm formulas may be inadequate for supporting optimal growth in this population. Important areas of future research include determining whether altered intravenous amino acid solutions can better effect reductions in proteolysis, investigating the effect of enteral nutrition on proteolysis and protein accretion, and conducting a large randomized controlled trial of formula with a higher protein content.     

Infection control of parenteral nutrition solutions

Microbial contamination of parenteral nutrition solutions is a preventable cause of in patients receiving nutrition support. The components of the parenteral nutrition solutions have variable microbial growth potential. Crystalline amino acid and dextrose solutions are poor growth media for bacteria but may support fungal growth. Lipid emulsions provide an excellent medium for growth of bacteria and fungal species. Total nutrient admixtures will support microbial growth better than standard parenteral nutrition solutions will but less well than will lipid emulsion alone. Control of infection related to contaminated infusate depends on compounding procedure, quality control, appropriate storage, and procedures to prevent in-use contamination. Guidelines are presented for the preparation and administration of parenteral nutrition infusates that will minimize microbial contamination.     

Home parenteral nutrition: a hospital-based program with commercial logistic support

Since home parenteral nutrition was introduced in the 1970's, a number of medical centers have formed successful home parenteral nutrition programs which have reduced expenses to the patient and third party payers by 50 to 73% over in hospital costs. However, the cost of maintaining these programs for training and follow-up has largely been absorbed by the hospital as a nonreimbursable teaching expense. To offset the costs of our growing program in these times of budget "caps," we have established an agreement between our hospital and commercial home care company which provides for patient instruction and follow-up by the hospital parenteral and enteral nutrition team and logistic support by the home care company. We used the average cost of our first five patients to establish a fee schedule which the commercial company agreed to pay the hospital parenteral and enteral nutrition team for its services. This agreement reduces the number of nurses and pharmacists that the commercial company would otherwise have to hire for teaching and follow-up of home care patients, and supports the concept of regional care in medical centers where parenteral and enteral nutrition teams maintain quality control, continuity of care, and efficient teaching programs for patients requiring home parenteral nutrition.     

Clinical Pathways in Home Nutrition Support

In home-care settings, physicians with various medical specialties may order home enteral and/or parenteral nutrition support. Clinical pathways may be used to provide a clear, concise, standardized method for ordering and monitoring home nutrition support. The clinical pathways should be appropriate for 80% of the patients placed on the pathways, allowing for a 20% variance, or deviation, from the pathway. In one home-care facility, disease-specific clinical pathways have been used for longer than 1 year for patients with a variety of diseases requiring home nutrition support. To determine the usefulness of the home nutrition support clinical pathways, data obtained from 20 patients were analyzed. Patients were followed up while being treated using home nutrition support clinical pathways designed for oncology (9 patients), human immunodeficiency virus/acquired immunodeficiency syndrome (2 patients), short bowel syndrome (6 patients), and hyperemesis (3 patients) for 191 weeks. Overall, an average variance (deviation from the pathway) of 22% (the number of variances divided by the total weeks of therapy) was observed. The use of the pathways to provide enteral or parenteral nutrition facilitated more cost-effective care by following pathway guidelines for obtaining laboratory values and patient visits. Communication between the home-care staff and the physician was also improved. Clinical pathways can enable standardization of care for patients receiving nutrition support at home.     

Sterility testing of home and inpatient parenteral nutrition solutions

The microbial contamination rate was compared for parenteral nutrition solutions prepared by patients for home use and by pharmacy personnel for inpatient use. Phase I validated the Ivex 0.22-micron inline filter as a tool for microbiological testing by inoculating small numbers of organisms in 5% dextrose injection and testing for recovery. Phase II validated the same method for determining microbial contamination of total parenteral nutrition (TPN) solutions. Phase III compared inpatient and home TPN microbial contamination rates using the methodology validated in phase II. Test organism inocula used in phase I and II were Candida albicans, Escherichia coli, Enterobacter cloacae, Klebsiella pneumoniae, Proteus vulgaris, Pseudomonas aeruginosa, Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus pyogenes. All contaminated solutions in phase I showed visual turbidity within 48 hr, and all test organisms were recovered and identified. All phase II-contaminated TPN solutions showed visual turbidity after 96 hr, and all test organisms were recovered and identified. One hundred postinfusion TPN samples were collected randomly during phase III from inpatient parenteral nutrition patients. Six patients and two hospitals participated in the study. None of the 44 home parenteral nutrition samples and none of the 56 inpatient TPN samples developed visible turbidity. Subcultures of each sample on blood agar were negative for microbial growth. This described methodology offers an effective means to establish contamination rates of parenteral nutrition solutions after administration.     

Apparent nitrogen balance and 3-methylhistidine urinary excretion in intravenously fed children with trauma and infection

This study was designed to compare and evaluate the effects of two isocaloric parenteral nutrition infusions, FreAmine and F080, differing in their amino acid composition, on the apparent nitrogen balance and urinary excretion of 3-methylhistidine in children with trauma (n = 27) or grave infection (n = 24). Trauma patients at the beginning of parenteral nutrition showed a more negative nitrogen balance than infected children, but in all children the apparent nitrogen balance increased to become positive and the 3-methylhistidine urinary excretion dropped. No differences related to the amino acid composition of the parenteral nutrition solutions were found. Apparent nitrogen balance and 3-methylhistidine excretion were correlated in all study groups irrespective of urine sample time. The enriched branched chain amino acid solution used for parenteral nutrition of trauma and infected children did not show a better effect than the non-enriched one in terms of muscle catabolism and nitrogen balance. The use of adequate nutritional support including both amino acids and energy source is of major importance in children recovering from trauma and infection.     

Early nutrition support in critical care: a European perspective

PURPOSE OF REVIEW: Today, early nutrition support is considered standard care in most ICUs. The recommended method is the enteral route, although there is only minor evidence for this. Often inadequate delivery of energy and a cumulative energy deficit are implied. The purpose of this paper is to evaluate the indication for early enteral nutrition or immunonutrition and to discuss the application of additional parenteral nutrition. RECENT FINDINGS: The indication for early enteral nutrition is also supported by guidelines for enteral nutrition recently published by the European Society for Clinical Nutrition and Metabolism. Some more recent results strengthen the indication for a special formula in acute respiratory distress syndrome and septic patients. A recent metaanalysis has shown that parenteral nutrition is superior to delayed enteral nutrition. Additional parenteral nutrition thus seems to be the way to avoid cumulative energy deficit associated with insufficient or no enteral nutrition. SUMMARY: Early enteral nutrition is recommended for critically ill patients, with special formulas indicated in specific subgroups of patients. If enteral nutrition is insufficient or fails, parenteral nutrition should be instituted, respecting the often reduced demand for exogenous substrates in critically ill patients.     

Effects of enteral and parenteral nutrition on appetite in monkeys.

Varied clinical observations of the presence of either hunger or anorexia during intragastric or intravenous alimentation have led to the current experiments. Nine rhesus monkeys (Macaca mulatta) were involved in studies of the long-term effects of enteral and parenteral nutrition on appetite as assessed by feeding behavior and gastric motility. The monkeys received either intragastric infusions of glucose or a complete liquid diet, or intravenous infusions of glucose or glucose/amino acid solutions. Oral intake was accurately adjusted to account for the calories administered by the intragastric route. Oral intake was also reduced in a calorically equivalent amount to account for the calories received during intravenous glucose. When glucose/amino acid solutions were administered parenterally, adjustments were less accurate, with resultant overeating and weight gain in some monkeys during parenteral nutrition, followed by prolonged suppression of appetite after cessation of the infusions. Further studies of the effects of varied compositions of parenteral nutrition, and varied methods of weaning from infusions, are indicated.     

Risk of Parenteral Nutrition in Neonates—An Overview

Healthcare-associated infections (HAI) in preterm infants are a challenge to the care of these fragile patients. HAI-incidence rates range from 6 to 27 infections per 1000 patient-days. Most nosocomial infections are bloodstream infections and of these, the majority is associated with the use of central venous catheters. Many studies identified parenteral nutrition as an independent risk factor for HAI, catheter-associated bloodstream infection, and clinical sepsis. This fact and various published outbreaks due to contaminated parenteral nutrition preparations highlight the importance of appropriate standards in the preparation and handling of intravenous solutions and parenteral nutrition. Ready-to-use parenteral nutrition formulations may provide additional safety in this context. However, there is concern that such formulations may result in overfeeding and necrotizing enterocolitis. Given the risk for catheter-associated infection, handling with parenteral nutrition should be minimized and the duration shortened. Further research is required about this topic.     

Total peripheral parenteral nutrition in pregnancy

Twenty pregnant patients needing nutritional support for various indications received hypercaloric, hyperosmotic, "3 in 1," peripheral parenteral nutrition as a bridge to enteral therapy. This system, named total peripheral parenteral nutrition, was evaluated as to tolerance and efficacy in pregnant patients. Patients were in various stages of pregnancy and had an average weight loss of 10.4 pounds prior to admission. Patients were maintained on total peripheral parenteral nutrition for an average of 5 days and gained an average of 4.1 pounds. Good tolerance with minimal side effects of the treatment was noted. Intravenous sites were changed an average of 1.1 times per patient during the course of therapy and only one serious complication was noted in 20 patients. Patients were followed through delivery and this information is presented. Total peripheral parenteral nutrition appears to be an acceptable alternative to conventional total parenteral nutrition to pregnant patients needing nutritional support. These hypertonic solutions can supply total caloric/metabolic needs without unacceptable side effects.     

Effects of glutamine infusion on colonic anastomotic strength in the rat

Glutamine is one of the primary respiratory fuels of the colon. However, it is not included in commercial preparations of parenteral nutrients because of its short shelf life. It has been suggested that colonic atrophy induced by conventional parenteral nutrition can be reversed by the intravenous infusion of fresh solutions of glutamine. This study evaluated the hypothesis that glutamine-enriched parenteral nutrition would enhance the strength of a standard colonic anastomosis in undernourished rats. After surgery, the rats were randomized to receive 6 days of postoperative support with either rat chow, conventional parenteral nutrition, or parenteral nutrition containing 1.2% glutamine. Measurement of colonic bursting tension failed to demonstrate any significant differences between the groups under study. In conclusion, the administration of 1.2% glutamine-enriched parenteral nutrition failed to influence the healing of colonic anastomoses in undernourished rats.     

Evaluation of indexes of in vivo manganese status and the optimal intravenous dose for adult patients undergoing home parenteral nutrition.

BACKGROUND: There are no accurate indexes for determining the status of manganese in humans, and there is no clear recommended daily dose of this essential trace element to be administered in total parenteral nutrition solutions. OBJECTIVE: The objectives were to evaluate accurate indexes of manganese status and elucidate the optimal manganese dose to be administered to adult patients undergoing home parenteral nutrition. DESIGN: Patients were administered total parenteral nutrition solutions providing 0, 1, 2, or 20 micromol Mn/d according to an on-off design, after which manganese concentrations in whole blood and plasma were determined. Magnetic resonance imaging (MRI) was performed to determine the intensity on T(1)-weighted images (MRI intensity) and T(1) values in the globus pallidus. Hematologic and biochemistry tests were also performed. RESULTS: High degrees of correlation were found between whole-blood manganese concentrations and both MRI intensity (r = 0.7728) and T(1) values (r = -0.7519) in the globus pallidus. A strong negative correlation was found between MRI intensity and T(1) values (r = -0.8407). The dose of 1 micromol Mn/d caused no change in MRI intensity or T(1) values, and the whole-blood manganese concentration remained within the normal range in all patients. CONCLUSIONS: Whole-blood manganese concentrations and MRI intensity and T(1) values in the globus pallidus are useful indexes of the status of manganese in humans. The optimal dose of manganese may be 1 micromol/d for adult patients undergoing home parenteral nutrition.