Assessing Appropriate Parenteral Nutrition Ordering Practices in Tertiary Care Medical Centers

Abstract

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.

When Is Parenteral Nutrition Appropriate?

“…In single‐center studies evaluating the appropriateness of PN, rates of inappropriate use have ranged from 5% to 45% 6 . ‐ 11 At four tertiary care hospitals in South Carolina, the rate of inappropriate PN use in hospitalized adult patients was 32% 12 …”

Appropriateness of Parenteral Nutrition Usage in Cancer Patients

“…Our finding is similar with that by Chan et al (9) in a local tertiary-care hospital that the rate of inappropriate usage of PN was 15.9% of 138 episodes of PN, but much higher than a recent study in an acute hospital (13) in which only 5% of 1409 episodes of PN usage were considered as inappropriate. In contrast, another study (8) even showed that PN therapy was inappropriately prescribed in 32% of 278 cases at 4 tertiary care hospitals. The differences among our study and previous studies (8,9,13) are presumed to be caused by different study design and population.…”

“…In contrast, another study (8) even showed that PN therapy was inappropriately prescribed in 32% of 278 cases at 4 tertiary care hospitals. The differences among our study and previous studies (8,9,13) are presumed to be caused by different study design and population. Although we may not make a solid conclusion based on our limited findings, our study focusing cancer patients still provide useful information about more than 10% of PN usage was inappropriate among cancer patients.…”

“…Based on this, clinicians can administrate PN support more appropriately and judiciously. However, it is possible that PN was used inappropriately in the hospital setting in the previous studies (8)(9)(10)(11)(12). To our knowledge, the appropriateness of PN usage in cancer patients is questionable in clinical practice.…”

Interdisciplinary Discrepancies Between Parenteral Nutrition Macronutrient Prescribing and Recommendations: Is Body Mass Index a Factor?

“…Most recently, a study by Martin and colleagues in 2011 found that PN was prescribed inappropriately in 32% of the cases (n = 278), costing 4 hospitals a total of $125,000 in preventable costs over a 15‐month period. Martin and colleagues saw a cost savings in appropriate PN, but it is important to note that sometimes the most appropriate intervention is the more expensive option 21 . One study demonstrated an increase in the cost of care when RDs were involved in the order‐writing process 22 .…”