Quality parenteral nutrition: an ideal mixed bag

Abstract

Professor Pennington was an advocate for quality in all aspects of nutrition support and its delivery, ensuring that the patient remained at the centre of all decisions, and that specialist artificial nutrition support was best managed by the multidisciplinary nutrition team and the education of the wider healthcare community. Within the conference theme of 'Quality', this commentary aims to outline drivers for and risks to aspects of quality in parenteral nutrition (PN) services. Quality is defined as a particular property or attribute associated with excellence; in the context of the provision of PN this can be translated to quality processes and standards in the assessment, prescription, preparation, administration and monitoring of PN. Quality products and services are delivered through the timely application of knowledge, competence, procedures and standards. Quality can be so easily compromised; inattention, ignorance and arrogance all play their part. PN is a high-risk therapy; the quality of its delivery should not be entirely dependent on the skills, knowledge and competence of those delivering this care but on accepted standards, procedures, communication, resource and infrastructure. Identification of key steps in the provision of PN and a review of the relevant patient safety data reveal points where safeguards can be put in place to ensure quality is not compromised. Full evaluation of standardisation, computerisation and competency-based training as risk-reduction strategies is required.

Quality and safety of parenteral nutrition for newborn and preterm infants as an on-ward preparation

“…The practices concerning the prescription, preparation, handling and administration of PN vary from one hospital to another 1. PN standardisation increases the quality of PN and the security of the patients 2 3. Nevertheless, there is still no common opinion on whether or not to standardise PN for neonatal patients, as individual PN can be more adapted to the patients’ needs 4…”

“…PN is usually prepared at hospital pharmacies as a ‘centralized preparation’, but at some hospitals PN is still prepared on ward by nurses 3. This is the case in two Swiss hospitals and in 20% of French hospitals 9.…”

“…A European survey performed in 2010 by Bouchoud et al 10 showed that 12% of PN are prepared on hospital wards. The requirements for the preparation area, the personnel’s training and the quality control regarding intravenous medication preparation including PN vary greatly 3. Hospital pharmacies mostly follow the current ‘EU guidelines to Good Manufacturing Practice’ (GMP)11 12 and are obliged to apply the guidelines of the ‘Pharmaceutical Inspection Convention/Pharmaceutical Inspection Co-Operation Scheme’ (PIC/S)13 for health system establishments, so they must produce in laminar airflow hoods in cleanrooms with validated operators.…”

“…Medicine preparation and administration are known to be at risk for nosocomial infection3 4 14 as PN preparation may include more than 10 raw products and administration is mainly done by central venous access 3 15. Following the death of three neonatal patients in the hospital of Chambéry in 2014 caused by PN contamination,16 a national enquiry concerning paediatric PN (PPN) practices has been conducted 9.…”

“…Only few commercialised PN are available for neonatal patients but not used routinely due to patients’ varying needs of nutrients and the limited composition flexibility 1517–20 and improves the medical treatment and clinical outcome of the treated inpatients 3 21…”