Parenteral nutrition (PN) is one of the most complex medications prescribed to hospitalized patients and is qualified by the Institute for Safe Medication Practices (ISMP) as a high-alert medication due to the potential for harm when used in error. PN also commonly contains other high-alert medications and is subject to the steps of the medication use process.1 Errors may occur at any point in this multistep process; thus, any opportunity to streamline the steps may reduce the chance for errors.2

PN Ordering

PN admixtures may be prescribed as a commercially available multi-chamber bag or as a customized, compounded product. In a survey conducted by the American Society for Parenteral and Enteral Nutrition (ASPEN) in 2011, 72% of organizations utilize compounded PN.3 Communicating the order for PN can be a more complex process than it may be for other medications. In 2011, 62% of institutions that took part in a PN use survey reported that they were still utilizing handwritten order forms, and 42% of pharmacy respondents utilized a separate computer system for PN compounding that required order transcription.3 According to a study evaluating PN-related errors over a 19 month period at an academic medical center, 39% of all reported errors occurred during the transcription step.4

The ASPEN PN Safety Consensus Recommendations published in 2014 outline key recommendations for each step in the PN use process. They state that PN shall be prescribed using a standardized order format, preferably via a computerized prescriber order entry (CPOE) system with clinical decision support incorporated within the electronic order form. Ideally, the CPOE system will fully integrate with an automated compounding device (ACD), eliminating the need for order transcription.2 Institutions’ ability to implement these recommendations may be limited by vendor-specific electronic health record (EHR) capabilities.

Eliminating Order Transcription

Duke University Hospital (DUH) is an academic learning center and the flagship hospital for Duke University Health System, which consists of three institutions in total. The 979-bed tertiary and quaternary care hospital is consistently rated as one of the top hospitals in the United States.5 As a teaching hospital for students of medicine, nursing, and the allied health sciences, DUH’s adult PN team comprises physicians, clinical pharmacists, and registered dietitians working collaboratively to provide PN therapy to patients who are unable to meet their nutritional needs via the enteral route. Nutrition support clinicians prescribe compounded PN for 20 to 30 adult inpatients daily.

New System Objectives

The DUH adult PN team partnered with the DUH department of pharmacy to eliminate order transcription from the EHR to the ACD for two primary purposes: to improve patient safety and to reduce pharmacy workload. Prior to this project, a PN team clinician prescribed customized PN via the CPOE system which was subsequently reviewed and verified by a clinical pharmacist. Following order verification, a pharmacist would transcribe the order into the ACD software, which then underwent an independent double check for transcription accuracy. At the time, the ACD software, rather than the CPOE system, provided the majority of clinical decision support warnings. This difference between the two systems was attributed to vendor-specific warning capabilities available when the CPOE system was initially adopted.

Since that time, the EHR vendor has expanded the warning limit capabilities to include additional ingredients and the ability to establish multiple warnings for each ingredient (such as total amounts, weight-based amounts, and concentration-based amounts). It was clear that enhancing clinical decision support limits in the EHR would eliminate the need for transcription into an external software system to perform safety checks on PN ingredients, meeting both objectives for the project.

Best Practices and a Team Approach

A process improvement project of this nature is a large undertaking; as such, the first step is to review the literature to determine best practice. Familiarity with the prescribing, order review, and order verification guidelines published by ASPEN enables the team to evaluate existing processes and identify gaps and opportunities for improvement in patient safety. Additionally, maintaining close communication with colleagues in the sterile products compounding area results in an important alliance that can bolster project success.

Once a gap is identified, the next step is to engage leadership and frontline staff in the following areas: nutrition, pharmacy, information technology (IT), and nursing (see the TABLE). A physician champion who is knowledgeable and passionate about the subject area should also be engaged. It is important to secure support from leadership in both pharmacy and nutrition services departments. The existence of a formal nutrition support team simplifies the identification of the appropriate team members, but for institutions without such a team, seeking out members of a nutrition subcommittee of the pharmacy & therapeutics committee is recommended. The process by which each institution orders and manages PN will likely vary considerably and should be taken into account when recruiting individuals to collaborate for such a project.

Technological Considerations

The success of a project such as this is dependent on EHR functionality—namely, two IT components: direct communication with the ACD and warning limit functionality. At DUH, although the PN order transmits directly from the EHR to the ACD, the ACD software is utilized as a clinical decision support tool and to generate labels for the PN formulations. IT provided the clinical team members with a desired format for warnings (eg, amounts per day, weight-based amounts, concentration-based amounts) as well as the list of warnings that were pre-built in the EHR (eg, electrolytes as ions, electrolytes as salts, macronutrients, etc). IT also revised the EHR-generated label that would be used to pump the bags from the ACD and serve as a double check for the nurse administering the PN.

It is also critical to examine the differences between the ACD limits and the limits that can be built directly into the EHR to determine if there are any clinically relevant gaps. A spreadsheet can be created to compare the existing limits between the two systems using the list provided by IT. At DUH, very few discrepancies were identified between the two systems, and none were considered clinically relevant, as they concerned ingredients that were never included in PN for inpatient orders.

The next step is to create hard and soft warning limits. Hard limits are considered catastrophic limits which should never be exceeded, while soft limits indicate stepping outside of standard doses, but in a way that may be required in certain patient populations. ASPEN offers a two-page document that contains typical requirements for patients requiring PN therapy.6 DUH sees high acuity patients with high electrolyte and fluid requirements, so some modifications were made based on clinical experience and this patient population. Once a list of proposed limits is compiled, the entire nutrition support team, including the physician champion, should review and discuss them, making modifications as needed.

At DUH, a group known as the Formulary Informatics Subcommittee reviews the proposed modifications to medication records prior to implementation. Its members represent each clinical area, including leadership, and they meet monthly to ensure that modifications do not negatively impact any patient care areas. Once committee approval is granted, the team can proceed with submitting a request to IT to build the limits.

After the limits are built in the testing environment, the same PN formulation in each system is ordered so that the clinical pharmacist can compare and evaluate the generated warnings. During DUH’s process, no clinically relevant discrepancies between the two systems were found, as expected. Following a review of approximately 50 unique PN orders, the limits can be deemed ready to move into the live environment. Pharmacists and prescribers are notified of the go-live date and given the opportunity to report any feedback to the implementation team.

Transitioning to Go-Live

During the first week of go-live at DUH, PN compounding pharmacists continued to transcribe orders into the ACD system in order to further observe any discrepancies between the two systems that might require attention. As an additional safeguard, the labels generated by the CPOE system should be compared to the ACD labels to note any issues. The CPOE labels also can be tested to ensure that they can be scanned and used to pump PN solutions using the ACD. Following this, nursing can be asked for their feedback on the CPOE-generated label. Prior to implementing the new label, a hospital-wide email should be sent to nursing to notify them of the expected changes. After the one-week go-live testing phase at DUH, no issues were noted, allowing for the elimination of the order transcription step.

System Results

Staff has reported positive results since go-live. Prescribers encounter alerts directly in the CPOE system, which prevents errors from being made at the point of order entry. This serves to minimize the need for communication of catastrophic limits that were once only available in the ACD software system. Additionally, the hospital has been able to incorporate limits that previously required manual calculation on the part of the pharmacist during order review and verification in the EHR. Elimination of order transcription and the independent double check resulted in improved workflow for the PN compounding pharmacists and allowed for a more streamlined process from order verification to time of compounding. Pharmacy and nursing also responded positively to comments about the readability of the new PN labels.

The neonatal and pediatric populations at DUH were not included in this rollout but will likely undertake this project in the future. Accordingly, the other two institutions in the health system compound PN and will use this experience to create institution-specific limits and streamline their pharmacy workflow. Any institution can use this process as a framework to implement similar changes.

Conclusion

When making changes that involve a high-alert medication, it is important to use evidence-based clinical guidelines and recommendations to adhere to best practices, such as ASPEN’s recommendations for the PN-use process. Most resources are available free of charge via ASPEN’s website, but membership with the organization can be invaluable, as it provides additional information for members only, as well as an active forum where members can ask questions and share experiences. Once it is time to begin implementation, a collaborative, multidisciplinary approach is essential for any process improvement project addressing medication use.

References

1. Institute for Safe Medication Practices (ISMP). ISMP list of high-alert medications in acute care settings. Accessed July 13, 2022. www.ismp.org/sites/default/files/attachments/2018-08/highAlert2018-Acute-Final.pdf.
2. Ayers P, et al. J Parenter Enteral Nutr. 2014;38(3):296-333.
3. Boullata JI, et al. J Parenter Enteral Nutr. 2013;37(2):212-222.
4. Sacks GS. J Parenter Enteral Nutr. 2012;36(2):20S-22S.
5. Duke University Hospital. U.S. News & World Report. health.usnews.com/best-hospitals/area/nc/duke-university-medical-center-6360355. Accessed July 13, 2022.
6. America Society for Parenteral and Enteral Nutrition. Appropriate Dosing for Parenteral Nutrition: ASPEN Recommendations. November 17, 2020. Accessed July 20, 2022. nutritotal.com.br/pro/wp-content/uploads/sites/3/2019/04/PN-DosingASPEN.pdf

Sara Bliss, PharmD, BCPS, BCNSP, BCCCP, is the pharmacy nutrition support coordinator at Duke University Hospital in Durham, North Carolina. She received her doctor of pharmacy degree from the University of Tennessee Health Sciences Center.