Parenteral nutrition safety: an interview with Dr. Phil Ayers, A.S.P.E.N PN Safety Task Force Chair and Dr. Peggi Guenter, Director of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)

Interview conducted by April Cashin-Garbutt, MA (Editor)Feb 11 2013

Please can you give a brief introduction to parenteral nutrition (PN)?

Parenteral nutrition is intravenous nutrition for patients who are unable to eat or be tube fed. It is used with more than 300,000 patients per year - a quarter of whom are children and newborns.

PN bypasses the normal digestion in the stomach and bowel. It is a sterile liquid formula given into the blood through an intravenous (IV) catheter (needle in the vein). The mixture contains proteins, carbohydrates (sugars), fats, vitamins and minerals (such as calcium).

People of all ages have received parenteral nutrition. People can live well on parenteral nutrition for as long as it is needed. Many times, parenteral nutrition is used for a short time; then it is removed when the person can begin to eat normally again.

Are there different types of PN?

There is peripheral PN (PPN) which is lower calorie and given into the peripheral veins, but most PN is given into a central large vein because it is very concentrated and needs a high flow vein to dilute it.

What conditions is PN used to treat?

Sometimes a person cannot eat any or enough food because of an illness. The stomach or bowel may not be working normally, or a person may have had surgery to remove part or all of these organs. When this occurs, and you are unable to eat, nutrition must be supplied in a different way.

Some of these conditions or illnesses include Short Bowel Syndrome, Bowel Dysmotility Disorders, or Necrotizing Enterocolitis.

What errors and patient harm can occur with PN?

PN is a sterile solution and if contaminated in any way, can be associated with infections and even death. Likewise it is a solution made up of sometimes 20 different ingredients, each of which needs to be carefully ordered, measured and delivered into the formula bag precisely. If a patient receives too much, or too little of any of these ingredients, you can have a drug overdose or deficiency, or even death.

In 2011 in Alabama, PN was prepared improperly in an outside compounding pharmacy and delivered to six hospitals in the region. Nineteen patients were infected with Serratia marcescens bacteria which resulted in nine deaths.

Another significant threat to PN is the escalating occurrence of drug shortages. The issue continues to threaten the integrity of the pharmaceutical supply chain and compromise patient care. The lack of available vitamins, electrolytes, and other IV nutrition ingredients has critically impacted hospitals, patients and home infusion companies nationwide.

How can these errors be prevented?

There are several steps that can help prevent PN errors:

• Prescribers need to order the solutions with the proper doses of ingredients.
• Pharmacists preparing these solutions need to use precise sterile technique and careful calculations to deliver the correct doses of ingredients into the formula bag.
• Dietitians need to verify appropriate nutrients being delivered to the patient.
• Nurses need to deliver these concentrated solutions using sterile technique, infusion pumps and filters to prevent complications.
• And, finally, patients and caregivers must be aware of how to work with health care providers, navigate through the complexity and ensure the health and safety those who require PN.

How many institutions in the US have precautions in place to prevent such PN errors?

All institutions that prescribe, prepare and deliver PN should have precautions in place to prevent such PN errors. However, only 58% of health care organizations do have precautions in place to prevent errors, according to the Institute for Safe Medication Practices.

In a recent survey conducted by A.S.P.E.N. - an interdisciplinary organization whose members are involved in the provision of clinical nutrition therapies - in The Journal of Parenteral and Enteral Nutrition, Dr. Boullata reports:

• A significant proportion of institutions (44%) do not track PN-related medication errors.
• A recognized ongoing clinical effectiveness or quality improvement process for PN exists in only 39.9% of organizations.

When present, this process typically addresses:

• Appropriateness of indication (17%)
• Pharmacist and nurse verification of the labels against the original orders (13% and 10%)
• Whether or not dietitian/nutrition team recommendations have been followed (10%)
• Pharmacist review of clinical dosing or stability/compatibility of PN orders (6%)and
• Double-check of pharmacy transcription processes (4%–7%).

An additional 26% of those surveyed indicated that most if not all of these were applicable.

How does the prevalence of PN precautions in the US compare to other countries in the world?

I am not aware of any comparisons. In 2010, Quality and Safety in Health Care published the UK National Aspectic Error Reporting Scheme(NAERS) and noted 15% of compounding errors reported involved adult PN .

Are there any plans in place to increase the number of organizations with precautions against PN errors?

A.S.P.E.N. will soon be publishing Parenteral Nutrition Safety Consensus Recommendations that will outline many steps to reduce PN risk of errors. Our goal is to disseminate these recommendations broadly and help to ensure they are implemented in every pharmacy and organization that prescribes, compounds and administers PN.

How do you think the future of PN will develop?

PN continues to grow as a therapy, with over 360,000 hospital discharges in 2010 where patients received it. Standardized systems to reduce patient risk will need to be in the forefront of PN development.

Please can you tell us about Clinical Nutrition Week 2013 (CNW13)?

CNW13, taking place February 9-12, Phoenix, AZ, is the premier conference on clinical nutrition and metabolism. Each year, the conference brings together 2,500 dietitians, nurses, pharmacists, physicians, scientists, students, and other health professionals from every facet of nutrition support clinical practice, research, and education.

Topics covered at this year’s event include:

• Best practices in parenteral nutrition safety as well as a first look at comprehensive, multiyear data on home parenteral nutrition
• Malnutrition: a survey of hospital-based clinicians as well as a sneak peak at forthcoming research analyzing and characterizing malnutrition in hospitalized patients
• The role of the intestinal microbiome on human health and disease
• The role of pre- and probiotics

For more information, your readers can visit www.nutritioncare.org/ClinicalNutritionWeek

What influence do you think Clinical Nutrition Week 2013 will have on the use of PN therapy?

CNW13 brings together the experts who will complete the PN Safety Consensus Recommendations and share it with the attendees. They will also plan dissemination strategies and partnering steps with such organizations as Institute of Safe Medication Practices, Joint Commission, Association of Health-system Pharmacists, Academy of Medical-Surgical Nurses, and others to ensure the recommendations are rolled out effectively.

Where can readers find more information?

Joseph I. Boullata, Peggi Guenter, and Jay M. Mirtallo A Parenteral Nutrition Use Survey With Gap Analysis JPEN J Parenter Enteral Nutr 0148607112464781, first published on October 30, 2012 as doi:10.1177/0148607112464781 http://pen.sagepub.com/content/early/recent

Would you like to make any further comments?

A.S.P.E.N. is a leader in developing standards for PN. The organization is dedicated to improving patient care by advancing the science and practice of nutrition support therapy.

Founded in 1976, A.S.P.E.N. is an interdisciplinary organization whose members are involved in the provision of clinical nutrition therapies, including parenteral and enteral nutrition.

With nearly 6,000 members from around the world, A.S.P.E.N.is a community of dieticians, nurses, pharmacists, physicians, scientists, students and other health professionals from every facet of nutrition support clinical practice, research and education.

For more information, visit https://www.nutritioncare.org/.

About Phil Ayers, Pharm.D., BCNSP, FASHP

Phil Ayers, Pharm.D., BCNSP received his Bachelor of Science degree in pharmacy from the University of Mississippi. He also received his Doctor of Pharmacy degree from the University of Mississippi. Dr. Ayers is currently employed by Baptist Health Systems in Jackson, MS. He is a clinical specialist in nutrition support and serves the Department of Pharmacy as Chief of Clinical Pharmacy Services.

Dr. Ayers is a Clinical Associate Professor, School of Pharmacy for the University of Mississippi. He was awarded the Clinical Science Teaching Award in 2007 and 2008 by the School of Pharmacy. Dr. Ayers was named the APPE Preceptor of the Year by the 2012 School of Pharmacy Graduating Class. Phil is currently serving on the Board of Pharmacy Specialties (BPS) Nutrition Support Council and the A.S.P.E.N. Board of Directors. Dr. Ayers was awarded the Excellence in Nutrition Support Education Award by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) in 2011. Phil is the current chair of the A.S.P.E.N. PN Safety Task Force.

About Peggi Guenter, Ph.D., R.N.

Peggi Guenter is the Senior Director of Clinical Practice, Advocacy, and Research Affairs for the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)