Quality evaluation of total parenteral nutrition in an acute care setting

To analyse the degree of compliance with internationally accepted standards defined for total parenteral nutrition (TPN) quality control in our hospital. The problems of quality which exist must be detected and possible solutions put into practice.

Retrospective study of critically ill patients treated with TPN during two years in a university teaching hospital (n=92). Assessment of quality was performed through measurements of compliance using 20 criteria. These were evaluated both individually and gathered in three categories: appropriate, safe and accurate TPN. Three summary/indicators were also established which assessed simultaneous compliance with all the criteria in each group. Criteria compliance was compared to standards values. Patient (age, sex, diabetes) and process (TPN indication, patient's outcome, type of diet used) variables were analysed (using logistic regression models) as factors potentially associated with compliance with the quality criteria. Corrective measures aimed at resolving the quality problem were applied to the deficient criteria, paying particular attention to those criteria which presented the highest percentage of errors in the study carried out using a Pareto analysis.

Compliance of six criteria was significantly below standard values. Simultaneous compliance of all criteria by group was 17% in adjusted TPN, 38% in safe TPN and 94% in exact TPN. There was a negative association between an age over 65 years and both a correct indication of TPN (OR: 9.4) and the indicator compliance of all criteria in the adjusted TPN group (OR: 2.9). The absence of metabolic complications was influenced (P<0.05) by the use of standardized diets (OR: 0.3). Effects of the change: the simultaneous compliance with all the criteria of a group improved in all three groups, but this was statistically significant in the 'appropriate' TPN and 'safe' TPN groups. The criteria analysed individually improved after the corrective measures in five of the six criteria which had been below standard in the first evaluation.

The correct understanding and application of the indications, physiology and potential complications of TPN constitute the hub of the improvement process.