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Audit of parenteral nutrition use in Guernsey
Lynn Harbottle1, Elmarie Brache, Janine Clarke
1Department of Dietetics, Princess Elizabeth Hospital, St Martin's, Guernsey, UK. lharbottle@hssd.gov.gg
Insights
Parenteral nutrition (PN) use in Guernsey generally followed guidelines, but weekend initiations led to assessment gaps. Improvements in PN monitoring and cessation are needed, especially for weekend admissions.
Area of Science:
- Clinical Pharmacy
- Nutritional Support
- Healthcare Auditing
Background:
- Rising parenteral nutrition (PN) prescriptions in Guernsey placed a significant burden on healthcare staff.
- There was a need to evaluate the appropriateness of PN use and adherence to national and local guidelines.
Purpose of the Study:
- To audit the initiation, monitoring, and cessation of parenteral nutrition (PN) at Princess Elizabeth Hospital.
- To assess compliance with UK National Institute for Health and Clinical Excellence and local Guernsey guidelines for PN therapy.
Main Methods:
- A retrospective audit of all PN patients over a one-year period (November 2006-December 2007).
- Data collection included assessment of feeding options, re-feeding risk, PN regime suitability, monitoring compliance, and patient outcomes.
- Pharmacists and dietitians completed data-collection forms for each patient.
Main Results:
- PN was initiated appropriately, primarily for gastrointestinal surgery.
- Re-feeding risk was assessed, but two patients admitted at weekends did not receive initial assessment.
- Only 11 out of 17 patients with planned PN cessation were weaned appropriately; two were readmitted for feeding issues.
Conclusions:
- Parenteral nutrition (PN) at Princess Elizabeth Hospital was generally initiated, monitored, and stopped in line with local guidelines.
- A key issue was PN initiation around weekends, potentially compromising appropriate assessment and initiation.
- Further attention to PN management, particularly during weekend transitions, is recommended.
Objectives:
This audit was precipitated by a huge increase in the local prescribing of parenteral nutrition (PN) in Guernsey and concomitant burden on pharmacy/sterile services unit staff. It aimed to establish whether PN was being used appropriately and the extent to which feeding prescriptions followed U.K. National Institute for Health and Clinical Excellence and local Guernsey guidelines with regard to the initiation, monitoring and cessation of feeding.
Method:
All PN patients at the Princess Elizabeth Hospital in Guernsey during a 1 year period (November 2006-December 2007) were subject to audit. A data-collection form was designed to ascertain exclusion of other feeding options, risk of re-feeding complications, suitability of PN regime, compliance with monitoring guidelines and patient outcomes. Copies of the form were completed by pharmacists/dietitians.
Key Findings:
Eighteen men and 12 women were included (average age 67 years). PN was initiated appropriately, with the most common indication being gastrointestinal surgery. Assessment of re-feeding risk and use of low-calorie starter regimes with full micronutrient and electrolyte additions was routinely carried out, except in the case of two patients admitted at weekends. Five patients were not given appropriate supplementary intravenous Pabrinex. The duration of PN ranged from 2 to 62 days (average 14 days). The majority of patients were fed continuously but three longer-term PN patients were fed cyclically (12-16 h). Only 13 patients had accurate daily fluid-balance charts kept. Seventeen had a planned cessation of PN, of whom only 11 were weaned off appropriately. Two patients were re-admitted for feeding problems within 28 days of discharge.
Conclusions:
The audit findings demonstrated that PN at the Princess Elizabeth Hospital was generally being initiated, monitored and stopped with a high level of consideration to local guidelines. The main problem identified was with PN started at or immediately prior to the weekend when appropriate assessment and initiation could not be guaranteed.
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