Drug shortages as an impetus to improve parenteral nutrition practices

A medical center's implementation of adult and pediatric parenteral nutrition (PN) algorithms and other strategies for managing PN ingredient shortages are described.

In response to nationwide shortages of amino acids and other PN ingredients in 2010, a large Massachusetts teaching hospital undertook a quality-improvement initiative to ensure appropriate patient selection for PN therapy. A clinical pharmacist was designated as a nutrition support leader with responsibility for the management of PN practices. Clinical pharmacists collaborated with clinical dietitians to establish PN eligibility criteria based on established practice guidelines and developed evidence-based adult and pediatric nutrition support algorithms. In addition, (1) physicians were required to obtain a nutrition service consultation before initial prescribing of PN therapy, (2) the initial ordering of PN therapy through the computerized prescriber-order-entry (CPOE) system was restricted to clinical dietitians and clinical pharmacists, (3) the use of premixed PN solutions at the discretion of dietitians was increased, and (4) the practice of adding i.v. multivitamins and trace elements to PN solutions was restricted. During the first year after implementation of the PN algorithms, CPOE restrictions, and other process changes, PN orders were reduced by an average of five orders per day relative to the preceding 11-month period, helping to ensure continued patient access to PN therapy.

PN ingredient shortages prompted changes in the decision-making process for the prescription of PN. Guidelines for ordering PN were successfully implemented and allowed for the appropriate selection of qualified patients and the management of PN ingredient shortages.