A tale of two analyses: Administrative vs primary review of nutrition support team performance

Our pharmacy department performed a medication-use evaluation using administrative data to assess prescription of parenteral nutrition (PN). They found that 31.6% (185 of 586) of nutrition support team (NST) patients received ≤5 days of PN, whereas 120 received ≤3 days. These results raised the question of NST prescribing practices given the incidence of short-duration PN. Since our NST evaluates all PN requests, the study prompted further review to identify reasons for short duration PN.

Charts of patients receiving PN for ≤3 days in the initial study underwent an in-depth review focusing on indications, reasons for discontinuation, and protein-calorie malnutrition (PCM) at time of NST consultation.

A total 120 of 586 patients had PN ≤3 days. PN was clearly indicated in 94 cases: 27 patients received home PN but resolved the need for admission, 11 were admitted to later discharge on PN, 18 chose alternative/palliative care soon after starting PN, and 38 were nil per os for ≥6 days because of ileus, bowel obstruction, or contraindication to enteral feeding. Of the remaining 26 patients, 15 had PCM with poor intake for ≥ 3 days, warranting PN; only nine cases had unclear indications for PN and 11 could have potentially been avoided.

Administrative data implied inappropriate PN use, whereas in-depth review confirmed appropriate prescription in most patients. Reducing short-duration PN in the management of ileus or obstruction remains difficult because of variable time to symptom resolution. In-depth chart review remains the best method to assess appropriateness of PN use.