A dietitian-led parenteral nutrition team: The impact of a change in service delivery

Abstract

Introduction: Parenteral nutrition (PN) is not a scheduled medication in Australia. However, medical officers are tasked with prescribing and ordering PN, working in consultation with dietitians. Despite being a high-risk form of nutrition support, PN orders are prone to error, with pilot audit data (March 1- 31, 2017) indicating that >50% of orders at the Queensland Children's Hospital (QCH; Brisbane, Australia) contained errors (e.g. inaccurate recording of allergies, infusion durations or solution volumes). As a result, a procedure, training package and competencies-aimed at the dietitians-for the safe ordering of PN was implemented. Initially, the responsibility of ordering PN was shared by dietitians and medical officers; however, training the large number of junior medical officers was not sustainable and order-related errors persisted. Consequently, a new model of service delivery (MOSD) was implemented in December 2018. In this model, the role of prescribing and ordering PN was assigned to a credentialled dietitian. Objectives and Study: This study aimed to evaluate the dietitian-led PN MOSD, by determining ordering accuracy, clinical incidents and inappropriate prescriptions. A secondary aim was to determine if the dietitian-led MOSD reduced the financial costs of PN. A single-centre, retrospective cohort design was used. Methods: Clinical chart reviews were conducted for two six-month time periods; before (n = 127 [54% male]; mean ± standard deviation age = 79.2 ± 70.7 months) and after (n = 123 [51% male]; age = 79.8 ± 67.2 months) implementation of the dietitian-led MOSD. Eligible participants were children admitted to inpatient wards (excluding the Paediatric intensive care unit) at the QCH who received PN. Clinical incidents were recorded via RiskMan™ and classified as order-, procedure- or equipmentrelated errors. Inappropriate prescriptions of PN were also documented, and financial reports of PN costs were retrieved from QCH pharmacy records. Data were analysed using Bayesian hypothesis tests (2 x 2 contingency tables), with Bayes Factors (BF10) used to determine the strength of evidence for (i.e., BF10 < 1) or against (i.e., BF10 >1) row x column independence. Results: There were 8/127 and 3/123 order-related errors with the original and new MOSD (1/3 dietitian errors), respectively. There was no statistical evidence that PN errors (BF10 = 0.37) or inappropriate prescriptions of PN (BF10 = 0.39) were different between the original and new MOSD. The relative cost of PN per day was 12% lower with the dietitian-led MOSD. Preliminary analysis of costings showed an increase in the absolute cost of lipids and clear phase of PN with the change in MOSD; and a 30% reduction in intravenous vitamins with the new model. Conclusion: While ordering-related errors were not statistically different between the original and new MOSD, the five-fewer errors with the dietitian-led MOSD are clinically significant, due to the clinical risk associated with PN provision. Preliminary analysis indicated that the dietitian-led MOSD may have been more cost-effective; however, further data are required to confirm the precise reason for this finding (e.g., labour costs and wastage). Findings from this study support the adoption of a dietitian-led PN MOSD.L6351742552021-06-08 <br />