Evaluation of parenteral nutrition service improvement interventions in an Australian Tertiary Paediatric Hospital

Abstract

Background: Parenteral nutrition (PN) is the administration of nutrients intravenously. It is used when enteral feeding is not possible or only partially possible to meet nutrition requirements. PN is associated with significant risks, including infections, metabolic and nutritional imbalances, reduction of gut integrity and fatality1-3; with reported rates of infection reaching up to 40% of PN patients4. This form of therapy also attracts a higher cost than enteral methods, with the cost of PN solution bags ranging between $100 and $380 at the hospital site. For these reasons, PN is recommended as a last resort, when all other methods of feeding have been exhausted or inappropriate5. Usage of PN has increased at the hospital site and consequently, so has the rates of inappropriate prescription and PN solution modifications. In response, a range of service improvement interventions were designed and implemented to help improve efficiency of the hospital's PN service, while reducing patient-risk. These incorporated a weekly ward round, development of new PN solutions, changes to the model of care and development of new hospital guidelines. Objective: To evaluate the cost effectiveness of a range of service improvement interventions on the PN services at an Australian paediatric hospital, to inform recommendations for future clinical practice. Methods: Three six-month time periods were selected to enable comparison of pre-implementation of quality improvement methodology (time period 1) to post-implementation (time period 2 and 3). Data was collected retrospectively, using hospital-specific PN prescription software and encompassed the total number of PN prescriptions, the number of these that were inappropriate (as defined as a prescription of five days or less), the number of PN solution modifications and the cost of the service. Results: Across the three time periods the mean number of patients on PN was 54 (SD = 8), resulting in a mean of 65 PN prescriptions (SD = 14) and a mean of 2053 bags dispensed (SD = 173). Despite a 27% increase in the number of PN prescriptions from time period 1 to time period 3, since implementing the host of service improvement activities, the overall cost of PN services decreased by $42,047. In addition the rate of inappropriate prescriptions also decreased progressively, from 21.6% of all prescriptions in time period 1, to 13.9% and 9.2% in time periods 2 and 3 respectively. Modifications of PN solution bags also decreased from 10.2% of all bags prescribed in time period 1, to 4.7% in time period 3. However, the time period immediately following the intervention strategies (time period 2) had the lowest incidence of modifications at 3.5% of all bags dispensed. Conclusion: Overall, the implementation of service improvement activities saw an enhancement in the cost-effectiveness of PN services at the participating hospital. This is reflected by the decrease in inappropriate prescriptions, solution modifications and costs of PN services postimplementation. PN is associated with high risk and cost and although no statistical significance is inferred from these results, the clinical importance of any improvement to the proficiency of PN supply to paediatric patients, grants regard.L720627552015-11-05 <br />