Read Improvement in Neonatal Total Parenteral Nutrition Ordering and Preparation text version

Improvement in Neonatal Total Parenteral Nutrition Ordering and Preparation

Laura Cummings, Pharm.D., BCPS and Sharon L. Groh-Wargo, PhD, RD, LD MetroHealth Medical Center, Cleveland, Ohio

Key Contact Person E-mail: [email protected]

Background: Neonatal total parenteral nutrition (TPN) presents unique challenges compared to adult TPN. All ingredients are ordered based on weight and are therefore not standard. In addition, electrolyte and glucose requirements fluctuate greatly in the preterm infant. Also, preterm infants have very high requirements for calcium and phosphate, frequently providing challenges due to solubility limitations of providing both ingredients in one solution. Purpose of the Study: The purpose of this project was to improve the ordering and preparation of neonatal TPN. This involved both changes to the TPN order form, which was based on safe practice recommendations from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) and changes to organizational specific guidelines for calcium and phosphate dosing. (See attached cause and effect diagram.) Methods: The neonatal TPN order form and institution specific guidelines for calcium and phosphate dosing were modified and implemented. Modifications included changing the ordered calcium units to mEq/kg to match the TPN label, changing the calcium/phosphate dosing guidelines to dose/kg to match the TPN label and tailored orders, and changing the trace elements from the pediatric trace package to individual components to provide more ideal dosing. Initial data collected was the number of verbal orders required per day. The number of verbal orders per day was the chosen measure used to identify clarity, order interpretation issues of the order form, and prescribing errors. From this data, it was identified that the changes to the dosing guidelines for calcium and phosphate needed further revisions. Additional issues with the TPN order design and clarity were also identified and addressed. After a second revision, the order form and guidelines were implemented and data were collected on both the number of verbal order changes required and laboratory values obtained with the new calcium/phosphate

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dosing guidelines. Statistical process control methods were employed to analyze these above data. Results: Reductions in both the total number of TPN verbal orders and the calcium/phosphate specific verbal orders were seen after the implementation of the second revision of the TPN order form. (See attached control charts.) Also, the calcium and phosphate dosing guidelines were used for 83.5% and 88.1% of TPNs, respectively. Of those patients who were dosed based on guidelines, 86% had normal serum calcium levels and 52% had normal serum phosphate levels. Patients with abnormal levels were further investigated and the abnormal calcium levels were determined to be clinically insignificant and the abnormal serum phosphate levels were determined to reflect our inability to provide adequate phosphate due to solubility limitations. (See attached laboratory data summary.) Conclusions and Implications: The modifications to neonatal TPN ordering and preparation have improved order clarity, streamlined the ordering and checking process, and enhanced dosing of calcium and phosphate. The modified neonatal TPN order form and calcium/phosphate dosing guidelines are being evaluated for use citywide for all area neonatal intensive care units.

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Calcium/Phosphate Serum Levels

DATES OF REVIEW: 7/8/2002 ­ 8/4/2002 NUMBER OF NICU TPNS: 462

Criteria 1: Dose: If the TPN had a pediatric AA/cysteine base, were NICU guidelines for calcium used? 386/462 (83.5 %) yes 76/462 (16.5%) no

yes no

Criteria 2: Dose: If the TPN had a pediatric AA/cysteine base, were NICU guidelines for phosphate used? 407/462 (88.1%) yes 55/462 (11.9%) no

yes no

Criteria 3: Monitoring: If the NICU guidelines for calcium were used [and labs were drawn], was the serum calcium level outside of the desired therapeutic range? 35/462 (7.6%) yes 209/462 (45.2%) no

Calcium Levels

13% 1%

218/462 (47.2%) N/A

wnl low high

86%

Of the results that were outside the desired therapeutic range... 3/35 (8.6%) were low 32/35 (91.4%) were high

Of the 32 results that were high, only two had serum calcium levels >10% above the upper end of the desired therapeutic range.

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Recommendation: continue to use the current NICU calcium/phosphate guidelines Criteria 4: Monitoring: If the NICU guidelines for phosphate were used [and labs were drawn], was the serum phosphate level outside of the desired therapeutic range? 111/462 (24%) yes 119/462 (25.8%) no

Phosphate Levels

1%

232/462 (50.2%) N/A

wnl

47% 52%

low high

Of the results that were outside the desired therapeutic range... 109/111 (98.2%) were low 2/111 (1.8%) were high

Of the 109 results that were low, 64 had serum phosphate levels >10% below the lower end of the desired therapeutic range. Although disappointing, this reflects our inability to provide adequate amounts of phosphate via TPN due to solubility restrictions. The current NICU calcium/phosphate guidelines maximize the amount of phosphate provided while maintaining the calcium/phosphate ratio recommended in the literature for bone mineralization. Decreasing the amount of calcium in the guidelines to allow for more phosphate to be administered would result in calcium acquisition from the bone to maintain serum calcium levels leading to osteopenia. Recommendation: continue to use the current NICU calcium/phosphate guidelines

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Factors Leading to Substandard Neonatal TPN

Inconsistencies

TPN Order Form

Cysteine dose not on original order

Ca ordered as mg/L, but guidelines state as meq/L

Flow not ideal

Ca ordered as mg/L, but labeled as meq/L

Check boxes not aligned

Infusion rates on more than one form

Multiple items to fill in

Substandard Neonatal TPN

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Trace element package

Dose based on weight

Dependent on volume

Solubility curves do not support ideal Ca/ Phos ratios

Need to maximize Ca & Phos

Calcium conversions

Solubility curves with limited data points

Dosing

Calculations

Ca/Phos Solubility

Confidential/QA Purposes

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22 24 M ay

Number of Verbal Orders

Moving Range

0

10 12 14 0 2 4 6 8

M a 27 y -M a 31 y -M ay 2Ju n 6Ju n 8Ju 11 n -J u 13 n -J u 18 n -J u 20 n -J u 22 n -J u 24 n -J u 27 n -J u 29 n -J un 1Ju l 3Ju l 5Ju l 7Ju l 9Ju 11 l -J u 13 l -J u 15 l -J u 17 l -J u 19 l -J u 21 l -J u 23 l -J u 25 l -J u 27 l -J u 29 l -J u 31 l -J u 2- l Au g 4Au g

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1 2 3 4 5 6 7 8

2nd revision of TPN order form implemented

Note: Control limits & mean have been calculated based on the data points prior to the 2nd form revision.

Moving Range

Verbal orders

All TPN Verbal Orders

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Average mR

Process Average

URL

UCL

LCL

22 -M a 24 y -M a 27 y -M a 31 y -M ay 2Ju n 6Ju n 8Ju 11 n -J u 13 n -J u 18 n -J u 20 n -J u 22 n -J u 24 n -J u 27 n -J u 29 n -J un 1Ju l 3Ju l 5Ju l 7Ju l 9Ju 11 l -J u 13 l -J u 15 l -J u 17 l -J u 19 l -J u 21 l -J u 23 l -J u 25 l -J u 27 l -J u 29 l -J u 31 l -J u 2- l Au g 4Au g

Moving Range

22 -M a 24 y -M a 27 y -M a 31 y -M ay 2Ju n 6Ju n 8Ju n 11 -J un 13 -J un 18 -J un 20 -J un 22 -J un 24 -J un 27 -J un 29 -J un 1Ju l 3Ju l 5Ju l 7Ju l 9Ju l 11 -J ul 13 -J ul 15 -J ul 17 -J ul 19 -J ul 21 -J ul 23 -J ul 25 -J ul 27 -J ul 29 -J ul 31 -J ul 2Au g 4Au g

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Number of Ca/Phos Verbal Orders

5 6 0 1 2 3 4

0

1

2

3

4

5

6

7

8

9

Note: Control limits & mean have been calculated based on the data points prior to the 2nd form revision.

2nd revision of TPN Order Form Implemented

Ca/Phos TPN Verbal Orders

Moving Range

Ca/Phos Verbal Orders

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Average mR

URL

Process Average

UCL

LCL

22 -M a 24 y -M a 27 y -M a 31 y -M ay 2Ju n 6Ju n 8Ju n 11 -J un 13 -J un 18 -J un 20 -J un 22 -J un 24 -J un 27 -J un 29 -J un 1Ju l 3Ju l 5Ju l 7Ju l 9Ju l 11 -J ul 13 -J ul 15 -J ul 17 -J ul 19 -J ul 21 -J ul 23 -J ul 25 -J ul 27 -J ul 29 -J ul 31 -J ul 2Au g 4Au g

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Improvement in Neonatal Total Parenteral Nutrition Ordering and Preparation

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