Comparison of PN Usage Before and After the Implementation of a PN Usage Policy

1. Comparison of PN Usage Before and After the Implementation of a PN Usage Policy Ali Ballard, RD, LD, CNSC Clinical Dietitian, MUSC

2. Background • EN is preferred method of nutrition support whenever possible • Better outcomes • Less costly • PN frequently prescribed unnecessarily by MUSC physicians (primarily GI surgery service)

3. Background: PN Sticker Policy • Stickers were created stating PN was “avoidable” or “no longer needed” • PN Usage was documented and noted whether to meet ASPEN guidelines or to be “avoidable”

4. PN Stickers Patient Name ____________________________________ MRN_____________________ The American Society of Parenteral and Enteral Nutrition (ASPEN) guidelines suggest that opportunities for discontinuing parenteral nutrition (PN) exist. Please document below an indication for continuing PN use. □ Intractable vomiting □ Intractable diarrhea □ Pancreatitis □ Stage 3-4 mucositis □ Unable to place feeding tube □ High residuals with gastric feedings and unable to obtain small bowel access □ Other _________________________________________________________________ Thank you, Nutrition Support Team Dr. DeLegge Pager ID 14373 Date / Time ________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Patient Name ____________________________________ MRN_____________________ Please consider discontinuing parenteral nutrition based on the following: □ Patient is receiving >50% of needs via enteral nutrition and/or oral intake. □ Patient is a candidate for oral or enteral feedings. □ Other: _________________________________________________________________ Thank you, Nutrition Support Team Dr. DeLegge Pager ID 14373 Date / Time _________________

5. Background: PN Sticker Policy • Data on “avoidable” PN usage presented to MEC • New PN Usage Policy proposed and passed by MEC 1/2011

6. New PN Policy 2011 • Identification of Appropriate PN Usage • Adult Guidelines: • The Nutrition Support Team (NST) will receive an automatic nutrition consult for adult PN orders. All consults must be ordered prior to the cut-off time indicated on the clinician order form. • The NST member (RD or PharmD) will determine if the PN complies with A.S.P.E.N. guidelines (Appendix B). • If the PN does not meet A.S.P.E.N. guidelines, the patient will not receive PN, and a sticker will be placed in the Progress Notes section of the patient’s chart documenting this. (Appendix C). • In the event PN is believed to be necessary but does not meet A.S.P.E.N. guidelines, the requesting physician may contact the Director of Nutrition (or other designated physician) for a case review. PN will not be provided until approved by the reviewer.

7. Adult Nutrition Guidelines Algorithm (Appendix B)

8. New PN Sticker (Appendix C) Patient Name ___________________ MRN ________________ Based on the American Society of Parenteral and Enteral Nutrition (A.S.P.E.N) guidelines this patient is not an appropriate candidate for parenteral nutrition (PN). Indications for PN include: 1. Patient has failed enteral nutrition trial with appropriate tube placement (post pyloric). 2. Enteral nutrition is contraindicated. Examples include: • Paralytic ileus (radiologic evidence AND NG output > 1000 mL) • Mesenteric ischemia • Small bowel obstruction • Short gut syndrome • GI fistula except when enteral access may be placed distal to the fistula or volume of fistula output is less than 200 mL/day • GVHD stage 2 or above of GI tract AND malabsorptive diarrhea • Grade 3 or above mucositis AND platelet count < 40 K/cumm 3. Wound healing would be impaired if PN is not started within 5 to 10 days postoperatively for patients unable to eat or tolerate enteral feeding. PN for this patient will: □not be initiated □ be discontinued Thank you, Nutrition Support Team ___________ Pager ID_______ Date Time_______

9. PN Usage Study • Purpose of the study: • to determine the effects of a PN usage policy on the ordering and usage of PN at our institution • Data collection: • from January to March of 2010 (prior to institution of the PN policy) and • from January to March of 2011 (after institution of the PN policy)

10. Results: PN Usage before Policy • PN usage January 2010: 643 PN • PN usage February 2010: 526 PN • PN usage March 2010: 457 PN • Total PN Jan-March: 1626 PN

11. Results: PN Usage after Policy • PN usage January 2011: 457 PN • PN usage February 2011: 463 PN • PN usage March 2011: 438 PN • Total PN Jan-March: 1358 PN

12. Results: PN Usage Decrease • PN decrease January: 28% • PN decrease February: 12% • PN decrease March: 4.2% • Overall PN decrease Jan-March: 16.5%

13. Conclusion • A nutrition-directed policy regarding PN usage was shown to decrease frequency of PN orders • Further research into whether this affected other outcomes such as line infection rates and LOS would be beneficial

14. Questions?? • Thank you! • Questions??