Parenteral Nutrition (PN) Use for Adult Hospitalized Patients: A Study of Usage in a Tertiary Medical CenterNutrition Services, Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina Correspondence: Mary D. Basel, RD, Nutrition Services, Digestive Disease Center, Medical University of South Carolina, 165 Ashley Avenue, Charleston, SC 29425. Electronic mail may be sent to Baselm{at}musc.edu. The use of parenteral nutrition (PN) is essential for patients who are unable to meet their nutrition requirements through oral or enteral nutrition. Many earlier studies have noted that PN is often inappropriately used in the hospital setting, thereby increasing the risk of associated complications and costs. A prospective study was performed at the Medical University of South Carolina (MUSC), using a nutrition support database to determine the appropriateness of PN use and the associated hospital costs for patients on 3 surgical services over a 6-month period. Appropriateness of PN therapy was determined according to the American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.) guidelines. A total of 139 new PN therapies were initiated in the 6-month period. Forty percent of the cases were deemed inappropriate. A total of 573 PN days ($80,000 hospital PN costs) could have been saved if inappropriate PN therapy had not been ordered. The avoidable costs only reflect the PN solution and not the additional costs associated with laboratory monitoring, central line placement and maintenance care, nursing administration, and ongoing pharmacy and dietitian clinical management. This study illustrated that PN was not always being provided according to A.S.P.E.N. guidelines. In addition, cost savings could be achieved if PN was provided only to MUSC patients who meet these guidelines. Parenteral nutrition (PN) is an essential feeding alternative for patients who cannot meet their nutrition requirements via oral intake or enteral tube feedings. Before initiating PN, patient factors such as gastrointestinal function, nutrition status, and overall clinical status should be evaluated. PN is an invasive, costly therapy that is associated with potential serious complications.1 Guidelines for the use of PN have been developed by the American Society of Parenteral Nutrition (A.S.P.E.N.; Table 1). These guidelines were developed with the intent of decreasing the inappropriate use of PN therapy. In addition, medical school curriculums, physician residency and physician fellowship curriculums, and postgraduate physician education programs have attempted to bolster physician knowledge of appropriate administration of nutrition and nutrition support.2–4 The intent of this study was to determine the appropriateness of PN usage according to the A.S.P.E.N. guidelines at a tertiary medical center with an associated medical school, a full complement of residency and fellowship training programs, and postgraduate physician education on topics including nutrition support. A nutrition support team (NST) was available at this tertiary medical center by voluntary consult. The NST responsibilities include conducting initial nutrition support patient assessments, monitoring the patients' progress, rounding with medical teams, and attending NST rounds with an NST physician.
A 6-month, prospective study was conducted on adult patients admitted to the Medical University of South Carolina (MUSC) hospital on the cardiothoracic surgery, general surgery, and transplant surgery services. These services were selected according to their previously measured, high-volume PN usage and consistent attending physician coverage throughout the year. Registered dietitians logged patients receiving PN into a database over a 6-month period. This database was created by the NST and included demographic information, the patient's primary medical diagnosis, the referral physician and their associated medical or surgical service, appropriateness of PN therapy as per the A.S.P.E.N. guidelines, initiation and termination dates of PN therapy, nutrition assessment information, and laboratory values associated with PN monitoring. Hospital PN cost information was obtained through a query of the MUSC Keane and Trendstar financial databases that allowed an analysis of PN therapy costs attached to individual inpatient billing accounts. An average PN daily hospital cost was compiled according to this financial analysis. The total number of inappropriate PN days was multiplied by the calculated average PN daily hospital cost to obtain a calculation of total cost for inappropriate PN therapy. A standard PN laboratory monitoring program was established (Table 2). The hospital costs for these laboratory evaluations were determined. These laboratory costs were used to estimate daily PN-associated laboratory monitoring costs.
All patients beginning to receive PN therapy were evaluated and subsequently followed by a registered dietitian or a pharmacist with clinical nutrition expertise. Patient information was logged into the NST database. Patients were reviewed daily by the NST with the oversight of a physician with expertise in clinical nutrition.
A total of 1383 patients were admitted to the identified services over the 6-month time period. Ten percent of these patients received PN therapy during the course of their hospitalization. The majority of these patients were receiving their care from the general surgery service (Figure 1). Of the 139 PN initiations, the majority of patients were white women, with a mean age of 50–59 years (Table 3). Of the 139 new PN initiations, 40% were deemed "inappropriate" according to the A.S.P.E.N guidelines. Eleven patients receiving PN inappropriately were discharged to home receiving PN. A total PN hospital cost of $80,000 and 573 PN-days could have been avoided if PN therapy had been used appropriately. The avoidable PN hospital cost only reflected PN solution and not the additional costs for laboratory monitoring, central line placement, ongoing access care, administration, and supply costs. In a separate analysis, the estimation of hospital costs for laboratory monitoring for the inappropriate PN-days was $11,874 (Table 4).
The results of this study are similar to those of earlier published reports. Over a 4-month period, Trujillo et al5 noted that 23% of PN initiations at a large tertiary medical center were preventable and 15% were not indicated when evaluated by the A.S.P.E.N. guidelines. Our 40% inappropriate PN therapy rate was similar to a combination of the Trujillo et al5 reported inappropriate PN therapy rates. Mauer and Weinbaum6 documented a 32% inappropriate PN use rate at a large teaching hospital over a 2-year period. This group also used the A.S.P.E.N. guidelines to determine whether a PN order was appropriate. Their estimated yearly costs were $81,000. We documented an $80,000 PN hospital cost over a 6-month time period for inappropriate PN therapy. These costs were for the PN formulation only and did not include the costs of laboratory monitoring, nursing administration, central line placement and maintenance, and ongoing dietitian or pharmacist clinical management. Previous studies have noted that inappropriate PN is less likely with a NST consult. Trujillo et al5 found that approximately 56% of PN starts ordered by physicians without the benefit of a NST consultation were appropriate, as determined by the A.S.P.E.N. guidelines. This appropriate PN use increased to 82% of PN initiations after a voluntary NST consult service was created. A study conducted by Maurer and Weinbaum6 demonstrated a reduction in PN patient days from 500 to 100 per month when a formal process was instituted that required previous PN therapy approval by a physician-directed, multidisciplinary advisory committee before PN was initiated. The importance of a NST in the oversight of the appropriate use of PN was also demonstrated by Saalwachter et al.7 These authors compared the appropriateness of the use of PN at their institution before and after a mandatory, surgeon-led NST was implemented. The NST used A.S.P.E.N. guidelines for determining appropriateness of PN therapy. The inappropriate PN use before NST-mandated oversight was 32%. This fell to 11% after the NST was initiated. Using a standardized laboratory monitoring package, we also attempted to analyze the hospital laboratory monitoring costs associated with a day of PN therapy. Using these costs and knowing the number of inappropriate PN days, we were able to estimate the total hospital PN laboratory monitoring cost for inappropriate PN therapy. This $11,874.00 estimate begins to establish an understanding of the other costs associated with inappropriate PN use besides the cost of the PN therapy itself.
Most alarming, 11 patients with inappropriate hospital-ordered PN therapy were ultimately sent home receiving PN. The length of time these patients remained at home receiving PN and their associated outcomes were not recorded. Home PN (HPN) therapy is a costly therapy with known significant complications, including catheter infection, sepsis, venous thrombosis, and metabolic abnormalities.8,9 These risks are unacceptable in the patient where PN therapy is inappropriate. Our study has its obvious weaknesses. It does not include all of the hospitalized patients from all the medical and surgical services at MUSC, and therefore we may have overestimated or underestimated the true percentage of inappropriate PN use. It very likely underestimated the total number of inappropriate PN-days. This was a 6-month study and may have missed trends of inappropriate PN use, either up or down, that a longer study would have identified. This study was an observational study performed by the NST. Our NST attempts to educate and suggest to ordering physicians what is appropriate and inappropriate PN use. This may have reduced the actual inappropriate PN use by ordering physicians if an observational, consultative NST had not been available. The results of this 6-month study were presented to the MUSC Medical Executive Committee (MEC). A request was made, according to the results, for the NST to be consulted on a mandatory basis for each new PN patient order. The NST would have the ability to approve or disapprove the PN request according to A.S.P.E.N. guidelines and clinical experience. The MEC denied this request but agreed to a new "sticker policy" approved by the MUSC legal department. This policy allowed a mandatory NST consult on all patients beginning to receive PN therapy. This new policy would allow a permanent sticker to be placed in the chart if a patient's PN order was deemed to be inappropriate by the NST per the A.S.P.E.N. guidelines (Figure 2). This sticker announced to the ordering physician that the NST had determined the PN order to be inappropriate. It also allowed the ordering physician to document why they were ordering PN for this patient. A second sticker was also developed for patients receiving PN therapy who originally were appropriate for PN therapy but were now ready for PN discontinuation as determined by the NST, again using the A.S.P.E.N. guidelines and clinical experience (Figure 3). If inappropriate PN use persists at a high percentage rate with the use of this new sticker program, a case will again be made to the MEC to allow the NST to have final approval authority for all PN orders within our institution. The results of physician recognition of the stickers, the actual physician response to justify inappropriate PN use, and the potential change in physician practice for PN prescribing with the sticker program will be reported in a future publication. It is our belief that this data collection and reporting process should allow our NST to overcome the reluctance of our hospital administrative body to approve mandatory NST approval for PN use, a hospital administrative reluctance reported upon by other authors.10
The findings of our study are in line with the results of other studies indicating that inappropriate usage of PN persists. This inappropriate use of PN therapy continues even with the establishment of rigorous, peer-reviewed A.S.P.E.N. guidelines for appropriate PN use and emphasis on nutrition education for medical students and training residents, an emphasis on postgraduate education in nutrition support for practicing physicians and the emphasis on nutrition education by major physician organizations such as the American Gastroenterological Association, the American Society of Surgery, the Society of Critical Care Medicine, the American Society of Clinical Nutrition, the American Medical Association, the American College of Physicians, and A.S.P.E.N. Increasing nutrition support education requirements and developing a nutrition consult service for mandatory approval of PN therapy before its initiation may provide the only structure to allow us to alter this very disturbing and continuing trend of inappropriate use of hospital PN therapy.
Nutrition in Clinical Practice, Vol. 22, No. 2,
246-249 (2007)
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