1
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Boullata JI, Salman G, Mirtallo JM, Canada TW, Monczka J, Gura KM, Kiritsy P. Parenteral nutrition compatibility and stability: Practical considerations. Nutr Clin Pract 2024. [PMID: 38994914 DOI: 10.1002/ncp.11189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/17/2024] [Accepted: 06/17/2024] [Indexed: 07/13/2024] Open
Abstract
Parenteral nutrition (PN) is a complex preparation that contains multiple component products with the associated risk for incompatibilities and diminished stabilities when combined together as an admixture. Significant patient harm can result from prescribing, preparing, and administering PN without confirming compatibility and stability. Incompatibility or instability is rarely obvious to the unaided eye, so safe PN admixture relies on incorporating physicochemical properties of the included components into compatibility and stability decisions. Practices include applying active ingredient concentration limits to reduce risk for incompatibilities and instabilities. The purpose of the current article is to distill the wide-ranging information on PN compatibility and stability into a feasible blueprint that individual healthcare organizations can then use to design and implement practical initiatives. Compatibility and stability considerations can be incorporated into the routine tasks of PN prescribing, order reviewing, preparing, and administering. The focus of this review is on identifying potential physicochemical interactions that can be addressed at each step in the PN use process. Organizations should incorporate compatibility and stability considerations into the routine procedures and practices of all clinicians involved with PN therapy. Those clinicians in healthcare organizations and caregivers in the home should then be in a position to safely provide the appropriate PN admixtures in terms of compatibility and stability.
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Affiliation(s)
| | - Genene Salman
- Department of Pharmacy Practice, College of Pharmacy, Marshall B. Ketchum University, Fullerton, California, USA
| | - Jay M Mirtallo
- The American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
| | - Todd W Canada
- MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | | | - Kathleen M Gura
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pharmacy, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Paul Kiritsy
- Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts, USA
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2
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Van den Broucke E, Deleenheer B, Meulemans A, Vanderstappen J, Pauwels N, Cosaert K, Spriet I, Van Veer H, Vangoitsenhoven R, Sabino J, Declercq P, Vanuytsel T, Quintens C. Offering Guidance and Learning to Prescribers to Initiate Parenteral Nutrition using a Validated Electronic Decision TREE (OLIVE TREE). J Med Syst 2022; 46:56. [PMID: 35804275 DOI: 10.1007/s10916-022-01835-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 05/16/2022] [Indexed: 11/29/2022]
Abstract
Parenteral nutrition (PN) is recommended in patients nutritionally at risk and unable to receive oral or enteral nutrition. A standardized electronic PN order format could enhance appropriate PN prescribing. We developed the OLIVE TREE (Offering guidance and Learning to prescribers to Initiate PN using a Validated Electronic decision TREE), embedded in our electronic health record. We aimed to evaluate its validity and impact on physicians' prescribing behavior. A non-randomized before-after study was carried out in a tertiary care center. The OLIVE TREE comprises 120 individual items. A process validation was performed to determine interrater agreement between a pharmacist and the treating physician. To estimate the proportion of patients for whom the OLIVE TREE had an effective and potential impact on physicians' prescribing behavior, a proof of concept study was conducted. The proportion of patients for whom PN was averted and the proportion of decisions not in line with the recommendation were also calculated. The process validation in 20 patients resulted in an interrater agreement of 95.0%. The proof of concept in 73 patients resulted in an effective and potential impact on prescribing behavior in 50.7% and 79.5% of these patients, respectively. Initiation of PN was not averted and recommendations of the OLIVE TREE were overruled in 42.5% of the patients. Our newly developed OLIVE TREE has a good process validity. A substantial impact on prescribing behavior was observed, although initiation of PN was not avoided. In the next phase, the decision tree will be implemented hospital-wide.
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Affiliation(s)
- Evelyne Van den Broucke
- Pharmacy Division, UZ Leuven, Louvain, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Louvain, Belgium
| | - Barbara Deleenheer
- Pharmacy Division, UZ Leuven, Louvain, Belgium. .,Department of Chronic Diseases and Metabolism - Translational Research in Gastrointestinal Disorders (TARGID), KU Leuven, Louvain, Belgium.
| | - Ann Meulemans
- Division of Endocrinology, UZ Leuven, Louvain, Belgium.,Department of Chronic diseases and Metabolism - Clinical and Experimental Endocrinology (CEE), KU Leuven, Louvain, Belgium
| | | | - Nelle Pauwels
- Division of Endocrinology, UZ Leuven, Louvain, Belgium.,Leuven Intestinal Failure and Transplantation (LIFT), UZ Leuven, Louvain, Belgium
| | | | - Isabel Spriet
- Pharmacy Division, UZ Leuven, Louvain, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Louvain, Belgium
| | - Hans Van Veer
- Division of Thoracic Surgery, UZ Leuven, Louvain, Belgium.,Department of Chronic Diseases and Metabolism - Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE) - Lung Transplant Unit, KU Leuven, Louvain, Belgium
| | - Roman Vangoitsenhoven
- Division of Endocrinology, UZ Leuven, Louvain, Belgium.,Department of Chronic diseases and Metabolism - Clinical and Experimental Endocrinology (CEE), KU Leuven, Louvain, Belgium
| | - João Sabino
- Department of Chronic Diseases and Metabolism - Translational Research in Gastrointestinal Disorders (TARGID), KU Leuven, Louvain, Belgium.,Division of Gastroenterology and Hepatology, UZ Leuven, Louvain, Belgium
| | - Peter Declercq
- Pharmacy Division, UZ Leuven, Louvain, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Louvain, Belgium
| | - Tim Vanuytsel
- Department of Chronic Diseases and Metabolism - Translational Research in Gastrointestinal Disorders (TARGID), KU Leuven, Louvain, Belgium.,Leuven Intestinal Failure and Transplantation (LIFT), UZ Leuven, Louvain, Belgium.,Division of Gastroenterology and Hepatology, UZ Leuven, Louvain, Belgium
| | - Charlotte Quintens
- Pharmacy Division, UZ Leuven, Louvain, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Louvain, Belgium
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3
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Iredell B, Mourad H, Nickman NA, Dieu H, Austin G, Goradia R, Wade JS, Goette J, Ezekiel TO, Begnoche BR, Liu A, English S. ASHP Guidelines on the Safe Use of Automated Compounding Devices for the Preparation of Parenteral Nutrition Admixtures. Am J Health Syst Pharm 2022; 79:730-735. [PMID: 35072701 DOI: 10.1093/ajhp/zxac004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | | | - Nancy A Nickman
- University of Utah College of Pharmacy, Salt Lake City, UT, and University of Utah Health, Salt Lake City, UT, USA
| | - Hao Dieu
- Kaiser Permanente, Walnut Creek, CA, USA
| | | | - Rani Goradia
- Marshfield Clinic Health System, Woodbury, MN, USA
| | | | | | | | | | | | - Stacey English
- Children's Hospital of the King's Daughters, Norfolk, VA, USA
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4
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Carter P, O'Donoghue KJM, Dworzynski K, O'Shea L, Roberts V, Reeves T, Bastounis A, Mugglestone MA, Fawke J, Pilling S. A demonstration of using formal consensus methods within guideline development; a case study. BMC Med Res Methodol 2021; 21:73. [PMID: 33865324 PMCID: PMC8052943 DOI: 10.1186/s12874-021-01267-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 04/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Recommendations within guidelines are developed by synthesising the best available evidence; when limited evidence is identified recommendations are generally based on informal consensus. However, there are potential biases in group decision making, and formal consensus methods may help reduce these. METHODS We conducted a case study using formal consensus, to develop one set of recommendations within the Neonatal Parenteral Nutrition guideline being produced for the National Institute for Health and Care Excellence. Statements were generated through identification of published guidelines on several topics relating to neonatal parenteral nutrition. Ten high quality guidelines were included, and 28 statements were generated; these statements were rated by the committee via two rounds of voting. The statements which resulted in agreement were then used to develop the recommendations. RESULTS The approach was systematic and provided transparency. Additionally, a number of lessons were learnt; including the value of selecting the appropriate topic, giving adequate time to the process, and ensuring methodologies are understood by the committee for their value and relevance. CONCLUSION Formal consensus is a valuable option for use within guideline development when specific criteria are met. The approach provides transparent methodology, ensuring clarity on how recommendations are developed.
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Affiliation(s)
- P Carter
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational & Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK.
| | - K J M O'Donoghue
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - K Dworzynski
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - L O'Shea
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - V Roberts
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational & Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - T Reeves
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - A Bastounis
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational & Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
- Division of Epidemiology & Public Health, School of Medicine, University of Nottingham, City Hospital, Nottingham, NG5 1PB, UK
| | - M A Mugglestone
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational & Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - J Fawke
- Leicester Neonatal Service, University Hospitals Leicester Infirmary Square, Leicester, LE1 5WW, UK
| | - S Pilling
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational & Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
- Camden and Islington NHS Foundation Trust, St Pancras, Hospital, 4 St Pancras Way, London, NW1 0PE, UK
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5
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Tucker EL, Cao Y, Fox ER, Sweet BV. The Drug Shortage Era: A Scoping Review of the Literature 2001–2019. Clin Pharmacol Ther 2020; 108:1150-1155. [DOI: 10.1002/cpt.1934] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 05/21/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Emily L. Tucker
- Department of Industrial Engineering Clemson University Clemson South Carolina USA
| | - Yizhou Cao
- Department of Industrial Engineering Clemson University Clemson South Carolina USA
| | - Erin R. Fox
- Drug Information and Support Services University of Utah Health Salt Lake City Utah USA
- College of Pharmacy University of Utah Salt Lake City Utah USA
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6
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Lashinsky JN, Suhajda JK, Pleva MR, Kraft MD. Use of Integrated Clinical Decision Support Tools to Manage Parenteral Nutrition Ordering: Experience From an Academic Medical Center. Nutr Clin Pract 2020; 36:418-426. [PMID: 32083350 DOI: 10.1002/ncp.10469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Parenteral nutrition (PN) is a complex therapy with numerous opportunities for error during the prescribing, preparation, and administration processes. Advances in technology, such as computerized provider order entry (CPOE), electronic health records (EHRs), and clinical decision support (CDS) have helped decrease the risks associated with PN therapy. These technologies can be utilized to guide prescribing, provide automated safety checks, and increase overall safety and accuracy in PN ordering, compounding, and administration. In recent years, increased awareness of the risks associated with PN therapy, in particular issues with ordering and transcription, have magnified the need for improved support of PN ordering within currently available systems. Additionally, drug shortages continue to impact key components of PN admixtures, further increasing the risks associated with this complex therapy. These concerns and risks present an opportunity for the development of new functionality, as well as improvements in and innovative utilization of available technology within systems supporting the PN use process. This discussion will highlight the risks associated with PN, examine the role of drug shortages on the safety of this therapy, describe the application of available technology to manage shortages, and report the experience of using commercially available CDS tools at one academic medical center. It will also include a discussion of the transition from paper orders to CPOE/EHR-based orders for PN and the transition from one commercially available electronic system to another at this particular institution.
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Affiliation(s)
- Jennifer N Lashinsky
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri, USA.,Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Jennilyn K Suhajda
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA.,Department of Pharmacy, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Melissa R Pleva
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Michael D Kraft
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA.,Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
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7
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Ayers P, Foster J, Kanorwala A, Jenkins A, Raymer K, Byrd L, Crumby T. Electronic Health Record and Parenteral Nutrition Functionality: A Gap Analysis. Nutr Clin Pract 2020; 36:433-439. [PMID: 32011007 DOI: 10.1002/ncp.10463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Parenteral nutrition (PN) is a complex, high-alert medication that contains up to 40 different ingredients. Surveys have shown that current electronic health record (EHR) systems may lack functionality for safe and optimal delivery of PN. A gap analysis was performed by a multihospital system to identify opportunities to enhance the current PN process using the EHR utilized by the organization.
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Affiliation(s)
- Phil Ayers
- Clinical Pharmacy Services, Mississippi Baptist Medical Center, Jackson, Mississippi, USA
| | - Jillian Foster
- Baptist Memorial Healthcare System, Memphis, Tennessee, USA
| | - Anees Kanorwala
- Mississippi Baptist Medical Center, Jackson, Mississippi, USA
| | - Anastasia Jenkins
- University of Mississippi School of Pharmacy, Oxford, Mississippi, USA
| | - Kelsey Raymer
- University of Mississippi School of Pharmacy, University, Mississippi, USA
| | - Laine Byrd
- Baptist Memorial Healthcare System, Memphis, Tennessee, USA
| | - Trey Crumby
- Baptist Memorial Hospital - North Mississippi, Oxford, Mississippi, USA
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8
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Dickerson RN, Kumpf VJ, Bingham AL, Blackmer AB, Canada TW, Chan LN, Cogle SV, Tucker AM. Significant Published Articles for Pharmacy Nutrition Support Practice in 2018. Hosp Pharm 2019; 54:285-293. [PMID: 31555003 DOI: 10.1177/0018578719851727] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Purpose: The purpose of this article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2018 considered important to their clinical practice. The citation list was compiled into a single spreadsheet where the author participants were asked to assess whether the article was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby the majority of author participants (at least 5 of 8) considered the paper to be important. Guideline and consensus papers from professional organizations, important to practice but not scored, were also included. Results: A total of 117 articles were identified; 8 from the primary literature were voted by the group to be of high importance. An additional 13 organizational guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were reviewed. Conclusion: We recommend that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.
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Affiliation(s)
| | | | | | - Allison B Blackmer
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Todd W Canada
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Sarah V Cogle
- Auburn University Harrison School of Pharmacy, Auburn, AL, USA
| | - Anne M Tucker
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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