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Senterre T, van den Akker CHP, Domellof M, Saenz de Pipaon M, Arnell H, Tabbers M, Valla FV, Tomlin S, Paulsson M, Wackernagel D, Haiden N, Luukkainen P, Orfeo L, Carnielli VP, Rigo J. Safe and efficient practice of parenteral nutrition in neonates and children aged 0-18 years - The role of licensed multi-chamber bags. Clin Nutr 2024; 43:1696-1705. [PMID: 38823267 DOI: 10.1016/j.clnu.2024.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 04/11/2024] [Accepted: 05/12/2024] [Indexed: 06/03/2024]
Abstract
Parenteral nutrition (PN) is recognized as a complex high-risk therapy. Its practice is highly variable and frequently suboptimal in pediatric patients. Optimizing care requires evidence, consensus-based guidelines, audits of practice, and standardized strategies. Several pediatric scientific organizations, expert panels, and authorities have recently recommended that standardized PN should generally be used over individualized PN in the majority of pediatric patients including very low birth weight premature infants. In addition, PN admixtures produced and validated by a suitably qualified institution are recommended over locally produced PN. Licensed multi chamber bags are standardized PN bags that comply with Good Manufacturing Practice and high-quality standards for the finished product in the frame of their full manufacturing license. The purpose of this article is to review the practical aspects of PN and the evidence for using such multi-chamber bags in pediatric patients. It highlights the safety characteristics and the limitations of the different PN practices and provides some guidance for ensuring safe and efficient therapy in pediatric patients.
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Affiliation(s)
- Thibault Senterre
- Baxter R&D Europe, Braine-l'Alleud, Belgium; University of Liège, Liège, Belgium.
| | - Chris H P van den Akker
- Department of Pediatrics - Neonatology, Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Amsterdam, the Netherlands; Amsterdam Reproduction and Development and Amsterdam Gastroenterology Endocrinology Metabolism Research Institutes, Amsterdam, the Netherlands.
| | - Magnus Domellof
- Department of Clinical Sciences, Umeå University, Umea, Sweden.
| | - Miguel Saenz de Pipaon
- Instituto de Investigación Sanitaria del Hospital Universitario La Paz - IdiPAZ, (Hospital Universitario La Paz - Universidad Autónoma de Madrid), Madrid, Spain.
| | - Henrik Arnell
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Astrid Lindgren Children's Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
| | - Merit Tabbers
- Amsterdam Reproduction and Development and Amsterdam Gastroenterology Endocrinology Metabolism Research Institutes, Amsterdam, the Netherlands; Department of Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Frederic V Valla
- Transversal dietetics and Nutrition Unit and Nutrition Unit (UTDN), Intensive Care Nutrition, Hospices Civils de Lyon, Lyon-Bron, France.
| | - Stephen Tomlin
- Pharmacy Department, Children's Medicines Centre, Great Ormond Street Hospital for Sick Children, London, UK.
| | - Mattias Paulsson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
| | - Dirk Wackernagel
- Department of Neonatology, Gutenberg University, Mainz, Germany; CLINTEC, Karolinska Institutet, Stockholm, Sweden.
| | - Nadja Haiden
- Department of Neonatology, Kepler University Hospital, Linz, Austria.
| | | | - Luigi Orfeo
- Neonatal Intensive Care Unit, Isola Tiberina Hospital Gemelli Isola, Rome, Italy.
| | - Virgilio P Carnielli
- Department of Mother and Child Health, Division of Neonatology, G. Salesi Children's Hospital - Azienda Ospedaliero Universitaria Ospedali Riuniti di Ancona, Ancona, Italy; Department of Odontostomatologic and Specialized Clinical Sciences, Polytechnic University of Marche, Ancona, Italy.
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Canales-Siguero MD, García-Muñoz C, Caro-Teller JM, Piris-Borregas S, Martín-Aragón S, Ferrari-Piquero JM, Moral-Pumarega MT, Pallás-Alonso CR. Impact of pharmaceutical validation on prescribing errors in a neonatal intensive care unit. Randomised and controlled study. Front Pediatr 2024; 12:1346090. [PMID: 38638590 PMCID: PMC11025468 DOI: 10.3389/fped.2024.1346090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 03/25/2024] [Indexed: 04/20/2024] Open
Abstract
Purpose To compare the frequency of electronic prescription errors when the prescription was validated by the clinical pharmacist vs. when it was not. Methods This prospective randomised controlled study was conducted in three phases. A randomised phase, in which patients were divided into control and intervention groups, and a pre- and post-intervention phase were consecutively performed to analyse the impact of pharmaceutical validation of prescriptions in a neonatal intensive care unit (NICU). This study was performed at a highly complex NICU at a tertiary hospital. All patients born during the study period who were admitted to the NICU, with a stay lasting ≥24 h, and received active pharmacological treatment were included in the study. Pharmaceutical validation was performed according to the paediatric pharmaceutical care model. A high level of validation was selected for this study. In the intervention group, discrepancies found during the review process were communicated to the medical team responsible for the patients and resolved on the same day. Results In total, 240 patients were included in this study. Sixty-two patients were allocated to the pre-intervention (n = 38) or post-intervention (n = 24) groups, and 178 patients were randomly sorted into two groups, control (n = 82 newborns) and intervention (n = 96 newborns). During the randomisation phase, the number of prescription errors detected was significantly lower in the intervention group than that in the control group (129 vs. 270; p < 0.001). Similarly, prescription errors reaching the patient were significantly reduced from 40% (n = 108) in the control group to 1.6% (n = 2) in the intervention group. In the pre- and post-intervention periods, the prescription lines containing prescription errors decreased from 3.4% to 1.5% (p = 0.005). Conclusions This study showed that the pharmaceutical validation process decreased both the number of errors in the electronic prescribing tools and the number of prescription errors reaching the patient.
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Affiliation(s)
- M. D. Canales-Siguero
- Department of Pharmacy, 12 de Octubre University Hospital, Madrid, Spain
- Researcher, Maternity and Childhood Health Research Group (Area 4), i+12 Research Institute, Madrid, Spain
| | - C. García-Muñoz
- Department of Pharmacy, 12 de Octubre University Hospital, Madrid, Spain
| | - J. M. Caro-Teller
- Department of Pharmacy, 12 de Octubre University Hospital, Madrid, Spain
| | - S. Piris-Borregas
- Department of Neonatology, 12 de Octubre University Hospital, Madrid, Spain
| | - S. Martín-Aragón
- Department of Pharmacology, Pharmacognosy and Botany, Complutense University, Madrid, Spain
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Goulet O. An Overview of Parenteral Nutrition from Birth to Adolescence Based on a Composite Fish Oil Containing Lipid Emulsion and a Pediatric Amino Acid Solution. Nutrients 2024; 16:440. [PMID: 38337724 PMCID: PMC10857063 DOI: 10.3390/nu16030440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/19/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Intestinal failure (IF) is characterized by a critical reduction in functional gut mass below the minimum needed for optimal growth in children. It requires parenteral nutrition (PN) and home-PN (HPN), which is challenging in terms of meeting nutritional needs according to age, growth velocity, clinical situation, and rapid changes in fluid and electrolyte requirements. Due to these complex requirements, age-adapted multi-chamber bags (MCBs) are important additions to the nutrition armamentarium. The launch of composite fish oil (FO)-containing intravenous lipid emulsions (ILEs) heralded the development of MCBs containing these ILEs in combination with a crystalline amino acid solution adapted for pediatric use. The safety and efficacy of lipid and amino acid components in this context have been widely documented in numerous published studies. This narrative manuscript includes a review of the articles published in PudMed, Embase, and Google Scholar up to June 2023 for the age groups of term infants to children and adolescents. Preterm infants with their highly specific demands are not included. It aims to offer an overview of the clinical experience regarding the use of a composite FO-based ILE and a developed specific amino acid solution.
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Affiliation(s)
- Olivier Goulet
- Faculté de Médecine Paris Centre, Descartes Medical School, Université de Paris, 75006 Paris, France
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Vega Díaz EN, Miranda Barros AA, Castelo Reyna MA, Tenelanda López D, Tubon I. Negative Outcomes Associated with Medication in Neonates on Parenteral Nutrition Therapy. Pediatr Rep 2023; 15:360-372. [PMID: 37368365 DOI: 10.3390/pediatric15020032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/15/2023] [Accepted: 05/19/2023] [Indexed: 06/28/2023] Open
Abstract
OBJECTIVE In Ecuador, studies on clinical daily practice problems focused on parenteral nutrition in neonates are scarce. Therefore, this research aimed to identify negative results associated with medications (NRAM) in neonates with parenteral nutrition (PN) in a third-level hospital in Ecuador. MATERIAL AND METHODS An observational, prospective, descriptive study was designed in the neonatology area of a tertiary-level public hospital, where, for over four months, the medical records, PN prescriptions, and pharmacy-managed databases of 78 patients were analyzed. Drug-related problems (DRPs) as possible causes of NRAM were classified through administrative, physicochemical, and clinical validation. RESULTS DRPs classified as follows were found: 78.81% by physicochemical, 17.62% by clinical, and 3.57% by administrative validation. The NRAM were 72% quantitatively uncertain, 16% needed, and 11% quantitatively ineffective. CONCLUSION The NRAM associated with DRPs were statistically related to prematurity condition, APGAR score, PN time, and the number of medications administered, which suggests the need to create a nutritional therapy committee at the health facility.
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Affiliation(s)
- Evelin Nataly Vega Díaz
- Agencia Nacional de Regulación, Control y Vigilancia Sanitaria (ARCSA), Quito 090112, Ecuador
| | - Aida Adriana Miranda Barros
- Grupo de Investigación de Tecnología y Atención Farmacéutica del Ecuador (GITAFEC), Escuela Superior Politécnica de Chimborazo (ESPOCH), Riobamba 060155, Ecuador
| | - Monica Alexandra Castelo Reyna
- College of Mechanics, School of Industrial Maitance, Escuela Superior Politécnica de Chimborazo (ESPOCH), Riobamba 060155, Ecuador
| | - Dennys Tenelanda López
- School of Dentistry, Universidad Nacional de Chimborazo (UNACH), Riobamba 060110, Ecuador
- College of Natural Resources, Escuela Superior Politécnica de Chimborazo (ESPOCH), Riobamba 060155, Ecuador
| | - Irvin Tubon
- Carrera de Biotecnología, Facultad de Ciencia e Ingeniería en Alimentos y Biotecnología, Dirección de Investigación y Desarrollo, Ambato 180207, Ecuador
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Krämer I, Goelz R, Gille C, Härtel C, Müller R, Orlikowsky T, Piening B, Schubert S, Simon A, Wolf K, Rösner B, Exner M. Good handling practice of parenterally administered medicines in neonatal intensive care units - position paper of an interdisciplinary working group. GMS HYGIENE AND INFECTION CONTROL 2023; 18:Doc10. [PMID: 37261055 PMCID: PMC10227494 DOI: 10.3205/dgkh000436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
This position paper, developed by an interdisciplinary expert group of neonatologists, paediatric infectious disease physicians, clinical pharmacists and specialists for the prevention and control of nosocomial infections, describes the "Good handling practice of medicines parenterally administered to patients on NICUs". It takes equal account of patient safety and the specialties of neonatal intensive care regarding feasibility and proportionality. The overall concept is perceived as a "learning system", in which open communication within the health-care team relating to medication errors and critical incidents enables continuous development and improvement to ensure patient safety. In our opinion, pharmacists, who are responsible for the supply of ready-to-administer parenteral medicinal products for neonatal intensive care patients, as well as the hygiene staff responsible on site are integral parts of the interdisciplinary treatment team. Risks of the current clinical practice of parenteral treatment of NICU patients are discussed in detail and recommendations for safety-relevant procedures are given.
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Affiliation(s)
- Irene Krämer
- Department of Pharmacy, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Rangmar Goelz
- Department of Neonatology, Tübingen University Children's Hospital, Tübingen, Germany
| | - Christian Gille
- Clinic for Neonatology, University Hospital for Paediatrics and Adolescent Medicine Heidelberg, Heidelberg, Germany
| | - Christoph Härtel
- University Hospital Würzburg, Department of Pediatrics, Würzburg, Germany
| | - Rachel Müller
- Pharmacy of Saarland University Hospital, Homburg, Germany
| | - Thorsten Orlikowsky
- Section of Neonatology and Paediatric Intensive Care Medicine, University Hospital Aachen, Aachen, Germany
| | - Brar Piening
- Institute for Hygiene and Environmental Medicine, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian Schubert
- Department of Pharmacy, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
- Special interest group for Paediatric Pharmacy, German Society of Hospital Pharmacists (ADKA e.V.), Germany
| | - Arne Simon
- Paediatric Oncology and Haematology, Children's Hospital, Saarland University Hospital, Homburg, Germany
- German Society for Paediatric Infectiology, Berlin, Germany
| | - Katharina Wolf
- University Pharmacy, Tübingen University Hospital, Tübingen, Germany
| | - Bianka Rösner
- Charité – Universitätsmedizin Berlin, Centre for Gynaecology, Paediatrics and Adolescent Medicine, Clinic for Neonatology, Specialist Paediatric Intensive Care Nurse, Berlin, Germany
| | - Martin Exner
- Prevention and Outbreak Management/One health at the Institute of Hygiene and Public Health, WHO CC University Hospital Bonn for the Board of the German Society for Hospital Hygiene (DGKH), Bonn, Germany
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Mistry P, Smith RH, Fox A. Patient Safety Incidents Related to the Use of Parenteral Nutrition in All Patient Groups: A Systematic Scoping Review. Drug Saf 2021; 45:1-18. [PMID: 34932206 DOI: 10.1007/s40264-021-01134-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION There is limited comprehensive literature focussing on the range of patient safety incidents related to parenteral nutrition (PN). OBJECTIVE The aim of this review was to examine patient safety incidents related to the use of PN in all patient age groups. METHODS Literature published in the English language between January 2000 and April 2020 were searched across the MEDLINE, CINHAL and Embase databases. Articles were included if they contained PN-related patient safety incidents related to an avoidable event. No restrictions were applied to patient populations. The screening process was undertaken independently by two authors. RESULTS In total, 108 records were included in the review: 52 case studies, 54 observation studies (e.g. prevalence studies, surveys) and two experimental studies. All age groups were represented, with 62% of studies in paediatrics (of which two-thirds were neonates) and 23% in adults. They included all medication processes: prescribing, dispensing, compounding, administration and monitoring. Incidents were related to microbial contamination, venous access and specific components (e.g. lipid emulsion, amino acids, glucose, micronutrients and electrolytes) or the whole product. Incident outcomes ranging from near miss to death were reported. Intervention studies looked at the impact on patient safety incidents of computerised tools, healthcare processes, e.g. pharmacist screening, and standardisation. One study demonstrated more severe outcomes with paediatric than with adult PN. CONCLUSIONS This review demonstrates the vast range of PN-related patient safety incidents in all patient age groups and all medication process stages. The need for a national study looking at patient safety incidents related to PN in England is highlighted.
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Affiliation(s)
- Priya Mistry
- Pharmacy Department, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK.
| | - Rebecca Heather Smith
- Gastroenterology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Andy Fox
- Pharmacy Department, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
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Kuitunen S, Niittynen I, Airaksinen M, Holmström AR. Systemic Causes of In-Hospital Intravenous Medication Errors: A Systematic Review. J Patient Saf 2021; 17:e1660-e1668. [PMID: 32011427 PMCID: PMC8612891 DOI: 10.1097/pts.0000000000000632] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
OBJECTIVES Delivery of intravenous medications in hospitals is a complex process posing to systemic risks for errors. The aim of this study was to identify systemic causes of in-hospital intravenous medication errors. METHODS A systematic review adhering to PRISMA guidelines was conducted. We searched MEDLINE (Ovid), Scopus, CINAHL, and EMB reviews for articles published between January 2005 and June 2016. Peer-reviewed journal articles published in English were included. Two reviewers independently selected articles according to a predetermined PICO tool. The quality of studies was assessed using the GRADE system and the evidence analyzed using qualitative content analysis. RESULTS Eleven studies from six countries were included in the analysis. We identified systemic causes related to prescribing (n = 6 studies), preparation (n = 6), administration (n = 6), dispensing and storage (n = 5), and treatment monitoring (n = 2). Administration, prescribing, and preparation were the process phases most prone to systemic errors. Insufficient actions to secure safe use of high-alert medications, lack of knowledge of the drug, calculation tasks, failure in double-checking procedures, and confusion between look-alike, sound-alike medications were the leading causes of intravenous medication errors. The number of the included studies was limited, all of them being observational studies and graded as low quality. CONCLUSIONS Current intravenous medication systems remain vulnerable, which can result in patient harm. Our findings suggest further focus on medication safety activities related to administration, prescribing, and preparation of intravenous medications. This study provides healthcare organizations with preliminary knowledge about systemic causes of intravenous medication errors, but more rigorous evidence is needed.
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Affiliation(s)
- Sini Kuitunen
- From the HUS Pharmacy, Hospital Pharmacy of Helsinki University Hospital (HUS), Finland
- Clinical Pharmacy Group, Faculty of Pharmacy, University of Helsinki, Finland
| | - Ilona Niittynen
- Clinical Pharmacy Group, Faculty of Pharmacy, University of Helsinki, Finland
| | - Marja Airaksinen
- Clinical Pharmacy Group, Faculty of Pharmacy, University of Helsinki, Finland
| | - Anna-Riia Holmström
- From the HUS Pharmacy, Hospital Pharmacy of Helsinki University Hospital (HUS), Finland
- Clinical Pharmacy Group, Faculty of Pharmacy, University of Helsinki, Finland
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Sommer I, Palmero D, Fischer Fumeaux CJ, Bonnabry P, Bouchoud L, Sadeghipour F. Parenteral Nutrition Process Management for Newborn and Preterm Infants - A Preliminary Risk Analysis. Ther Clin Risk Manag 2021; 17:497-506. [PMID: 34093016 PMCID: PMC8169048 DOI: 10.2147/tcrm.s280938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 04/13/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND There are variable practices in the management of the parenteral nutrition (PN) process in hospitals having a neonatal intensive care unit (NICU). In our hospital, PN is prepared partially on the neonatal ward by nurses but also at the central pharmacy by trained pharmacy technicians. A previous study showed a concentration non-conformity of 34% of on-ward PN preparations potentially resulting in under- or overfeeding of the patients. OBJECTIVE The objectives were to perform preliminary risk analyses (PRA) in preparation for our hospital's transition to universal central pharmacy PN compounding. METHODS A working group including pharmacists, neonatologists, nurses, and pharmacy technicians performed two PRA. The risks of 9 management steps of the PN process were identified, evaluated, and quoted. A comparison of the number of risks and their criticality index (CI) was conducted. RESULTS A total of 36 and 39 risks were identified for PN preparation in the NICU and the pharmacy, respectively. For the NICU, ten risks (28%) had an "acceptable" CI, 15 risks (42%) were "under control" and eleven (31%) were defined as "non-acceptable". For the pharmacy, 14 risks (36%) had an "acceptable" CI, 19 risks (49%) were "under control" and six (15%) were defined as "non-acceptable". Risks directly related to the preparation process, including the steps preparation hood, PN preparation and analytical quality control, represented a cumulated CI of 145 for eleven NICU-risks vs 108 for twelve pharmacy risks (-26%). The implementation of immediate improvement measures, eg, an electronic prescription form, reduces the total CI by 5.7% and 2.2% for the NICU and the pharmacy, respectively. CONCLUSION This PRA highlighted the safety differences between PN preparation in the NICU vs the pharmacy at our institution, and facilitated our moving forward with a process change that should improve the care of our neonatal patients. Nevertheless, long-term improvement measures have to be implemented to further reduce risks related to the PN management process.
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Affiliation(s)
- Isabelle Sommer
- Service of Pharmacy, Lausanne University Hospital, Lausanne, Switzerland
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - David Palmero
- Service of Pharmacy, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Pascal Bonnabry
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
- Service of Pharmacy,Geneva University Hospital, Geneva, Switzerland
| | - Lucie Bouchoud
- Service of Pharmacy,Geneva University Hospital, Geneva, Switzerland
| | - Farshid Sadeghipour
- Service of Pharmacy, Lausanne University Hospital, Lausanne, Switzerland
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
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Kumar V, Rahim A, Choudry E, Jabbar R, Khowaja WH, Ariff S, Ali SR. A Pre-Post Intervention-Based Study Investigating the Impact of Standardized Parenteral Nutrition at Tertiary Neonatal Intensive Care Unit in Karachi, Pakistan. Cureus 2021; 13:e15226. [PMID: 34178539 PMCID: PMC8223258 DOI: 10.7759/cureus.15226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction Conventionally, various parenteral nutrition (PN) components are individually administered considering an individual neonate's requirements. More recently, standardized PN (SPN) formulations have been initiated for preterm neonates, which may benefit from the enhanced nutrient supply, less administration and prescription errors, reduced risk of infectious disease, and cost-effectiveness. Methodology A multicentered, pre-post intervention-based study was conducted at tertiary neonatal intensive care units (NICUs) in Karachi, Pakistan. Post-graduate residents of neonatology and pediatrics working in NICUs were included in the study, and their perspective was attained regarding PN formulation and a prescription for time consumption, ease, calculation errors, and general feedback. Independent T-test was applied to assess the statistical difference between the pre-and post-implementation of PN formulation for total time required for PN calculation, whereas for the rest of the quantitative variables Mann-Whitney U test was computed. Results The total time required to do the entire writing process, calculating and ordering PN, was 17.1±6.9 whereas significantly (p-value of <0.0001) reduced to 10.5±5.7 after implementing SPN prescriptions. Calculation errors were reduced from 32% to 12%, and writing errors were also decreased from 35% to 8% when the standardized parenteral nutritional formulation was applied. Conclusion Our findings show that implementing standardized prescriptions in the NICU has improved medication safety, with the most consistent benefit by reducing medication errors and time management. The SPN prescriptions save time for post-graduate residents, physicians, and pharmacists by eliminating previously required repetitive activities and calculations.
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Affiliation(s)
- Vikram Kumar
- Neonatology, Indus Hospital and Health Network, Karachi, PAK
| | - Anum Rahim
- Indus Hospital Research Center, Indus Hospital and Health Network, Karachi, PAK
| | - Erum Choudry
- Indus Hospital and Research Center, Indus Hospital and Health Network, Karachi, PAK
| | - Rafia Jabbar
- Pediatrics, Indus Hospital and Health Network, Karachi, PAK
| | - Waqar H Khowaja
- Pediatrics and Child Health, Aga Khan University Hospital, Karachi, PAK
| | - Shabina Ariff
- Pediatrics and Child Health, Aga Khan University Hospital, Karachi, PAK
| | - Syed Rehan Ali
- Neonatology, Indus Hospital and Health Network, Karachi, PAK
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Kraft MD, Tucker AM, Durfee SM, Jones T, Guenter P, Banko DE, Ayers P, Boullata J, Raymond E, Sacks GS. Parenteral Nutrition Prescribing and Order Review Safety Study: The Need for Pharmacist Intervention. Nutr Clin Pract 2020; 36:480-488. [PMID: 33275303 DOI: 10.1002/ncp.10600] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 10/14/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Errors have been reported in the literature to occur at each step of the parenteral nutrition (PN) use process, necessitating standardized processes, clinician competence, and open communication for those involved. This study was performed at Central Admixture Pharmacy Services (CAPS®) in collaboration with the American Society for Parenteral and Enteral Nutrition (ASPEN) with the purpose to study the need for and success of PN pharmacist interventions. METHODS A survey was developed and sent to all CAPS customers for study enrollment and to identify their demographic and practice characteristics. For those enrolled, CAPS pharmacists reviewed every PN order in a 1-month period using an error/intervention tool to capture data on prescription elements requiring intervention, along with acceptance of that intervention. RESULTS Two hundred thirty-two unique CAPS customers (23% response rate) participated in the study, representing 37,634 unique PN prescriptions. Two hundred forty-eight PN prescriptions (0.66%) from 59 customers required ≥1 intervention. The top 3 intervention types were electrolyte dose clarification, calcium/phosphorus incompatibility, and amino acid dose clarification. A greater number and percentage of interventions were required for neonatal prescriptions, as compared with adult and pediatric prescriptions. No significant difference was found in many of the other customer characteristics. CONCLUSION This study supports the need for institutions to develop systems to comply with published PN safety recommendations, including knowledgeable and skilled pharmacists to complete the order review and verification steps for this high-alert medication.
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Affiliation(s)
- Michael D Kraft
- Department of Pharmacy Services Ann Arbor, University of Michigan College of Pharmacy, Michigan, USA
| | - Anne M Tucker
- Critical Care/Nutrition Support The University of Texas M D Anderson Cancer Center, Houston, Texas, USA
| | - Sharon M Durfee
- Central Admixture Pharmacy Services, Inc, Denver, Colorado, USA
| | - Todd Jones
- Marketing Central Admixture Pharmacy Services, Inc, Denver, Colorado, USA
| | - Peggi Guenter
- Clinical Practice, Quality, and Advocacy American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
| | - David E Banko
- Health Economics & Outcomes, Research B Braun Medical Inc, Bethlehem, Pennsylvania, USA
| | - Phil Ayers
- Clinical Pharmacy Services, Mississippi Baptist Medical Center, Jackson, Mississippi, USA
| | - Joseph Boullata
- Clinical Nutrition Support Services, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erica Raymond
- Patient Food and Nutrition Services, Michigan Medicine, Ann Arbor, Michigan, USA
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Current State of Nutrition Education in Pediatric Critical Care Medicine Fellowship Programs in the United States and Canada. Pediatr Crit Care Med 2020; 21:e769-e775. [PMID: 32740183 DOI: 10.1097/pcc.0000000000002504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess the current state of nutrition education provided during pediatric critical care medicine fellowship. DESIGN Cross-sectional survey. SETTING Program directors and fellows from pediatric critical care medicine fellowship programs in America and Canada. SUBJECTS Seventy current pediatric critical care medicine fellows and twenty-five pediatric critical care medicine fellowship program directors were invited to participate. INTERVENTIONS Participants were asked demographic questions related to their fellowship programs, currently utilized teaching methods, perceptions regarding adequacy and effectiveness of current nutrition education, and levels of fellow independence, comfort, confidence, and expectations in caring for the nutritional needs of patients. MEASUREMENTS AND MAIN RESULTS Surveys were sent to randomly selected program directors and fellows enrolled in pediatric critical care medicine fellowship programs in America and Canada. Twenty program directors (80%) and 60 fellows (86%) responded. Ninety-five percent of programs (19/20) delivered a formal nutrition curriculum; no curriculum was longer than 5 hours per academic year. Self-reported fellow comfort with nutrition topics did not improve over the course of fellowship (p = 0.03), with the exception of nutritional aspects of special diets. Sixty-five percent of programs did not hold fellows responsible for writing daily parenteral nutrition prescriptions. There was an inverse relationship between total number of fellows in a pediatric critical care medicine program and levels of comfort in ability to provide parenteral nutrition support (p = 0.01). Program directors perceived their nutritional curriculum to be more effective than did their fellows (p ≤ 0.001). CONCLUSIONS Nutrition education was reported as highly underrepresented in pediatric critical care medicine fellowship curricula. The majority of programs rely on allied health care professionals to prescribe parenteral nutrition, which may influence trainee independence in the provision of nutritional therapies. Improving the format of current nutrition curriculums, by relying on more active teaching methods, may improve the delivery and efficacy of nutrition education. The impact of novel training interventions on improving the competency and safety of enteral and parenteral nutrition delivery in the PICU must be further examined.
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Mourkogianni E, Karatza A, Vinni E, Papadimitriou E, Avgoustakis K, Panagi Z. Assessment and Optimization of the Pediatric Parenteral Nutrition Preparation Process in a Hospital Pharmacy. JPEN J Parenter Enteral Nutr 2020; 44:928-939. [PMID: 32026498 DOI: 10.1002/jpen.1787] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 01/06/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Parenteral nutrition (PN) is associated with risks that could threaten the clinical condition of premature neonates hospitalized in the neonatal intensive care unit. In this work, risk-analysis methodology was implemented to contain the risks associated with the PN production process and improve PN safety. METHODS The Failure Modes, Effects, and Criticality Analysis was performed by a multidisciplinary team. All potential failure modes of the PN preparation process were recorded, and associated risks were scored based on their severity, occurrence, and detectability, with a risk priority number (RPN). All identified failure scenarios and the respective work stages were ranked in descending order of criticality. Corrective actions were proposed to address critical points, and the safety of the process was reassessed by the same method in a prospective manner. RESULTS The highest RPN scores were obtained with the PN composition calculation performed manually (RPN: 530) or electronically (RPN: 478), completion of the PN medical order form (RPN: 354), manual compounding of PN admixtures (RPN: 258), and the structure/organization/maintenance of the PN preparation unit (RPN: 133). The quality and safety of PN admixtures could be compromised by many critical factors, such as the increased particle-microbial load in the unit and the inadequate training/experience of the involved health professionals and their incompliance with the given instructions. The implementation of the proposed corrective measures is expected to reduce the risks of the overall PN production process by 67.5%. CONCLUSIONS Improvement of the PN production process through risk-analysis methodologies enhances safety for premature neonates.
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Affiliation(s)
- Eleni Mourkogianni
- Laboratory of Molecular Pharmacology, Department of Pharmacy, School of Health Sciences, University of Patras, Patras, Greece
| | - Aggeliki Karatza
- Department of Pediatrics, School of Medicine, University of Patras, University Hospital of Patras, Patras, Greece
| | - Eleni Vinni
- Central Sterile PN Compounding Unit, Department of Pharmacy, University Hospital of Patras, Patras, Greece
| | - Evangelia Papadimitriou
- Laboratory of Molecular Pharmacology, Department of Pharmacy, School of Health Sciences, University of Patras, Patras, Greece
| | - Konstantinos Avgoustakis
- Laboratory of Pharmaceutical Technology, Department of Pharmacy, School of Health Sciences, University of Patras, Patras, Greece
| | - Zoi Panagi
- Central Sterile PN Compounding Unit, Department of Pharmacy, University Hospital of Patras, Patras, Greece
- Laboratory of Pharmaceutical Technology, Department of Pharmacy, School of Health Sciences, University of Patras, Patras, Greece
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Parenteral nutrition: a call to action for harmonization of policies to increase patient safety. Eur J Clin Nutr 2020; 75:3-11. [PMID: 32523089 DOI: 10.1038/s41430-020-0669-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 04/30/2020] [Accepted: 05/26/2020] [Indexed: 01/07/2023]
Abstract
Unsafe medication practices and medication errors are leading causes of injury and avoidable harm worldwide and are highest in vulnerable groups. In 2017, the World Health Organization launched the third Medication Without Harm Global Patient Safety Challenge to try to reduce risks related to medical treatment. Parenteral nutrition (PN) is in the unique position that, although licensed products are available from manufacturers, formulas may be prepared ad hoc for first-line use that might not be subject to the same regulatory oversight. Safety issues around PN can arise through lack of harmonization in practices, misinterpretation and product unfamiliarity and can occur at any stage from prescription to preparation to administration. Government legislation and regulation vary considerably, with PN not explicitly handled in many countries. We therefore call on policy leaders in all countries to establish policies that ensure patient safety, and that these include PN along with medicines. The available evidence supports obtaining industry prepared PN as first-line therapy for reasons of safety, primarily, and of cost. If a suitable industry prepared ready-to-use PN is not available, standardized all-in-one PN admixtures should be the next line of care, with individualized PN being reserved for patients whose complex nutritional needs cannot be met using standardized admixtures.
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Adil MS, Sultana R, Khulood D. PRIME study: Prescription review to impede medication errors. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2020; 31:67-79. [DOI: 10.3233/jrs-191025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Haddad N, Paranjpe R, Rizk E, Basit SA, McNamara C, Okoro E, Gilmore J, Liebl M, Swan JT. Value of pharmacy services in an outpatient, preoperative, anesthesia clinic. J Am Pharm Assoc (2003) 2020; 60:e264-e278. [PMID: 32303426 DOI: 10.1016/j.japh.2020.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/11/2020] [Accepted: 03/14/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE This pilot study assessed the expansion of pharmacy services to a preoperative, anesthesia clinic. SETTING Tertiary care academic medical center. PRACTICE DESCRIPTION Medication histories were routinely obtained by clinic nurses, and pharmacy services were not available. PRACTICE INNOVATION A prospective, single-center, pilot study enrolled English-speaking patients aged 65 years or older in a preoperative clinic before a scheduled surgery. Patient attributes including health literacy and preparatory activities were measured using verbal and written questionnaires. Home medication lists were obtained by both clinic nurses (routine care) and a pharmacist (research), and the 2 lists were compared to identify medication discrepancies for each patient. Discrepancies were categorized by type and severity. EVALUATION This study evaluated the potential impact of medication histories obtained by pharmacists compared with those obtained by clinic nurses during geriatric preoperative clinic visits. RESULTS Of the 44 patients who gave their consent and were included in this pilot study, 25% (n = 11) had limited/marginal written and verbal health literacy, and 20% (n = 9) had limited/marginal numerical health literacy. Of the 38 patients who completed the pharmacist medication history interview, only 21% (n = 8) brought a complete list of their current medications to the preoperative clinic, 95% (n = 36) had at least 1 medication discrepancy, and 61% (n = 23) had at least 1 clinically meaningful discrepancy. Clinically meaningful discrepancies were identified for 8% (35 of 459) of medications and occurred most commonly for blood pressure medications, nonsteroidal anti-inflammatory drugs, and beta blockers. CONCLUSION In this study, medication history discrepancies identified by pharmacists suggest that the expansion of pharmacy services into the preoperative clinic is feasible and could potentially prevent meaningful medication errors among geriatric patients being admitted for a scheduled surgery.
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Sommer I, Bouchoud L, Berger-Gryllaki M, Bonnabry P, Sadeghipour F. Quality and safety of parenteral nutrition for newborn and preterm infants as an on-ward preparation. Eur J Hosp Pharm 2019; 27:292-296. [PMID: 32839262 DOI: 10.1136/ejhpharm-2018-001788] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/03/2019] [Accepted: 01/11/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND For newborn and preterm infants, standardised and individual parenteral nutrition (PN) is used. PN preparation is at risk for contamination and dosing errors. The quality of PN is crucial for infants and has a direct impact on their health status and safety. PURPOSE The aim of this study is to evaluate the physicochemical and microbial quality of PN for newborn and preterm infants prepared on a neonatal ward. METHODS Sampling of various individual PN prepared by nurses on a neonatal ward was performed. Formulations included maximal four electrolytes, variable dextrose and amino acid concentrations. Depending on the sample volume, up to three quality analyses were performed: (1) test for bacterial endotoxins by kinetic-chromogenic method, (2) sterility according to the European and US Pharmacopoeia, and (3) quantification of electrolytes by capillary electrophoresis and of dextrose by ultraviolet detection after enzymatic reaction of hexokinase. The concentrations obtained were evaluated based on the US and Swiss Pharmacopoeia specifications for compounded preparations and compared to the widened pharmacy specifications. RESULTS The composition of 86% of the 110 analysed PN prepared by nurses on the neonatal ward corresponded to their medical prescription. 14% were out of the acceptable widened pharmacy ranges. We found no microbial contamination in the samples. All PN were free from endotoxins. CONCLUSION Component concentrations of PN prepared on wards by nurses differed frequently and significantly from their medical prescription, and the deviation can be critical depending on the component and its mode of action. The sample size is too small to evaluate the microbial contamination.
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Affiliation(s)
- Isabelle Sommer
- Department of Pharmacy, University Hospitals of Lausanne CHUV, Lausanne, Switzerland
- School of Pharmaceutical Sciences EPGL, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Lucie Bouchoud
- Department of Pharmacy, University Hospitals of Geneva HUG, Geneva, Switzerland
| | | | - Pascal Bonnabry
- School of Pharmaceutical Sciences EPGL, University of Geneva, University of Lausanne, Geneva, Switzerland
- Department of Pharmacy, University Hospitals of Geneva HUG, Geneva, Switzerland
| | - Farshid Sadeghipour
- Department of Pharmacy, University Hospitals of Lausanne CHUV, Lausanne, Switzerland
- School of Pharmaceutical Sciences EPGL, University of Geneva, University of Lausanne, Geneva, Switzerland
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Jafarian K, Allameh Z, Memarzadeh M, Saffaei A, Peymani P, Sabzghabaee AM. The Responsibility of Clinical Pharmacists for the Safety of Medication Use in Hospitalized Children: A Middle Eastern Experience. J Res Pharm Pract 2019; 8:83-91. [PMID: 31367643 PMCID: PMC6636415 DOI: 10.4103/jrpp.jrpp_19_66] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Objective: We aimed to detect and report the frequency of occurrence of drug-related problems (DRPs) in a Middle Eastern University Children's Hospital (Isfahan, Iran) and classify them in terms of their nature and cause to clarify the responsibility of clinical pharmacists for the safe utilization of medications in hospitalized children. Methods: In this cross-sectional study which was carried out in Imam Hossein Children's University Hospital affiliated with Isfahan University of Medical Sciences (Isfahan, Iran) from September 2017 to May 2018, DRPs during the hospitalization of pediatric patients in three medical wards, the pediatric intensive care unit, and two neonatal intensive care units were detected and identified concurrently with the treatment process using Pharmaceutical Care Network of Europe data gathering form for DRPs v. 8.01. All cases were verified and validated in a professional focus group before documentation. Findings: We detected 427 DRPs in 201 out of 250 randomly included hospitalized children in which 86% of them were directly reported by the hospital's clinical pharmacist. The highest frequency of DRPs (47.3%) was observed in the age range of 1 month–2 years. Safety of treatment was the most frequently reported as the nature of the problem (43.5%), followed by effectiveness issues (36.8%). The most frequent cause of DRPs was dose selection issues (34.2%), followed by drug-type selection (25.5%), and unavailability of appropriate dosage forms (13.6%). Ninety-eight interventions were proposed by the clinical pharmacist, in which 59.2% of them were accepted. Conclusion: This study confirms the necessity for the active role of clinical pharmacists before, during, and after drug therapy in hospitalized pediatric patients for the safety and proper utilization of drugs in this vulnerable population.
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Affiliation(s)
- Khatereh Jafarian
- Pharmacy Students' Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Allameh
- Department of Pharmaceutical Care, Imam Hossein Children's Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehrdad Memarzadeh
- Department of Pediatric Surgery, Imam Hossein Children's Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Saffaei
- Department of Clinical Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Payam Peymani
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Mohammad Sabzghabaee
- Department of Pharmaceutical Care, Imam Hossein Children's Hospital, Isfahan University of Medical Sciences, Isfahan, Iran.,Isfahan Clinical Toxicology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Boulé M, Lachapelle S, Collin-Lévesque L, Demers É, Nguyen C, Fournier-Tondreau M, Thibault M, Lebel D, Bussières JF. Failure Mode, Effect, and Criticality Analysis of the Parenteral Nutrition Process in a Mother-Child Hospital: The AMELIORE Study. Nutr Clin Pract 2018; 33:656-666. [PMID: 29846961 DOI: 10.1002/ncp.10094] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The parenteral nutrition (PN) process is complex and involves multiple steps and substeps, especially in pediatrics and neonatology, given the particular needs of these patients. The objective of this study was to perform a critical analysis of the PN process at the Centre Hospitalier Universitaire Sainte-Justine to determine which potential pitfalls are related to this process and which should be prioritized when implementing corrective measures. METHODS This is a Failure Mode, Effect, and Criticality Analysis (FMECA) study. A multidisciplinary team assessed each step of the PN process and identified associated failure modes. Adapted rating scales were used to determine severity, frequency, and detectability of the failure modes. Ratings were established through multidisplinary consensus, and a criticality index (CI) was calculated for each failure mode. RESULTS A total of 265 failure modes were identified in the 5 major steps of the PN process. The failure mode with the highest CI was the inscription of an inaccurate weight at prescription, with a CI of 800. The step with the highest cumulative CIs was administration to patients, with a CI sum of 7691. Various recommendations aimed at minimizing the risks associated with the PN process were made following this FMECA. Additional interventions are expected to emanate from this project because data will be presented throughout the departments involved. CONCLUSION This study is a successful example for other hospitals interested in carrying out the same kind of healthcare improvement initiative.
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Affiliation(s)
- Marianne Boulé
- University of Montréal, Québec, Canada.,Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Sophie Lachapelle
- University of Montréal, Québec, Canada.,Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Laurence Collin-Lévesque
- University of Montréal, Québec, Canada.,Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Émile Demers
- University of Montréal, Québec, Canada.,Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Christina Nguyen
- Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | | | - Maxime Thibault
- Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Denis Lebel
- Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
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Ayers P, Boullata J, Sacks G. Parenteral Nutrition Safety: The Story Continues. Nutr Clin Pract 2018; 33:46-52. [DOI: 10.1002/ncp.10023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 11/08/2017] [Indexed: 01/06/2023] Open
Affiliation(s)
- Phil Ayers
- Mississippi Baptist Medical Center; Jackson Mississippi USA
| | - Joseph Boullata
- Hospital for the University of Pennsylvania; Philadelphia Pennsylvania USA
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