1 / 11

Improved Parenteral Nutrition Safety

Improved Parenteral Nutrition Safety. Proper Catheter Care Improves Parenteral Nutrition Safety . Potential Sources of Infection. Contaminated Catheter hub Endogenous Skin flora Extrinsic HCW hands. Major sources of IV device-related bloodstream infections (BSI) 1

vic
Download Presentation

Improved Parenteral Nutrition Safety

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Improved ParenteralNutrition Safety

  2. Proper Catheter Care Improves Parenteral Nutrition Safety Potential Sources of Infection • Contaminated • Catheter hub • Endogenous • Skin flora • Extrinsic • HCW hands • Major sources of IV device-related bloodstream infections (BSI)1 • Colonization of the device (catheter-related) • Contamination of the infusate • Prospective study of 1,098 patients showed 2.7% of CVC BSI1 • 45% extraluminal, 26% intraluminal, 29% unknown • Catheter care effectively reduces PN-related infections2 • Misunderstood risks should not deter clinicians from using PN2 Skin organisms Endogenous Skin flora Extrinsic HCW hands Contaminated disinfectant • Contaminated • Infusate • Extrinsic • Fluid • Medication • Intrinsic • Manufacturer Fibrin sheath,thrombus Skin Vein • Hematogenous • From distant infection Source: Safdar N. Intensive Care Med. 2004;30:62-67. Dimick JB, et al. Am J Crit Care. 2003;12:328-335.

  3. Pharmacy Compounded Bag Customized combining, mixing, or altering of ingredients State-regulated Follow USP 797 compounding standards Multi-Chamber Bag (MCB) Products produced by pharmaceutical companies FDA-regulated Commercially manufactured Follows Good Manufacturing Practices (GMPs) Expiration dating 2 years (in unopened package) Multi-Chamber Bag Premix Offers an Alternative to Compounded PN

  4. Outbreak of Bloodstream Infections (BSI)Associated With Compounded Injections Recent Patient Adverse Events From Compounded Solutions Cited by FDA1,2 • Multiple outbreaks of infection caused by contaminated compounding preparations • Compounding under heavy scrutiny • FDA aware of >200 adverse events (AE’s) with compounded products since 19902 • Reported AE’s resulted in recalls, patient injury, and death • Consumers should ask doctor if an FDA approved drug is available vs compounded solutions Source: 1. Civen R. Clinical Infectious Diseases. 2006;43:831-837; 2. www.fda/gov/consumer/updates/compounding053107.html; Sunenshine RH. Clin Infect Dis. 2007;45(5):527-533.

  5. PN-Related Ordering and Compounding Errors Are Common # Errors per Month Related to PN2 • ASPEN survey on PN ordering and compounding (n = 651)1 • 88% use standardized PN order forms • Almost 2/3 observed 1-5 errors/month related to PN1 • PN electrolytes 71% of errors • 46% reported AE’s related to PN • 35% required increase monitoring, 25% resulted in harm, 3.3% near death, 1.5% death • Standardization for PN must be explored to improve patient safety, clinical appropriateness3 • Includes commercial PN products (eg, multi-chamber bags) Survey Respondents (%) Source: 1. Seres, et al. JPEN. 2006; 2. ASPEN Task ForceJPEN. 2004;28:6; 3. ASPEN Task Force JPEN. 2007;31(5):441-448.

  6. Standardized PN Prescribing Reduces Medication Errors Types of All Compounded Drug Preparation Errors (2008) Type of Error (n = 277) % Prescribing error 23 Omission 21 Improper dose/quantity 21 Unauthorized/wrong drug 12 Drug prepared incorrectly 9 Wrong time 6 Extra dose 3 Wrong patient 3 Wrong administration technique 2 Mislabeling 1 Deteriorated product 1 Wrong route 0.36 • 2004 MEDMARX report showed patient harm resulted in 4.4% of reported PN errors (n = 2,519) • Compared to 2.5% harm rate for all MEDMARX error reports • 71% errors prescribing, transcribing, administration • Medication Error Reporting (MER) show PN harm rate 18% (vs 14% overall) • Dispensing problems with automated compounding devices and labeling • 2008 MEDMARX report shows 60% of injection compounding errors(n = 70) involved PN • Suggestions for improved PN safety • Standardized order forms • Validate hospital compounding • Policies for outsourcing • Visually inspect bags • Catheter care policy Source: USP Patient Safety CAPSLink Report February 2004 and March 2008.

  7. Standardized PN Has Shown Comparable Electrolyte Management vs Customized PN Electrolytes Within Normal Limit (WNL) vs Abnormal (ABN) • Prospective study at academic hospital of 4 standard formulations • Peripheral, central, high stress, fluid restricted • Patient acuity not controlled • Compare metabolic parameters • Standard 76% • Customized 24% • Laboratory electrolytes (Na, K, CO2, Mg, PO4, Cl) • WNL = % normal • ABN = % abnormal • Significantly less electrolyte abnormalities with the standardized PN p=0.01 PN, % Source:Hayes EM, et al. P&T. 2000;25:78-87.

  8. Multi-Chamber Bag PN May Reduce Number of PN Compounding Errors Type of Errors Observed in Compounded IV Admixtures Error Category Errors Wrong dose 69% Wrong base solution 16% Unauthorized drug 7% Wrong preparation technique 5% Omission 3% • Compounding errors in 1,679 IV doses at 5 large US acute care hospitals • Considered “progressive” hospitals • Academic, not-for-profit,for-profit • Mean compounding error rate 9% • PN compounding errors highest (26%) of all products • Ready-to-use products (0.3% error rate) may reduce PN errors by decreasing • # preparation steps • Dose calculations Source: Flynn EA, et al. Am J Health-Syst Pharm. 1997;54:904-912.

  9. Multi-Chamber Bag PN Can Effectively Substitute Compounded Formulas Formula Comparison Between TNA and MCB TPN (PTPN) • Retrospective study 100 patients to assess PN formula substitution with multi-chamber bag (MCB) • Total Nutrition Admixture (TNA): compounded PN • MCB TPN (PTPN): dextrose+A.A. • 20% lipid sol. added if needed • Formulas matched by nutrition content and volume • PTPN can effectively replace TNA in some patients • 3 PTPN products met all TNA formula needs • Volume ↑ may preclude use in fluid-restricted patients p=0.0001 p=NS p<0.001 p=0.0075 p=NS Source: Banchik LH. Nutr Clin Pract. 2005;20:153.

  10. Multi-Chamber Bag PN Formulations Are Widely Used in Europe 90 83% 80% 80 70 60 50 40 30 20 10 0 Switzerland France Belgium Survey Response of PN Multi-Chamber Bag Use for Standard Formulas • Hospital pharmacy survey of MCB use in 3 European countries • Adult PN represented the main type of prescription • >80% use of MCB in Switzerland and France • MCB includes 2- and 3-chamber bags • 3-chamber bag not available in the US • Limiting the use of customized PN formulas to decrease compounding error rates 44% % MCB Use Source: Maisonneuve N, et al. Nutr. 2004;20:528-535.

  11. Improved Parenteral Nutrition Safety • Proper insertion and care of catheters are essential to reduce risk of infection • Multi-chamber bag PN may lower risk of infection related to contamination compared to compounded solutions • Standardized multi-chamber bag PN may reduce errors associated with prescribing and transcription 801033R-1 02/09

More Related