Parenteral nutrition (PN) should be provided to the malnourished patient if enteral feeding is insufficient or unsafe. A nutrition support team (NST) may improve PN services. We compared the use and complications of hospital PN before and after the implementation of an NST.
All inpatients referred for PN outside of the intensive care unit and the intestinal failure unit were prospectively included from 2009 to 2012. The NST was introduced in 2010. Quality improvement methodology was applied.
In 2009, a mean of 16 (limits of normal variation 4–28) patients were referred for PN each month. After introduction of the NST, this rose to 26 (10–42) referrals per month. The percentage of referrals where PN was not initiated increased from 5.3% in 2009 to 10.1% in 2012 (P=0.03). This increase was restricted to teams that infrequently referred for PN, and enteral nutrition could replace PN in 31 of 51 patients (61%) as compared with 8 of 32 (25%) patients referred from teams that frequently referred for PN (P=0.001). The frequency of PN started owing to an insufficient oral or enteral intake decreased from 11% to 3% (P=0.01). The catheter-related bloodstream infection rate dropped from 6.7 to 0.7 episodes per 1000 catheter days (P<0.001).
Introduction of an NST increased both the total PN use and the percentage of referrals where enteral nutrition could replace PN. Medical specialty influenced the referral pattern and the likelihood that a referral resulted in PN being initiated. Safety of PN catheters improved significantly following NST introduction.
Malnutrition remains a major risk factor for in-hospital morbidity and mortality.1,2 A stepwise algorithm can be applied to patients who do not meet their nutritional requirements,3,4 and oral or enteral nutrition should be instigated instead of parenteral nutrition (PN) if safe enteral access can be achieved.5,6 In the malnourished patient who has a non-functioning or inaccessible gastrointestinal tract, PN may be life-saving.7
PN may improve clinical outcomes in both surgical and medical patients,8,9 but PN-related complications are associated with significant morbidity and sometimes mortality.10 Catheter-related bloodstream infections (CRBSIs) and metabolic abnormalities have been described in up to 40% of parenterally fed patients.10, 11, 12 A high frequency of inappropriate PN has been documented in both national surveys13 and prospective regional studies.14 It remains of prime importance to deliver PN safely to an appropriately selected patient group to optimise overall patient care.
Improvement of PN delivery may be achieved via a dedicated nutrition support team (NST).15 The multidisciplinary NST usually consists of a surgeon or a physician, a nutrition nurse specialist, a clinical dietician and a pharmacist.7 The NST may convert inappropriate PN referrals into enteral feeding, which, in a recent British study, was demonstrated in 41% of cases.10 Further, reductions in the occurrence of CRBSI10, 11, 12,16,17 and electrolyte disturbances18,19 have been observed after NST introduction. It is unclear whether inappropriate PN referrals relate to medical or surgical specialties and whether the introduction of an NST influences the indications for referral, the number of patients referred or the mean duration of PN.20,21
The compositions of reported NSTs and their implementations are heterogeneous, not only between countries22,23 but also within a single country.13,14 Most previous studies used retrospective control groups,10,11,24 which can introduce selection bias and lead to an overestimation of the improvements achieved. Often, studies included both patients in and outside of intensive care units (ICUs).10,14,24 Because the management of critically ill patients in ICU may differ from that of patients on general medical or surgical wards, studies including patients on both ICU and stationary wards may report biased effect measures favouring NST interventions.
The aim of this study was to investigate the impact of focused quality improvement (QI) initiatives including a non-randomised introduction of an NST in a general hospital ward setting. In particular, we wished to investigate the effect of an NST on PN referrals by speciality, indications for referral, subsequent use and related complications.
Materials and methods
The Salford Royal NHS Foundation Trust in the United Kingdom is a public acute teaching hospital with 850 stationary beds and highly specialised services in gastrointestinal (GI) surgery, neurosurgery, urology, nephrology, gastroenterology and dermatology. The hospital houses one of the national intestinal failure units (IFUs) in the United Kingdom. Patients within the IFU are tertiary or quaternary referrals, the majority being referred from outside the hospital, and are managed by a separate multidisciplinary team. These patients were therefore excluded from this study.
Data on hospital admissions and GI surgical procedures were obtained from the patient-administrative system. Prospective documentation of all PN referrals from hospital wards outside of the ICU and IFU was commenced in November 2008, using a hospital-based database. Concurrently, a dedicated intravenous (IV) team providing a dedicated IV service was established. The role of the IV team was to place all IV feeding catheters in patients referred for PN.
Non-randomised, organisational changes were implemented using the QI methodology adapted from the Model for Improvement25 and using dynamic Plan-Do-Study-Act cycles. Sustained improvements were demonstrated using statistical process control (SPC) charts, as described below.
Before February 2010, all PN referrals were directed to the hospital pharmacy and processed by a consultant biochemist integrated into the hospital pharmacy team. Provision of PN included a review of patient record and biochemistry and the prescription of PN. In February 2010, a complete NST was introduced alongside a number of QI initiatives. The organisational QI initiatives that were carried out included the following:
Hospital guidelines and a formal pathway for PN referrals
Re-training of ward staff in aseptic non-touch technique (ANTT) for accessing IV catheters and with annual ANTT assessment
Use of micron filters in PN giving sets
Dedicated IV access for PN; that is, restriction of a PN catheter use to PN alone
Monthly NST Governance Meeting
Regular Nutrition Training for staff nurses on mandatory teaching days
Scheduled daily NST PN ward round
The NST consisted of two nutrition nurse specialists, a clinical dietician, a pharmacist and a consultant gastroenterologist. During 2010 and 2011, further initiatives followed, including repeated ANTT training launched by the IV team (March, 2010), monthly hospital-wide ANTT and venous catheter care audits (January, 2011), a weekly PN multidisciplinary team meeting (July, 2011), a monthly PN workshop for ward staff (August, 2011), introduction of a PN patient information leaflet and revision of PN guidelines (April, 2012).
Registration of all PN referrals was established in November 2008 by the consultant biochemist. Only hospitalised patients admitted to general wards were included, and the PN course in the NST database was terminated if the patient was transferred to another hospital, to the ICU or to the IFU for long-term PN. This study included referrals from 1 January 2009 to 31 December 2012, with a subsequent follow-up period of 6 months. At the end of the study, all patients who had been referred for PN during the study period had terminated their PN or had been transferred to the IFU or to another hospital.
The collected data included patient demographics; referral and review dates; details regarding referring consultant; ward and specialty; indication for referral; PN start and finish dates and reason why PN was stopped or not initiated; occurrence of venous catheter sepsis (for definition, see below) or mechanical, thromboembolic or metabolic complications;26 and survival 30 days after stopping PN.
In all PN courses where a CRBSI was suspected, paired qualitative and semiquantitative blood cultures were taken from peripheral blood and from the central line. Diagnosis of a CRBSI was based on qualitative and quantitative assessment of central and peripheral blood cultures and pour plates, as recommended by European guidelines.26 All cases of a suspected CRBSI were evaluated by the NST Governance board and classified as a confirmed or disproved CRBSI.26
Referral data were stratified by month (mm-yyyy) and by year according to establishment of the NST. Process stability and change were analysed using SPC charts generated in QI Macros for Excel (KnowWare International Ltd, Denver, CO, USA). Non-random patterns (special cause variation) were determined according to standard definitions.27 In SPC charts, mean and limits for normal variation are provided. For descriptive variables, mean and 95% confidence intervals are provided. Frequencies in 2 × 2 tables were compared using χ2-test. Ordinal 2 × n tables were analysed using the Mantel–Haenszel χ2-test (linear-by-linear association). Variables following the normal distribution were evaluated by mean and standard deviation (s.d.) and compared by parametric statistics. The chosen two-sided level of statistical significance was 0.05. For statistical analyses, SPSS 11.0 (SPSS Inc., Chicago, IL, USA) was used.
This piece of work was undertaken as part of a service evaluation and development initiative and therefore did not require ethical approval. All patient data presented are fully anonymised.
Increased number of referrals for PN
During the study period, the number of patients referred for PN increased from 188 in 2009 to 337 in 2012 (Table 1). This corresponded to an increase from 3.6 to 7.9 PN referrals per 1000 admissions (P<0.001). In 2009, before NST formation, referral for PN was a stable process with a mean of 16 (4–28) referrals per month (Figure 1). The NST was implemented in February 2010. After a run-in period, in which the monthly number of referrals increased gradually, a special cause variation was identified on the SPC chart (Figure 1). It was therefore necessary to set a new point for a stable level of referrals after the introduction of a complete NST. This was reached in July 2010, at mean 26 (10–41) referrals per month (Figure 1). Although the annual number of referrals continued to rise during 2011 and 2012, a stability analysis within the SPC charts demonstrated that this did not represent a system change because all data remained within the limits of normal variation. The mean age of patients referred for PN increased slightly and not statistically significantly from 60 years (95% confidence interval=58–63) in 2009 to 64 (62–66) years in 2012.
The main service user of PN was GI surgery, accounting for 60% of all referrals both before and after NST introduction (Table 1). Referral distribution between surgical and medical specialties remained constant before and after NST formation. The total number of surgical procedures performed at the hospital during the study period was analysed using SPC charts, demonstrating a stable process with 618 procedures per months (limits of normal variation 518–720).
Among patients in whom PN was started, the indications for PN changed significantly after NST formation (Table 1). Thus, the frequency of patients in whom PN was started owing to an insufficient oral or enteral intake decreased from 11% to 3% (P=0.01, χ2-test), whereas the frequency of patients who were started on PN because of an ‘inaccessible gut’ increased concurrently. The percentages of patients with unsafe enteral access, GI obstruction, malabsorption or postoperative ileus or leak all remained constant during the study period (Table 1).
The mean PN duration was unchanged from 2009 to 2012 and was thus unaffected by NST introduction. In all, 30% of all PN courses were <5 days and 10% were >28 days. This was unrelated to the referring specialty and to NST implementation.
Increased number of referrals where PN was not started
The overall percentage of PN referrals where PN was not started increased from 5.3% in 2009 to 10.1% in 2012 (P=0.03, Mantel–Haenszel χ2-test; Figure 2a). This increase was, however, restricted to consultants who infrequently referred for PN (Figure 2b). On the basis of visual inspection of histograms displaying the yearly number of referrals from each consultant, those who made 10 or more PN referrals in any 1 year were identified and then categorised as frequent referrers. Thus, although a total of 125 consultants referred patients for PN, 18 (14%) of these consultants made 10 or more PN referrals per year, accounting for 68% of all PN referrals. When stratifying by specialty, the proportion of referrals where PN was not started only increased in referring specialties other than GI surgery and gastroenterology (Figure 2c).
The reasons why PN was not initiated are outlined in Table 1. Overall, enteral feeding could be established in up to half of the cases, and this percentage increased during the study period. In teams that infrequently referred for PN, enteral nutrition could be established in 31 of 51 (61%) of cases where PN was not started, as compared with 8 of 32 (25%) in teams in which the referring consultant made 10 or more PN referrals per year (P=0.001, χ2-test).
Reduced occurrence of complications following NST introduction
In most (75.0%) patients, PN could be stopped because sufficient oral or enteral nutrition had been established (Table 1). Furthermore, although 10% of patients had to discontinue PN owing to complications before NST introduction, this was only necessary in 2.1% of patients after NST formation (P<0.001, Mantel–Haenszel χ2-test; Table 1).
Reduced occurrence of CRBSI
The occurrence of CRBSIs dropped from 13 (7.2%) of 178 patients in 2009 to 4 (1.7%) of 230 patients in 2010 and further to 3 (1.0%) of 303 patients in 2012, corresponding to a CRBSI rate of 6.8 per 1000 catheter days in 2009 and 0.7 per 1000 catheter days in 2012 (Figure 3). A dedicated IV service team had been established in 2008, that is, before the present study. The reduction in CRBSI rate therefore occurred with the IV team in function throughout the study period. The use of peripherally inserted central catheters was documented after NST introduction in 2010 and increased from 39 (17%) of 230 in 2010 and 79 (28%) of 279 in 2011 to 116 (38%) of 303 in 2012 (P<0.001, Mantel–Haenszel χ2-test).
Thirty-day mortality (after stopping PN) dropped slightly after introduction of the NST from 15.6% in 2009 to 12.2% in 2012 (P=0.63, χ2-test). However, 30-day mortality was associated with the referral pattern, in that patients referred from consultants who made <10 PN referrals per year had a significantly higher 30-day mortality than patients referred by frequent referrers (P<0.001, Mantel–Haenszel χ2-test; Figure 4a). Mean age of these patients was slightly higher (64 years, s.d.=17) than of those referred by teams that frequently referred for PN (62 years, s.d.=14; P=0.05, Student’s t-test). Furthermore, when stratified by medical specialty, patients referred by GI surgery or gastroenterology teams had a significantly lower 30-day mortality than those referred from other specialties (P<0.001, Mantel–Haenszel χ2-test; Figure 4b). These associations were not affected by NST introduction.
This study highlights the dynamic impact of introducing an NST on the number of patients referred for PN, the indications for referral and core complications associated with PN. We found that the introduction of an NST led to a significant increase in the number of patients referred for PN; this increase was paralleled by the NST optimising the appropriateness of PN commencement, as reflected by an increased conversion from parenteral to enteral nutrition, principally among medical teams that infrequently referred to PN. Enhanced appropriateness for PN was further reflected by a shift in the indications for PN commencement following NST implementation, in that there was a reduction in patients commencing PN owing to an insufficient oral or enteral intake, with a concomitant increase in those starting PN because of an inaccessible gut. The CRBSI rate dropped significantly during the study period, and this may have been largely as a result of integrating the IV team into PN delivery. Notably, the NST also set into place measures (for example, ward ANTT retraining and dedicated PN catheter use) aimed at sustaining the low CRBSI rate throughout the study period.
Our finding that more patients started PN after the introduction of an NST is in contrast to previous studies that demonstrated reduced PN use following NST implementation, mainly owing to increased conversion to enteral nutrition.10,18 The increased number of PN referrals and subsequent PN utilisation in the present study is likely to reflect an increased awareness of the option of PN for malnourished patients after publicising the development of the NST in the hospital, particularly among non-GI specialties. Although the latter specialties referred more patients for PN, our data demonstrate that the NST selected out inappropriate requests for PN. This was reflected not only by an increased conversion rate of PN to enteral nutrition, which is in accordance with previous reports,10,21,24,28 but also by a reduction in the number of patients who started PN owing to an insufficient oral or enteral intake, by optimising oral and enteral nutrition delivery. Potentially, it is possible that the introduction of the NST biased the increase in PN courses in this study; however, this did not appear to be the case because there was a clear increase in the conversion rate of patients referred for PN being administered EN after NST review. This approach clearly underscores that it is important for the NST to maintain an undiminished priority to ensure the safest nutrition route for each patient.
The sustained reduction in CRBSI rate observed in this study was achieved with a functioning IV team established before the start of data collection. Previous studies demonstrated marked improvements in CRBSI rates following the introduction of an enhanced IV service, with or without simultaneous introduction of an NST alongside.10, 11, 12,16,17,29 Factors leading to improved CRBSI rates implemented by the IV team included integrated ANTT training sessions, improved catheter choice and improved line care protocols. Further improvements were obtained after NST introduction through measures such as regular and repeated staff education programmes in aseptic techniques and optimising the choice of venous catheter used for PN; the latter included the increased use of peripherally inserted central catheters. These measures also resulted in a reduction in the number of occasions in which PN had to be ceased as a result of catheter complications, which is a vital factor in the safe optimisation of a patient’s nutritional status.
Although PN complications improved during the study period, 30-day mortality remained unchanged. One previous study reported reduced in-hospital mortality from 43% to 24% following NST implementation, but this may result from improved patient selection, as PN was only started in 59% of referrals after the NST formation in that study.10 Our finding that 30-day mortality was increased in patients referred by non-GI surgery and non-gastroenterology teams, who also infrequently referred for PN, may reflect the higher incidence of comorbid illnesses seen in these patient groups, as reflected by the slightly higher mean age of patients referred by these teams.
Our study has obvious limitations. Patients were not randomised to be managed with or without the NST. Such a design may be perceived to be more rigorous but would be logistically cumbersome and not necessarily in patients’ immediate best interests. Rather, the pragmatic prospective evaluation of NST implementation using cyclic QI methodology provides clinically useful insight into the quality impact that a cohesive team can provide on service outcomes. The QIs observed in this study are difficult to attribute to specific team members or QI initiatives. Before NST introduction, a single consultant biochemist handled PN referrals, a practice similar to that used in some countries.23 We speculate that the introduction of a multidisciplinary team optimised all steps of the patient care pathway before and during receipt of PN, thereby improving the overall care delivered. Some authors examined whether a NST should be advisory or have the authority to terminate inappropriate PN.21,30,31 In the present study, the NST worked in close collaboration with the surgical or medical team responsible for the patient and facilitated joint decisions in the patients’ care. Finally, we did not collect data on electrolyte levels because these were adjusted for during PN prescription both before and after NST introduction.
In summary, the introduction of an NST resulted in an increased number of PN referrals and a concomitant reduction in the fraction of inappropriate PN courses, particularly in patients referred by teams that made less than 10 PN referrals per year and specialties other than GI surgery and gastroenterology. Because the NST was able to facilitate optimisation of enteral nutrition in patients referred from these specialties, more focused education and clinical input to patients admitted to wards outside GI surgery and gastroenterology should provide a better hospital-wide nutrition service.
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We thank Dr Aram Rudenski.
CH analysed the data and wrote the first manuscript draft. KF took part in data collection and analysis. ED participated in data collection and analysed SPC charts. BB, HL and CF collected most data and discussed data analysis. PP took part in data collection and data interpretation. SL conceived the study and took part in data interpretation. All authors discussed data analysis and manuscript drafts. All authors read and approved the final manuscript.
The authors declare no conflict of interest.
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Hvas, C., Farrer, K., Donaldson, E. et al. Quality and safety impact on the provision of parenteral nutrition through introduction of a nutrition support team. Eur J Clin Nutr 68, 1294–1299 (2014). https://doi.org/10.1038/ejcn.2014.186
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