Unnecessary Labor
Like many dietitians who work in small community hospitals, it has become not only safer but also easier for the RD to be able to enter orders for nutrition support under a physicians’ order. Training PCPs on how to enter orders for PN seems like a road with no ending. Most PCPs know very little about nutrition much less PN, so the nuances and important factors get lost.
During regular work hours this doesn’t seem to be as big of an issue as after hours and weekends when staffing is less and normal communication channels may be different. We found ourselves being called upon to put in orders for PN (and enteral feeds) very often during off hours. Our group found that the most call backs on weekends were for basically starting nutrition support.
This seemed unnecessary. We were putting in orders that anyone could do but PCP and nursing staff had not been taught how during computer training. They also complain that they do not feel comfortable because there are so many issues to evaluate when starting PN. These are valid issues, and I honestly would not feel comfortable with many floor nurses putting in orders for PN. We have all become specialized and the many facets of PN can be complicated to staff who deal with a myriad of other things throughout their shift.
New Formulas, New Orders
When we decided to add Baxter premixed PN to our formulary, we also decided to change our orders for PN to make it more simplistic. Things we needed to consider:
- That PCPs could order PN and feel comfortable
- That nurses would feel comfortable when the order was put in.
- All labs were ordered, lab values were addressed, ivf that were currently infusing reviewed, and Nutrition and Pharmacy were consulted to manage the PN.
- An initial or “starter bag” was available that all patients could use for the first 24 hour infusion.
How it works
When a PCP decides that PN should be started (generally from direction of the RD), they will put in a specific order that pharmacy and nutrition services put together. The PCP simply has to type in “tpn” into our order section anytime they want to start TPN or PPN. When this order is put in, an specific order pops up that they click and accept. The dietitians and pharmacists are automatically consulted, labs are ordered as well as SSI. The orders follow the policy below (the policy is attached to the order).
If this is ordered during regular office hours, the RD will then add an order for the specific PN, generally a pre-mixed bag. If the PCP orders PN during off hours, then the pharmacists will put in an order for a 4.25/5 solution without electrolytes to be run at 42 ml/hour. Basically, we run a PPN solution for the first day, until 1800 the next day.
The 4.24/5 solution is beneficial because it can infuse through a peripheral vein if the patient does not have central access. It is easily tolerated and low enough in macronutrients that it should avoid refeeding syndrome issues. We have a universal hang time of 1800. All new bags of PN are hung at 1800, and any bag that is currently hanging will be taken down and the new bag that was re-ordered that day will be hung at that time. Rate changes are also done at 1800.
Infusing at a lower rate for the first day also assists with decreasing fluid overload. Changes can then be made the next day for the new bag.
What We Had to do to Get Here
Many, many, many meetings with pharmacy, nutrition, IT, physicians and the control groups of our hospital. It had to pass policy and procedure committees, physician committees, hospitalists and intensivists groups. It took several months, but most of the PCPs were very supportive.
The biggest hurdle was education with the PCPs and nursing. This occurred through emails, meetings, huddles and many one on ones with specific individuals when PN was ordered incorrectly. It took about 6 months for it to run smoothly. We made it as simple as possible but still have to do some education with staff every now and then.
The Benefits
PN can be initiated when needed, not just when an RD is available. The patient can get a day’s worth of a small amount of nutrition, labs can be assessed and supplemented, ssi can be started. The RD can then adjust the PN as needed when they are available, generally the next morning A new order can then be placed and the new bag will be hung at 1800. If the patient is unable to have a central access placed, the PN can still be started because it is a peripheral solution. The access issues can be sorted out the next day.
These new orders have decreased our call backs for PN to almost zero. We no longer have to physically come into the facility to put in orders or log in from home to do it there.
There has been good tolerance to patients using these new orders, decreases in glucose, better control of blood sugars on the whole and better electrolyte control, quicker initiation of PN. All in all, I think it has been a success.
Enteral
My next installment will be how we did the same think except with enteral orders. This has really saved us time!
Let me know what you think or if you have any questions!