Phil Ayers

A.S.P.E.N. Parenteral Nutrition Safety Consensus Recommendations

Parenteral nutrition (PN) serves as an important therapeutic modality that is used in adults, children, and infants for a variety of indications. The appropriate use of this complex therapy aims to maximize clinical benefit while minimizing the potential risks for adverse events. Complications can occur as a result of the therapy and as the result of the PN process. These consensus recommendations are based on practices that are generally accepted to minimize errors with PN therapy, categorized in the areas of PN prescribing, order review and verification, compounding, and administration. These recommendations should be used in conjunction with other A.S.P.E.N. publications, and researchers should consider studying the questions brought forth in this document.

Standardized Competencies for Parenteral Nutrition Prescribing The American Society for Parenteral and Enteral Nutrition Model

Parenteral nutrition (PN) provision is complex, as it is a high-alert medication and prone to a variety of potential errors. With changes in clinical practice models and recent federal rulings, the number of PN prescribers may be increasing. Safe prescribing of this therapy requires that competency for prescribers from all disciplines be demonstrated using a standardized process. A standardized model for PN prescribing competency is proposed based on a competency framework, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)-published interdisciplinary core competencies, safe practice recommendations, and clinical guidelines. This framework will guide institutions and agencies in developing and maintaining competency for safe PN prescription by their staff.

Diagnosis and Treatment of Simple Acid-Base Disorders

The ability to diagnose and treat acid-base disorders is an important component in the practice of the nutrition support clinician. A complete understanding of the basic principles of metabolic and respiratory disorders allows the practitioner to formulate educated decisions regarding fluids, parenteral nutrition salts, and the management of electrolytes. This review will discuss the diagnosis and treatment of common metabolic and respiratory disorders encountered in nutrition support practice.

Implementation of a pharmacist-led, multidisciplinary diabetes management team.

PURPOSE The development, implementation, and evaluation of a pharmacist-led, multidisciplinary diabetes management team (DMT) at a 564-bed medical center in Jackson, Mississippi, are described. SUMMARY The overwhelming prevalence of diabetes in Mississippi has a major impact on the states health care system. Mississippi Baptist Health Systems (MBHS) developed a consultation-driven DMT in November 2008. The DMT embraced the multidisciplinary approach by uniting pharmacists, physicians, and other health care providers to optimize the care of patients with diabetes. The DMT initially focused on patients undergoing coronary artery bypass graft (CABG) surgery but also manages patients with a variety of causes of hyperglycemia. To evaluate the success of the DMT, postoperative serum blood glucose levels were collected from January 2008 through December 2010 for patients undergoing CABG at MBHS before and after the implementation of the DMT. The primary outcome was the number of patients with serum blood glucose concentrations exceeding 200 mg/dL. Secondary outcomes measured included the rates of sternal surgical-site infection and the frequency of hypoglycemia. CONCLUSION Implementation of a pharmacist-led, multidisciplinary DMT helped to achieve intensive glycemic control in CABG patients and decrease the rate of infection.

Follow-Up Survey on Functionality of Nutrition Documentation and Ordering Nutrition Therapy in Currently Available Electronic Health Record Systems

BACKGROUND This is a follow-up survey to reassess the safety and efficacy of nutrition content in the available electronic health record (EHR) systems. MATERIALS AND METHODS Members of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), American Society for Nutrition, and the Academy for Nutrition and Dietetics were asked to participate in an online survey. The survey included questions from a 2012 EHR survey on the safety and efficacy in 5 nutrition content areas as well as questions from previous 2003 and 2011 A.S.P.E.N. parenteral nutrition (PN) surveys. RESULTS Percent of respondents using an EHR and using the EHR for less than 1 year increased between 2012 and 2014 (86%-94%, P < .05; 11%-16%, P < .05, respectively). However, there was no improvement in the safety and efficacy of the 5 nutrition content areas, with a significant decrease in 2 of these areas, ordering oral nutrition supplements and ordering PN. The top-rated EHR vendors had a higher average favorable response rate in regards to safety and efficacy in the nutrition content areas but even the top-rated EHR vendor had only a 60% average in favorable responses. Reported use of electronic PN ordering and a direct interface between the EHR and the automated compounding device (ACD) significantly increased from 2003 to 2011 to 2014 (29% to 33% to 63% and 16% to 19% to 28%, respectively, P < .05). CONCLUSIONS This is a call to action to nutrition support clinicians, societies, and organizations to proactively be involved in initiatives to educate clinicians and collaborate with EHR vendors to enhance the EHR systems to improve the safety and efficacy of providing nutrition therapy in hospitalized patients.

Standardized Competencies for Parenteral Nutrition Order Review and Parenteral Nutrition Preparation, Including Compounding The ASPEN Model

Parenteral nutrition (PN) is a high-alert medication with a complex drug use process. Key steps in the process include the review of each PN prescription followed by the preparation of the formulation. The preparation step includes compounding the PN or activating a standardized commercially available PN product. The verification and review, as well as preparation of this complex therapy, require competency that may be determined by using a standardized process for pharmacists and for pharmacy technicians involved with PN. An American Society for Parenteral and Enteral Nutrition (ASPEN) standardized model for PN order review and PN preparation competencies is proposed based on a competency framework, the ASPEN-published interdisciplinary core competencies, safe practice recommendations, and clinical guidelines, and is intended for institutions and agencies to use with their staff.

Parenteral Nutrition Errors and Potential Errors Reported Over the Past 10 Years

Parenteral nutrition (PN) is a complex, high-alert medication, and errors associated with the use of this therapy may lead to significant harm to patients. This document reviews error reports from the Institute for Safe Medication Practices’ Medication Errors Reporting Program that are associated with the PN use process over the past 10 years. Actual PN-related errors are outlined, with most occurring in the PN-compounding/dispensing and PN administration steps. Clinicians involved in any phase of the PN use process should review their institutional or homecare company’s processes for reporting of PN errors and collaborate with their medical safety officer and/or committees involved with medication error reporting.

Lipid Injectable Emulsion Survey with Gap Analysis

Background: Lipid injectable emulsion (ILE) is an integral part of parenteral nutrition (PN), providing energy and essential fatty acids. With recent consensus recommendations for PN, clinical guidelines for ordering and preparation of PN, the U.S. Food and Drug Administration approval of new ILE products, and revised ILE labeling to include a 1.2-micron filter, a gap in current practice knowledge was apparent. Materials and Methods: The American Society for Parenteral and Enteral Nutrition PN Safety Committee surveyed clinicians on how ILE products are prescribed, prepared, and administered to patients from neonates to adults. Results: The results of this survey conducted in late 2016 found a wide variation in practice, particularly across patient age groups. Conclusion: These findings demonstrate the need for ongoing dissemination and education on standardized safe practices for ILE use.

Acid-Base Disorders Learning the Basics

Nutrition support practitioners should be confident in their ability to recognize and treat various metabolic and respiratory disorders encountered in daily practice. A clinicians comprehension of the underlying physiologic processes and/or exogenous causes that occur during acid-base disorders is essential when making therapeutic decisions regarding fluids, parenteral nutrition, and electrolyte management. This invited review will discuss basic metabolic and respiratory disorders while briefly addressing mixed acid-base disorders.

Simple Acid-Base Tutorial

The nutrition support practitioner is confronted with numerous metabolic abnormalities in the daily care of patients. An understanding of the basic principles of acid-base balance, along with the ability to recognize common causes of the various disorders, enhances the clinicians ability to provide specialized nutrition support. The basic metabolic and respiratory disorders, along with common causes, are reviewed in this tutorial.