Nutrition Assistant

Nutrition Assistant© is a clinical suite of modules tailored to help providers create Parenteral Nutrition (PN) orders for distinct patient age groups. The modules use over 100 clinical algorithms to ensure appropriate, compatible solutions are written and errors are addressed in a prospective manner. The modules are designed to deliver the optimum parenteral feeding for each patient age group whether neonate, pediatric, or adult. Compounder interfacing limits potential transcription errors and improves workflow efficiency.

Writing Parenteral Nutrition (PN) orders for pediatric and neonatal patient populations is a time consuming and clinically difficult process. Most hospitals still use hand written physician orders for this task despite many problems with this paradigm.

Challenges of Writing TPN Orders

A typical pediatric hospital has a pre-printed TPN order form that is filled in by a physician on the floors. The order is usually a 2 or 3 part form where the top copy is left in the chart and the other copies are sent to nursing/dietary and pharmacy for compounding.

Calculation Errors

Handwritten orders involve physicians having to base dosing decisions off of calculated values. These calculations are often done on the nursing unit with or without the aid of a calculator. For example, if a new 2 year old patient needs 80 kcal per kilogram per day, the physician must calculate the percentage of dextrose that is required to provide these calories. The rate of the TPN infusion must also be calculated to ensure that the dextrose is not infused too quickly as this can cause negative clinical outcomes for the patient. These are just two examples of the type of thought that must be given to each TPN order. Much of the logic that is used in writing a pediatric or neonatal TPN is rules based and can be done by a series of calculations and “if / then” statements within a computer program.

Legibility Errors

Another problem with handwritten orders is that the pharmacy is usually receiving the 2nd or sometimes 3rd copy of the form. Other institutions fax the order to the pharmacy for compounding. Either a carbon copy or faxed order will not help the pharmacist with an age old quandary for hospitals, legibility. Physicians are usually writing these orders in haste and they are difficult to decipher. An order for 1.0 mEq of Sodium Chloride could be misread by the compounding pharmacist as 10 mEq. These types of transposition errors occur every day in hospitals around the country and cause patient harm in many instances.

Inefficiency

One of the biggest drawbacks with handwritten TPN orders is that any dosing or calculation errors are caught at the end of the process by the compounding pharmacist rather than at the point of order generation. At the time the pharmacist might catch an error, the physician may have already left the hospital and the pharmacist must track them down to get a verbal order for the changes that are needed. There is a great amount of both pharmacist and physician time spent on the fixing of TPN problems. If an order is misread by the pharmacist during compounding and the nurse catches the error, the TPN must be wasted and a new one made usually when staffing is not adequate for such a task.

Calcium - Phosphate Solubility

The most difficult aspect of writing a neonatal or pediatric TPN order is how to maximize the amount of calcium and phosphate that can be added to the TPN. Growing children need larger amounts of these electrolytes than adults. It is critical for proper bone development that children and neonates receive as much of these elements as clinically appropriate. The problem is that these elements will bind to each other if the concentrations are too high. When they bind, a precipitate salt is formed in the TPN. If precipitation occurs and is not noticed before administration, patient death can occur.

  • Reduce available options: Use either calcium gluconate or calcium chloride in an institution, but not both.
  • To avoid calcium phosphate precipitation, prepare solutions containing calcium and phosphorus only in the pharmacy, using standard protocols. Avoid mixing with lipids because visible precipitation will be obscured.
  • Standardize ordering: calcium should be ordered based on the number of mEq of calcium. Calcium should never be ordered by number of "amps" or "mLs." The salt should always be expressed.
  • Standardize administration: Develop a standard administration protocol including rules for rate of administration and monitoring of calcium, phosphate and albumin levels prior to administration.

The Solution: Computerized Order Entry

By utilizing technology to help with the problems of handwritten neonatal and pediatric orders, a safer more efficient model can be achieved.

Calculation

Computerized physician order entry (CPOE) would allow calculations to be done by a computer rather than by a process that will ultimately fall prey to human error. All aspects of dosing could be considered by the program and the correct amount of nutrition can be evaluated in seconds rather than minutes or hours. In the image below, values are calculated for the physician rather than by the physician.

Legibility

With computer order entry, legibility issues are greatly reduced because the order is printed rather than hand written. Printed orders are much easier to read and multiple copies can be produced without any degradation of the quality. The image below is a printed order.

Inefficiency

The inefficiency of retrospective evaluation of TPN orders rather than prospective results in lost pharmacist, nursing, and physician time. The time spent clarifying, correcting, and evaluating TPN orders could be spent on other patient care activities if a CPOE model was adopted. A computer program could warn the provider of any deviation from accepted standards or protocols before the order was ever completed or printed. In the image below, the user is being warned that one the values entered is not acceptable. The program will not allow the order to be completed until the problem is rectified.

Calcium - Phosphate Solubility

The most difficult aspect of writing a neonatal or pediatric TPN order is how to maximize the amount of calcium and phosphate that can be added to the TPN. This is a perfect job for a sophisticated computer program. A program can perform linear regression of published calcium-phosphate solubility curves to determine if entered values are compatible or not. The text in red below is telling the provider that this solution is not compatible.

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