A Call to Action for Optimizing the Electronic Health Record in the Parenteral Nutrition Workflow
Vincent W. Vanek MD, FACS, FASPEN
St Elizabeth Youngstown Hospital, Youngstown, Ohio, USA
Search for more papers by this authorPhil Ayers PharmD, BCNSP, FASHP
Mississippi Baptist Medical Center, Jackson, Mississippi, USA
Search for more papers by this authorMichael Kraft PharmD, BCNSP
University of Michigan, Ann Arbor, Michigan, USA
Search for more papers by this authorJean M. Bouche RD, CD
Option Care Home Infusion, Wauwatosa, Wisconsin, USA
Search for more papers by this authorVan T. Do PharmD
Oregon Health & Science University, Portland, Oregon, USA
Search for more papers by this authorCharles W. Durham PharmD, BCPS
Sentara Healthcare, Virginia Beach, Virginia, USA
Search for more papers by this authorCorresponding Author
Peggi Guenter PhD, RN, FAAN
American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
Corresponding Author:
Peggi Guenter, PhD, RN, FAAN, FASPEN, Senior Director of Clinical Practice, Quality, and Advocacy, American Society for Parenteral and Enteral Nutrition (ASPEN), 8401 Colesville Road, Suite 510, Silver Spring, MD 20910.
Email: [email protected]
Search for more papers by this authorLindsey Hoggle MS, RDN, PMP
Academy of Nutrition and Dietetics, Chicago, Illinois, USA
Search for more papers by this authorSteven W. Plogsted PharmD, BCNSP, CNSC
Nationwide Children's Hospital, Columbus, Ohio, USA
Search for more papers by this authorJessica M. Poehls PharmD, BCPPS
University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
Search for more papers by this authorPeggy Turner MS, RD, LD, FAND
University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
Search for more papers by this authorCharles Van Way III MD, FACS, FCCM, FCCP, FASPEN
University of Missouri, Kansas City, Missouri, USA
Search for more papers by this authorAmerican Society for Parenteral and Enteral Nutrition, Academy of Nutrition and Dietetics, American Society of Health-System Pharmacists
Search for more papers by this authorVincent W. Vanek MD, FACS, FASPEN
St Elizabeth Youngstown Hospital, Youngstown, Ohio, USA
Search for more papers by this authorPhil Ayers PharmD, BCNSP, FASHP
Mississippi Baptist Medical Center, Jackson, Mississippi, USA
Search for more papers by this authorMichael Kraft PharmD, BCNSP
University of Michigan, Ann Arbor, Michigan, USA
Search for more papers by this authorJean M. Bouche RD, CD
Option Care Home Infusion, Wauwatosa, Wisconsin, USA
Search for more papers by this authorVan T. Do PharmD
Oregon Health & Science University, Portland, Oregon, USA
Search for more papers by this authorCharles W. Durham PharmD, BCPS
Sentara Healthcare, Virginia Beach, Virginia, USA
Search for more papers by this authorCorresponding Author
Peggi Guenter PhD, RN, FAAN
American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
Corresponding Author:
Peggi Guenter, PhD, RN, FAAN, FASPEN, Senior Director of Clinical Practice, Quality, and Advocacy, American Society for Parenteral and Enteral Nutrition (ASPEN), 8401 Colesville Road, Suite 510, Silver Spring, MD 20910.
Email: [email protected]
Search for more papers by this authorLindsey Hoggle MS, RDN, PMP
Academy of Nutrition and Dietetics, Chicago, Illinois, USA
Search for more papers by this authorSteven W. Plogsted PharmD, BCNSP, CNSC
Nationwide Children's Hospital, Columbus, Ohio, USA
Search for more papers by this authorJessica M. Poehls PharmD, BCPPS
University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
Search for more papers by this authorPeggy Turner MS, RD, LD, FAND
University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
Search for more papers by this authorCharles Van Way III MD, FACS, FCCM, FCCP, FASPEN
University of Missouri, Kansas City, Missouri, USA
Search for more papers by this authorAmerican Society for Parenteral and Enteral Nutrition, Academy of Nutrition and Dietetics, American Society of Health-System Pharmacists
Search for more papers by this authorLinked content: This article is related to this executive summary by Vanek et al.: https://doi.org/10.1002/ncp.10202
This article is being copublished by the American Society of Health-System Pharmacists (ASHP), the Academy of Nutrition and Dietetics (AND), and the American Society for Parenteral and Enteral Nutrition (ASPEN). Minor differences in style may appear in each publication, but the article is substantially the same in each journal.
Financial disclosure: None declared.
Conflicts of interests: None declared.
Podcast available: Listen to a discussion of this manuscript with NCP Editor-in-Chief Jeanette M. Hasse, PhD, RD, LD, FADA, CNSC, and author Vincent W. Vanek, MD, FACS, FASPEN. This and other NCP podcasts are available at: https://onlinelibrary.wiley.com/page/journal/19412452/homepage/podcasts
Abstract
Parenteral nutrition (PN) is a complex therapeutic modality provided to neonates, children, and adults for various indications. Surveys have shown that current electronic health record (EHR) systems are in need of functionality enhancement for safe and optimal delivery of PN. This is a consensus statement from the American Society for Parenteral and Enteral Nutrition, the Academy of Nutrition and Dietetics, and the American Society of Health-System Pharmacists outlining some of the key challenges to prescribing, order review/verification, compounding, and administration of PN using EHRs today and is a call to action for clinicians and vendors to optimize their EHRs regarding the PN build and workflow.
References
- 1Ayers P, Guenter P, Holcombe B, Plogsted S. How to prescribe parenteral nutrition therapy. In: P Ayers, P Guenter, B Holcombe, S Plogsted, eds. ASPEN Parenteral Nutrition Handbook, 2nd ed. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 2014: 111-134.
- 2 National Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP) from the Agency for Healthcare Research and Quality (AHRQ). http://hcupnet.ahrq.gov/. Accessed December 10, 2015.
- 3 Institute for Safe Medication Practices. 2016-2017 Medication Safety Best Practices for Hospitals. http://www.ismp.org/tools/bestpractices/TMSBP-for-Hospitals.pdf. Accessed January 2017.
- 4Worthington P, Balint J, Bechtold M, et al. When is parenteral nutrition appropriate? JPEN J Parenter Enteral Nutr. 2017; 41: 324-377.
- 5Boullata JL, Guenter P, Mirtallo JM. A parenteral nutrition use survey with gap analysis. JPEN J Parenter Enteral Nutr. 2013; 37: 212-222.
- 6Ayers P, Adams S, Boullata JL, et al. ASPEN parenteral nutrition safety consensus recommendations. JPEN J Parenter Enteral Nutr. 2014; 38: 296-333.
- 7Boullata JI, Gilbert K, Sacks G, et al. American Society for Parenteral and Enteral Nutrition. ASPEN clinical guidelines: parenteral nutrition ordering, order review, compounding, labeling, and dispensing. JPEN J Parenter Enteral Nutr. 2014; 38(3): 334-377.
- 8Kochevar M, Guenter P, Holcombe B. ASPEN statement on parenteral nutrition standardization. JPEN J Parenter Enteral Nutr. 2007; 31: 441-448.
- 9Vanek VW, Ayers P, Kraft M, et al. Follow-up survey on functionality of nutrition documentation and ordering nutrition therapy in currently available electronic health record (EHR) systems. Nutr Clin Pract. 2016; 31: 401-415.
- 10Mirtallo J, Canada T, Johnson D, et al. ASPEN Board of Directors and Task Force for the Revision of Safe Practices for Parenteral Nutrition. Safe practices for parenteral nutrition [published correction appears in JPEN J Parenter Enteral Nutr. 2006;30:177]. JPEN J Parenter Enteral Nutr. 2004; 28: S39-S70
- 11 Agency for Healthcare Research and Quality. Standardized ordering and administration of total parenteral nutrition reduces errors in children's hospital. https://innovations.ahrq.gov/profiles/standardized-ordering-and-administration-total-parenteral-nutrition-reduces-errors. Accessed April 11, 2016.
- 12Ayers P, Guenter P, Holcombe B, Plogsted S. Review and verification of parenteral nutrition orders, preparing parenteral nutrition formulations, and labeling. In: P Ayers, P Guenter, B Holcombe, S Plogsted, eds. ASPEN Parenteral Nutrition Handbook, 2nd ed., Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 2014: 135-163.
- 13Sacks GS. Safety surrounding parenteral nutrition systems. JPEN J Parenter Enteral Nutr. 2012; 36(2 Suppl.): 20S-22S.
- 14Boullata JI. Overview of the parenteral nutrition use process. JPEN J Parenter Enteral Nutr. 2012; 36(2 Suppl.): 10S-13S.
- 15Singer P, Berger MM, Van den Berghe G, et al. ESPEN. espen guidelines on parenteral nutrition: intensive care. Clin Nutr. 2009; 28(4): 387-400.
- 16Braga M, Ljungqvist O, Soeters P, Fearon K, Weimann A, Bozzetti F; ESPEN. ESPEN guidelines on parenteral nutrition: surgery. Clin Nutr. 2009; 28(4): 378-386.
- 17 Fat Emulsion: Drug Information. Lexicomp Online®. https://online.lexi.com. Accessed December 2015 through UpToDate.
- 18Vanek VW, Borum P, Buchman A, et al. Novel Nutrient Task Force, Parenteral Multi-Vitamin and Multi-Trace Element Working Group; American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors. ASPEN position paper: recommendations for changes in commercially available parenteral multivitamin and multi-trace element products. Nutr Clin Pract. 2012; 27(4): 440-491.
- 19Vanek VW, Borum P, Buchman A, et al; Novel Nutrient Task Force, Parenteral Vitamin and Trace Element Working Group and the American Society for Parenteral and Enteral Nutrition (ASPEN): A call to action to bring safer parenteral micronutrient products to the U.S. market. Nutr Clin Pract. 2015; 30(4): 559-569.
- 20Driscoll DF, Bhargava HN, Li L, Zaim RH, Babayan VK, Bistrian BR. Physicochemical stability of total nutrient admixtures. Am J Health Syst Pharm. 1995; 52(6): 623-634.
- 21Gervasio J. Total nutrient admixtures (3-in-1): pros vs cons for adults. Nutr Clin Pract. 2015; 30(3): 331-335.
- 22Mirtallo JM, Dasta JF, Kleinschmidt KC, Varon J. State of the art review: intravenous fat emulsions: current applications, safety profile, and clinical implications. Ann Pharmacother. 2010; 44: 688-700.
- 23Driscoll DF. Lipid injectable emulsions: 2006. Nutr Clin Pract. 2006; 21: 381-386.
- 24Trissel LA. Phosphates. Trissel's™ 2 clinical pharmaceutics database. Cashiers, NC: TriPharma Communications. https://www.micromedexsolutions.com. Accessed January 2016.
- 25Kraft MD, Btaiche IF, Sacks GS, Kudsk KA. Treatment of electrolyte disorders in adult patients in the intensive care unit. Am J Health Syst Pharm. 2005; 62(16): 1663-1682.
- 26 Potassium chloride: drug information. Lexicomp Online®. https://online.lexi.com. Accessed December 2015 through UpToDate.
- 27Pittiruti M, Hamilton H, Biffi R, MacFie J, Pertkiewicz M; ESPEN. ESPEN guidelines on parenteral nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr. 2009; 28(4): 365-377.
- 28 ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr. 2002; 26(1 Suppl.): 1SA-138SA.
- 29Sathe MN, Patel AS. Update in pediatrics: focus on fat-soluble vitamins. Nutr Clin Pract. 2010; 25(4): 340-346.
- 30Koletzko B, Goulet O, Hunt J, et al. Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society of Clinical Nutrition and Metabolism (EPSEN), supported by the European Society of Paediatric Research (ESPR). J Pediatr Gastroenterol Nutr. 2005; 41(Suppl. 2): S19-S27.
- 31Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics. 1957; 19: 823-832.
- 32Greene HL, Hambidge KM, Schanler R, Tsang RC. Guidelines for the use of vitamins, trace elements, calcium, magnesium, and phosphorus in infants and children receiving total parenteral nutrition: report of the Subcommittee on Pediatric Parenteral Nutrient Requirements from the Committee on Clinical Practice Issues of the American Society for Clinical Nutrition. Am J Clin Nutr. 1988; 48(5): 1324-1342.
- 33Koo W, Christie J, Saba M, Lulic-Botica M, Warren L. Water-soluble essential micronutrients. In: MR Corkins, ed. ASPEN Pediatric Nutrition Support Core Curriculum, 2nd ed. Silver Spring, MD: ASPEN; 2015: 69-90.
- 34Dudrick SJ. Rhoads lecture: a 45-year obsession and passionate pursuit of optimal nutrition support: puppies, pediatrics, surgery, geriatrics, home TPN, ASPEN, et cetera. JPEN J Parenter Enteral Nutr. 2005; 29(4): 272-287.
- 35Wilmore DW, Dudrick SJ. Growth and development of an infant receiving all nutrients exclusively by vein. JAMA. 1968; 203(10): 860-864.
- 36Dudrick SJ, Wilmore DW, Vars HM, Rhoads JE. Long-term total parenteral nutrition with growth, development, and positive nitrogen balance. Surgery. 1968; 64(1): 134-142.
- 37Driscoll DF. Pharmaceutical and clinical aspects of lipid injectable emulsions JPEN J Parenter Enteral Nutr. 2017; 41: 125-134.
- 38Allwood MC, Kearney MC. Compatibility and stability of additives in parenteral nutrition admixtures. Nutrition. 1998; 14(9): 697-706.
- 39Sacks GS, Rough S, Kudsk KA. Frequency and severity of harm of medication errors related to the parenteral nutrition process in a large university teaching hospital. Pharmacotherapy. 2009; 29: 966-974.
- 40Bonnabry P, Cingria L, Sadeghipour F, Ing H, Fonzo-Christe C, Pfister RE. Use of a systematic risk analysis method to improve safety in the production of paediatric parenteral nutrition solutions. Qual Saf Health Care 2005; 14: 93-98.
- 41Brown CL, Garrison NA, Hutchinson AA. Error reduction when prescribing neonatal parenteral nutrition. Am J Perinatol. 2007; 24: 417-427.
- 42 American Society of Health-System Pharmacists. ASHP guidelines on the safe use of automated compounding devices for the preparation of parenteral nutrition admixtures. Am J Health-Syst Pharm. 2000; 57: 1343-1348.
- 43MacKay M, Anderson C, Boehme S, Cash J, Zobell J. Frequency and severity of parenteral nutrition errors at a large children's hospital after implementation of electronic ordering and compounding. Nutr Clin Pract. 2016; 31: 195-206.
- 44Hilmas E, Peoples JD. Parenteral nutrition prescribing processes using computerized prescriber order entry: Opportunities to improve safety. JPEN J Parenter Enteral Nutr. 2012; 36 (Suppl. 2): 32S-35S.
- 45 Institute for Safe Medication Practices. Another tragic parenteral nutrition compounding error. ISMP Medication Safety Alert! April 21, 2011. https://www.ismp.org/newsletters/acutecare/articles/20110421.asp. Accessed May 12, 2016.
- 46 Institute for Safe Medication Practices. Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors. ISMP Medication Safety Alert! June 28, 2012. https://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=25. Accessed April 11, 2016.
- 47 FDA. First Annual Report on Drug Shortages for Calendar Year 2013. http://www.fda.gov/downloads/drugs/drugsafety/drugshortages/ucm384892.pdf. Accessed May 12, 2016.
- 48 U.S. Food and Drug Administration. Drug shortages infographic. http://wayback.archive-it.org/7993/20170111082354/http://www.fda.gov/downloads/Drugs/DrugSafety/DrugShortages/UCM384892.pdf. Updated December 15, 2016. Accessed March 27, 2018.
- 49Staes C, Jacobs J, Mayer J, et al. Description of outbreaks of health-care-associated infections related to compounding pharmacies, 2000-12. Am J Health-Syst Pharm. 2013; 70: 1301-1312.
- 50Davis C, Javid PJ, Horslen S. Selenium deficiency in pediatric patients with intestinal failure as a consequence of drug shortage. JPEN J Parenter Enteral Nutr. 2014; 38: 115-118.
- 51Pramyothin P, Kim DW, Young LS, et al. Anemia and leukopenia in a long-term parenteral nutrition patient during a shortage of parenteral trace element products in the United States. JPEN J Parenter Enteral Nutr. 2013; 37: 425-429.
- 52Robbins R. “Children are dying”. The Washingtonian, May 22, 2013. www.washingtonian.com/articles/people/children-are-dying/index.php. Accessed Jan 1, 2016.
- 53 Institute for Safe Medication Practices. Drug shortages: national survey reveals high level of frustration, low level of safety. ISMP Medication Safety Alert 2010;15(15):Sept 23.
- 54 Institute for Safe Medication Practices. Survey links PN component shortages to adverse outcomes. ISMP Medication Safety Alert 2014;19(3):Feb 13.
- 55Wright L, Grisso AG, Feldott CC, et al. Using computerized prescriber order entry to implement actions of the pharmacy and therapeutics committee. Hosp Pharm. 2007; 42: 763-766.
10.1310/hpj4208-763 Google Scholar
- 56Hassig TB, McKinzie TB, Fortier CR, et al. Clinical management strategies and implications for parenteral nutrition shortages in adult patients. Pharmacother. 2014; 34: 72-84.
- 57 Health Level Seven International. HL7 Messaging Standard Version 2.8.2. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=403. Accessed April 25, 2017.
- 58Chaffee BW, Bonasso J. Strategies for pharmacy integration and pharmacy information system interfaces, part 2: scope of work and technical aspects of interfaces. Am J Health-Syst Pharm. 2004; 61(5): 506-514.
- 59 Health Level Seven (HL7) Pharmacy Working Group. Attach 7.06 PN in EHRs Pharmacy WG Meeting. January 11, 2016. http://www.hl7.org/Special/committees/medication/minutes.cfm. Accessed March 27, 2018.
- 60Jones SS, Rudin RS, Perry T, Shekelle PG. Health information technology: an updated systematic review with a focus on meaningful use. Ann Intern Med. 2014; 160: 48-64.
- 61Van der Sijs H, Aarts J, Vulto A, Berg M. Overriding of prescribing alerts in computerized physician order entry. J Am Med Inform Assoc. 2006; 13: 138-147.
- 62Stout SM, Cober MP. Metabolic effects of cyclic parenteral nutrition infusion in adults and children. Nutr Clin Pract. 2010; 25(3): 277-281.
- 63Krzywda EA, Andris DA, Whipple JK, et al. Glucose response to abrupt initiation and discontinuation of total parenteral nutrition. JPEN J Parenter Enteral Nutr. 1993; 17(1): 64-67.
- 64Suryadevara S, Celestin J, DeChicco R, Austhof S, Corrigan M, Speerhas R, Steiger E. Type and prevalence of adverse events during the parenteral nutrition cycling process in patients being prepared for discharge. Nutr Clin Pract. 2012; 27(2): 268-273.
- 65Eisenberg PG, Gianino S, Clutter WE, Fleshman JW. Abrupt discontinuation of cycled parenteral nutrition is safe. Dis Colon Rectum. 1995; 38(9): 933-939.
- 66Wagman LD, Newsome HH, Miller KB, Thomas RB, Weir GC. The effect of acute discontinuation of total parenteral nutrition. Ann Surg. 1986; 204(5): 524-529.
- 67Nirula R, Yamada K, Waxman K. The effect of abrupt cessation of total parenteral nutrition on serum glucose: a randomized trial. Am Surg. 2000; 66(9): 866-869.
- 68Werlin SL, Wyatt D, Camitta B. Effect of abrupt discontinuation of high glucose infusion rates during parenteral nutrition. J Pediatr. 1994; 124(3): 441-444.
- 69Bendorf K, Friesen CA, Roberts CC. Glucose response to discontinuation of parenteral nutrition in patients less than 3 years of age. JPEN J Parenter Enteral Nutr. 1996; 20(2): 120-122.
- 70Ireton-Jones C, DeLegge M. Home parenteral nutrition registry: a five-year retrospective evaluation of outcomes of patients receiving home parenteral nutrition support. Nutrition. 2005; 21(2): 156-160.
- 71Howard L. Home parenteral nutrition: survival, cost, and quality of life. Gastroenterology. 2006; 130(2 Suppl. 1): S52-S59.
- 72 Office of the National Coordinator of Health IT Website: A shared nationwide interoperability roadmap. https://www.healthit.gov/policy-researchers-implementers/interoperability. Accessed November 21, 2016.
- 73 Office of the National Coordinator of Health IT Website: ONC Health IT Certification Program. https://www.healthit.gov/policy-researchers-implementers/about-onc-health-it-certification-program. Accessed November 21, 2016.
- 74 Centers for Medicare and Medicaid Services. IMPACT Act of 2014 Data Standardization & Cross Setting Measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-of-2014-Data-Standardization-and-Cross-Setting-MeasuresMeasures.html. Updated September 14, 2016. Accessed March 27, 2018.
- 75 Office of the National Coordinator of Health IT Website: 2015 Edition Health IT Standards Criteria. https://www.healthit.gov/policy-researchers-implementers/2015-edition-final-rule. Accessed November 21, 2016.
- 76 Office of the National Coordinator of Health IT Website: 2017 Interoperability Standards Advisory. https://www.healthit.gov/isa/. Accessed April 25, 2017.