Standardized Competencies for Parenteral Nutrition Administration: The ASPEN Model

Abstract

Parenteral nutrition (PN) is a highly complex medication and its provision can be prone to a variety of errors. Safe administration of this therapy requires that the competency of clinicians, particularly nurses, be demonstrated using a standardized process. In this document, a standardized model for PN administration competency is proposed based on a competency framework, the ASPEN-published interdisciplinary core competencies, discipline-specific standards of practice, safe practice recommendations, and clinical guidelines. ASPEN recognizes that all healthcare institutions may not currently meet the aspirational goals of this document. This framework will guide institutions and agencies in developing tools and procedures and maintaining competency of staff members around safe PN administration. The ASPEN Board of Directors has approved this document.

Introduction

Parenteral nutrition (PN) is a high-alert medication and prone to a variety of potential errors. In 2014, patients received PN during approximately 300,000 hospital stays, about 25,000 patients on home PN, and many others received it in a long-term care setting.1, 2 Because many PN administration errors occur at the point of patient contact, mistakes in this phase of the medication delivery process are less likely to be intercepted and more likely to cause harm than other types of PN errors. In addition, the broad range of healthcare settings in which PN administration takes place—from critical care to home care—creates the potential for disparities to exist in technology and equipment, as well as in the knowledge and skills of the nursing staff and other caregivers responsible for administering PN. Regardless of the setting or the number of patients receiving this therapy in a facility, the classification of PN as a high-alert medication requires healthcare organizations to develop evidence-based policies and procedures designed to promote safe PN administration and to validate the competence of those responsible for delivering this complex form of intravenous (IV) therapy.3

Safe provision of PN therapy requires standardized protocols, interprofessional communication, and vigilant surveillance for complications. The PN use process is associated with a variety of potential errors, from ordering the PN prescription to administering the therapy to a patient. Appropriate practices and safeguards are critical to assuring patient safety. ASPEN recognizes that all healthcare institutions may not currently meet the aspirational goals of this document. This document will focus on those competencies required for PN administration, which are generally performed by nurses. This document will not address the specifics of PN administration by patients and/or caregivers. This article is a companion to the ASPEN PN Prescribing and the PN Order Review and Compounding Competency model articles that have been previously published.4, 5

PN administration errors have been well documented. A recently published paper by members of the ASPEN PN Safety Committee, based on data from the Institute for Safe Medication Practices Medication Errors Reporting Program (ISMP MERP) reports, noted that the greatest number of errors were associated with compounding and dispensing PN. The second most common errors were those associated with the administration process.6 Many of the errors reported involved the infusion pump programming: incorrect infusion rates, failure to turn the pump on, or incorrect infusion times. Inadvertent rate and line mix-ups were among the most common errors reported, particularly when the lipid injectable emulsion (ILE) was administered as a separate infusion from the dextrose/amino acid admixture.7, 8

In another series by Sacks et al, 67% of the errors associated with patient harm occurred during PN administration. For example, infusing the PN over 12 hours instead of the prescribed 24 hours resulted in hyperglycemia and fluid overload in patients who cannot tolerate a cycled infusion.9 Data from MacKay et al demonstrated that the most common administration errors were associated with PN infusion rate changes (34%), adjustments in ILE after the PN infusion started (23%), or PN component incompatibilities (13%). As a result of these findings, McKay's organization implemented smart pump administration of PN with hard and soft limits for infusion, as well as barcoding for PN order administration.10

PN admixtures are prepared and sent to the bedside in a variety of delivery systems, which can contribute substantially to staff member confusion. In a study by Boullata and colleagues conducted in 2011, PN was administered as compounded admixtures by 72% of institutions, while 21% used standardized commercially available multi-chamber PN products; the remainder of the respondents used both types. Forty-five percent used 2-in-1 (dextrose/amino acids admixtures with separate ILE infusions), while 28% used 3-in-1 (total nutrient admixtures [TNA]), with the remainder using both types.11 Multi-chamber bag PN admixture systems have been associated with reported infusion errors caused by lack of activation of the individual chambers.12 The variety of PN delivery types requires that the nurse be competent with all types of PN products in use by their institution or agency.

General PN Safety

The 2014 ASPEN PN Safety Consensus Recommendations document provides guidance on using in-line filters for PN administration to reduce the potential for patient harm due to particulates, micro-precipitates, microorganisms, and air emboli. The recommendations are to use a 0.22-micron filter for dextrose/amino acids admixtures and to use a 1.2-micron filter for TNAs.3 The filter should be placed as close to the patient as possible on the administration system. The filter and administration set should be changed with each new PN container or every 24 hours for 3-in-1 or TNAs and 2-in-1 or dextrose/amino acids admixtures. An occluded filter should be removed and replaced with a new filter. An unfiltered PN admixture should not be infused.3

Since the publication of the ASPEN PN Safety Consensus Recommendations document, the manufacturers of ILE products for use in the United States have revised their administration instructions to include a statement to filter all ILE infusions using a 1.2-micron in-line filter.13 To comply with this new recommendation, practitioners must use 2 filters when administering PN as dextrose/amino acids (2-in-1) admixture and the ILE as a separate infusion. A 0.22-micron in-line filter is used for the dextrose/amino acids solution. The second filter, a 1.2-micron filter, is for the ILE, which is infused by means of a Y-connector placed closer to the patient than the 0.22-micron filter for the dextrose/amino acids admixtures or via a separate vascular access device such as a peripheral catheter. The recommendation for filtering TNAs using a single 1.2-micron in-line or add-on filter has not changed.13 In a recent survey on ILE use, the issue of filters was raised and the findings demonstrated a gap in knowledge regarding the appropriate use of filters and an opportunity for continued education and further research.13 Up to 20% of respondents did not filter ILE when administered as a separate infusion despite a recent call by the FDA to do so.13

Point of care drug administration systems may also decrease administration errors. For example, interfacing computerized provider order entry (CPOE) systems with automated compounding device (ACD) technologies can permit checking the dose of PN components, and the PN label barcode can provide information for administration to prevent wrong-patient errors. Beyond root cause analysis, which allows response to isolated errors, a methodical systems review of the full PN use process can enhance contextual learning and allow for system improvements to advance safety.14 Healthcare institutions must emphasize reporting of PN medication errors to enhance safe use of this important therapeutic intervention. Error reporting is a vital tool that can be used as a mechanism to identify opportunities for improvements in the medication management processes. Medication error reporting provides insight and assists institutions in improving all aspects of medication management. The World Health Organization notes medication error reporting can be summarized and prioritized for action using the following categories listed by ISMP.15

• Patient outcome
• Medication use process
• Medication problem
• Therapeutic group or individual medicine

Many of the individuals involved in administering PN may be unaware of best practice standards. Using ASPEN best practice recommendations and professional competencies for all steps in the PN use process should assist with decreasing PN-related errors.3-5, 16

The competency recommendations within this document are intended for discussion and adoption over time by organizations involved in the delivery of PN for patients requiring this therapy. The competency recommendations are not intended to supersede the judgment of the employing institution or individual clinicians in light of the circumstances of each case.

General Nutrition Competencies

Competencies define expectations for knowledge, skills, and traits for effective role implementation. Without documented competencies, an assessment of an individual clinician at regular intervals cannot be performed adequately.17

In 1999, ASPEN published interdisciplinary core competencies designed for all nutrition support clinicians to help meet performance expectations and demonstrate the knowledge and skills necessary to adapt care to the physical, psychosocial, cultural, and age-related needs of patients. These core competencies are examples of critical aspects of job performance that supervisors, managers, or directors may use and/or adapt for performance appraisal of nutrition support practitioners.18 There are numerous ways to gather data to evaluate practitioner performance, which include but are not limited to 1 or more of the following:18

1. Direct observation of a practitioner demonstrating skills or tasks
2. Observation of participation in interprofessional clinical rounds
3. Evaluation of an approach to practice in clinical simulations
4. Evaluation of care plan for specific case examples
5. Review of results of written examinations
6. Verification of nutrition support certification
7. Analysis of performance on nutrition support-related self-assessment programs
8. Evaluation of educational presentations on nutrition support-related topics
9. Confirmation of participation in local or national professional organization activities
10. Documentation of continuing education in activities related to nutrition support practice
11. Confirmation of participation in mentoring or peer review programs
12. Confirmation of participation in quality improvement programs

Administration Competencies Framework

A competency framework is a collection of competencies thought to be central to effective performance and includes guiding principles to optimize patient safety. Developing competencies should help individuals to continually improve their performance and to work more effectively.19 General competencies for PN administration were outlined in the recently published ASPEN nurse standards of practice.20 These standards were set at the following levels: nutrition support nurse specialist, nurse practitioner, and bedside nurse. The competencies listed below are for the bedside nurse who most often performs PN administration:

• Administers parenteral and enteral nutrition (EN) in a safe, comfortable, and effective manner
• Cares for the EN and PN access devices according to evidence-based and institutional guidelines
• Uses evidence-based interventions designed to prevent, detect, and manage complications related to the feeding formulation, infusion rate, equipment and supplies, and/or access devices
• Uses technology and electronic health systems for nutrition implementation

A model for PN standardized competencies would allow for consistency between institutions and offer to a variety of nutrition professionals a template to use to identify a minimum standard level of knowledge and skills for administering this complex medication. Regardless of whether PN admixtures are compounded or activated from multichamber fixed-dose products, a standardized model for PN administration could be applied in an interprofessional fashion, used to educate physicians in training (residents and fellows), medical students, dietitians, nurse practitioners, clinical nurse specialists, physician assistants, pharmacists, and others, as appropriate. While many of these clinicians will not directly administer PN, knowledge of the correct process and the associated care concepts are important. For example, while physicians, nurse practitioners, dietitians, and pharmacists may not perform PN tubing and dressing changes, all clinicians should have some knowledge about central venous catheter infection prevention.

The competency recommendations within this document are intended for discussion and adoption over time by organizations involved in the administration of PN. The competency recommendations are not intended to supersede the judgment of the employing institution considering the individual circumstances of each case.

ASPEN Model for PN Administration Competencies

Based on the recommendations from the ASPEN PN Safety Consensus Recommendations (Table 1) and the Essential Components of Nursing Policies and Procedures for PN Administration (Table 2), the following competencies should be met for the institutions to sign off on the administration competency:

• 1. If not certified in nutrition support, a clinician should complete a facility- or organization-developed program (such as 1 from ASPEN) for initial competency with content including:
  • PN indications/appropriate use
  • PN venous access devices and care
  • Volume/fluid, macronutrient and micronutrient components, and usual dosing range
  • Fluid, electrolyte, and acid-based balance basic concepts and principles
  • Drug-nutrient interactions
  • Nutrient-nutrient interactions
  • PN ordering and labeling
  • Types of PN admixtures and correct use/placement of associated medical devices such as filters and infusion pumps
  • Common complications associated with PN and appropriate monitoring, prevention, and management strategies

• 2. The program should assess prior knowledge and effective learning using tools such as a pretest and post-test or interactive question and answer session. Some of this content may be included in other programs such as medication and IV management.

• 3. The nurse will administer a minimum of 6 PN admixtures for the initial competency evaluation (via patient case scenarios and/or actual patients) under the supervision of an experienced preceptor. These cases should reflect the spectrum of medical and nutrition conditions, body weights, and age ranges cared for by the institution or home care company.

• 4. The nurse should follow these patients over a period of several days when possible. In home care, follow-up visits or phone contacts are crucial to optimize patient and caregiver understanding and mastery of home PN administration procedures. This follow-up step allows the nurse to demonstrate the ability to monitor the effectiveness and tolerance of the PN in the event of changing clinical conditions.

• 5. During evaluation of competency, the preceptor should use the PN Administration Competency Tool (Figure 1).

• 6. For annual (preferred) or periodic competency re-evaluation, completion of institutional-set required number of ongoing continuing education hours on PN therapy, and review of 3 patients should be performed using the Competency Tool (Figure 1).

Table 1. ASPEN Recommendations for Safe PN Administrationa

What system-based measures can organizations implement to enhance the safety of PN administration?

Recommendations

Written policies and procedures shall be developed to standardize nursing practices for the administration of PN throughout the organization. Education and competency assessment shall be provided to newly hired nurses and patients or caregivers who are responsible for PN administration. Healthcare organizations should conduct ongoing validation of competency in PN administration based on changes in practice related to PN administration, results of medication error monitoring, and/or the vulnerability of the patient population (eg, high acuity patients, including neonates and the critically ill). Healthcare organizations that provide nursing services related to home infusion shall establish mechanisms for periodic reassessment of knowledge and techniques used by patient or caregivers for home PN. Interdisciplinary quality improvement programs shall incorporate analysis of medication errors associated with PN administration and knowledge of errors that occur in other institutions. Safeguards shall be implemented to address specific problem areas as indicated by analysis of PN administration errors. An interdisciplinary process should be employed for selecting and evaluating equipment and technological aids, such as smart pumps and barcoding to reduce errors in PN administration. Healthcare organizations shall develop policies and procedures that address extravasation of PN formulations. Acute care facilities should establish a policy that prohibits the use of a PN formulation prepared for administration at home or in subacute or long-term care facilities. Protocols for safe operation of infusion pumps shall stipulate rules regarding alarm silencing, modification, and disabling. Healthcare organizations should purchase infusion pumps with capacity to reduce errors due to incorrect programming. Whenever possible, infusion pumps should be standardized throughout the organization.

What strategies can prevent errors in the verification phase of PN administration?

Recommendations

The verification process of PN administration should be presented in a bundle format, which uses a set of evidence-based interventions for a defined patient population or care setting. Nurses, caregivers, and patients shall visually inspect the integrity of the PN container and formulation before spiking the container. The PN label shall be verified against the original prescriber order. No verbal orders shall be accepted. a. Check the patient identifiers, product name, route of administration (central vs peripheral), designated initiation time, infusion rate, and beyond use date and time. b. Match all components listed on the label of the formulation to the PN order. A printed copy of the PN prescription shall be provided to home PN consumers initially and with each formulation change to allow this verification step. Patient identity shall be confirmed using 2 identifiers according to organizational policy. The administration tubing shall be traced to the point of origin in the body at the initiation of the infusion and at all handoffs. An independent double-check process and verification of infusion pump settings should be performed by a second clinician before beginning the PN infusion and documented in the medical record.

What practices maintain patient safety during the infusion of PN?

Recommendations

PN shall be administered by or under the supervision of trained, competent personnel. Organizations shall establish evidence-based policies to guide the selection, insertion, care, and maintenance of vascular access devices (VADs) used to administer PN. PN protocols shall include measures to reduce contamination through manipulation of the catheter hub. VADs used for PN administration should not be used to obtain blood samples for laboratory tests unless no peripheral access is available. PN infusions shall be infused through a filter appropriate for the type of formulation. An occluded filter shall never be removed in response to occlusion alarms, thus allowing the unfiltered formulation to continue to infuse. Administration tubing should be attached to PN containers immediately prior to use. Administration tubing and filters shall be changed with each new PN container (every 24 hours for TNAs and dextrose/amino acid formulations; 12 hours for ILE infused separately). For prolonged infusions of ILE (20–24 hours), the daily dose should be divided into 2 parts, with a new container and tubing every 12 hours. Policies regarding PN multi-chamber bags should be developed using a multidisciplinary approach. The PN infusion shall be maintained at the prescribed rate: a. Correct pump settings shall be verified at regular intervals and at each hand-off. b. The PN infusion rate shall not be adjusted if the infusion is off schedule. c. The rate of PN shall not be increased in response to changes in fluid needs; additional hydration should be provided as a separate infusion. d. The PN should not be interrupted for routine care or patient transport for diagnostic studies. e. Organizations shall develop policies regarding PN infusion and appropriate metabolic monitoring during surgery. The timing and frequency for blood glucose monitoring shall be based on clinical status and performed in a manner appropriate for the PN infusion schedule (cycled vs continuous). Caution shall be used when administering subcutaneous insulin coverage prior to a scheduled interruption of the PN infusion. In acute care acute settings (including long-term acute care), no additions should be made to PN formulations outside the compounding pharmacy; in home settings, additions to PN formulations should be limited in number and be made as close as possible to initiating the infusion. In long-term care facilities and in home care, education should be provided and caregiver competency regarding proper technique for the addition of prescribed additives to PN formulations should be verified. Co-infusion of medications through PN lines shall require a review of compatibility and stability data by a pharmacist. PN should be discontinued prior to transfer to another facility. The administration of PN and the patient's tolerance shall be documented in the medical record.

• ^a Adapted with permission from Ayers P, Adams S, Boullata J, et al. A.S.P.E.N. parenteral nutrition safety consensus recommendations. JPEN J Parenter Enteral Nutr. 2014 38(3):296–333.

Table 2. Essential Components of Nursing Policies and Procedures for PN Administrationa

Role responsibilities, delegation considerations Required equipment Verification procedures Confirmation of patient identity according to organizational policy Use of PN formulas prepared in another institution Checking PN label against the order including formulation components, route, and rate of delivery, expiration date Inspection of formulation to detect defects or visual changes Verification of appropriate vascular access prior to initiating PN infusion • Tip location: newly inserted VADs and those in place on admission • Safeguards to avoid tubing misconnections—trace tubing to the body before making the connection • Confirm patency Administration Policy regarding verification of pump settings Observation of integrity during infusion Importance of maintaining PN infusions at the prescribed rate—avoid interruptions for routine care or adjustments for infusions that are off schedule Guidelines for medication administration for patients receiving PN • Policies for co-infusing ILE or other medications with PN • Policies prohibiting additions to PN formulations on clinical units Recognizing a compromised PN formulation Significance of clogged filters Infection control measures VAD dressing care procedures, aseptic management of catheter hub Frequency of tubing and filter change Hang time Minimizing manipulations • Dedicated line, lumen • Blood-drawing practices Monitoring Appropriate blood glucose monitoring based on clinical condition and infusion schedule (cycled vs continuous infusion) Laboratory monitoring Evaluating response to therapy Recognition and intervention for extravasation Complications and troubleshooting Termination of therapy Patient education Documentation.

• ^a Adapted with permission from Ayers P, Adams S, Boullata J, et al. A.S.P.E.N. parenteral nutrition safety consensus recommendations. JPEN J Parenter Enteral Nutr. 2014 38(3):296–333.

Figure 1

ASPEN Parenteral Nutrition (PN) Administration Competency Tool. EHR, electronic health record; IV, intravenous; VAD, vascular access device.

Figure 1 (continued)

ASPEN Parenteral Nutrition (PN) Administration Competency Tool. EHR, electronic health record; IV, intravenous; VAD, vascular access device.

The model of standards for competency described in this paper will require time and resources for implementation at the organizational level. Processes and interventions to achieve this level of competence may require customized solutions at individual institutions, based on their existing PN administration structure. Each institution needs to incorporate this model in a way that is practical within its resources and capacity. The competency program may be slightly different for each nurse, even within a single institution. At a minimum, competency validation should occur in the following circumstances: as part of orientation for newly hired nurses, when a change in protocol or procedure takes place, with the introduction of new equipment or technology, and when quality improvement monitoring or other data sources reveal a gap in skills or knowledge related to PN administration.3 The ultimate goal is to achieve safe PN administration, based on evaluation of individual patients, which is achieved by an interprofessional collaboration among physicians, dietitians, nurses, and pharmacists. The role of electronic health records in providing a layer of safety with built-in checks cannot be overstated. See Figure 2 for the PN administration checklist. This checklist can serve as an adjunct to the competency tool.3

Figure 2

Parenteral nutrition (PN) Administration Checklist. VAD, vascular access device.

Conclusion

PN is a complex therapeutic medication and should be administered by those clinicians with demonstrated competency in PN administration to optimize the delivery of safe and effective therapy. Participation in interdisciplinary rounds to discuss patients requiring PN is an excellent way to develop knowledge about the therapy. In order to deliver safe and competent care for patients receiving PN, institutions must implement policies and procedures which assure assessment of staff members’ ability to perform competent PN administration. The ASPEN model presented in this article can be used to develop and implement such policies and procedures.