241 - Reducing custom TPN orders via utilization of evidence-based nutrition and enteral feeding strategies in NICU patients

Poster Number: 241
Publication Number: 241.128

James E. Jones, Levine Children's Hospital, charlotte, NC, United States; Julie R. Gooding, Atrium Health Levine Children’s, Waxhaw, NC, United States; Suzanne L. Smith, Atrium Health Levine Children’s Hospital, Charlotte, NC, United States; William Minor, Levine Children's Hospital, Charlotte, NC, United States

Background: Data showed that in the Neonatal Intensive Care Unit (NICU) at Atrium Health Levine Children’s Hospital (LCH) some customized total parenteral nutrition (TPN) is avoidable. Examples of this include larger birth weight infants or infants who may only need premixed IV fluid supplementation. Also, TPN can often be avoided if enteral nutrition is started sooner. Ordering and preparing custom TPN is labor intensive and expensive. The current estimated pharmacy charge for custom TPN is $407 versus $45 for standard premixed TPN. The literature notes that commercially available premixed parenteral nutrition formulations may be safer and more efficient delivery systems for macro- and micronutrients compared with traditional custom formulations when needed for short periods of time.

Objective: While custom TPN is necessary in some neonatal clinical circumstances, premixed formulations are suitable, cost effective, and safe for many neonates. This project aimed to standardize the ordering criteria of custom mixed TPN and avoid overutilization.  This was further optimized by revised enteral nutrition guidelines to initiate enteral feeds earlier and to standardize advancement. The goal of this project was to improve the reliability of ordering <18 custom TPN orders per day from a mean 62% to 80% of the days each month by October 2021.

Design/Methods: This QI project used the Model for Improvement. The multi-disciplinary project team used rapid plan, do, study, act (PDSA) cycles to assess the process, identify successes, barriers, or adverse effects, and improve the safety and quality of the care provided to these neonates. Interventions included guidelines for initiation and discontinuation of custom TPN and standardization of enteral feeding initiation and advancement allowing for reduction in variation and thereby minimizing reliance on custom TPN.

Results: Run chart data showed a sustained 33% reduction in monthly percent of days that exceeded 18 custom TPN orders after implementing nutrition guidelines, resulting in greater than $628,992/year in projected labor and supply cost savings.  There was no increase in NEC complications during and after implementation.Conclusion(s): Standardization of parenteral and enteral feeding strategies using rapid cycle improvement methodology can show sustainable results in quality of care, efficiency, and cost without increasing risk in the very low birthweight infant. Efficiency and cost savings can be attained through a feeding guideline that promotes early initiation, standardizes advancement, and minimizes reliance on custom TPN. 
Key Driver DiagramKey Driver Diagram summarizing AIM, primary drivers, and interventions
Project Run ChartPercent days per month that the 7 month baseline median custom TPN orders