1 of 44

IMPROVED CARE THROUGH BETTER NUTRITION: VALUE AND EFFECTS OF MEDICAL NUTRITION

Prepared by :

Premium Nutritional Care Team

2 of 44

PROJECT GROUP MEMBERS

NATIONAL QUALITY ASSURANCE CONVENTION 2022

2

Jasreena Kaur Gill

Pharmacy Department

Karthikayini Krishnasamy

Nursing Department

Poh Kai Ling

Dietetics Department

Dr Wong Wei Jin

Surgical Department

3 of 44

OUTLINE

NATIONAL QUALITY ASSURANCE CONVENTION 2022

3

1

Introduction

2

Selection of Opportunities for Improvement (Outline of Problem)

3

Key Measures for Improvement

4

Process of Gathering Information

5

Analysis and Interpretation

6

Strategy for Change

7

Effects of Change

8

The Next Step

4 of 44

INTRODUCTION

  • Nutrition is a process of food intake for growth, metabolism and repair.

​

  • Types:
    • Oral Nutrition (ON): method of providing nutrition via mouth
    • Enteral Nutrition (EN): method of providing nutrition via feeding tubes
    • Parenteral Nutrition (PN) : method of providing nutrition via intravenous

​

NATIONAL QUALITY ASSURANCE CONVENTION 2022

4

5 of 44

INTRODUCTION

  • Parenteral Nutrition (PN)
    • Given to patients who cannot be fed through oral and gut.
    • consist of protein, carbohydrates, fats, electrolytes, vitamins and minerals.

​

  • Provides energy in the form of calories – post surgical healing and preventing malnutrition

​

​

NATIONAL QUALITY ASSURANCE CONVENTION 2022

5

6 of 44

SELECTION OF OPPORTUNITIES FOR IMPROVEMENT

7 of 44

SELECTION OF OPPORTUNITIES FOR IMPROVEMENT

NATIONAL QUALITY ASSURANCE CONVENTION 2022

7

Incidence of malnutrition in UMMC patients is 55% (Krishnasamy K, 2015)

Lead to increased morbidity and mortality, extended hospital stays, and care that is associated with higher costs.

Poor therapy management due to inadequate nutrition assessment and poor medical practice in the field of nutrition

PN management handled and managed by untrained personnel

Absence of dedicated team to manage PN therapy

8 of 44

IDENTIFICATION OF PROBLEMS

NATIONAL QUALITY ASSURANCE CONVENTION 2022

8

No

Problem

Justification

Proposer

1.

No proper prescribing pathway

PN prescribed and managed by many subspecialties

Physician

2.

Increased patient’s PN related complications.

Longer hospitalization for nutrition stabilization

3.

Lack of planned PN duration

PN therapy initiated and continued till patient discharged

Dietitians

4.

Infusion errors

Administration and infusion duration errors

Nurses

5.

Lack of training among prescribers.

Student medical officers (MO) unaware of PN therapy

Physician

Nurses

Dietitians

Pharmacist

9 of 44

IDENTIFICATION OF PROBLEMS

NATIONAL QUALITY ASSURANCE CONVENTION 2022

9

No

Problem

Justification

Proposer

6.

Unnecessary PN request

Therapy requested without indication

Pharmacist

7.

PN prescription is not tailored to patient’s needs

Calories provided through PN too much or too little

8.

Wastage of TPN bags

High return rates and discarding on PN bags

9.

Unnecessary preparations of compounded bags.

Increased material purchasing cost

10.

Incomplete prescriptions

Orders received by pharmacist not in order

10 of 44

PROBLEM SELECTION

NATIONAL QUALITY ASSURANCE CONVENTION 2022

10

No

Problem

Critical Point

Ability

Total

1.

No proper prescribing pathway

10

8

18

2.

Increased patient’s PN related complications.

10

8

18

3.

Lack of planned therapy duration

8

8

16

4.

Infusion errors

9

7

16

5.

Lack of training among prescribers.

8

8

16

6.

Unnecessary PN request

8

9

17

7.

PN prescription is not tailored to patient’s needs

9

8

17

8.

Wastage of TPN bags

7

7

14

9.

Unnecessary preparations of compounded bags.

8

7

15

10.

Incomplete prescription request

6

7

13

Scale

0-3

4-6

7-10

Not critical

Critical

Very critical

11 of 44

AIM & OBJECTIVES

  • 1. To ensure
    • high-quality care– reduce prescribing errors
    • safe nutritional support – reduce complications
    • cost-effective – reduce wastage & hospitalization cost

​

  • 2. To establish a standard nutrition care pathway for UMMC patients

​

  • 3. To evaluate effectiveness of interventions made by group members

​

NATIONAL QUALITY ASSURANCE CONVENTION 2022

11

UMMC Vision

To establish UMMC as a leading teaching hospital with international repute

UMMC Mission

To empower human capital with high competency

​

To drive excellence in clinical research.

​

To sustain a strong financial standing.

​

To uplift the institution standard with education and healthcare related recognitions and accreditations.

​

12 of 44

KEY MEASURES FOR IMPROVEMENT

13 of 44

KEY MEASURES FOR IMPROVEMENT

  • The indicator of this study is the percentage of prescribing and administration errors of Parenteral Nutrition in surgical wards and Intensive Care Unit (ICU), with the standard set as 0%.

​

​

​

​

​

NATIONAL QUALITY ASSURANCE CONVENTION 2022

13

0% of PN prescribing and administration errors in surgical wards and ICU

ABNA 40%

14 of 44

PROCESS OF GATHERING INFORMATION

15 of 44

METHODOLOGY

Project Design

  • Retrospective pre- & post-interventional study
  • Pre-intervention: January 2012 – June 2015
  • Post intervention: July 2015 – December 2021

Inclusion Criteria

  • All patients on PN in Surgical ward and ICU

NATIONAL QUALITY ASSURANCE CONVENTION 2022

15

16 of 44

DATA COLLECTION

NATIONAL QUALITY ASSURANCE CONVENTION 2022

16

Data to collect

Pre- & Post-Intervention

Where

How

Incidence of complications

Pharmacy & Wards

Medical notes

Data on improvement of malnutrition status

Wards

Medical notes

Number of bags supplied

Pharmacy

PN order forms

Cost

Pharmacy & Wards

Costing calculation

17 of 44

REQUEST & SUPPLY PROCESS �

NATIONAL QUALITY ASSURANCE CONVENTION 2022

17

Prescribe PN in order form

Receive & Screen order

Minimal or no intervention

Prepare PN

Deliver PN

Administer PN

Adult ICU & Surgery

Wards

Pharmacy

Primary team rounds

10 am -12 noon

12 noon – 2 pm compile and plan

​

Compound PN bags/ supply ready-to-use

5 pm

6 pm

  • Standard prescribing of calories regardless of diagnosis
  • Regimens available as compounded bags and ready-to-use (RTU)

​

    • Duration of PN : until patient discharge
  • Infuse PN on available infusion line

18 of 44

18

​

What

    • Mishandling and misuse of PN → high incidence of complications & cost

​

Where

    • UMMC wards:
      • Surgical
      • Intensive care unit (ICU)

​

Who

    • Involves patients who cannot be fed orally or via enteral

​

When

    • Daily basis in affected wards among malnourished patients

​

Why

    • Lack of awareness on therapy
    • Lack of exposure to manage therapy
    • Absence of dedicated team

​

How

    • Identified by observation and communication between managing teams

19 of 44

ANALYSIS AND INTERPRETATION

20 of 44

PROBLEM ANALYSIS

20

Health & PN related complications

Method

Not tailored to patient’s need

Lack of planned therapy duration

Unnecessary request

Materials

Complicated prescribing

Incomplete request forms

Multiple prescribing teams

Lack of training to prescribe PN

Manpower

Measurements

Unnecessary preparations

Unaware of contents in bag

Costly

Verification process

Daily preparations

Prescribing errors

No prescribing pathway

New teams every 3 months

Unclear administration instructions

21 of 44

ANALYSIS OF KEY MEASURES

NATIONAL QUALITY ASSURANCE CONVENTION 2022

21

Problem

Source

Findings

Method:

  1. No prescribing pathway
  2. Unnecessary request/ orders

​

  • Clinical notes
  • Pharmacy notes
  • Survey among masters medical officers
  • Therapy not tailored to patients needs
  • Lack of planned therapy
  • Therapy not indicated for patient

Measurements:

  1. Type of therapy
  2. Preparations
  • Physicians unaware of components of PN therapy
  • Pharmacy prepare bags as per order received – no intervention
  • Wastage of bags – unused

Materials:

  1. Prescribing errors
  2. Incomplete orders
  • Complicated prescribing
  • Unclear administration instructions

Manpower:

  1. 3 monthly prescriber rotation
  2. Multiple prescribers

​

  • Wards

​

  • Lack of trained personnel for therapy prescribing

22 of 44

ANALYSIS AND INTERPRETATION

NATIONAL QUALITY ASSURANCE CONVENTION 2022

22

RM 712,250.00

RM 2,993,680.00

​

High PN cost and high PN wastage

​

23 of 44

ANALYSIS AND INTERPRETATION

NATIONAL QUALITY ASSURANCE CONVENTION 2022

23

Complication

Pre NST

Prescribing errors

80%

Administration errors

58%

Nutrients deficiency

61%

Line infection

69%

Organs function impairment

54%

Appropriateness of caloric supply

13%

Appropriateness of amino acid supply

45%

Length of ICU stay

15 days

24 of 44

STRATEGY FOR CHANGE

25 of 44

25

Problems

Method

Materials

Measurements

Manpower

Findings

Who involved

Nutrition Support Team (NST)

Lack of prescribing pathway

Incomplete nutritional plans

Type of therapy

Untrained healthcare providers

Physician

Physician, Pharmacist, Dietitian, Nurses

Pharmacist, Dietitian

Physician, Pharmacist, Dietitian, Nurses

STRATEGY FOR CHANGE

26 of 44

NUTRITION SUPPORT TEAM (NST)

  • Introduced in July 2015

​

  • Multidisciplinary (MDT) team: physicians, nurses, pharmacist and dietitians

​

  • Performs weekly rounds on Tuesday

​

  • Discussion on patient’s progress on Thursday

​

NATIONAL QUALITY ASSURANCE CONVENTION 2022

26

27 of 44

ROLES OF NST

  1. Early recognition and treatment of malnutrition
  2. Reduction of mechanical and metabolic complications of PN & EN
  3. Reduction morbidity & mortality
  4. Provision of more cost-effective selection of products
  5. Selection of appropriate nutrition support equipment and devices.

27

  1. Reduction in length of stay and costs to the hospital
  2. Selection and monitoring of appropriate laboratory tests
  3. Selection and monitoring of appropriate intravenous catheter
  4. Reduce central venous catheter related sepsis

28 of 44

REQUEST & SUPPLY PROCESS �

Prescribe PN in order form

Receive order

Minimal or no intervention

Prepare PN

Deliver PN

Administer PN

Adult ICU & Surgery

Wards

Pharmacy

10 am -12 noon

All interventions made during rounds

Supply ready-to-use

5 pm

6 pm

  • Regimens: ready-to-use with different volume & calories

​

    • Duration of PN : until patient ready for EN or ON
  • Infuse PN through suggested infusion line

Primary team rounds NST Rounds

  • Standard prescribing by patient’s caloric need

29 of 44

NATIONAL QUALITY ASSURANCE CONVENTION 2022

29

30 of 44

EFFECTS OF CHANGE

31 of 44

EFFECTS OF CHANGE

31

Primary team prescribing of PN

98% PN prescribing after NST screening

Prolonged duration on PN

Timely de-escalation from PN to EN or ON

Unplanned administration

Administration as per order

Incomplete PN regimen

100% RTU PN bags with volume and calories tailored to patient population

Prescribing errors

NST provides complete plan with infusion methods

32 of 44

INCIDENCE OF COMPLICATIONS

32

​

Pre NST

Post NST

Complication

Incidence

Prescribing errors

80%

35%

Administration errors

58%

10%

Nutrients deficiency

61%

20%

Line infection

69%

45%

Organs function impairment

54%

40%

Appropriateness of caloric supply

13%

57%

Appropriateness of amino acid supply

45%

59%

Length of ICU stay

15 days

8 days

Chi Square test p<0.05 (JK Gill, ND Jamil; 2020)

48%

45%

ABNA 40%

33 of 44

NUMBER OF BAGS SUPPLIED

NATIONAL QUALITY ASSURANCE CONVENTION 2022

33

​

Higher number of PN bags dispensed post NST due to increased number of patients and interventions performed by NST.

​

34 of 44

COST COMPARISON FOR PN BAGS

NATIONAL QUALITY ASSURANCE CONVENTION 2022

34

22%

> RM530,000

35 of 44

ADDITIONAL COST SAVINGS

  • When team was initiated, the existing physicians, nurses, pharmacist and dietitians were included, no new employment

​

  • Cost saved from 2016 till date: RM1,728,000
  • Cost savings per year: ~ RM288,000

​

​

NATIONAL QUALITY ASSURANCE CONVENTION 2022

35

36 of 44

WASTAGE OF PN BAGS

NATIONAL QUALITY ASSURANCE CONVENTION 2022

36

​

Number of wastage reduced post NST.

​

37 of 44

WASTAGE OF PN BAGS

NATIONAL QUALITY ASSURANCE CONVENTION 2022

37

712,250.00

260,400.00

63%

> RM450,000

38 of 44

THE NEXT STEP

39 of 44

THE NEXT STEP

  • Inclusion of physiotherapist and psychiatrist on board

​

  • Increase number of ward rounds weekly

​

  • Provide 5-day traineeship program for institutions to set-up nutrition support teams

​

  • Develop education programs to support new nutrition support teams within MOH and private hospitals

NATIONAL QUALITY ASSURANCE CONVENTION 2022

39

40 of 44

GOVERNANCE : NST → NTT

40

Nutrition Support Team (NST)

Nutritional Therapy Team (NTT)

APPROVED

41 of 44

GOVERNANCE : HOME PN SERVICE

41

In-house & Home PN policy

42 of 44

TRAINING & COMPETENCY

NATIONAL QUALITY ASSURANCE CONVENTION 2022

42

NST

Nutrition Webinar and courses to train healthcare providers

Physicians

Nutrition support included in MO masters curriculum

Nursing

Line care training with catheter care workshops

Dietitians

Standardized enteral feeding protocol

Pharmacy

PN clinical and compounding training

​

43 of 44

SUMMARY

NATIONAL QUALITY ASSURANCE CONVENTION 2022

43

Formation of NST

1. Reduced feeding complications

2. Reduced cost

Established standard and quality of care

44 of 44

THANK YOU

44