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Parenteral Nutrition Use at a University Hospital Factors Associated With Inappropriate Use STEVEN J. KATZ, MD, Seattle, and ROBERT K. OYE, MD, Los Angeles
To evaluate the appropriateness of parenteral nutrition in hospital inpatients, we retrospectively reviewed the medical record of every third consecutive patient receiving parenteral nutrition admitted to a university hospital over 10 months. Of 186 patients, 71 (38%) were given this nutritional support for 7 days or fewer (short-term use). Patients who received it exclusively through peripheral catheters were more likely to receive it short term. Among 72 patients receiving itperioperatively, those who were given support for uncomplicated surgicalprocedures or procedures complicatedby postoperative ileus were more likely to receive it short term. We conclude that a substantial amount of parenteral nutrition use results in brief durations of support for conditions that are uncomplicated or self-limited. We have identified factors associated with this inappropriate use. A prospective consideration of these data could lead to the better use of this expensive form of nutritional support. (Katz SJ, Oye RK: Parenteral nutrition use at a university hospital-Factors associated with inappropriate use. West J Med 1990 Jun; 152:683-686)
Parenteral nutrition has become an accepted form of nutritional support in patients admitted to hospital, and there has been a dramatic increase in its use over the past ten years. Anderson and Steinberg estimated that 550,000 patients received some form of parenteral nutrition in 1985 at a cost of more than $1 billion. 1 Like many medical technologies, the diffusion of parenteral nutrition into clinical practice has been unpredictable. Initial studies examined its role in the perioperative setting. Subsequent studies examined its use in patients undergoing cancer chemotherapy or patients with poor oral intake due to inflammatory bowel disease, renal failure, hepatic failure, cancer, or pancreatitis.2-'2 Recent clinical trials have raised some doubt about the efficacy of parenteral nutrition in reducing morbidity and mortality in several of these clinical settings. Detsky and coworkers did a meta-analysis of its perioperative use to ascertain whether published studies show more good than harm. 13 Pooled data from randomized controlled trials failed to show a statistically significant benefit in patients undergoing gastrointestinal surgical procedures. Because of the low number of severely malnourished patients included in the analysis, however, the results for this group were inconclusive. Detsky and colleagues then examined the use of parenteral nutrition during intensive chemotherapy (12 trials), renal failure (4 trials), inflammatory bowel disease (3 trials), and hepatic failure (9 trials). They concluded that for three of four conditions, the evidence was inconclusive and that for patients receiving chemotherapy, parenteral nutrition may be harmful. 14 The American College of Physicians Health and Policy Committee's position paper on the perioperative use of parenteral nutrition stated that it should only be used in severely malnourished patients in hospital undergoing major
gastrointestinal surgical procedures or in moderately to wellnourished patients who will not use their gastrointestinal tract for ten days or more. 15 Koretz summarized randomized clinical trials of the use of parenteral nutrition in patients with cancer anorexia, perioperatively, and in patients with inflammatory bowel disease and concluded that no clinical trial on its use has shown a statistically significant reduction in morbidity or mortality for these indications.16 In contrast, the American Society for Parenteral and Enteral Nutrition published guidelines for its use in adults admitted to hospital in 1986.17 The society recommended it be used for patients undergoing chemotherapy or a major operation or who have pancreatitis, sepsis, inflammatory bowel disease, severe diarrhea, or trauma. Parenteral nutritional support was deemed appropriate under these conditions if an enteral diet could not be resumed for seven to ten days depending on the nutritional state of the patient. We used a conservative measure of inappropriateness derived from this literature (administration for seven days or fewer) to evaluate its use at a university hospital.
Patients and Methods The study took place at a 700-bed university teaching hospital. We identified the inpatient use of parenteral nutrition over a ten-month period (March 1987 to January 1988) from a log maintained by the parenteral nutrition pharmacist. All such orders were filled by the parenteral nutrition pharmacist. We retrospectively reviewed the medical records of every third patient within this sample. Parenteral nutrition was defined as an intravenous feeding regimen containing hypertonic glucose (at least 10%) and either amino acids, lipids, or both. Only patients 18 and older were included in the study group.
From the Robert Wood Johnson Clinical Scholars Program, University of Washington School of Medicine, Seattle (Dr Katz), and the Department of Medicine, University of Califomia, Los Angeles, School of Medicine (Dr Oye). Reprint requests to Steven J. Katz, MD, Robert Wood Johnson Clinical Scholars Program, HQ-18, University of Washington, Seattle, WA 98105.
684
PARENTERAL NUTRITION~~~~~~~~ NUTRITION
684
The following data were abstracted: age, sex, attending physician, admitting service, insurance status, length of stay, discharge diagnoses, surgical procedures, indication for parenteral nutrition, type and duration of support, reason for cessation, route of administration, monitoring, duration of no oral intake (defined as the duration from the initiation of no oral intake to the restoration of a full diet), the presence of gastrointestinal symptoms or an altered mental state, albumin level, weight, height, disposition, and the presence of a consultation note on the use of parenteral nutrition. In addition, for four days of its administration per admission, we collected data on the infusion ordered and the infusion received. These days were chosen at a time when the infusion regimen was steady with no changes during the 24-hour sample period. The average caloric intake was determined by averaging the daily dextrose and amino acid infusion over the sample days for each patient. The amount of lipids infused was averaged for a 24-hour period and added to the caloric intake. We considered the use of parenteral nutrition to be inappropriate if the duration of administration was seven days or fewer. Patients who received this support for seven days or fewer were considered to have "short-term use" versus receiving it longer (long-term use). Data on the average daily charges for parenteral nutrition were obtained through the medical center pharmacy and therapeutics division. Records were abstracted by four trained abstractors: three nurse specialists in parenteral nutrition and a medical student. Differences among patient subgroups with regard to the duration of use, caloric intake, and other data were tested using X2 and the Mann-Whitney rank sum test. A two-tailed P value of .05 was considered significant.
Results Over a ten-month period (March 1987 to January 1988), 670 patients received parenteral nutrition during 710 admissions. We sampled 238 patients for whom the medical records of 86% (205) were available for review. The median patient age was 50 years, 100 were men and 105 women, and the median length of hospital stay was 21 days. In all, 87 patients were admitted to a medicine service and 128 to one of four surgery services-general surgery 70%; obstetrics and gynecology 12%; urology 8%; and ears, nose, and throat 2 %. These patients had a variety of insurance sources: 165 patients had private insurance, 60 had Medicare, and 36 had medicaid. During admission 32 patients (16%) died, 25 while receiving parenteral nutrition. Malignant tumors were the most common discharge diagnosis (Table 1). Gastrointestinal operations accounted for 67 % of the 72 patients undergoing surgical procedures. The most common indications for initiating parenteral nutrition were perioperative support through the no-oralintake period, cancer anorexia associated with chemotherapy, nonspecific cachexia (defined as prolonged periods of anorexia not attributable to a specific cause), and inflammatory bowel disease (Table 2). A few patients (19) were admitted to the hospital while receiving parenteral nutrition at home or for initiating its use at home, while 186 received it only in the hospital. The rest of the analysis excludes those receiving home parenteral nutrition (n = 186). The median duration of the administration of parenteral
PARENTERAL
TABLE 1.-Most Common Discharge Diagnoses (n=205) Diagnosis
Patients No. (%)
Solid tumors ......................
54 (26) 22 (11) Inflammatory bowel disease ...................... 16 ( 8) Liver disease ...... ................ 16 ( 8) Cardiovascular disease ...................... 15 ( 7) Sepsis ...................... 14 ( 7) Pneumonia ..... ................. 13 ( 6) Trauma ...................... 11 ( 5) Altered mental state ...................... 9 ( 4) Renal failure ...... ................ 5 ( 2) Acquired immunodeficiency syndrome .................. 4 ( 2) Pancreatitis ...................... 4 ( 2) Other* ...................... 22(11)
Leukemia/lymphoma ......................
*Other diagnoses include (
*i
il
0
-.d
0
I
W.
#
6
1 W4
0
e)-.
Parenteral Nutrition Use at a University Hospital Factors Associated With Inappropriate Use STEVEN J. KATZ, MD, Seattle, and ROBERT K. OYE, MD, Los Angeles
To evaluate the appropriateness of parenteral nutrition in hospital inpatients, we retrospectively reviewed the medical record of every third consecutive patient receiving parenteral nutrition admitted to a university hospital over 10 months. Of 186 patients, 71 (38%) were given this nutritional support for 7 days or fewer (short-term use). Patients who received it exclusively through peripheral catheters were more likely to receive it short term. Among 72 patients receiving itperioperatively, those who were given support for uncomplicated surgicalprocedures or procedures complicatedby postoperative ileus were more likely to receive it short term. We conclude that a substantial amount of parenteral nutrition use results in brief durations of support for conditions that are uncomplicated or self-limited. We have identified factors associated with this inappropriate use. A prospective consideration of these data could lead to the better use of this expensive form of nutritional support. (Katz SJ, Oye RK: Parenteral nutrition use at a university hospital-Factors associated with inappropriate use. West J Med 1990 Jun; 152:683-686)
Parenteral nutrition has become an accepted form of nutritional support in patients admitted to hospital, and there has been a dramatic increase in its use over the past ten years. Anderson and Steinberg estimated that 550,000 patients received some form of parenteral nutrition in 1985 at a cost of more than $1 billion. 1 Like many medical technologies, the diffusion of parenteral nutrition into clinical practice has been unpredictable. Initial studies examined its role in the perioperative setting. Subsequent studies examined its use in patients undergoing cancer chemotherapy or patients with poor oral intake due to inflammatory bowel disease, renal failure, hepatic failure, cancer, or pancreatitis.2-'2 Recent clinical trials have raised some doubt about the efficacy of parenteral nutrition in reducing morbidity and mortality in several of these clinical settings. Detsky and coworkers did a meta-analysis of its perioperative use to ascertain whether published studies show more good than harm. 13 Pooled data from randomized controlled trials failed to show a statistically significant benefit in patients undergoing gastrointestinal surgical procedures. Because of the low number of severely malnourished patients included in the analysis, however, the results for this group were inconclusive. Detsky and colleagues then examined the use of parenteral nutrition during intensive chemotherapy (12 trials), renal failure (4 trials), inflammatory bowel disease (3 trials), and hepatic failure (9 trials). They concluded that for three of four conditions, the evidence was inconclusive and that for patients receiving chemotherapy, parenteral nutrition may be harmful. 14 The American College of Physicians Health and Policy Committee's position paper on the perioperative use of parenteral nutrition stated that it should only be used in severely malnourished patients in hospital undergoing major
gastrointestinal surgical procedures or in moderately to wellnourished patients who will not use their gastrointestinal tract for ten days or more. 15 Koretz summarized randomized clinical trials of the use of parenteral nutrition in patients with cancer anorexia, perioperatively, and in patients with inflammatory bowel disease and concluded that no clinical trial on its use has shown a statistically significant reduction in morbidity or mortality for these indications.16 In contrast, the American Society for Parenteral and Enteral Nutrition published guidelines for its use in adults admitted to hospital in 1986.17 The society recommended it be used for patients undergoing chemotherapy or a major operation or who have pancreatitis, sepsis, inflammatory bowel disease, severe diarrhea, or trauma. Parenteral nutritional support was deemed appropriate under these conditions if an enteral diet could not be resumed for seven to ten days depending on the nutritional state of the patient. We used a conservative measure of inappropriateness derived from this literature (administration for seven days or fewer) to evaluate its use at a university hospital.
Patients and Methods The study took place at a 700-bed university teaching hospital. We identified the inpatient use of parenteral nutrition over a ten-month period (March 1987 to January 1988) from a log maintained by the parenteral nutrition pharmacist. All such orders were filled by the parenteral nutrition pharmacist. We retrospectively reviewed the medical records of every third patient within this sample. Parenteral nutrition was defined as an intravenous feeding regimen containing hypertonic glucose (at least 10%) and either amino acids, lipids, or both. Only patients 18 and older were included in the study group.
From the Robert Wood Johnson Clinical Scholars Program, University of Washington School of Medicine, Seattle (Dr Katz), and the Department of Medicine, University of Califomia, Los Angeles, School of Medicine (Dr Oye). Reprint requests to Steven J. Katz, MD, Robert Wood Johnson Clinical Scholars Program, HQ-18, University of Washington, Seattle, WA 98105.
684
PARENTERAL NUTRITION~~~~~~~~ NUTRITION
684
The following data were abstracted: age, sex, attending physician, admitting service, insurance status, length of stay, discharge diagnoses, surgical procedures, indication for parenteral nutrition, type and duration of support, reason for cessation, route of administration, monitoring, duration of no oral intake (defined as the duration from the initiation of no oral intake to the restoration of a full diet), the presence of gastrointestinal symptoms or an altered mental state, albumin level, weight, height, disposition, and the presence of a consultation note on the use of parenteral nutrition. In addition, for four days of its administration per admission, we collected data on the infusion ordered and the infusion received. These days were chosen at a time when the infusion regimen was steady with no changes during the 24-hour sample period. The average caloric intake was determined by averaging the daily dextrose and amino acid infusion over the sample days for each patient. The amount of lipids infused was averaged for a 24-hour period and added to the caloric intake. We considered the use of parenteral nutrition to be inappropriate if the duration of administration was seven days or fewer. Patients who received this support for seven days or fewer were considered to have "short-term use" versus receiving it longer (long-term use). Data on the average daily charges for parenteral nutrition were obtained through the medical center pharmacy and therapeutics division. Records were abstracted by four trained abstractors: three nurse specialists in parenteral nutrition and a medical student. Differences among patient subgroups with regard to the duration of use, caloric intake, and other data were tested using X2 and the Mann-Whitney rank sum test. A two-tailed P value of .05 was considered significant.
Results Over a ten-month period (March 1987 to January 1988), 670 patients received parenteral nutrition during 710 admissions. We sampled 238 patients for whom the medical records of 86% (205) were available for review. The median patient age was 50 years, 100 were men and 105 women, and the median length of hospital stay was 21 days. In all, 87 patients were admitted to a medicine service and 128 to one of four surgery services-general surgery 70%; obstetrics and gynecology 12%; urology 8%; and ears, nose, and throat 2 %. These patients had a variety of insurance sources: 165 patients had private insurance, 60 had Medicare, and 36 had medicaid. During admission 32 patients (16%) died, 25 while receiving parenteral nutrition. Malignant tumors were the most common discharge diagnosis (Table 1). Gastrointestinal operations accounted for 67 % of the 72 patients undergoing surgical procedures. The most common indications for initiating parenteral nutrition were perioperative support through the no-oralintake period, cancer anorexia associated with chemotherapy, nonspecific cachexia (defined as prolonged periods of anorexia not attributable to a specific cause), and inflammatory bowel disease (Table 2). A few patients (19) were admitted to the hospital while receiving parenteral nutrition at home or for initiating its use at home, while 186 received it only in the hospital. The rest of the analysis excludes those receiving home parenteral nutrition (n = 186). The median duration of the administration of parenteral
PARENTERAL
TABLE 1.-Most Common Discharge Diagnoses (n=205) Diagnosis
Patients No. (%)
Solid tumors ......................
54 (26) 22 (11) Inflammatory bowel disease ...................... 16 ( 8) Liver disease ...... ................ 16 ( 8) Cardiovascular disease ...................... 15 ( 7) Sepsis ...................... 14 ( 7) Pneumonia ..... ................. 13 ( 6) Trauma ...................... 11 ( 5) Altered mental state ...................... 9 ( 4) Renal failure ...... ................ 5 ( 2) Acquired immunodeficiency syndrome .................. 4 ( 2) Pancreatitis ...................... 4 ( 2) Other* ...................... 22(11)
Leukemia/lymphoma ......................
*Other diagnoses include (
