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Offering Guidance and Learning to Prescribers to Initiate Parenteral Nutrition using a Validated Electronic Decision TREE (OLIVE TREE)

  • Clinical Systems
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Abstract

Parenteral nutrition (PN) is recommended in patients nutritionally at risk and unable to receive oral or enteral nutrition. A standardized electronic PN order format could enhance appropriate PN prescribing. We developed the OLIVE TREE (Offering guidance and Learning to prescribers to Initiate PN using a Validated Electronic decision TREE), embedded in our electronic health record. We aimed to evaluate its validity and impact on physicians’ prescribing behavior. A non-randomized before-after study was carried out in a tertiary care center. The OLIVE TREE comprises 120 individual items. A process validation was performed to determine interrater agreement between a pharmacist and the treating physician. To estimate the proportion of patients for whom the OLIVE TREE had an effective and potential impact on physicians’ prescribing behavior, a proof of concept study was conducted. The proportion of patients for whom PN was averted and the proportion of decisions not in line with the recommendation were also calculated. The process validation in 20 patients resulted in an interrater agreement of 95.0%. The proof of concept in 73 patients resulted in an effective and potential impact on prescribing behavior in 50.7% and 79.5% of these patients, respectively. Initiation of PN was not averted and recommendations of the OLIVE TREE were overruled in 42.5% of the patients. Our newly developed OLIVE TREE has a good process validity. A substantial impact on prescribing behavior was observed, although initiation of PN was not avoided. In the next phase, the decision tree will be implemented hospital-wide.

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References

  1. Khalatbari-Soltani S, Marques-Vidal P. The economic cost of hospital malnutrition in Europe; a narrative review. Clin Nutr ESPEN. 2015;10(3):e89-e94. https://doi.org/10.1016/j.clnesp.2015.04.003.

    Article  PubMed  Google Scholar 

  2. Felder S, Lechtenboehmer C, Bally M, Fehr R, Deiss M, Faessler L, et al. Association of nutritional risk and adverse medical outcomes across different medical inpatient populations. Nutrition. 2015;31(11-12):1385-93. https://doi.org/10.1016/j.nut.2015.06.007.

    Article  PubMed  Google Scholar 

  3. Barker LA, Gout BS, Crowe TC. Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system. Int J Environ Res Public Health. 2011;8(2):514-27. https://doi.org/10.3390/ijerph8020514.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Meulemans A, Matthys C, Vangoitsenhoven R, Sabino J, Van Der Schueren B, Maertens P, et al. A multicenter propensity score matched analysis in 73,843 patients of an association of nutritional risk with mortality, length of stay and readmission rates. Am J Clin Nutr. 2021;114(3):1123-30. https://doi.org/10.1093/ajcn/nqab135.

    Article  PubMed  Google Scholar 

  5. Cederholm T, Barazzoni R, Austin P, Ballmer P, Biolo G, Bischoff SC, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr. 2017;36(1):49-64. https://doi.org/10.1016/j.clnu.2016.09.004.

    Article  CAS  PubMed  Google Scholar 

  6. Kondrup J, Allison SP, Elia M, Vellas B, Plauth M, Educational and Clinical Practice Committee ErSoPaENE. ESPEN guidelines for nutrition screening 2002. Clin Nutr. 2003;22(4):415-21. https://doi.org/10.1016/s0261-5614(03)00098-0.

    Article  CAS  PubMed  Google Scholar 

  7. Worthington P, Balint J, Bechtold M, Bingham A, Chan LN, Durfee S, et al. When Is Parenteral Nutrition Appropriate? JPEN J Parenter Enteral Nutr. 2017;41(3):324-77. https://doi.org/10.1177/0148607117695251.

    Article  PubMed  Google Scholar 

  8. Guenter P, Ayers P, Boullata JI, Gura KM, Holcombe B, Sacks GS. Parenteral Nutrition Errors and Potential Errors Reported Over the Past 10 Years. Nutr Clin Pract. 2017;32(6):826-30. https://doi.org/10.1177/0884533617715868.

    Article  PubMed  Google Scholar 

  9. Montalvo-Jave EE, Zarraga JL, Sarr MG. Specific topics and complications of parenteral nutrition. Langenbecks Arch Surg. 2007;392(2):119-26. https://doi.org/10.1007/s00423-006-0133-6.

    Article  PubMed  Google Scholar 

  10. Sobotka L, Maria C. Basics in clinical nutrition: metabolic complications of parenteral nutrition. E-spen, The European E-journal of Clinical Nutrition and Metabolism. 2010;5(3):e153-154. https://doi.org/10.1016/j.eclnm.2009.01.001.

  11. Seres DS, Valcarcel M, Guillaume A. Advantages of enteral nutrition over parenteral nutrition. Therap Adv Gastroenterol. 2013;6(2):157-67. https://doi.org/10.1177/1756283X12467564.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Wong AT, Ong JP, Han HH. The Use of Parenteral Nutrition Support in an Acute Care Hospital and the Cost Implications of Short-term Parenteral Nutrition. Ann Acad Med Singap. 2016;45(6):237-44. https://doi.org/10.47102/annals-acadmedsg.V42n8p395

    Article  PubMed  Google Scholar 

  13. Deleenheer B, Declercq P, Van Veer H, Nafteux P, Spriet I. Evaluation of parenteral nutrition use in patients undergoing major upper gastro-intestinal surgery. Int J Clin Pharm. 2015;37(4):579-82. https://doi.org/10.1007/s11096-015-0099-y.

    Article  CAS  PubMed  Google Scholar 

  14. Declercq P, Van der Aa F, De Pourcq L, Spriet I. Impact of an oral nutrition protocol in patients treated with elective radical cystectomy: a long term follow-up. Int J Clin Pharm. 2019;41(2):408-13. https://doi.org/10.1007/s11096-019-00800-y.

    Article  PubMed  Google Scholar 

  15. Declercq P, De Win G, Van der Aa F, Beels E, Elodie B, Van der Linden L, et al. Reduced length of stay in radical cystectomy patients with oral versus parenteral post-operative nutrition protocol. Int J Clin Pharm. 2015;37(2):379-86. https://doi.org/10.1007/s11096-015-0072-9.

    Article  CAS  PubMed  Google Scholar 

  16. Adams KM, Kohlmeier M, Powell M, Zeisel SH. Nutrition in medicine: nutrition education for medical students and residents. Nutr Clin Pract. 2010;25(5):471-80. https://doi.org/10.1177/0884533610379606.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Broad J, Wallace M. Nutrition and public health in medical education in the UK: reflections and next steps. Public Health Nutr. 2018;21(13):2523-5. https://doi.org/10.1017/S1368980018000800.

    Article  PubMed  Google Scholar 

  18. Lenders CM, Deen DD, Bistrian B, Edwards MS, Seidner DL, McMahon MM, et al. Residency and specialties training in nutrition: a call for action. Am J Clin Nutr. 2014;99(5 Suppl):1174S-83S. https://doi.org/10.3945/ajcn.113.073528.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Ayers P, Adams S, Boullata J, Gervasio J, Holcombe B, Kraft MD, et al. A.S.P.E.N. parenteral nutrition safety consensus recommendations. JPEN J Parenter Enteral Nutr. 2014;38(3):296-333. https://doi.org/10.1177/0148607113511992.

    Article  PubMed  Google Scholar 

  20. Boullata JI, Gilbert K, Sacks G, Labossiere RJ, Crill C, Goday P, et al. A.S.P.E.N. clinical guidelines: parenteral nutrition ordering, order review, compounding, labeling, and dispensing. JPEN J Parenter Enteral Nutr. 2014;38(3):334-77. https://doi.org/10.1177/0148607114521833.

    Article  PubMed  Google Scholar 

  21. Riskin A, Picaud JC, Shamir R. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Standard versus individualized parenteral nutrition. Clin Nutr. 2018;37(6 Pt B):2409-17. https://doi.org/10.1016/j.clnu.2018.06.955.

    Article  PubMed  Google Scholar 

  22. Reber E, Strahm R, Bally L, Schuetz P, Stanga Z. Efficacy and efficiency of nutritional support teams. J Clin Med. 2019;8(9):1281. https://doi.org/10.3390/jcm8091281.

  23. Katoue MG. Role of pharmacists in providing parenteral nutrition support: current insights and future directions. Integr Pharm Res Pract. 2018;7:125-40. https://doi.org/10.2147/IPRP.S117118.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Akbar Z, Saeed H, Saleem Z, Andleeb S. Dosing errors in total parenteral nutrition prescriptions at a specialized cancer care hospital of Lahore: The role of clinical pharmacist. J Oncol Pharm Pract. 2021;27(3):531-40. https://doi.org/10.1177/1078155220923014.

    Article  PubMed  Google Scholar 

  25. Boitano M, Bojak S, McCloskey S, McCaul DS, McDonough M. Improving the safety and effectiveness of parenteral nutrition: results of a quality improvement collaboration. Nutr Clin Pract. 2010;25(6):663-71. https://doi.org/10.1177/0884533610385349.

    Article  PubMed  Google Scholar 

  26. Alomi YA FA, Al-Shubaar N, Alameer LY. The Clinical Outcomes of Pharmacist Interventions in Total Parenteral Nutrition services in Riyadh City, Saudi Arabia. Int J Pharm Health Sci. 2019;2(2):135-40. https://doi.org/10.5530/IJPCS.2019.8.23.

    Article  Google Scholar 

  27. Wang Z, Peng Y, Cai X, Cao Y, Yang G, Huang P. Impact of total parenteral nutrition standardization led by pharmacist on quality in postoperative patients with colorectal cancer. Eur J Clin Nutr. 2019;73(2):243-9. https://doi.org/10.1038/s41430-018-0281-0.

    Article  CAS  PubMed  Google Scholar 

  28. Crews J, Rueda-de-Leon E, Remus D, Sayles R, Mateus J, Shakeel F. Total Parenteral Nutrition Standardization and Electronic Ordering to Reduce Errors: a Quality Improvement Initiative. Pediatr Qual Saf. 2018;3(4):e093. https://doi.org/10.1097/pq9.0000000000000093.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Foulks CJ, Krenek G, Maxwell K. The effect of changing the total parenteral nutrition order form on resident physician ordering behavior. Nutr Clin Pract. 1997;12(1):30-4. https://doi.org/10.1177/011542659701200130.

    Article  CAS  PubMed  Google Scholar 

  30. MacKay M, Anderson C, Boehme S, Cash J, Zobell J. Frequency and Severity of Parenteral Nutrition Medication Errors at a Large Children's Hospital After Implementation of Electronic Ordering and Compounding. Nutr Clin Pract. 2016;31(2):195-206. https://doi.org/10.1177/0884533615591606.

    Article  CAS  PubMed  Google Scholar 

  31. Hilmas E, Peoples JD. Parenteral nutrition prescribing processes using computerized prescriber order entry: opportunities to improve safety. JPEN J Parenter Enteral Nutr. 2012;36(2 Suppl):32S-5S. https://doi.org/10.1177/0148607111435510.

    Article  CAS  PubMed  Google Scholar 

  32. Lashinsky JN, Suhajda JK, Pleva MR, Kraft MD. Use of Integrated Clinical Decision Support Tools to Manage Parenteral Nutrition Ordering: Experience From an Academic Medical Center. Nutr Clin Pract. 2020. https://doi.org/10.1002/ncp.10469.

    Article  PubMed  Google Scholar 

  33. Papandreou P, Ntountaniotis D, Skouroliakou M, Massara P, Siahanidou T. Does a parenteral nutrition decision support system for total nutrients improve prescription procedure and neonatal growth? J Matern Fetal Neonatal Med. 2021;34(5):747-54. https://doi.org/10.1080/14767058.2019.1615432.

    Article  PubMed  Google Scholar 

  34. Gallagher V, Berlana D, Paulsson M, White RJ. Parenteral nutrition: a call to action for harmonization of policies to increase patient safety. Eur J Clin Nutr. 2021;75(1):3-11. https://doi.org/10.1038/s41430-020-0669-5.

    Article  PubMed  Google Scholar 

  35. Xu ZW, Li YS. Pathogenesis and treatment of parenteral nutrition-associated liver disease. Hepatobiliary Pancreat Dis Int. 2012;11(6):586-93. https://doi.org/10.1016/s1499-3872(12)60229-x.

    Article  CAS  PubMed  Google Scholar 

  36. Kumpf VJ. Parenteral nutrition-associated liver disease in adult and pediatric patients. Nutr Clin Pract. 2006;21(3):279-90. https://doi.org/10.1177/0115426506021003279.

    Article  PubMed  Google Scholar 

  37. Walmsley RS. Refeeding syndrome: screening, incidence, and treatment during parenteral nutrition. J Gastroenterol Hepatol. 2013;28 Suppl 4:113-7. https://doi.org/10.1111/jgh.12345.

    Article  CAS  PubMed  Google Scholar 

  38. National Institutes of Health, National Cancer Institute. Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 November 2017 [Internet]. Available from: https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/CTCAE_v5_Quick_Reference_8.5x11.pdf. Accessed on 16 Jul 2020

  39. Vera E. Todorovic AM, on behalf of the Parenteral and Enteral Nutrition Group of the British Dietetic Association. A Pocket Guide To Clinical Nutrition, Chapter 3: Adult Requirements. 4th ed Birmingham (UK): Parenteral and Enteral Nutrition Group of the British Dietetic Association, 3.10–3.11.

  40. (NICE) NIfHaCE: Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. https://www.nice.org.uk/guidance/cg32/resources/nutrition-support-for-adults-oral-nutrition-support-enteral-tube-feeding-and-parenteral-nutrition-pdf-975383198917 (2006, last updated 2017). Accessed on 16 Jul 2020

  41. Rodrigues IB, Adachi JD, Beattie KA, MacDermid JC. Development and validation of a new tool to measure the facilitators, barriers and preferences to exercise in people with osteoporosis. BMC Musculoskelet Disord. 2017;18(1):540. https://doi.org/10.1186/s12891-017-1914-5.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Polit DF, Beck CT. The content validity index: are you sure you know what's being reported? Critique and recommendations. Res Nurs Health. 2006;29(5):489-97. https://doi.org/10.1002/nur.20147.

    Article  PubMed  Google Scholar 

  43. Gisev N, Bell JS, Chen TF. Interrater agreement and interrater reliability: key concepts, approaches, and applications. Res Social Adm Pharm. 2013;9(3):330-8. https://doi.org/10.1016/j.sapharm.2012.04.004.

    Article  PubMed  Google Scholar 

  44. Hripcsak G, Heitjan DF. Measuring agreement in medical informatics reliability studies. J Biomed Inform. 2002;35(2):99-110. https://doi.org/10.1016/s1532-0464(02)00500-2.

    Article  PubMed  Google Scholar 

  45. Vanek VW, Ayers P, Kraft M, Bouche JM, Do VT, Durham CW, et al. A call to action for optimizing the electronic health record in the parenteral nutrition workflow. Am J Health Syst Pharm. 2018;75(18):1400-20. https://doi.org/10.2146/ajhp180276.

    Article  PubMed  Google Scholar 

  46. Skouroliakou M, Koutri K, Stathopoulou M, Vourvouhaki E, Giannopoulou I, Gounaris A. Comparison of two types of TPN prescription methods in preterm neonates. Pharm World Sci. 2009;31(2):202-8. https://doi.org/10.1007/s11096-009-9281-4.

    Article  PubMed  Google Scholar 

  47. Anderson CF, MacBurney MM. Application of A.S.P.E.N. clinical guidelines: parenteral nutrition use at a university hospital and development of a practice guideline algorithm. Nutr Clin Pract. 1996;11(2):53-8. https://doi.org/10.1177/011542659601100253.

    Article  CAS  PubMed  Google Scholar 

  48. Simmer K, Rakshasbhuvankar A, Deshpande G. Standardised parenteral nutrition. Nutrients. 2013;5(4):1058-70. https://doi.org/10.3390/nu5041058.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, Bozzetti F, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr. 2017;36(1):11-48. https://doi.org/10.1016/j.clnu.2016.07.015.

    Article  PubMed  Google Scholar 

  50. Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, et al. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr. 2017;36(3):623-50. https://doi.org/10.1016/j.clnu.2017.02.013.

    Article  PubMed  Google Scholar 

  51. Bischoff SC, Bernal W, Dasarathy S, Merli M, Plank LD, Schütz T, et al. ESPEN practical guideline: Clinical nutrition in liver disease. Clin Nutr. 2020;39(12):3533-62. https://doi.org/10.1016/j.clnu.2020.09.001.

    Article  PubMed  Google Scholar 

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Author notes

  1. Evelyne Van den Broucke and Barbara Deleenheer are shared first authors as they made equal contributions to the conception of the work, the analysis and interpretation of data and to the writing of the manuscript.

Authors and Affiliations

  1. Pharmacy Division, UZ Leuven, Louvain, Belgium

    Evelyne Van den Broucke, Barbara Deleenheer, Katrien Cosaert, Isabel Spriet, Peter Declercq & Charlotte Quintens

  2. Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Louvain, Belgium

    Evelyne Van den Broucke, Isabel Spriet, Peter Declercq & Charlotte Quintens

  3. Department of Chronic Diseases and Metabolism - Translational Research in Gastrointestinal Disorders (TARGID), KU Leuven, Louvain, Belgium

    Barbara Deleenheer, João Sabino & Tim Vanuytsel

  4. Division of Endocrinology, UZ Leuven, Louvain, Belgium

    Ann Meulemans, Julie Vanderstappen, Nelle Pauwels & Roman Vangoitsenhoven

  5. Department of Chronic diseases and Metabolism – Clinical and Experimental Endocrinology (CEE), KU Leuven, Louvain, Belgium

    Ann Meulemans & Roman Vangoitsenhoven

  6. Leuven Intestinal Failure and Transplantation (LIFT), UZ Leuven, Louvain, Belgium

    Nelle Pauwels & Tim Vanuytsel

  7. Division of Thoracic Surgery, UZ Leuven, Louvain, Belgium

    Hans Van Veer

  8. Department of Chronic Diseases and Metabolism - Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE) - Lung Transplant Unit, KU Leuven, Louvain, Belgium

    Hans Van Veer

  9. Division of Gastroenterology and Hepatology, UZ Leuven, Louvain, Belgium

    João Sabino & Tim Vanuytsel

Authors
  1. Evelyne Van den Broucke
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  2. Barbara Deleenheer
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  7. Isabel Spriet
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  8. Hans Van Veer
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Contributions

All authors made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; or the creation of the tool discussed in this work. All authors drafted the work or revised it critically for important intellectual content and approved the final version to be published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Evelyne Van den Broucke and Barbara Deleenheer are shared first author because they contributed equally to the design of the project, analysis and interpretation of the data and writing of the manuscript.

Corresponding author

Correspondence to Barbara Deleenheer.

Ethics declarations

Ethics approval

Approval by the education-support committee of the Catholic University of Leuven (KU Leuven) (MP014038) was granted.

Consent to participate

The recommendations generated by the OLIVE TREE were provided directly to the prescribing physician, who finally had to decide on PN prescribing. Patients were therefore not obliged to provide informed consent.

Consent for publication

The recommendations generated by the OLIVE TREE were provided directly to the prescribing physician, who finally had to decide on PN prescribing. Patients were therefore not obliged to provide informed consent.

Conflicts of interest/Competing interests

B. Deleenheer: None Declared, E. Van den Broucke: None Declared, A. Meulemans: None Declared, J. Vanderstappen: None Declared, N. Pauwels: None Declared, K. Cosaert: None Declared, I. Spriet: None Declared, H. Van Veer Speakers Bureau of: Fresenius, R. Vangoitsenhoven: None Declared, J. Sabino: Consultant for Janssen, Speakers Bureau of Abbvie, Falk and Takeda., P. Declercq: None Declared, T. Vanuytsel: None Declared, C. Quintens: None Declared.

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Van den Broucke, E., Deleenheer, B., Meulemans, A. et al. Offering Guidance and Learning to Prescribers to Initiate Parenteral Nutrition using a Validated Electronic Decision TREE (OLIVE TREE). J Med Syst 46, 56 (2022). https://doi.org/10.1007/s10916-022-01835-x

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