Development and implementation of an audit tool for quality control of parenteral nutrition.

BACKGROUND: The aim of this article is to describe the development of a quality control methodology applied to patients receiving parenteral nutrition (PN) and to present the results obtained over the past 10 years. Development of the audit tool: In 1995, a total of 13 PN quality criteria and their standards were defined based on literature and past experiences. They were applied during 5 different 6-month audits carried out in subsequent years. According to the results of each audit, the criteria with lower validity were eliminated, while others were optimized and new criteria were introduced to complete the monitoring of other areas not previously examined. Currently, the quality control process includes 22 quality criteria and their standards that examine the following 4 different areas: (1) indication and duration of PN; (2) nutrition assessment, adequacy of the nutrition support, and monitoring; (3) metabolic and infectious complications; and (4) global efficacy of the nutrition support regimen. The authors describe the current definition of each criterion and present the results obtained in the 5 audits performed. In the past year, 9 of the 22 criteria reached the predefined standards. The areas detected for further improvements were: indication for PN, nutrition assessment, and management of catheter infections. CONCLUSIONS: The definition of quality criteria and their standards is an efficient method of providing a qualitative and quantitative analysis of the clinical care of patients receiving PN. It detects areas for improvement and assists in developing a methodology to work efficiently.

[Prevention of adverse events through renal dosage adjustment in institutionalized elders]. / Prevención de acontecimientos adversos mediante ajuste posológico renal en pacientes ancianos institucionalizados.

INTRODUCTION: To present a protocol based on renal dosage adjustment developed to reduce the risk of adverse events in elderly people institutionalized in a geriatric centre and to determine the degree of adaptation to this protocol. MATERIAL AND METHOD: First, we designed a renal adjustment protocol to identify residents with creatinine clearance below 60ml/min, review drug therapy and optimize dosage regimens, if necessary. Then, we evaluated the feasibility of this protocol and adaptation of clinical practice to this protocol through a cross-sectional study of all the residents in the centre. RESULTS: Among the 163 residents assessed by Cockroft-Gault, there were 126 residents with creatinine clearance below 60ml/min (77%; 95% CI, 70-83). Seventeen residents were excluded due to intake of protein supplements or to extreme body mass index. Once the treatments were reviewed, 152/876 (17%; 95% CI, 15-20) prescriptions suitable for renal adjustment were found. In 135/152 prescriptions (89%; 95% CI, 83-93) the dosage was appropriate to creatinine clearance and 17 (11%; 95% CI, 6-17) were considered as potentially optimizable. For these 17 prescriptions, a proposal for dosage adjustment or monitoring was made, which was accepted in 16 cases and rejected in 1 case (metformin in a patient with 44ml/min creatinine clearance and poor glycemic control). CONCLUSIONS: A high percentage of the institutionalized elderly have a creatinine clearance below 60ml/min. Given that a not inconsiderable proportion of their prescribed medication is susceptible to renal adjustment, the implementation of a protocol for renal adjustment and renal function follow-up could help to reduce the risk of adverse events.

[Training degree assessment of staff producing parenteral nutrition in Pharmacy Services]. / Evaluación del grado de formación del personal que elabora las nutriciones parenterales en los Servicios de Farmacia.

OBJECTIVE: To assess the level of expertise of Pharmacy personnel in the manufacturing of total parenteral nutrition. MATERIAL AND METHODS: An on-line survey including 17 questions concerning key aspects of TPN manufacturing was designed. Survey monkey software was used to create the survey and to analize its results. RESULTS: 135 answers were received. 95% of the participant Pharmacy services had written standard manufacturing procedures. 67% answered that phosphate salts should be the first electrolite to be additioned into the total parenteral nutrition and 34% affirmed that validation of the aseptic manufacturing technique was not performed. As far as personnel training was concerned, 19% of respondents had not received any specific training, although 99% considered it would be necessary to receive it. CONCLUSIONS: The polled personell has an acceptable level of expertise but adequate training courses are still necessary and should be promoted from Pharmacy services.

Objetivo: Evaluar el grado de formación del personal que elabora nutrición parenteral en los Servicios de Farmacia. Material y métodos: Se diseñó una encuesta on-line con 17 preguntas en la que se incluyeron los puntos más importantes en la elaboración de nutriciones parenterales. Para el diseño de la encuesta y el análisis posterior se utilizó la aplicación informática Survey monkey®. Resultados: Se obtuvieron un total de 135 respuestas. En el 95% de los Servicios de Farmacia existían normas escritas de elaboración. El 67% contestó que el fosfato se debía añadir cuando se empiezan a añadir los electrolitos y el 34% que no se realizaba la validación de la técnica aséptica de elaboración. En cuanto a la formación, el 19% no la había recibido, considerando necesario recibirla el 99%. Conclusiones: El personal encuestado presenta un grado de formación aceptable, pero son necesarios los cursos de formación que se deben fomentar desde los Servicios de Farmacia.

[Availability of antidotes in the event of accidents or attacks with chemical weapons]. / Disponibilidad de antídotos en caso de accidentes o atentados con armas químicas.

BACKGROUND: In this report, we aimed to determine the availability of six antidotes for victims of accidents or attacks with chemical weapons. MATERIAL AND METHOD: Telephone interviews with 6 Catalan hospitals and 8 hospitals from the community of Castilla y León. We evaluated the availability of antidotes in the hypothetical event of a massive intoxication with 600 affected people. RESULTS: Only 3 out of the 14 hospitals had all 6 antidotes. Only atropine and, in Catalan hospitals, sodium thiosulfate were available in enough quantities to treat all victims. With regard to the remaining antidotes, the percentage of treated patients would have been fewer than 50%. The less available antidote was hydroxocobalamine. CONCLUSIONS: We have found both qualitative and quantitative deficiencies of antidotes for the treatment of people intoxicated by chemical weapons.

[Indicators monitoring the process of specialized nutritional support. Grupo de Nutrición de la SEFH]. / Indicadores de monitorización del proceso de soporte nutricional especializado.

OBJECTIVE: To identify and develop monitoring indicators of the process of specialized nutritional support that will allow measuring the level of adherence to the established practice standards. METHODS: Those practice standards considered to be key elements of the process were selected to develop performance indicators. The construction of these indicators combined the scientific evidence with expert opinion. Key goals were identified within each standard provided that its consecution would allow increasing the achievement of the standard. Particular improvement initiatives associated to each key goal were generated. Lastly, monitoring indicators were defined allowing undertaking a follow-up of the implementation of the improvement initiatives or either to assess the level of achievement of the key goals identified. RESULTS: Nineteen practice standards were selected representative of the critical points of the process. The strategic map for each standard has been defined, with the identification of 43 key goals. In order to achieve these key goals, a portfolio of improvements has been generated comprising 56 actions. Finally, 44 monitoring indicators have been defined grouped into three categories: 1. Numeric: they assess the level of goal achievement; 2. Dichotomic (yes/no): they inform on the execution of the improvement actions; 3. Results of the practice audits. CONCLUSIONS: We have made available monitoring indicators that allow assessing the level of adherence to the practice standards of the process of specialized nutritional support and the impact of the implementation of improvement actions within this process.