Application of quality improvement techniques to reduce parenteral nutrition wastage in a national intestinal failure unit.

OBJECTIVES: Parenteral nutrition (PN) costs approximately £80 per day per bag. Unpredictable changes in patients' clinical condition, venous access loss or reasons related to the processes involved in administering PN can lead to PN wastage. Cost efficiencies are imperative to optimise limited resource utilisation in all current healthcare economies. We undertook a quality improvement (QI) project to reduce PN wastage in an adult acute hospital setting. The project SMART's (specific, measurable, achievable, realistic, time-based) objective was reducing in-patient PN wastage by 10% in 9 months using QI methodology on a national intestinal failure unit (IFU). METHOD: Wastage reasons were evaluated through pareto charts to target waste reduction using 'Plan, Do, Study, Act' (PDSA) cycles. Variation was mapped using c-charts. RESULTS: 12-week baseline wastage data predicted 1000 bags wasted per annum (p.a.). PDSA cycles actioned included: regular enhanced clinical team awareness of wastage; unused PN bags redistributed within expiry date; stock bag rotation; critical path analysis of PN bag journey; enhanced discharge planning/coordination; reorganisation of fridge PN storage according to weekday; changing ordering frequency and bag type (from tailored to standard) to increase flexibility around discharge date and PN weaning. Implementation of PDSA cycles led to a 34% reduction in PN wastage in 9 months. CONCLUSION: In a high-use IFU, PN wastage is common and costly. Using a QI approach with concurrent PDSA cycles and a motivated multidisciplinary team, high levels of wastage reduction are possible with associated significant cost savings and from this study a predicted cost saving of approximately £30 000 p.a.

Management of intestinal failure in inflammatory bowel disease: small intestinal transplantation or home parenteral nutrition?

Inflammatory bowel disease and Crohn's disease in particular, is a common cause of intestinal failure. Current therapeutic options include home parenteral nutrition and intestinal transplantation. For most patients, home intravenous therapy including parenteral nutrition, with a good probability of long-term survival, is the favoured choice. However, in selected patients, with specific features that may shorten survival or complicate home parenteral nutrition, intestinal transplantation presents a viable alternative. We present survival, complications, quality of life and economic considerations that currently influence individualised decision-making between home parenteral nutrition and intestinal transplantation.