Peripheral parenteral nutrition: An evaluation of its use, safety and cost implications in a tertiary hospital setting.

BACKGROUND AND AIMS: Malnutrition is a common challenge among hospitalised patients and its associatiation with poor patient health-related outcomes places a significant financial burden on the healthcare system. Total parenteral nutrition (TPN) is the primary means for providing nutrition to individuals in whom enteral feeding is not possible but is costly and requires invasive central venous access. Peripheral parenteral nutrition (PPN) provides a suitable option for early nutrition provision in select patients; however, its routine use has been limited by safety and tolerability concerns, with high rates of phlebitis reported in previous studies. The objectives of this study were to review the use, safety, and costs of PPN in an Australian tertiary hospital. METHODS: A single-site, prospective observational study was conducted over 15 months in a tertiary hospital. 139 participants (87 male and 52 female) were enrolled in the study. Data collected assessed the indication for PPN initiation, compliance with the hospital's protocols for PPN, total fasting days, the proportion of the patient's total energy and protein requirements provided by PPN, the incidence of phlebitis and potential cost implications associated with the use of PPN. RESULTS: 139 patients (62.6% male), median age 62 years (IQR (interquartile range) 48-74) were enrolled. Most patients had an emergency admission (80.6%) under a general surgical team (84.2%). Forty-eight patients (34.5%) were malnourished, as assessed by the Subjective Global Assessment tool (SGA). Patients fasted for a median of 3 days (IQR 2-5) before PPN commencement, with a median duration of PPN use of 3 days (IQR 2-4). PPN provided an average of 61.6% of the patients' required caloric intake and 46.4% of protein requirements. Progression to TPN was observed in 34.5% of patients. There were low rates of complications with phlebitis observed in 3.7%, extravasation in 1.1%, and no patients developed septicaemia, despite suboptimal compliance with the recommended cannula management guidelines for PPN (66.4% compliant). The cost of PPN was estimated to be AUD$187 per patient day. CONCLUSION: PPN is an effective short-term nutrient delivery solution to facilitate early feeding with small numbers of patients requiring transition to TPN. PPN was safe with low rates of cannula complications. Costs were favourable, with potentially significant cost savings as compared with TPN.

Barriers to Optimal Surgical Antimicrobial Prophylaxis for Methicillin-Resistant Staphylococcus aureus-Colonized Patients at an Australian Tertiary Teaching Hospital.

Background: Surgical antimicrobial prophylaxis (SAP) is a leading indication for antibiotic use in Australian hospitals with established high rates of inappropriate prescribing. Optimal administration of SAP for patients at high risk of methicillin-resistant Staphylococcus aureus (MRSA) infections presents additional complexities. A greater understanding of barriers to optimal SAP in this cohort is required to inform targeted antimicrobial stewardship strategies, optimize SAP, and reduce the rate of surgical site infections (SSIs). Methods: A multiple-choice questionnaire appraising knowledge and barriers to optimal SAP was electronically distributed to key stakeholders. Data from the questionnaire were collated and analyzed using Survey Monkey® (Momentive Inc., San Mateo, CA) data analysis tools. Results: Eighty-three persons provided full or partial responses to the questionnaire. There were 19% of respondents who considered MRSA colonization status of patients to be only "somewhat important" when selecting appropriate SAP. Additionally, 62% of responses did not correctly identify the appropriate SAP regimen for patients who are colonized with MRSA. Several barriers to optimal SAP were identified including poor understanding of SAP guidelines, lack of timely identification of patients confirmed to be colonized with MRSA, inaccurate documentation of antibiotic and surgical start times, and limitations of the current operating room management software program. Conclusions: The high level of engagement from most key stakeholders demonstrates accountability and an overall desire to improve SAP. Barriers identified in this audit should be considered by facilities wishing to optimize compliance with SAP guidelines and consequently reduce SSIs, in particular for patients who are at high risk of MRSA infections.