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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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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
(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
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.
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.
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.
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.
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.
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.
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.
Simmer K, Rakshasbhuvankar A, Deshpande G. Standardised parenteral nutrition. Nutrients. 2013;5(4):1058-70. https://doi.org/10.3390/nu5041058.
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.
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.
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.
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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.
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Approval by the education-support committee of the Catholic University of Leuven (KU Leuven) (MP014038) was granted.
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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.
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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.
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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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DOI: https://doi.org/10.1007/s10916-022-01835-x