1. How successful are we at delivering nutrition?
Zoe Lansdowne
Lead Pharmacist for Neonatology
November 2014
Sheffield Teaching Hospitals NHS Foundation Trust

2. Overview Introduction Aim Method Results Conclusions Actions
So, I am going to tell you why I did this audit, what the results showed and how our unit is working to change current practice

3. Introduction
Need to optimise nutrition to promote growth and neurodevelopmental outcomes
2012 VON data showed that the unit’s mean growth velocity was less than for the network
Unit set up a MDT working group to identify problem areas and explore possible solutions
My focus was PN and the nutritional intake in the first 14 days of life
Gestational age (weeks) Centre Mean growth (g/kg/day) Network Mean growth (g/kg/day)
MDT working group consisting of doctors, nurses, the dietician and of course, myself
Many possible names
Nutrition group … growth group … but unfortunately the name that got most response and has therefore stuck is ‘fat club’
My role in the MDT was to focus on PN and the nutritional intake in the first 14 days of life

4. Aim
Aim – to establish how successful the unit is at delivering nutrition over the first 14 days of life
Audit criteria –
1. Time from birth to PN:
Target- within 6hours if <750g
within 12 hours if g or
1000g-1500g with absent or reversed EDF
2. Time from line position confirmed safe for PN use to PN starting: Target- within 1 hour
3. Nutritional intake g/kg/day protein in first 24 hours: Target- minimum 1.25g/kg/day(1)
1.25g/kg/day ESPGHAN target to prevent a negative nitrogen balance
Tsang target is 2g/kg/day
1.2g amino acid=1g protein=0.16g nitrogen

5. Method Admitted to the unit within 24 hours of birth
<28/40 or <1kg
From 1st January to 31st March 2014
Retrospective
Data from patient medical notes, including parenteral nutrition (PN) prescriptions, fluid prescriptions and observation charts
Used protein intake as a marker to quantify nutritional delivery
Audit inclusion criteria were…

6. Results 20 infants Birth weight mean 0.763kg (range 0.432 to 0.96kg)
Gestation
mean 26+3 (range 23+4 to 32+2)

7. Time from birth to PN (Hours)
Mean time from birth to PN 15hrs 27mins (range 4hrs 12mins to 45hrs 40mins)
Only 13% of all infants <750g received PN within 6 hours of birth
Time from birth to PN (Hours)
Met target?
Mean
Range
All infants (n=20)
15.45
4.2 to 45.67 -
Inborn only (n=15)
10.98
4.2 to 19.18
Within 6 hours all (n=8)
18.27
5.15 to 45.67
13%
Within 6 hours inborn (n=6)
11.81
5.15 to 18
17%
Within 12 hours all (n=12)
13.56
4.2 to 31.75
67%
Within 12 hours inborn (n=9)
10.43
78%
Of the infants that should have received PN within 6 hours of life only 13% met this target, this was increased to 17% if you only included the infants actually born within our trust.
For infants that should have received PN within 12 hours of life, this target was met in 78% born within our trust

8. Time from line position confirmation to PN
Mean time from line position confirmation to PN starting 4hrs 40mins (range 15mins to 20hrs 10mins)
Only 20% of all infants had PN connected to a line confirmed safe for PN use within 1hr
Time from line position confirmation to PN (Hours)
Met target of within 1 hour?
Mean
Range
All infants (n=20)
4.67
0.25 to 20.17
20%
Inborn only (n=15)
4.46
0.5 to 15
13%
Within 6 hours all (n=8)
4.93
0.5 to 20.17
Within 6 hours inborn (n=6)
2.56
0.5 to 5.5
17%
Within 12 hours all (n=12)
4.49
0.25 to 15
25%
Within 12 hours inborn (n=9)
5.73
11%
Medical and nursing staff handover times, day of the week or time of the day did not correlate with the delays in PN administration.

9. Intake in the first 24 hours of life
All infants (n=20)
Mean 24.6ml/kg/day of aqueous PN
0.66g/kg/day protein
3 patients received >1.25g/kg/day protein
Other fluids = 15.8ml/kg/day
Only infants that received PN (n=16)
Mean 30.4ml/kg/day of aqueous PN
0.83g/kg/day protein
On average infants received 24.6ml/kg/day of aqueous PN on day 1 of life which equated to 0.66g/kg/day of protein in the first 24 hours of life. Only 3 infants received more than 1.25g/kg/day of protein on day 1 of life, but 1 didn’t achieve this until day 5.
Excluding the infants that did not received any PN in the first 24 hours of life (n=4), this average is increased to 30.4ml/kg/day aqueous PN, equating to 0.83g/kg/day protein.

10. Nutritional intake over the first 14 days of life (n=17)
Mean protein intake of all infants 2.15g/kg/day
Max protein intake of any individual infant 3.46g/kg/day
13% of aqueous PN r’xd was never administered
3 infants were excluded from further data analysis (1 died and 2 discharged before day 14) n=17
The blue bars show average protein intake for all infants on each day of life
And the pink life shows what the 2005 Tsang targets are for ELBW (<1000g) infants
Day 0 parenteral protein 2g/kg/day
Growing parenteral protein g/kg/day

11. Growth velocity (1) Mean growth velocity was 3.04g/kg/day (n=16)
(range -7.56g/kg/day to 13.82g/kg/day)
Inverse relationship between growth and number of hours from birth to PN
After taking into account 1 obvious outlier, average weight gain was 3.04g/kg/day, with a maximum weight gain of 13.82g/kg/day.
The greatest weight loss was 7.56g/kg/day.
Weight gain was found to be inversely related to the number of hours until PN was first started (R2=0.59)

12. Growth velocity (2)
Positive correlation between growth velocity and protein intake on day 1
Not seen with any other day of protein intake, or total protein intake
There was also a positive correlation between weight gain and protein intake on day 1 (R2=0.45).
Such a strong correlation is not seen with any other day of protein intake or even total protein intake.

13. Conclusions
How successful are we at delivering nutrition? We are not!!
Mean nearly 11hrs from securing central access to starting PN (inborn infants)
Mean day 1 protein intake 0.66g/kg/day
Mean protein intake over first 14 days 2.15g/kg/day
Max protein intake in first 14 days 3.46g/kg/day
Mean growth velocity 3.04g/kg/day
It has been shown that a delay in the time from birth to starting PN has detrimental effects on weight gain, therefore it is imperative that new ways are found to reduce the amount of time it takes to commence PN, and also to increase the amount of protein administered, so how are we planning on doing this???
So we have our ‘fat club’ that can drive this forward, but from a PN point of view here are my starting points

14. Actions Publicity campaign – posters, training Join the ‘Push for PN’
4 P’s of PN
Prompt
Protected
Protein
Peripheral
Re-audit
4 P’s of PN
Prompt
Protected
Protein
Peripheral
PROMPT:
We need to reduce the time it takes for PN to first be administered
Interim poster highlighting the audit findings with a big push for getting PN connected as soon as the line is confirmed safe for PN use
Consultants: to highlight to medical staff the importance of securing central access, confirming it safe for use and then prescribing PN
Nurses: to push for line positions to be checked in a timely manner and to get PN connected asap
Doctors: Dr that is scrubbed to insert and secure line to help nurse connect PN to new line, therefore only the nurse looking after that baby is needed (and they should have been assisting the doctor with putting in the line already)
PROTECTED:
Change to a 3 fluid system so PN volume is protected from other infusion requirements (aqueous phase, lipid phase and 5% glucose infusion)
Always prescribe PN in least volume necessary and have an extra infusion of 5% glucose
This glucose infusion rate can then be changed according to other fluid requirements
Change the fluid and electrolytes guideline to give better guidance on how to administer additional electrolytes in less fluid volumes, e.g. 5-10ml/kg/day of glucose 5%, as we found that quite often 30ml/kg/day was used and this significantly reduces the amount of nutrition administered
PROTEIN:
Increase the amount of protein administered
Reformulate PN recipe
Source more concentrated bags of PN so better intake from same volumes (from current volumes this would lead to a 22% increase in protein intake)
Maximise fluid volumes e.g. total fluids to 180ml/kg/day before reducing PN rates (ie 60ml/kg/day enteral feeds + 120ml/kg/day PN)
PERIPHERAL:
Possible use of peripheral PN if central access lost, e.g. line removed due to sepsis, NBM for ?NEC etc.
Or infants without central access but need nutrition, eg delay in EBM <32weeks gestation
Or use this bag for central lines that are not in the optimal position for PN
GROWTH GROUP/FAT CLUB: to highlight to everyone why nutrition is important, and to drive the changes forward. Education and training
REAUDIT

15. References
ESPGHAN Guidelines on paediatric parenteral nutrition. Journal of Paediatric Gastroenterology and Nutrition 2005 Vol. 41:S12–S18
Tsang RC, Uauy R, Koletzko B (Eds) Nutrition of the preterm infant. 2nd ed Digital Education Publishing, Inc. Cincinnati, Ohio.