1. STILL A MIXED BAG? A REVIEW OF NCEPOD STANDARDS WITHIN THE NEONATAL UNIT ANTRIM AREA HOSPITAL
McVea S, Stobo A, Bali S
Introduction
Results
In total 13 neonates admitted to AAH NNU in January 2015 received TPN. In all cases this therapy was initiated and managed by neonatal staff working within the unit. None of the neonates had received parenteral nutrition previously.
In only 4 cases was an indication for TPN therapy clearly documented within the notes. These indications included being high risk for enteral feeds in 2 cases, being in severe respiratory distress in 1 case and to allow establishment of enteral feeds in the final case.
There did not appear to be an unreasonable delay in recognizing the need for or starting TPN in any of the infants audited. However, in only 1 case was a treatment goal documented for the termination of TPN. This goal was the establishment of full enteral feeding, a goal which whilst not documented could be inferred from the remaining 12 cases based on when TPN was discontinued.
A “standard” TPN bag was used in 7 cases (54%) as the initial TPN source whilst the remainder received a bespoke bag (46%). In all cases the constitution of initial TPN was deemed appropriate. All cases had detailed TPN prescription proformas filed within their notes. The proformas detailed the neonate’s nutritional requirements and constitution of TPN prescribed in adequate detail.
All neonates receiving TPN received daily review of clinical status, biochemical indices, weight, TPN constitution and ongoing need for TPN.
In 4 cases neonates receiving TPN suffered complications. These included hyponatraemia in 2 cases, hypernatraemia in 1 case, hyperglycaemia in 1 case and 1 case of hyperkalaemia. In all cases these complications were deemed unavoidable and all were managed appropriately with no long term sequelae.
All neonates audited were weaned onto enteral feeds, 12 were subsequently discharged home whilst a single neonate was transferred to another unit to continue their neonatal management.
The report, “A Mixed Bag” (1), published by NCEPOD in 2010 was a review of Parenteral Nutrition (PN) in hospitalised patients.
Within this report a number of areas where parentral nutrition delivery could be improved to maintain patient safety were identified. From this a range of recommendations were made to ensure appropriate parentral nutrition usage within a wide range of clinical settings.
Aim
To assess the delivery of parentral nutrition in Antrim Area Hospital Neonatal Unit in relation to recommendations with the NCEPOD report.
Standard
Conclusion
Recommendations from the NCEPOD “A Mixed Bag” 2010 executive summary (1), namely;
Careful and early consideration should be given to the need for PN in neonates and once the decision to commence PN is made it should be started without undue delay.
The first PN given must be appropriate to the neonate’s requirements.
Close monitoring of the patient must be achieved so that metabolic complications can be avoided.
Neonatal Units should have an agreed policy for nutritional requirements and use a proforma that includes this information which is tailored for each infant and placed in the case notes.
Neonatal units should undertaken regular audit of PN practice which should include the complications of PN
This small audit has shown that parentral nutrition delivery within the neonatal unit in Antrim Area Hospital followed NCEPOD recommendations. In all cases TPN was considered in an early and timely manner with no unreasonable delay in administration.
All neonates received appropriate TPN initially which was then tailored to their ongoing needs. Whilst on TPN all neonates received appropriate monitoring and review. Through this close monitoring complications were identified early allowing institution of appropriate management.
Unfortunately, documentation of TPN indication and treatment goal in audited neonates was suboptimal.
Recommendations
Remodel TPN prescription chart to include area for documentation of TPN indication and treatment goal.
Continue with daily review of TPN management to limit complications and respond to their development in a timely and appropriate manner.
Regular audit of TPN administration practices within the Neonatal Unit against NCEPOD recommendations
Methodology
Neonates admitted to Antrim Area Hospital neonatal unit in January 2015 were identifed retrospectively. Notes were then reviewed with data collected using the standardized NCEPOD audit proforma available online from the NCEPOD website. This data was collated, stored and analysed using Microsoft Excel.
Reference
A Mixed Bag – An enquiry into the care of hospital patients receiving parenteral nutrition. NCEPOD 2010