Experts In Compounding Total Parenteral Nutrition and Other Hospital Pharmacy Related Topics and Issues of Interest

Lou Diorio, RPh, and Dave Thomas, RPh, MBA

Certified Consultant Pharmacists, Inc.  

Lou Diorio and Dave Thomas have written a technical paper for Baxa Corporation titled, "Premix vs. Custom TPN."

Overview

America’s health-system resources are often stretched to the extreme. So the critical question becomes, how can hospital management and staff achieve that fine balance between patient care and cost? In the past decade, hospital and health systems have attempted a myriad of solutions to address this tough question.

Introduction of premixed parenteral nutrition (PN) in different strengths and volumes goes against the industry trend to control inventory (reduce the number of products) in order to decrease the opportunity for errors. Premixed PN can meet the needs of a limited number of adult patients. It’s important to note, however, that premixed PN is not appropriate for pediatric, neonate or premature patients1 nor does it provide for any specialty amino acid formulations or formulations for fluid-restricted patients. Despite this, the industry is being encouraged to revert to a standard of practice that was abandoned in the mid 1980’s. An established facility Clinical Nutritional Committee can help determine the best clinical nutritional therapy for a patient and reduce costs through the proper utilization of parenteral and enteral nutrition therapies.

Process control is an integral part of any successful PN program. This starts with having a well-defined policy on PN usage. Developing a clear, concise order form based on the actual PN practice at individual facilities will assist practitioners in the prescribing process. Limiting the PN ingredients available, developing in-depth competency-based training for all personnel, as well as solid Standard Operating Procedures will assist the pharmacy team in addressing the most common critical points of failure. Following these standard practices will provide the nursing staff with consistent, accurate, timely and clearly labeled PN product. By having clearly defined roles and working in concert, the care team will have a tailored PN solution that meets these specific needs and provides the best possible outcome for the patient.

The lack of commercially available software to utilize premixed PN solutions that require additives makes proper labeling, calculations to determine flow rate and setting hang time(s) complex and difficult to achieve. In addition, the facility must manage patients receiving multiple bags per day, multiple hang times, and determine whether incomplete bags are kept hanging into the next 24-hour period or discarded to begin the next order period. Using multiple bags per day doubles or triples the nursing time needed to manage TPNs. Clinicians then must decide how to incorporate these decisions into the patients’ daily nutritional calculations. The complexity of these decisions, impact on staff and calculations makes the final determination of nutritional delivery extremely difficult. Policies also must be put in place to prevent the administration of premixed PN bags and lipid piggybacks beyond their labeled expiry.

click here to access the Technical Paper pdf

Lou Diorio, RPh, is a graduate of Long Island University’s Schwartz College of Pharmacy.  An adjunct Professor of Pharmacy Practice for the college and a preceptor of pharmacy students, he is a member of the Executive Dean’s experiential education committee.  Lou has extensive experience in IV and extemporaneous compounding, and lectures and consults on these topics.  He has managed an FDA-registered cGMP manufacturing operation for Coram Healthcare (SoluNet™ LLC).  Most recently Lou was asked by the NJ Board of Pharmacy to join a select committee reviewing the Board’s regulatory changes in response to changes in regulation as a direct result of USP 797.  Since 1985 Lou has practiced in many clinical settings fulfilling many roles, including Chief Operating Officer of Hebrew Hospital Corporate services, a multi-centered sub acute and LTC hospital system in NY. He has also managed & practiced in home-care, hospital, and retail settings, plus lectured and developed educational materials for several big-pharma companies on sales and marketing topics.

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