# An Audit of the Use of Total Parenteral Nutrition: Are We Using It Correctly?

## TL;DR

This study audits how total parenteral nutrition is used in a hospital, checking if it aligns with guidelines and identifying areas for improvement.

## Contribution

The study evaluates adherence to guidelines for TPN use and tracks improvements over multiple audit cycles.

## Key findings

- TPN was prescribed appropriately for all patients, with 100% having documented indications.
- Dietitian review and correct TPN prescriptions improved significantly over four audit cycles.
- Documentation of BMI/weight declined over time, and 31% of TPN was started by out-of-hours doctors.

## Abstract

Background

Total parenteral nutrition (TPN) provides essential nutritional support when the gastrointestinal (GI) tract is non-functional or inaccessible. Its use should be limited to situations where enteral feeding is not possible or contraindicated. Enteral nutrition remains the preferred option whenever feasible. Clinicians should ensure an informed discussion regarding the relative risks and benefits of parenteral versus enteral nutrition.

Objectives

To evaluate adherence to local and national guidelines in the use of TPN, including frequency of emergency TPN prescriptions, duration of therapy, and dietitian review of TPN regimens.

Methods

This retrospective audit was conducted over a three-month period from August to October 2019. All adult patients prescribed TPN under general surgery were included, while those managed in the intensive care unit were excluded. Data were collected on TPN indication, assessment of alternative feeding routes, body mass index (BMI)/weight changes, duration, prescription appropriateness, delivery route, dietitian review, and complications. Findings were benchmarked against the National Institute for Health and Care Excellence (NICE, 2017) and the National Confidential Enquiry into Patient Outcome and Death (NCEPOD, 2010) standards, and compared with three previous audit cycles (2013-2016). Data were analysed descriptively, with categorical variables expressed as counts and percentages. Differences across audit cycles were assessed using the chi-square or Fisher’s exact test, with p < 0.05 considered statistically significant.

Results

Sixteen patients met the inclusion criteria. Indication for TPN was documented for 100% of the patients. Thirteen (81.25%) of our patients had other modes of feeding excluded. The Malnutrition Universal Screening Tool (MUST) was used for all patients included in the study. Fifteen (93.75%) patients had no documentation of their weight/BMI at the end of the TPN regimen. Five (31.25%) patients were started on emergency TPN by an out-of-hours doctor. All the patients had their TPN prescribed adequately. None of our patients had any significant metabolic complications or re-feeding syndrome.

We compared the outcomes of this audit with the previous three cycles. There was improved documentation of the indication of TPN across four cycles. Statistically significant improvement was found in the dietitian review (p = 0.002) and correct TPN prescription (p < 0.001). Documentation of BMI/weight declined across four cycles (p = 0.008). The majority of TPN was dietitian-led, and the need for TPN was reviewed regularly.

Conclusion

This study highlights the importance of multidisciplinary team involvement to improve care in TPN delivery. All efforts should be taken to use the GI tract for nutrition provision if it is available for use. The findings of this audit may relate to local practices; however, the lessons learnt may be applicable to other healthcare systems seeking to review and improve governance and quality assurance in TPN service delivery.