Standardize Parenteral Nutrition for Adult Patients

May 2019 - Vol.16 No. 5 - Page #28
Category: IV Workflow Management

Parenteral nutrition (PN) provides critical IV nutrition for patients who cannot tolerate enteral nutrition, but it is vulnerable to medication errors due to its ordering complexities.1 Standardizing electronic PN ordering has been shown to decrease ordering errors, including errors of omission, resulting in safer, more uniform provision of PN.1,2

University Hospitals (UH) is a 15-hospital health system that includes 28 outpatient health centers and primary care physician offices in 15 counties in and around Cleveland, Ohio. Four disparate electronic medical records (EMRs) are utilized throughout the health system: the core EMR covers nine hospitals; the remaining three EMRs will be integrated over the next year.

UH manages its formulary process through two system-level pharmacy and therapeutics (P&T) committees, one for adults and one for pediatrics. The formulary process is designed to:

  • Encourage policies that reduce variation by introducing high reliability medicine programs
  • Lower costs through value improvement programs
  • Implement standardized ordering capabilities in the EMR utilizing clinical effectiveness teams3

More information about these initiatives is available in an article previously published in Pharmacy Purchasing & Products, Implementing a Strategy for Drug Cost Management, available at:

Historically, electronic ordering for adult PN at UH had been a complex process utilizing seven PN order sets within the core EMR. Further complicating this process, sites utilized a variety of PN products, and some sites relied on an outsourced service for compounding PN. UH had attempted to standardize adult PN for several years, which resulted in key clinical decisions that were not operationalized. In order to implement changes, the PN ordering process needed to be streamlined and standardized across the EMR. Additionally, significant coordination across the health system would be required.

Establishing a Standardization Process

Interest in standardizing PN products and ordering piqued within the health system when one of our manufacturers notified UH that several of the premixed PN products we had been using would soon be discontinued from the market. Thus, implementing thorough and timely PN standardization became critical.

Utilizing the formulary process to reduce orderable products was identified as an important goal, as this would deliver cost savings and provide consistency for prescribers. Product standardization would also support the value improvement program at UH and help the health system prepare for EMR integration. Further, it would improve our ability to anticipate product availability changes from manufacturers and facilitate drug shortage management.4

We utilized the Institute for Healthcare Improvement’s Plan-Do-Study-Act model for implementing change,5 which is recommended for managing changes of any size. Driving this project’s success was the involvement of an engaged team, including a physician champion. An interdisciplinary workgroup of dietitians and pharmacists, under the guidance of the system formulary/policy pharmacist, met eight times over a 4-month period to discuss standardization requirements. These included:

  • Evaluating the products being removed from the market by the manufacturer
  • Comparing products available at each hospital, as well as the various order sets utilized
  • Evaluating electrolytes, amino acids, lipids, insulin, multivitamin, and trace elements in PN ordering
  • Identifying ordering needs, such as cycling time, administration time, order cutoff time, and maximum administration rate
  • Notifying and educating staff regarding the changes

Creating New PN Order Sets

Our discussions led to the creation of two standardized order sets for adult PN, one for initial orders and one for daily orders, as well as three standard PN premixed products that the hospital pharmacies could stock. Order set contents also were standardized, including the following:

  • Lipid volume and infusion time were specified.
  • Amino acid products were removed from the order sets (note that additional amino acids can be ordered in the EMR).
  • After discussions with nephrology, electrolyte content was updated to match the standard product. If a patient requires more electrolytes than are provided in the premixed solutions, additional electrolytes can be ordered.
  • Insulin was removed from order sets, as safe ordering processes were already in place.
  • Minimum hours for cycling were specified.
  • Hang time, order cutoff time, maximum administration rate, trace elements, and recommended and optional laboratory orders were standardized.
  • Multidose vitamins were standardized, and coverage of vitamin requirements was confirmed.

Implementing the New Process

Because timing was critical, the order set recommendations were reviewed and approved through the adult system formulary process within 1 month. Changes were communicated to prescribers, dietitians, pharmacists, and nurses via memorandum, which outlined ordering standardization, order time, start time, maximum infusion rate, order stop date, lipids, available premixed PN products, multivitamins, trace elements, laboratory orders, and cycling instructions. When the changes were implemented, the discontinued products and old PN order sets were retired from the EMR.

After implementing the standardized PN order sets, the workgroup met on additional occasions in the ensuing months to fine-tune the process and answer staff questions, explaining the reasons driving certain decisions as well as making necessary adjustments. A nursing survey was conducted to assess whether any additional changes were needed. The survey focused on uptake of the standardized hang time for PN and the need to update the nomenclature for peripheral PN. A majority of nurses supported the nomenclature update and were comfortable with the standard hang time. There were questions about how multivitamin and trace element standardization was determined, how lipid orders were calculated in the EMR, and why insulin was not included in the order set. We also helped troubleshoot issues with the medication label printer. Finally, concerns related to pharmacist workflow for order entry in the community hospitals versus the main campus academic medical center were clarified.

Two updates were necessary, which were subsequently completed and communicated to staff via memorandum. Synonyms were added to order sets to increase clarity; for example, order sets can now be located when searching the terms TPN (total parenteral nutrition) and PPN (peripheral parenteral nutrition) in the EMR. The order set names were revised as Parenteral Nutrition Initial Orders Adult and Parenteral Nutrition Daily Orders Adult. In addition, the order set name for peripheral PN was clarified from TPN Standard—Amino Acid 4.25%—Dextrose 5% mL to the more accurate Peripheral Parenteral Nutrition (PPN) Standard—Amino Acid 4.25%—Dextrose 5% mL. Finally, the default rate for lipid functionality was modified to allow for appropriate calculation, including a smaller volume, if needed.

Results and Future Goals

UH’s project to standardize PN order sets and ensure access to products was a success, due largely to our focus on process improvement and engagement from key stakeholders. To implement a change of this magnitude within a short time frame, gaining the buy-in and support from critical staff, as well as the leadership of a project coordinator, are critical. In addition, it is important to note that our previous attempts to standardize PN at UH laid the necessary groundwork for this endeavor to flourish. Because the workgroup already had a clear understanding of the importance of this effort, the final push to completion was effective.

The PN order set standardization process clarified the need for additional projects. For example, with UH hospitals integrating onto a single EMR platform, further discussions are required to determine if these sites will continue to rely on the outsourced PN compounding service or if they will utilize the UH standard order sets and premixed PN products. As the UH hospitals not yet using the core EMR begin adopting it, these discussions will continue.


Our PN order set standardization project has instituted a safer ordering process that has helped control costs and increased the health system’s ability to manage future drug shortages. This process improvement effort showcases how engaged stakeholders with a sustained focus and the support of system leadership can successfully and efficiently implement a critical change in an environment with multiple competing priorities.


  1. Crews J, Rueda-de-Leon E, Remus D, et al. Total parenteral nutrition standardization and electronic ordering to reduce errors: A quality improvement initiative. Pediatr Qual Saf. 2018;3(4):e093.
  2. Mitchell KA, Jones EA, Meguid MM, et al. Standardized TPN order form reduces staff time and potential for error. Nutrition. 1990;6(6):457-460.
  3. Kar I, Osborne SM, Glowczewski JE. Implementing a strategy for drug cost management. Pharm Purch Prod. 2017;14(9):6-8.
  4. Drug shortages roundtable: minimizing the impact to patient care. Am J Health Syst Pharm. 2018;75(11):816-820.
  5. Institute for Healthcare Improvement. Plan-Do-Study-Act (PDSA) Worksheet. Accessed April 10, 2019.

Indrani Kar, PharmD, is the drug policy/formulary pharmacist at University Hospitals (UH).

Jodie Fink, PharmD, BCPS, is the clinical pharmacy specialist at UH Ahuja.

Weston Bush, PharmD, BCPS, is the clinical pharmacy specialist at UH, Cleveland Medical Center.

Madison Bluemel is a 2019 PharmD candidate attending the University of Cincinnati College of Pharmacy.

Rachael Lerman, PharmD, BCPS, is the pharmacy director, UH, Community Hospitals East.

John A. Dumot, DO, is the director of the Digestive Health Institute—UH.

Shawn Osborne, PharmD, MBA, is the vice president, pharmacy/supply chain, UH.


The authors would like to thank the following individuals at University Hospitals, who were crucial to the success of this initiative:

Pharmacists: Mike Carlin, Carl Lufter, Tanya Mounts, Don Halliday, Stan Fabianich, Jason Makii, Rachana Patel, Cheryl Wood, Bridget Gegorski, Patty Tumbush, Scott Naples, Brad Best, Mark Fondriest, Mary Williams, Mark Phillips, Frances Manning, Robyn Hunter, Christine Cortese, Hellene Speicher, Patrick Divoky, Lukas Everly

Pharmacy IT: Kathy Price, Amber Jones

Dietitians: Felicia Vatakis, Melissa Hudak, Jennafer Rabuzzi, Kathleen Best, Molly Gourash, Erin Ress, Melanie Oster, Jennifer Miavitz, Rebecca Camposo, Beatrice Crawford

Nursing Leadership: Kim Schippits

Physician Leadership: Dr. Robyn Strosaker


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