Considerations for Sourcing Parenteral Nutrition

August 2020 : Parenteral Nutrition - Vol.17 No. 8
Category: Outsourced Compounding Services (503B)

Q&A with M. Petrea Cober, PharmD, BCNSP, BCPPS, FASPEN
Clinical Coordinator
Akron Children’s Hospital

 Pharmacy Purchasing & Products: What were Akron Children’s Hospital’s considerations for outsourcing parenteral nutrition versus compounding it in-house?

M. Petrea Cober, PharmD, BCNSP, BCPPS, FASPEN: Akron Children’s Hospital, which comprises a network of two hospitals and 50 primary and specialty clinics, purchases all its parenteral nutrition (PN) from one vendor that operates both 503A and 503B pharmacies. We utilize standardized starter PN for our seven neonatal intensive care units for the first 24 hours of life. All of Akron Children’s inpatients receive patient-specific PN from this point forward.

When determining whether to purchase PN from an outsourcer versus compounding it in-house, our primary considerations were the time commitment required for PN compounding, available resources, and ensuring USP compliance.

  • Time. All medications other than PN are compounded in-house. We do a high volume of patient-specific compounding, so freeing up staff to compound other medications was one of the main reasons we chose to outsource our PN. In addition, prior to outsourcing PN, nurses had been preparing a large number of emergency medications on the floors, and we wanted to bring that duty into the pharmacy, allowing nurses to focus on other tasks. Outsourcing freed up time for pharmacists to take on this responsibility.
  • Resources. Outsourcing PN ensures that we have sufficient hood space available for compounding patient-specific medications.
  • USP Compliance. We always seek to maintain USP <797> compliance, and outsourcing PN to a reputable company provided peace of mind, as we were confident our vendor was compliant with the chapter.

PP&P: What were your considerations for choosing an outsourcing vendor to produce PN?

Cober: Reliability and superior customer service were our chief concerns when we chose our outsourced PN vendor 11 years ago. We sought out a dependable company with a long history in the industry. The vendor we chose is located within 30 minutes of our hospital, and we are the first stop on their route. In northeastern Ohio, it is critical that the vendor be able to provide us with PN during inclement weather. The fact that our vendor is located within close proximity ensures that our patients consistently receive the PN they require in a timely manner.

Another concern was PN availability during shortages. As an outsourced compounder, our vendor has the purchasing power to gain access to medications on shortage that we would not be able to acquire otherwise. In fact, during the electrolyte shortages our vendor was able to provide us with sufficient electrolytes. It is also important to note that the American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines for addressing PN shortages state that PN products should be conserved for the pediatric and neonatal population.1

Excellent customer service was another requirement when we were choosing a vendor. The vendor we contracted with is extremely responsive and capable of addressing any issue we are experiencing; they are especially helpful when dealing with shortages.

PP&P: How did you gain buy-in from prescribers for standardizing the starter PN?

Cober: As additional neonatal intensive care units were incorporated into our health system, we noted that they all were using slightly different starter PN formulas. To ensure standardization, it was important to gain buy-in from prescribers in order to utilize our two standard starter formulas.

We began by presenting ASPEN recommendations for the early use of protein in premature infants at 3-4 g/kg/day.1 In addition, we conducted and presented a drug use evaluation that highlights the prescriber’s current use of the two standard PN starter formulas. Once prescribers see that many of their patients are already using the two standard formulas, gaining buy-in is typically simple. Another strategy to gain buy-in is to bring prescriber groups together with the attendings to discuss the advantages of standardization. Each of our attending groups have extensive experience using the PN starter formulas and are well aware of the benefits of PN standardization.

After gaining buy-in from prescribers, we were able to develop starter PN guidelines for our health system; following implementation these are re-evaluated every 6 months.

PP&P: How does outsourcing PN affect waste?

Cober: Outsourced PN has longer expiration dating than PN produced in-house. For example, our outsourced PN is assigned a 45-day expiration date, while PN produced in-house receives 9-day dating. Therefore, utilizing outsourced PN is critical to reducing waste.

PP&P: How do you plan ordering, delivery, and hang times for patient-specific PN?

Cober: Patient-specific PN must be ordered by 1pm for it to hang that evening. The orders are due to the outsourcer by 2 pm, which is a straightforward process, as our EHR is interfaced directly to the outsourcer. The various pharmacies in our health system receive their PN between approximately 6pm and 8pm. The time from admission to first patient-specific PN bag is approximately 14 hours at our Level IV neonatal intensive care unit.

PP&P: How has outsourcing PN affected your staffing levels?

Cober: We have not reduced staff numbers as a result of outsourcing; in fact, because our health system has grown since we began outsourcing more than a decade ago, we have only increased our staffing levels. However, outsourcing provides the freedom to utilize our pharmacists in other patient care-centered ways. As mentioned previously, time saved by outsourcing PN provides pharmacists the opportunity, for example, to prepare emergent medications, rather than having nurses prepare these medications on the floor. Because pharmacists have been able to take more responsibility in preparing emergent medications in the pharmacy, there are only a small number of emergent medications that our nurses still prepare.

PP&P: What are your future outsourcing considerations?

Cober: Looking to the future, we are considering outsourcing OR medications, as well as some of our narcotics. Outsourcing a morphine infusion would be useful, as it could be standardized for use on the units and allow longer beyond-use dating for the products.


    1. American Society for Parenteral and Enteral Nutrition (ASPEN). Product Shortage Management. Accessed July 21, 2020.

M. Petrea Cober, PharmD, BCNSP, BCPPS, FASPEN, is the clinical coordinator in the NICU and PGY1 residency program director at Akron Children’s Hospital. She is also the section lead for specialty care and a professor in the Department of Pharmacy Practice at Northeast Ohio Medical University. Petrea attended the University of Tennessee College of Pharmacy in Memphis, TN, and completed her PGY1 pharmacy residency at Penn State Milton S. Hershey Medical Center in Hershey, PA and her PGY2 pharmacy residency in pediatrics at the University of Michigan Hospitals and Health System in Ann Arbor, MI.



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