Best pharmaceutical practices in a nutrition support team : an in-depth scientific analysis with focus on parenteral nutrition in an established nutritional team in a swiss university hospital

Malnutrition in hospitalised patients is a serious and often underestimated problem. It is well established that the recognition and adequate treatment of malnutrition upon hospitalisation is of highest importance for a successful patient outcome. Nevertheless, the knowledge level for most health care professionals insofar as nutritional assessment and appropriate nutritional support is still low and training inadequate, especially that of the attending physicians who have first contact with patients. Errors in medication and nutritional therapy lead to increased morbidity and mortality, as well as prolonged treatment. Prevention of these oversights enables optimised and safe clinical nutritional therapy and also medication treatment. An interdisciplinary nutrition support team (NST) comprising a physician, dietitian, nurse and pharmacist is necessary for the good nutritional management of a patient from admission until discharge as well as further care at home. Their function includes nutritional assessment, evaluation and determination of individual nutritional requirements, recommendations for nutritional therapy and management of the nutritional care plan. There are different forms of clinical nutrition therapy to prevent and treat malnutrition when physiological feeding is not possible or insufficient. In particular, patients who are to receive home parenteral nutrition (HPN) require continuous monitoring by a well-educated NST. From the outset, the patient will be in steady contact with the hospital due to the need for long-term follow-up and mandatory monitoring for this complex and challenging treatment.1,2
The pharmacy profession is undergoing major transformations, therefore additional skills and knowledge are required to achieve best pharmaceutical practice and care. Many changes have occurred and thus, interdisciplinary cooperation becomes more important and HPN is used more and more, increasing the challenges of the pharmacist with these complex parenteral nutrition (PN) formulations. Technical and pharmaceutical developments have helped to establish safe, convenient and effective HPN. The pharmacist, as a member of an NST, can contribute by defining and evaluating best practices and efficiency to prevent medication errors, thus ensuring an increased quality of life (QoL). The role of the pharmacist as part of an NST depends on specific pharmaceutical expertise, including knowledge, experience and skills in the field of clinical nutrition, particularly in PN. Nutritional therapy as part of a patient’s overall treatment plan and therefore embedded in the medication therapy, requires the involvement of the pharmacy.3
This thesis investigates pharmaceutical aspects in the field of clinical nutrition, focusing on aspects of PN in particular. The main objective of this thesis is to illustrate the various pharmaceutical activities in an NST throughout the clinical nutrition process with a focus on PN. To clarify, the research aims are:
• What role should the pharmacist play in an NST?
• Is he/she prepared for the professional challenges?
• Which best practices can the pharmacist provide to increase the quality of treatment, safety and QoL for a patient?
To this end, four independent projects were defined in order to reach the aims:
(I) What is the importance and role of the pharmacist?
• Identification of malnourished patients or patients at nutritional risk, where the pharmacist can make an important contribution.
• Responsibility for maintenance of professional competence in nutrition support management by providing education and skills training.
(II a +b) Which contributions can the pharmacist give to provide a safe and effective drug and nutritional therapy and therefore an improved QoL?
• Monitoring and optimisation of nutrition support therapies including care for HPN patients and management of good nutritional supply, providing safe and effective treatment and therefore improving the patient’s QoL. Specific focus was given to the so far not prospectively analysed situation in Swiss adult HPN patients and benefit of HPN on QoL in patients with specific disease.
(III) Which compounding related questions arise and which stability and compatibility assessments have to be done to ensure medication safety?
• Patients with long-term PN or critically ill patients especially need additional components or medications added to a PN admixture, requiring strict aseptic compounding and previous stability and compatibility assessments.