Ergonomic and economic aspects of total parenteral nutrition

Laurence Gentona, Stephan Mühlebachb, Yves M. Dupertuisa and

Claude Picharda

Purpose of review Introduction

Ergonomics in total parenteral nutrition include the work Ergonomics can be defined as the ‘scientific study of the
performed in the (hospital) pharmacy and on the medical efficiency of man in his working environment’, according
ward. This article reviews the developments in total to the Oxford dictionary. Regarding total parenteral
parenteral nutrition ergonomics and the related cost- nutrition (TPN), this efficiency includes the work per-
savings. formed in the (hospital) pharmacy and on the medical
Recent findings ward [1]. As a consequence, better TPN ergonomics
Research focuses on the ergonomic advantages of multi- result from an improvement in any of the activities
compartment total parenteral nutrition bags compared with mentioned in Fig. 1, and aims at a better patient care
the multi-bottle system, of multi versus single-layered total as well as time and cost savings.
parenteral nutrition bags and of the presence of a nutritional
team and training in clinical nutrition to improve regimen As papers on this topic are scarce, this article reviews both
prescription and delivery. the improvements in TPN ergonomics and economics
Summary performed and published over the last 12 months, but
Three-compartment bags are safe, economic and also publications from the last 10 years. It focuses on the
ergonomic. It is important, however, to keep the knowledge ergonomic advantages of multi-compartment TPN bags
of pharmacies to compound total parenteral nutrition for compared with the multi-bottle system, of multi versus
children and (adult) patients with specific pathologies. single-layered TPN containers including wrapping and of
Research is ongoing in the development of bags with more the presence of a nutritional support team and training in
than three compartments, to include for instance vitamins. clinical nutrition in order to improve regimen prescrip-
This necessitates improvements in bag materials and tion and TPN use.
wrapping. Progress can be made regarding total parenteral
nutrition prescription and delivery, as well as in the Total parenteral nutrition practices
incidence of related infections by promoting training in In the past, lipids, amino acids and glucose were admi-
clinical nutrition and the implementation of a nistered in separate bottles and infused through separate
multidisciplinary nutritional support team. intravenous lines (multi-bottle system). Presently,
healthcare institutions increasingly use all-in-one (AIO)
Keywords systems, with which nutrients are mixed in a single bag
economics, ergonomics, multi-compartment bags, and infused simultaneously through a single intravenous
nutritional support team, parenteral nutrition line [2
]. The hypothetical advantage is that AIO systems
reduce the manipulations and monitoring and, con-
Curr Opin Clin Nutr Metab Care 9:149–154. ß 2006 Lippincott Williams & Wilkins. sequently, the risk of TPN-related complications as
a
infections, the risk of prescription, production or adminis-
Clinical Nutrition, University Hospital, Geneva and bPharmacopoeia, Swissmedic
for Therapeutic Products, National Agency for Medical Products, Bern, Switzerland
tration error, and the global workload [3]. The associated
savings may overcome the higher manufacturing costs of
Correspondence to Claude Pichard MD, PhD, Clinical Nutrition, University Hospital
Geneva, 24, Rue Micheli-du-Crest, 1211 Geneva 14, Switzerland the multi-compartment bags. AIO TPN bags can be
Tel: +41 22 372 93 49; fax: + 41 22 372 93 63; compounded by hospital pharmacies (hospital-compoun-
e-mail: claude.pichard@medecine.unige.ch
ded TPN) and their composition can be standardized or
Sponsorship: We thank the Foundation Nutrition 2000Plus for financial support. tailor-made to match the individual requirements of a
Current Opinion in Clinical Nutrition and Metabolic Care 2006, 9:149–154 patient. AIO bags can also be manufactured industrially,
in a standardized way, as two or three-compartment bags.
Abbreviations
AIO all-in-one
EVA ethyl vinyl acetate The use of industrially prepared or individually com-
TPN total parenteral nutrition pounded AIO systems still varies greatly between
countries. For instance, over the years 1996 to 1998,
ß 2006 Lippincott Williams & Wilkins Switzerland and France relied mostly on industrial
1363-1950
TPN while Belgium used rather hospital-compounded
TPN [2
]. All three countries globally preferred standard
to tailor-made TPN regimens. The use of tailor-made
149

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 150 Nutrition and the intensive care unit

Figure 1 Workload related to total parenteral nutrition ergonomics and economics for nurses, physicians and pharmacists

TPN, total parenteral nutrition.

Physicians
Indications/contraindications
Monitoring
Procedures

TPN
Nurses ERGONOMICS Pharmacists
Administration Purchasing and stock control
Procedures (Quality control)
Equipments Compounding and ready-to
Single-use device TPN use admixing
ECONOMICS TPN delivery
procedures (transportation)
Physico-chemical stability
assessment
Compatibility evaluation
Monitoring of use

TPN remained particularly frequent, however, for three-compartment bags may not be available in some
hospitalized children and home patients [2
,4], demon- countries. The ergonomic consequences of multi-com-
strating the need for expertise preservation in TPN- partment bags are summarized in Table 1.
compounding [5].
Three-compartment bags versus
Two-compartment bags versus multi-bottle system
multi-bottle system Three-compartment TPN bags arrived on the market in
Two studies have demonstrated the ergonomic and the 1990s. They are thought even more ergonomic than
economic benefit of two-compartment bags containing two-compartment bags as they require fewer manipula-
glucose and amino acids over the separate bottle system. tions. Unfortunately, only very few papers have studied
The first study compared the use of two-compartment the ergonomics and economics of three-compartment
TPN bags with lipids, vitamins and trace elements bags so far.
admixed in the pharmacy to ward-prepared TPN as a
multi-bottle system over 5600 TPN days in a Swiss In the United Kingdom, Raper et al. [3] randomized 22
university hospital [6]. The use of two-compartments critically ill patients in two groups receiving TPN from
bags decreased product cost by 17%, disposable cost three-compartment bags or three separate bottles during
by 80% and nurse workload by 66%, which corresponds 27 days each. The three-compartment bags were related
to about 600 working hours per year in the studied
hospital. A similar study performed in Germany and
Table 1 Fields of research in total parenteral nutrition ergo-
Switzerland compared two-compartment bags with sub- nomics and results
sequent addition of lipids with the multi-bottle system in
patients who had undergone major abdominal surgery. Field of research Ergonomic consequences
Both groups were comparable with regard to TPN Multi-compartment TPN bag # Total workload
duration, energy and micronutrient delivery, and ICU # Global application costs
stay. The authors reported a decrease in total TPN costs " Inquiries on drug compatibility
Multi-layered TPN bag # Ascorbic acid and thiamine
by 17% for 10 TPN days when using two-compartment degradation
TPN bags instead of multi-bottles [7]. Even if these (" increased stability and storage)
observations may seem out-of-date with the actual Presence of a nutritional # Inappropriate TPN use
support team # Water and ions dysbalances
shift to three-compartment TPN bags, they have to be
# Metabolic complications
kept in mind. Indeed, the multi-bottle system or two- # Catheter-related sepsis
compartment systems with separate infusion of lipids # Mechanical complications
may still be indicated in severe hyperlipaemia, adverse # Wastage of venous catheter
drug–lipid interactions, and in paediatrics. Furthermore, TPN, total parenteral nutrition.

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Total parenteral nutrition Genton et al. 151

to slightly higher daily product costs than the multi-bottle verified in other countries with low cost manpower and
system. The authors did not take into account, however, low buying capacity on the international market, by
the waste costs for the extra bulk of the individual performing a local financial analysis using the data pre-
components and for the disposable items used with the sented on Table 2.
bottle system, nor the pharmacy cost for storage and
dispensing. This only partial cost analysis neglecting Total parenteral nutrition stability
hidden costs has certainly biased the results. Therefore TPN stability of the AIO system depends on TPN
this study should be interpreted very cautiously. composition and the bag material. For instance, the
addition of calcium and inorganic phosphate salts to
In contrast, in a study in Switzerland, the use of three- intravenous lipid emulsions may lead to potentially invis-
compartment bags instead of multi-bottles over 5100 ible dibasic calcium phosphate precipitates, according to
TPN days decreased product and disposable costs by the free calcium and phosphate concentrations at a given
24.5% and nurse workload by 66% in Switzerland [8]. In pH [9]. In addition, lipid emulsion destabilization may
this study, the nurses, and not the pharmacist, added the occur and lead to increased lipid droplet size and even-
vitamins and trace elements, which explains the similar tually to oiling out [10
]. A selection of AIO formulas for
reduction of nurse workload when using two [6] or three- children were stable for at least 10 days, however, when
compartment bags [8]. The authors reported that the they were stored at 48C in the dark [11
].
three-compartment bags were preferred by 96% of the
nurses and doctors because they were convenient to use, On the other hand, research focuses on new bag material,
easy to prescribe and available on wards but required including wrapping, to reduce the chemical degradation
pharmaceutical assistance for drug compatibility in 82% by oxidation of components. This is crucial for instance
of newly started treatments. regarding vitamins, which are often the least stable
ingredients of TPN admixtures. The bag containers
Finally, Pichard et al. performed the most detailed study presently on the market differ with regard to the number
on this topic so far [1]. They timed precisely the duration of plastic layers, their chemical composition and the
of manpower work necessary for one TPN administration resulting physical properties, like (oxygen) permeability.
using the multi-bottle system, the hospital-compounded Figure 2 represents a simplified drawing of a three-
system and the three-compartments bag system: the work compartment, three-layered TPN bag to clarify the terms
performed by the physician, the nurse, the pharmacy used in this paper. Dupertuis et al. [12] added a fixed
technician and the pharmacist. For nurses and physicians, amount of multivitamin solution and trace elements,
the time was averaged between a junior and a senior partially able to catalyse vitamin degradation, to
(Table 2). Three-compartment bags required the least 2500 ml of TPN solution contained either in a mono-
manpower time for one TPN administration. The differ- layered ethyl vinyl acetate (EVA) bag or a three-layered
ent types of TPN systems were associated with a redis- bag supposedly less permeable to oxygen. They com-
tribution of workload among healthcare givers. Compared pared the vitamin degradation up to 72 h after TPN
to the multi-bottles and hospital-compounded bags, the compounding in both bags, stored at different tempera-
reduction of manpower work with the use of three- tures [12]. Retinol palmitate and a-tocopherol were rela-
compartment bags represented, in the studied hospital, tively stable but ascorbic acid and, to a lesser extent,
a daily saving of 20% and 50% of the global TPN costs, thiamine were degraded in both bags. After 12 h at 48C,
respectively, or a saving of s133 333 and s326 666 for only 50% of the original ascorbic acid was left in the EVA
10 000 TPN days. As manpower usually represents up to bag compared with 80% in the three-layered bag. The
85% of global hospital costs in Europe and North Amer- degradation increased concomitantly with the storage
ica, the use of three-compartment bags by reducing temperature in both bags. After 12 h at 408C, no ascorbic
manpower need is likely to be a cost-saving strategy in acid was left in the EVA bag and around 40% in the three-
most of these countries. This statement should be layered bag. Thus, three-layered bags reduce but do not

Table 2 Mean W SD manpower work in minutes per day for one total parenteral nutrition administration according to the type of
administration

Multi-bottle TPN Hospital-compounded TPN Three-compartment bag TPN

Physician 2.3  1.5 0.2  0.1 0.3  0.1

Nurses 20.8  4.3 5.0  0.8 10.2  1.6
Pharmacy technician 2.3  0.4 0.2 0.8
Pharmacist 15
Total manpower 25.4  5.2 20.4  0.8 11.3  1.6
TPN, total parenteral nutrition. Reprinted with permission from Elsevier Ltd. and European Society for Clinical Nutrition and Metabolism [1]. ß 2000
Elsevier Ltd. and European Society for Clinical Nutrition and Metabolism.

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 152 Nutrition and the intensive care unit

Figure 2 Total parenteral nutrition bag

Simplified drawing of a total parenteral

nutrition bag, clarifying the terms of
‘three-compartment bag’ and ‘three-
layered bag’ used in this paper.

hinder oxidation of ascorbic acid compared with EVA Total parenteral nutrition prescription
bags, which was confirmed by Balet et al. [13

]. The and delivery
authors conclude that, to meet the patients’ requirements Ergonomics of TPN delivery should not only be viewed
and compensate for losses occurring between TPN com- using economics as final endpoint but also as a quality
pounding and the end of infusion, a higher initial dose of treatment for the patient. There is no logic of prescrib-
ascorbic acid has to be added to the TPN admixture. In ing and administering TPN to a patient who does not
selected patients, however, the total amount of oxalate, a need it.
degradation product of vitamin C, has to be considered as
it may lead to the formation of renal oxalate stone and Jetzer et al. [15] evaluated the indication and delivery of
potential renal failure. TPN in 180 consecutive patients. Indication was con-
sidered adequate in cases of a non-functional gastroin-
In another study, the same authors compared the stability testinal tract, an impossible oral or enteral feeding and an
of ascorbic acid between the aforementioned three- estimated survival over 14 days. Energy supply was
layered bag, another three-layered bag made of a fluid- optimal when covering 100–150% of the requirements
tight layer with increased flexibility compared with the calculated by the Harris–Benedict formula and vitamins
former and a newly developed six-layered bag, which and trace elements were included in the regimen. The
includes a specific gas-impermeable layer [14

]. The six- results showed that TPN was not indicated in 8% of the
layered bag, although not yet commercialized, nearly patients. Moreover, there was no administration of trace
completely prevented the degradation of ascorbic acid elements or vitamins in 23% of the patients, and over-
during 48 h, at a temperature varying from 4 to 408C. feeding or underfeeding occurred in 52% of the patients.
Thus, new bag materials can improve the stability of AIO Similarly, Chan et al. showed that, in a retrospective study
TPN admixtures, especially if we are heading to multi- performed in Singapore, 16% of parenteral nutrition
compartment bags including a vitamin component. prescriptions were inappropriate based on the American

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Total parenteral nutrition Genton et al. 153

Society for Parenteral and Enteral Nutrition (ASPEN) Conclusion

2002 guidelines [16
]. This study, as the former one, Three-compartment bags are safe, economic and ergo-
highlights the need for a nutritional team, which was nomic. They allow a convenient TPN treatment for most
lacking at the time of the investigation, and for infor- adult patients during their acute care in hospitals. It is
mation and education regarding artificial nutrition in important, however, to maintain the competences of the
order to improve ergonomics. hospital pharmacies to compound TPN for children and
(adult) patients with specific pathologies. Research is
Naylor et al. [17
] reviewed the effectiveness of multi- ongoing regarding the development of bags with more
disciplinary TPN teams in decreasing the incidence of than three compartments, to include for instance vita-
total mechanical complications. They could not demon- mins, which necessitates improvements in bag materials
strate a reduction in catheter-related sepsis nor in meta- to reduce their oxidative degradation. Progress is possible
bolic and electrolyte complications, nor in inappropriate regarding TPN prescription and delivery and TPN-
TPN use [17
]. Johansen et al. [18] created a nutritional related complications, including infections, may be
discharge index, the criteria for which were adequate reduced by promoting education and training in clinical
mobilization, no fever reflecting the absence of infection nutrition and the implementation of a multidisciplinary
and no intravenous access reflecting the absence of nutritional support team.
complications. On the day when these criteria were
fulfilled, hospitalization was no longer considered to be
References and recommended reading
sensitive to nutritional support. They showed that a Papers of particular interest, published within the annual period of review, have
nutritional support team combined with a detailed nutri- been highlighted as:

of special interest
tional plan increased the protein and energy intake of

of outstanding interest
nutritionally at-risk patients which eventually led to a Additional references related to this topic can also be found in the Current
World Literature section in this issue (pp. 170–171).
shorter length of hospital stay that was considered sensi-
tive to nutritional support [18]. 1 Pichard C, Schwarz G, Frei A, et al. Economic investigation of the use of three-
compartment total parenteral nutrition bag: prospective randomized
unblinded controlled study. Clin Nutr 2000; 19:245–251.
A few studies tried to detail the composition of the 2 Maisonneuve N, Raguso CA, Paoloni-Giacobino A, et al. Parenteral nutrition
nutritional team to improve ergonomics. Saalwachter
practices in hospital pharmacies in Switzerland, France, and Belgium.
Nutrition 2004; 20:528–535.
et al. showed that a nutrition support team led by a This paper highlights the differences of TPN practices in Switzerland, France and
surgeon decreased the inappropriate TPN orders by Belgium.
from 32% to 8% over 24 months [19]. The same results 3 Raper S, Milanov S, Park GR. The cost of multicompartment ‘big bag’ total
parenteral nutrition in an ICU. Anaesthesia 2002; 57:96–97.
may have been found with a physician of another speci-
4 Pichard C, Muhlebach S, Maisonneuve N, et al. Prospective survey of
ality, however, as they did not compare both competen- parenteral nutrition in Switzerland: a three-year nation-wide survey. Clin Nutr
cies. On the other hand, the introduction of a clinical 2001; 20:345–350.
nurse specialist in a nutritional team was shown to 5 Muhlebach S. Practical aspects of multichamber bags for total parenteral

nutrition. Curr Opin Clin Nutr Metab Care 2005; 8:291–295.
reduce the overall sepsis rate infection rate from 52 to This review focuses on the importance of preserving the expertise of parenteral
2.3% over 4 years as well as the costs related to TPN nutrition compounding, of the pharmacist in the nutritional team and on the
characteristics of multi-compartment TPN bags.
and central venous catheters wastage [20
]. Con-
6 Udriot-Tristan M, Pichard C, Sierro C, et al. Total parenteral nutrition:
sequently, TPN prescription, and delivery may be advantages and disavantages of all-in-one bag [in French]. Méd Hyg
improved and TPN-associated complications decreased 1993; 51:1668–1671.
by the presence of a multidisciplinary nutritional support 7 Frei A, Dinkel R, Kemen M, et al. A new model for economic studies of
therapies exemplified by postoperative parenteral nutrition [in German].
team. Zentralbl Chir 1997; 122:358–365; discussion 366.
8 Velickovic G, Pichard C, Sierro C, et al. Total parenteral nutrition: the concept
Other considerations of the all-in-one bag [in French]. Méd Hyg 1995; 53:1976–1980.

The chemical composition of the multi-chamber bag 9 Parikh MJ, Dumas G, Silvestri A, et al. Physical compatibility of neonatal total
parenteral nutrient admixtures containing organic calcium and inorganic
solution has not been discussed in this review. Indeed phosphate salts. Am J Health Syst Pharm 2005; 62:1177–1783.
recent findings in term of proteins and lipids profile are 10 Driscoll DF. Stability and compatibility assessment techniques for total
usually not immediately taken into account to modify the
parenteral nutrition admixtures: setting the bar according to pharmacopeial
standards. Curr Opin Clin Nutr Metab Care 2005; 8:297–303.
solution. For example, there is currently no three-com- This review outlines the efforts made to improve the stability and compatibility
partment bag enriched with glutamine, although gluta- issues for safety of TPN all-in-one mixtures. It suggests standardizing pharmacy
practices to limit lipid size and concentration and thus limiting the risk of
mine is now recognized as a needed component for TPN precipitation.
in intensive care patients. Clear guidelines should be 11 Rey JB, Faure C, Brion F. Stability of all-in-one standard formulae for paediatric

parenteral nutrition. PDA J Pharm Sci Technol 2005; 59:206–220.
proposed by international clinical nutrition societies such This study demonstrated that selected all-in-one standard formulae are stable for at
as ESPEN (Europe), ASPEN (America), Parenteral and least 10 days when kept away from light and stored at 48C.
Enteral Nutrition Society of Asia (PENSA) to stimulate 12 Dupertuis YM, Morch A, Fathi M, et al. Physical characteristics of total
parenteral nutrition bags significantly affect the stability of vitamins C and
TPN-producing companies to adapt and improve their B1: a controlled prospective study. J Parenter Enteral Nutr 2002; 26:310–
solution. 316.

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 154 Nutrition and the intensive care unit

13 Balet A, Cardona D, Jane S, et al. Effects of multilayered bags vs ethylvinyl- 17 Naylor CJ, Griffiths RD, Fernandez RS. Does a multidisciplinary total par-


acetate bags on oxidation of parenteral nutrition. J Parenter Enteral Nutr 2004;
enteral nutrition team improve patient outcomes? A systematic review. J
28:85–91. Parenter Enteral Nutr 2004; 28:251–258.
This study highlighted the fact that multi-layered bags minimize the formation of This meta-analysis reports that a multidisciplinary nutritional support team may
hydroperoxides and lipoperoxides and the oxidation of a-tocopherol, ascorbic acid reduce the incidence of total mechanical complications and be of financial
and dehydroascorbic acid compared with bags made of ethyl vinyl-acetate. benefit, although its effect on catheter-related sepsis, metabolic and electroly-
tic complications and appropriateness of parenteral nutrition use is inconclu-
14 Dupertuis YM, Ramseyer S, Fathi M, et al. Assessment of ascorbic acid
sive.


stability in different multilayered parenteral nutrition bags: critical influence of
the bag wall material. J Parenter Enteral Nutr 2005; 29:125–130. 18 Johansen N, Kondrup J, Plum LM, et al. Effect of nutritional support on
This research clearly shows that ascorbic acid can be preserved over 48 h by using clinical outcome in patients at nutritional risk. Clin Nutr 2004; 23:539–
a six-layered bag material, which is not yet commercialized, instead of three-layered 550.
bags.
19 Saalwachter AR, Evans HL, Willcutts KF, et al. A nutrition support team led by
15 Jetzer J, Schwarz G, Kyle U, et al. Optimal prescription and follow-up of total general surgeons decreases inappropriate use of total parenteral nutrition on
parenteral nutrition in 180 patients: role of the specialized dietician [in a surgical service. Am Surg 2004; 70:1107–1111.
French]. Méd Hyg 1997; 55:2214–2221.
20 Sutton CD, Garcea G, Pollard C, et al. The introduction of a nutrition clinical
16 Chan SL, Luman W. Appropriateness of the use of parenteral nutrition in a
nurse specialist results in a reduction in the rate of catheter sepsis. Clin Nutr

local tertiary-care hospital. Ann Acad Med Singapore 2004; 33:494–498. 2005; 24:220–223.
This article shows that there are still 16% inappropriate parenteral nutrition This article outlines the importance of a multidisciplinary nutritional team including
prescriptions although guidelines on this topic have been published. a clinical nurse specialist for improving the cost-effectiveness of TPN.

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.