Impact of a standardised parenteral nutrition protocol: A quality improvement experience from a NICU of a developing country

Objective: Nutrition societies recommend using standardised parenteral nutrition (SPN) solutions. We designed evidence-based SPN formulations for neonates admitted to our neonatal intensive care unit (NICU) and evaluated their outcomes.Design: This was a quality improvement initiative. Data were collected retrospectively before and after the intervention.Setting: A tertiary-care level 3 NICU at the Aga Khan University in Karachi, Pakistan.Patients: All NICU patients who received individualised PN (IPN) from December 2016 to August 2017 and SPN from October 2017 to June 2018.Interventions: A team of neonatologists and nutrition pharmacists collaborated to design two evidence-based SPN solutions for preterm neonates admitted to the NICU.Main outcome measures: We recorded mean weight gain velocity from days 7 to 14 of life. The other outcomes were change in weight expressed as z-scores, metabolic abnormalities, PN-associated liver disease (PNALD), length of NICU stay and episodes of sepsis during hospital stay.Results: Neonates on SPN had greater rate of change in weight compared with IPN (β=13.40, 95% CI: 12.02 to 14.79) and a smaller decrease in z-scores (p\u3c0.001). Neonates in the SPN group had fewer hyperglycemic episodes (IPN: 37.5%, SPN: 6.2%) (p\u3c0.001), electrolyte abnormalities (IPN: 56.3%, SPN: 21%) (p\u3c0.001), PNALD (IPN: 52.5%, SPN: 18.5%) (p\u3c0.001) and sepsis (IPN: 26%, SPN: 20%) (p\u3c0.05). The median length of stay in NICU was 14.0 (IQR 12.0-21.0) for the IPN and 8.0 (IQR 5.0-13.0) days for the SPN group.Conclusions: We found that SPN was associated with shorter NICU stay and greater weight gain. In-house preparation of SPN can be used to address the nutritional needs in resource-limited settings where commercially prepared SPN is not available