spotlight-tpn-chkd nicu

The Right Solution

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By Danielle DeVenio • Photography by Susan Lowe

As the home of the region’s most advanced neonatal intensive care unit (NICU), CHKD cares for the area’s smallest and most critically ill infants – many weighing barely more than a pound. When extreme prematurity or medical complications prevent these babies from nursing or eating normally, they often depend on a feeding method called total parenteral nutrition (TPN) to survive.

TPN is a solution of vitamins and nutrients given through an IV infusion, directly into the patient’s bloodstream. The hospital pharmacy creates this customized solution daily for each patient based on their specific nutritional needs. After a period of infusion time, blood tests are done to measure the effect on the baby, and the next order is formulated based on those results.

“We believed there was a way to enhance the nutrition of these fragile babies by streamlining the TPN process,” says Christopher Mangum, manager of quality and performance engineering at CHKD. “So we assembled a team to make it happen.”

That multidisciplinary team included staff members from pharmacy, nursing, neonatology, information services, and quality improvement, as well as NICU family members.

“One of our main goals was to allow babies to receive the TPN solution for a longer period of time before daily lab tests were taken,” says Dr. Jamil Khan, a neonatologist and medical director of the NICU at CHKD. “This would give us a more complete picture of its effects before placing the next day’s order.”

To create more time for infusion, the complex production process would need to happen faster. The team started with the pharmacy space where the TPN is created. “By moving all the necessary components closer together and assembling kits of supplies in advance, the average production time decreased significantly,” says Jim Dice, PharmD, director of pharmacy at CHKD.

The ordering process was also streamlined. By establishing an electronic ordering system to communicate directly with the machine that formulates the TPN, a customized recipe is immediately available to the pharmacy staff when the order is entered. “Everything is done online now. What once took a few hours is instantaneous,” says Laura Biava, RN, director of patient care services at CHKD’s NICU.

The time saved in the ordering and production process has successfully extended the average time a baby spends on a single recipe of TPN from 8 to nearly 14 hours before labs are drawn. The project was so effective, it has been nationally recognized by the Children’s Hospital Association.

“These babies are now getting better nutrition, faster,” says Dr. Sandip Godambe, vice president of quality and clinical integration at CHKD. “It doesn’t always take lots of big steps to create meaningful change. Sometimes, several little steps can make a big difference.”


This story was featured in the summer 2018 edition of Kidstuff magazine, a quarterly publication from CHKD that features inspiring stories about patients, physicians and friends of CHKD.

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