Parenteral nutrition (PN) is an important and widely used component in the care of neonates and children when gastrointestinal immaturity or disease precludes nutritional needs being met via the enteral route. The process of providing PN is complex, technically demanding, requires skill and judgement, and is fraught with the risk of complications. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD), an independent charity, has recently completed a case-based observational peer review of PN clinical practice in England, Wales and Northern Ireland—the first large-scale review of this type conducted in the UK.1 Based on the findings of the studies undertaken, NCEPOD makes recommendations to clinicians and management aimed at improving the quality of patient care. While undoubtedly this current report identifies evidence of good clinical practice it also highlights deficiencies that need careful evaluation by the healthcare community.

Patients of all ages who received PN between 1 January and 31 March 2008 were identified from local pharmacy records in hospitals in England, Wales and Northern Ireland and Offshore Islands. A random selection of these cases was chosen for inclusion using Access (Microsoft, Redmond, Washington). For each patient a confidential questionnaire was sent to the consultant in charge with a limit of two cases per consultant. The questionnaire was returned to NCEPOD with copied extracts of the case notes. The case notes were anonymised and peer-reviewed by a multidisciplinary group of advisors. For neonates and children, this group comprised neonatologists, gastroenterologists, dietitians, nutrition nurses and clinical pharmacists.

A total of 1211 cases were reviewed: 877 adults, 70 children and 264 neonates. Much of the report focuses on PN in neonatal practice. Overall ‘good practice’ in PN care, defined for the Advisors as a ‘standard that you would accept from yourself, your trainees and your institution,’ was identified in only 24% (62/264) of the neonates. The report presents data following the clinical path from the decision to commence PN, its composition, administration, review and complications. There were delays in recognising the need for PN in 28% of neonates, and in starting PN once the decision to commence had been made in 17%. Most of the delays were in the order of a few days from birth; however in some cases the delays were up to a week or more during which time nutritional requirements had not been met. NCEPOD recommends that the need for PN in the preterm neonate be given careful and early consideration, with minimal delay once the decision to commence PN has been made.2

Documentation by the healthcare team is an important part of clinical practice. NCEPOD has been highly critical over the last 22 years of the quality of note keeping in UK hospitals, and the findings in this study prove no exception. For example, the requirements for PN were documented in only 28% of neonates. While in many circumstances, the requirements and nutritional goals might be considered self evident, NCEPOD recommends that neonatal units have not only an agreed policy for nutritional requirements, but also a standard prescription proforma that includes this information, tailored for each infant, with a copy filed in the case notes.

Of particular concern in the report was that in 37% of neonates, the first PN provided was considered inadequate for the patient's needs. The advisors commented that there was a large variation in neonatal PN practice in different units. This is a surprising finding in the face of both guidelines and scientific evidence that in extremely low-birth-weight infants growth outcome is improved if PN is started soon after birth so that nutritional requirements are met early in postnatal life.3,–,6 It is possible that in many neonatal units some neonatologists still hold the traditional view that delayed or gradual progression of amino acid and lipid content of PN is best practice.7 NCEPOD recommends that the first PN given must be appropriate to the neonate's requirements. Furthermore, NCEPOD expressed the view that there is urgent need for the neonatal units to have a consensus on best PN practice and that the National Institute for Health and Clinical Excellence should develop guidelines on nutritional support for neonates and children in a similar manner to their recommendations for adults.8

While the majority of neonates had an appropriate level of senior reviews, the monitoring of PN was deemed inadequate in 19% of cases. Basic monitoring in relation to regular review of PN composition, biochemical status (including blood glucose) and fluid balance was often not undertaken. Metabolic complications related to PN were identified in 63 neonates; in 25 these were considered avoidable, and 12 were thought to have been managed inappropriately. Examples of complications included hyponatraemia from insufficient sodium content of PN, hyperglycaemia due to excessive glucose intake from a combination of PN and non-PN fluids, and hypophosphataemia (recognised but not treated). NCEPOD recommends that for metabolic complications to be avoided, close monitoring of the patient is mandatory.

NCEPOD also collected information from hospitals on the neonatal PN service infrastructure; an important finding was that only 15/131 (11%) of hospitals reported having a multidisciplinary nutrition support team (NST). The majority of infants included in this study were cared for on a neonatal unit, and it is clear that most units manage nutritional support without reference to an NST. Since nutritional expertise will be available within the neonatal unit among consultants, pharmacists, dietitians and senior nursing staff, this is perhaps not surprising. However, some surgical neonates are cared for in a different clinical environment where this level of expertise may not be available. NCEPOD was of the opinion that delegating management of PN in neonates to those who have the greatest experience would be of clinical benefit to patients. Furthermore, NCEPOD stated that it would be valuable in hospitals caring for neonates to develop a team approach to nutritional support, recognising that this should be a multidisciplinary exercise with sharing of expertise. Depending on the type of institution and availability of personnel, the composition of these teams may vary. Good levels of communication and team working with all those involved in administration of PN should ensure safe and effective nutritional support.9 10 NST could also provide support to other clinical areas caring for children with complex nutritional needs, and have a role in education and training for those involved in PN care.2

NCEPOD also reviewed intravascular access for PN. While in the majority of neonates there was evidence of good intravascular catheter care, documentation of the insertion site and type of catheter could only be determined from the case notes in 74% and 69% of neonates, respectively. Where there was documentation, the site of insertion and type of catheter was deemed appropriate in most cases. In a quarter of neonates (56/226) catheter-related complications occurred. These included catheter-related bloodstream infection in 36 patients, catheter misplacement in nine and extravasation of PN in seven. Furthermore, where it could be determined, complications were deemed avoidable for 6/32 cases. Recommendations are made on the need for improved documentation in relation to intravascular catheters for delivery of PN and the necessity of hospital policies on insertion and care, surveillance and management of complications. Moreover, NCEPOD recommends improved education of healthcare professionals in all of the above aspects of intravascular catheter care.11

The small numbers of case notes returned for children other than neonates meant that only a limited analysis of PN could be made in this group. The age range was from 1 month to 19 years, with half the children being cared for in an intensive care or high-dependency setting. The overall quality of PN care for children was found to be slightly better than that in neonates with 24/70 judged to have received good care. There was evidence of NST involvement in 40/70 cases. In addition, where it could be determined PN was considered adequate for needs in 41/45 children. The advisors considered that there was an adequate frequency and level of senior review of ongoing PN (59 cases) but in a quarter of children biochemical monitoring was inadequate, and metabolic complications occurred in 10/70. NCEPOD recommends that a large-scale national audit of PN care in children should be undertaken to determine the quality of PN care in this group of patients.

While it is possible that this report will prompt a defensive reaction from some who will point out its recommendations are based neither on hard science nor on outcome measures, this would be to misunderstand the intention behind any NCEPOD study. In fact, NCEPOD's modus operandi is to use a tried and tested qualitative approach to reviewing the processes of healthcare that occur in hospitals. Peer review of these processes on a case-by-case basis by a multidisciplinary group of healthcare professionals who work ‘at the coal face’ of PN care is a powerful tool. This report reflects no more and no less than the opinions of these advisors based on information received from senior clinicians and gleaned from the case notes of individual patients. There is no reason to suppose that the findings do not reflect the state of PN clinical practice for neonates and children in the UK.7 Whether there is agreement or disagreement with the content of the report, it raises the profile of PN in neonates and children, providing readers with an opportunity to reflect on clinical practice by posing the question: ‘could you and your colleagues do better’? Certainly NCEPOD thinks so. This report should at the very least be considered as a ‘call to arms’ summoning those professional organisations representing clinicians who care for neonates and children to work together in reviewing current PN practice on a national basis with the aim of improving quality in this important aspect of clinical care.