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The Clinical Outcomes of Pharmacist Interventions in Total Parenteral Nutrition services in Riyadh City, Saudi Arabia

Objectives: Total parenteral nutrition (TPN) is the perilous component of nutritional care for neonatal, pediatric and adult patients. TPN is designated for someone who cannot or should not consume nutrients through their regular oral pathway. In this study, we explored the clinical outcomes of pharmacist intervention in Parenteral Nutrition at the public hospital in Riyadh city, Saudi Arabia. Methods: In prospective cohort studies, we simulated the data of 12 months of 2015 related to TPN services for neonatal, pediatric and adult patients. Most of the TPN units at hospitals works eight hours per day and seven days per a week. The hospital in Riyadh, Saudi Arabia has 300 beds. The pharmacist intervention consisted of an International Study Model, measure level of activity, rational of clinical intervention, recommendation, and patient with outcome impact. The data were analyzed through Survey Monkey system. Results: The total number of pharmacist interventions were 402 of recognized TPN-related problems. The total number of TPN orders was 394 prescribed to 82 patients. The majority of patients were neonates 303 (75.56%) followed by Pediatrics 97 (24.19%). The highest number of critical care interventions were found to be potentially serious 108 (28.8%) and potentially significant 174 (46.4%). The documented rationale of clinical intervention activities was inappropriate dose 93 (24.8%) drug therapy omission 50 (13.3%) and inappropriate route of administration 41 (10.9%). Most of the patient outcomes were laboratory value improved 170 (45.33%) and patient condition improved 137 (36.53%). Conclusion: TPN clinical pharmacist had an essential vital role of preventing a TPN-related problem, improve patient outcome, and avoid the unnecessary supplementary cost. Increasing TPN clinical pharmacist assigned for all TPN services at all health care system in Saudi Arabia.


INTRODUCTION
Total Parenteral Nutrition (TPN) is the life-threatening part of nutritional care for neonatal, pediatric and adult patients. TPN is specified for somebody who cannot or should not ingest nutrients through their regular oral pathway. Over the past few years, the American Society of Parenteral and Enteral Nutrition (ASPEN) releases several guidelines for the assessment, prescription, Access this article online www.ijpcs.net preparation, administration and follow-up of the TPN with an importance on patient safety. [1] All the major nutrients you need to survive for a while, but sometimes they may progress diseases that make them entirely or partially stop feeding. Some disorders may affect the digestive system or surgery to cut parts of the intestine; the person becomes incapable to supply his body with the food they need. One of the ways to help dazed these conditions is so-called Total Parenteral Nutrition. [1] Total Parenteral Nutrition (TPN) may be defined as an alternative or an additional selection when other options are useless or unsafe. Nutrition Support Professionals (NSP) are dietitians, pharmacists, nurses, and physicians who are specialists in providing and managing enteral and parenteral nutrition in diverse patient populations, from pediatrics to geriatrics. They may work either independently or as part of a nutrition support team. [2][3][4] The pharmacist plays an excellent role in in this field. The ASPEN published general guidelines to assure patient safety and prevent nutrition-related problems to avoid needless and added economic burden on the healthcare system. The story role of pharmacists started with choosing the best formulation of nutrition support services, preparation of parental nutrition and dispensing of parenteral nutrition. Pharmacists are an integral part of the team because they knows the structures or elements involved in the composition of the intravenous solutions, pharmacodynamics and pharmacokinetics. [5] The pharmacy technician prepares TPN as a sterile parenteral solution under supervision by pharmacists for the compounding of intravenous solutions according to the patient's condition or designs the regimens of TPN. [6] Pharmacists have varied roles in relation to Parenteral Nutrition (PN) therapy including the following: the assessment of patients' nutritional needs; the design, compounding, dispensing, and quality management of PN formulations; monitoring patients' response to PN therapy; supervision of Home Parenteral Nutrition (HPN) programs; education of patients, caregivers, and other health care professionals on nutrition support and conducting PN-related research and class development activities. However, each of these practice fields helps to funding the delivery of safe and effective PN therapy to patients. The clinical pharmacist may be involved in the prescribing of parental nutrition and follow-up with TPN related problems and complications. The pharmacy nutrition program started in mid-1980s with the beginning of clinical pharmacy services in Saudi Arabia. Pharmacist's interventions in patients receiving TPN orders and revising them before they are prepared and given to the patient contributed to reducing the complication that may follow the false choice of the TPN type, dose and route of administration. Complete follow-up and monitoring patients' response to treatment may limit the values, risks of intravenous solutions and reduce the costs. [7] Several international investigations explored pharmacist interventions in TPN services. The studies reported in Kuwait and was designed to explore pharmacists' role in PN therapy in hospitals of Kuwait. [2] Data were collected via face-toface semi-structured interviews with the senior Total Parenteral Nutrition (TPN) pharmacists at all the hospitals; which provide TPN preparation services (six governmental hospitals and one private hospital). The study focused on comparing pharmacist roles in TPN services, pharmacists educational, training need and how can improvement of pharmacist role in patient care and TPN services. The results did not explain clearly the numbers and numerical ratios of the role of the pharmacist and its intervention in orders and how to correct them, but only by comparing the number of pharmacists and their educational certificates and the number of orders contained in each of the seven centers studied. A prospective study of the interventions in PN was conducted (January-June 2011) the pharmacist intervention with TPN in Spain. [8] The study was conducted for 6 months compared to the current 12-month period. But the number of prescriptions were greater where 1420 prescriptions for PN were documented for 250 patients with 99 interventions were recorded for 65 patients, 35.2% were made at the beginning of the prescription and 55.3% of the pharmacist's interventions were made about pediatrics prescriptions corresponding to 33 patients. Based on best of our knowledge; there is no study occurred at Saudi Arabia, the Gulf, or Middle Eastern countries. [9] Therefore, the goal of this study was to explore the impact of the clinical outcome of pharmacist intervention through Total Parenteral nutrients at the public hospital in Riyadh city, Kingdom of Saudi Arabia.

METHODS
In prospective cohort studies, we simulated the data of 12 months of 2015 related to TPN services for neonatal, pediatric and adult patients. Most of the TPN units at hospitals works eight hours per day and seven days per a week. The hospital in Riyadh, Saudi Arabia has 300 beds. The hospital provides clinical services in different specialties such as adults endocrinology, adults nephrology pediatrics, adults cardiology, adults internal medicine, adults surgery, adults critical care, The Neonatal Intensive Care Unit (NICU), The Pediatric Intensive Care Unit, Obstetrics and Gynecology in addition to ambulatory care services and emergency services. Also, the hospital pharmacy offers very comprehensive pharmaceutical services including inpatient pharmacy, ambulatory care pharmacy, Total parenteral nutrition (TPN) services, drug information services, and computerized physician order entry system inpatient and outpatient units.
In 2009, the pharmacy services established TPN services starting from physician's prescription; the pharmacist reviews the order and prepares and dispenses the order; the nurse administers the preparation to the patients. TPN is prepared through sterile USP (797) standards and automated compounding facilities. The cost of TPN in MOH hospitals calculated by counting the personal cost including the cost of doctor, pharmacist and pharmacy technician per hour and the cost calculation based on preparation time of each TPN bag. Then, the total prices of the overhead cost for the bed and all machines will be used to evaluation the cost of TPN service. Also, the cost of purchased materials and supplies plus non-salary cost. They also considered the purchased prices of TPN lab tests and average length of stay of neonatal, pediatric and adult patients. The pharmacist intervention consisted of an International Study Model, measure level of activity, rational of clinical intervention, recommendation, patient and outcome impact. [10][11] The data were analyzed through Survey Monkey system. The study was conducted according to the ethics guidelines set out in the Declaration of Helsinki and written consent from was obtained from the institution.

RESULTS
The total number of pharmacist interventions were 402 of identified TPN-related problems. The total number of TPN orders was 394 prescribed to 82 patients. The rate of intervention was 4.9 interventions per patient. Out of 402 patients, 209 (51.99%) was male, 193 (48.01%) was female. The majority of patients were Saudi 266 (66.2%), while the non-Saudi was 136 (33.8%). The majority of patients were neonates 303 (75.56%) followed by Pediatrics 97 (24.19%) ( Table 1). Most of the interventions were provided by senior registrar 265 (65.9%) followed by consultant 103 (25.6%). The highest number of critical care interventions were found to be potentially serious 108 (28.8%) and potentially significant 174 (46.4%) ( Table   Table 1

DISCUSSION
In this study, we aimed to explore the clinical outcomes of pharmacist intervention in Parenteral Nutrition at the public hospital in Riyadh city, Saudi Arabia. In the past 5 years, the general administration of pharmaceutical care at the MOH executed several pharmacy practice programs including total parenteral nutrients for neonates, pediatrics and adults. [12,13] The program was part of pharmacy strategic plan at the Ministry of Health hospital. [14] The program was a part of Pharmacy services operated trained pharmacist. The pharmacist  would document all pharmacist's interventions during preparation and dispensing the TPN orders. This study sought to identify the cohort pharmacist intervention for one year. In this, the findings displayed most of the patients were neonates and pediatrics because of most of TPN patients for neonates and pediatrics. The adults TPN not well established during the conducting of the study.
The results of the study showed that the rate in intervention per patient was higher than the previous study because of the newly built TPN services in the current site research. [15] The majority of the patients were Saudi because the hospital treats citizens only. The hospitals have newly added the non-Saudi though health insurance system of the program. Most of the interventions were provided by senior registrar physician because of the profound experiences with TPN or involved under the residency training program. The highest number of critical care interventions were potentially severe or significant because TPN considered as high alert medications by Institute for Safe Medication Practices (ISMP) and may lead to serious complications and death. [16] The documented rationale of clinical intervention activities was inappropriate dose, drug therapy omission and inappropriate route of administration similar to the previous studies. [8,15] [15] Thus, the pharmacist approvals would meet the appropriate interventions though change the dose or add new medications or choose the proper route of administration. [15] Most of the patient outcomes were laboratory value and patient condition improved reflected the excellent performance of TPN pharmacist

CONCLUSION
Pharmacists have been energetically contributing in providing PN-related services to patients in different countries. TPN clinical pharmacist had an essential vital role of preventing a TPN-related problem, improve patient outcome, and avoid the unnecessary supplementary cost. Increasing TPN clinical pharmacist assigned for all TPN services at all health care system in Saudi Arabia. The empowerment of pharmacists to accept a stronger leadership role in this measurement of pharmacy practice will improve the quality of care provided to patients getting PN therapy and improve PN services.