Ordering Paediatric Parenteral

Nutrition (PN)

All paediatric parenteral nutrition should be ordered within the Parenteral Nutrition (TPN) Paediatric Power Plan. Parenteral Nutrition (PN) is a complex and expensive process with potential risks and complications. Please refer to The Townsville Hospital Paediatric Parenteral Nutrition (PN) – commencement of procedure https://qheps.health.qld.gov.au/__data/assets/pdf_file/0032/476474/thhscli110542.pdf before ordering PN to ensure safe prescribing and administration. ONLY MEDICAL STAFF AND DIETITIANS TO PLACE ORDERS FOR PN.

Placing the PN order – initial prescribing

1. Navigate to Orders and click

2. Search for the Power Plan

3. Click on the order and click Done

4. There are multiple phases in the Power Plan. They should all be in the Planned Pending state

TPN Cares, Labs and Consults Phase

Patients receiving PN require careful monitoring. Refer to the local TTH procedure https://qheps.health.qld.gov.au/__data/assets/pdf_file/0032/476474/thhscli110542.pdf to ensure appropriate monitoring of PN is ordered.

▪ To select an order, place a tick in the check box next to the order you require ie. Blood Glucose Monitoring POC

▪ To modify any of these orders, right click on the order and select Modify

▪ Do not Initiate or Sign the order until you have completed all the required phases in the Power Plan.

Dietitians will be required to enter a physician name and select Co-sign Required if selecting Lab orders at this point. Until the Doctor co-signs this order, it will appear greyed-out on the Medication Administration Record (MAR) and there will be no task available for nursing staff to administer.

Medical staff will be able to sign own order for initiation of PN so will not need to complete this step.

Order phase according to patient weight

Neonatal Intensive Care / Special Care – this phase in the PowerPlan is not to be used at TTH.

5. Choose the appropriate phase that corresponds to the patient weight

6. The orders for the lipid phase and vitamins will be pre-selected

7. Tick the box that corresponds to the PN solution required for the patient

8. Right click on the orders and select Modify to review and adjust the order details

9. Follow these steps to adjust each order (Vitamins, Lipids and Parenteral Nutrition):

Continuous Details tab

a) Remove the Bag Volume

b) Enter the Rate and Infuse Over time

c) Press Enter on your keyboard. The bag volume will auto-calculate - this will reflect the total volume to be delivered across the infuse over period, NOT the bag volume

Details tab

d) Remove the default Duration and change Duration unit to none. this will make the order a true continuous infusion, meaning that multiple bags can be commenced from the one order

e) Adjust the Requested start date/time if required, otherwise it will set to the current date/time

It is likely that the start date of the Vitamins will need to be adjusted to a future date to allow for product delivery time. Please liaise with pharmacy to determine approximate delivery date and enter this into the requested start date/time for the Vitamins.

f) Review special instructions and clearly document the run time and any titration details e.g.

Run PN at 60ml/hr from 1200 - 0700, then run at 30ml/hr from 0700 - 0800. Break between 0800 - 1200. Hang a new bag as per instruction

It is important to consult with the ward pharmacist regarding the number of bags likely to be needed and with nursing staff to ensure bags aren’t wasted.

10. Once the Vitamins, Lipids and Clear Phase Parenteral Nutrition Solution are ordered, click Initiate

11. Review the interaction checking alert and click OK for each order

https://qheps.health.qld.gov.au/__data/assets/pdf_file/0032/476474/thhscli110542.pdfhttps://qheps.health.qld.gov.au/__data/assets/pdf_file/0032/476474/thhscli110542.pdfhttps://qheps.health.qld.gov.au/__data/assets/pdf_file/0032/476474/thhscli110542.pdfhttps://qheps.health.qld.gov.au/__data/assets/pdf_file/0032/476474/thhscli110542.pdf

12. Click Orders for Signature, confirm all orders are correct and Sign

ALWAYS review the MAR/MAR Summary once the order is signed for by the MO to ensure it appears as expected.

Orders placed by the Dietitian will appear with the

status On Hold, Med Student. Until the Doctor co-signs this order, it will appear greyed-out on the MAR and there will be no task available for nursing staff to administer. For the Doctor to co-sign this they will need to right click on the order and select Cosign OR click on the Orders For Cosignature button below the orders screen.

Medical Staff will not need to complete this step as they can sign their own order.

Ordering a PN Solution that is not within the

PowerPlan

The Smofkabiven Triple Phase TPN (electrolyte free) solution is not included within the Paediatric TPN Power Plan. If required, it should be ordered within the Power Plan by following the below steps:

13. Navigate to the Children >45kg phase of the power plan

14. Order the PN solution from within the Power Plan by

clicking on Add to Phase and selecting Add Order…

15. Search for and select the correct solution

16. Click Done

17. Adjust the infusion details, following the instructions in Steps 8-12.

Modifying the rate of the initial PN solution, lipids

or vitamins

If the rate needs to be modified for the PN solution, lipids or vitamins, follow the below steps:

18. Navigate to Orders

19. Right click the order that requires the rate change and select Cancel/discontinue

20. Enter a discontinue reason ie different dose

Dietitians will not be able to complete this step. Only a Doctor can Cancel/Discontinue the original order.

21. Order the PN solution/ lipids/ vitamins again from within the Power Plan by clicking on Add to Phase

and selecting Add Order…

22. Search for and select the correct order

23. Click Done

24. Adjust the infusion details, following the instructions in Steps 8-12.

When placed by the Dietitian this order will appear with the status of Proposal. For the Doctor to co-sign this they will need to right click on the order and select Accept, or Co-Sign at the bottom of the screen.

Medical Staff do not need to complete this step as the orders they place will appear with the status Ordered.

Changing from one PN solution to another PN

solution

25. Right click the PN solution that you no longer require and select Cancel/discontinue

Dietitians will not be able to complete this step. Only a Doctor can Cancel/Discontinue the original order.

26. From within the Initiated PowerPlan phase, select the

lightbulb . This will show all the components within the Power Plan that have previously been used

27. Select the new PN solution by placing a tick in the check-box

28. Adjust the infusion details, following the instructions in Steps 8-12.

The Dietitian will transcribe all PN orders for patient transfers from PICU to the Paeds Ward. Ensure Dietetics are aware of all transfers.

Exceptional Circumstances

The following information is for action by medical staff, nursing and pharmacy staff only. Dietitians may be involved in the process but are not experts in these areas. This information is for situations which may arise which prevents the ordering of PN in the usual way as outlined above.

Ordering vitamins

If vitamins are required and the pre-prepared Vitamins in Fat Emulsion 20% (Soluvit 5mL + Vitalipid 10mL + SMOFlipid FKS020V) are not available, the following process can be followed.

1. Add Order for Parenteral Nutrition Paediatric PowerPlan

2. The orders for the lipid phase and vitamins will be pre-selected

3. UNTICK THE VITAMIN PHASE

4. Order the Vitamins from within the PowerPlan by clicking

on Add to Phase and selecting Add Order

5. Refer to local TTH procedure and discuss with pharmacy to determine which multivitamin is required and search for either:

▪ TPN Cernevit Multivitamin infusion OR

▪ Soluvit N intravenous solution

6. Click Done

TPN Cernevit Multivitamin infusion

7. Click the Cernevit order

8. Navigate to the Ingredient Details tab

9. Adjust the Dose in mL and Infuse Over time in hours, refer to local procedure

10. Navigate to the Details tab

▪ Complete the mandatory field, Indication

▪ Review order details and ensure accuracy.

Soluvit N intravenous solution

1. Click the Soluvit order

2. Navigate to the Ingredient Details tab

3. Select the Add Ingredient button

4. Search for either:

▪ Sodium chloride 0.9% OR

▪ Glucose 5%

11. Enter the Dose for the Soluvit and the sodium chloride or glucose

12. Enter the Infuse Over time and Frequency

13. Navigate to the Details tab and complete the mandatory fields. Ensure all other details are accurate

14. Complete the order following instructions from Steps 8-12 (Ordering Paediatric Parenteral Nutrition: TPN Cares, Labs and Consults Phase). Initiate and Sign the order.

Ordering pre-prepared vitamins

Once the pre-prepared vitamins are available, you can modify the PowerPlan as follows:

15. Navigate to Orders

16. Select the initiated phase of the PowerPlan

17. Right click on the Cernevit or Soluvit vitamin order and select Cancel/Discontinue

From within the Initiated PowerPlan phase, select the

lightbulb . This will show all the components within the PowerPlan that have not yet been used

18. Select the Vitamins in Fat Emulsion order by putting a tick in the check-box

19. Right click the new order and select Modify and complete order following instructions from Steps 8-12 (Ordering Paediatric Parenteral Nutrition: TPN Cares, Labs and Consults Phase). Initiate and Sign the order.

Making a modification to a standard bag

1. Navigate to the Orders screen and the Parenteral Nutrition (TPN) Paediatric PowerPlan

2. Navigate to the base solution bag that will require modification and “copy” the composition of the bag from the Infusion Instructions

3. In the same phase of the PowerPlan click on the lightbulb icon in the top left hand of the orders screen. This will bring all the previously unordered items to the order screen

4. Tick the box of the Parenteral Nutrition (Parenteral Nutrition Paediatric Modified IV Infusion) solution at the bottom of the screen. The item will then have a light bulb appear and will be highlighted

5. In the details screen for the modified bag you will notice the Infusion Instructions containing the contents is not complete. “Paste” the previously copied bag contents into this section over the top of the current content

6. Within the Composition section, document the modifications to the bag. Use the + or - to show how the component has been modified and then have the total of the bag clearly documented in brackets. E.g (Potassium 30mmol + 30 mmol = (Total 60mmol).

7. Navigate to the Details tab and in Special Instructions insert the name of the base solution and the component modified. E.g Modified TPN 20/100 with 7.5mL Trace Elements and additional potassium

8. Input the calculated rate for the patient in mL/hr

9. Enter the Infuse Over duration. The bag volume will auto-populate based on the Infuse Over and Rate. Communicate bag numbers required with Pharmacy

10. If the patient is clinically stable and to continue this type of Parenteral Nutrition for a significant duration of time, the order can be changed to a true continuous order. In the Order Details screen the Duration of 1 should be removed and Duration Unit changed to (none)

11. Right click on the parenteral nutrition order currently prescribed and Cancel/ Discontinue the order

12. Input the Discontinue reason from the dropdown menu then sign the order.

Alternatively, if you are copying a base composition from a bag that has not already been commenced, ensure you de-select the checkbox – as you do not want to place two orders.