Mangum Christopher D, Stanley Andrew J, Peterson Catherine C, Biava Laura, Dice James, Khan Jamil, Godambe Sandip A
Department of Quality and Patient Safety, Children's Hospital of The King's Daughters, Norfolk, Va.
Department of Pharmacy, Children's Hospital of The King's Daughters, Norfolk, Va.
Pediatr Qual Saf. 2019 Nov 26;4(6):e233. doi: 10.1097/pq9.0000000000000233. eCollection 2019 Nov-Dec.
Total parenteral nutrition (TPN) is one of the most frequently used pharmaceuticals administered to patients in our Neonatal Intensive Care Unit (NICU). Initially, the total interdepartmental processing time (ordering, manufacturing, and delivery between NICU and Pharmacy) averaged 15.2 hours. Inefficiencies in this process only allowed TPN to infuse 8.8 hours on average before labs were collected the next morning. Given the short administration-to-laboratory collection time, we hypothesized that laboratory samples would not adequately reflect the effect of the current TPN infusion. Furthermore, clinicians would be making decisions based on suboptimal data and ultimately nourish this patient population inadequately.
The project team and the frontline staff created an efficient process for the manufacture and delivery of TPN. They removed waste in the process associated with manufacturing TPN and created capacity for change upstream (ordering process) and downstream (TPN infusion process) of the internal pharmacy process. The use of selection criteria and new standard operating procedures allowed for controlled PDSA testing of changes on a subset of patients. After we attained proven, sustainable results, we scaled the improvement efforts to the entire NICU patient population.
After 4 cycles of change, patients now receive TPN on average 14.2 hours before new labs are collected. The interventions over the continuum of this project yielded statistically significant results, increased infusion times to our patients by 61.4% ( < 0.001), improved glucose homeostasis, and decreased average length of stay.
In conclusion, creating process capacity from incremental changes and iterative PDSA cycles has yielded sustained results.
全胃肠外营养（TPN）是我们新生儿重症监护病房（NICU）最常给患者使用的药物之一。最初，跨部门的总处理时间（在NICU和药房之间的下单、配制和配送）平均为15.2小时。这个过程中的低效状况导致TPN平均只能输注8.8小时，直到第二天早上采集实验室检查样本。鉴于给药到实验室检查样本采集的时间较短，我们推测实验室样本无法充分反映当前TPN输注的效果。此外，临床医生将基于次优数据做出决策，最终对这一患者群体的营养支持不足。
项目团队和一线工作人员创建了一个高效的TPN配制和配送流程。他们消除了与TPN配制相关的流程中的浪费现象，并在内部药房流程的上游（下单流程）和下游（TPN输注流程）创造了变革的空间。使用选择标准和新的标准操作规程允许对一部分患者的变更进行可控的计划-执行-检查-处理（PDSA）测试。在我们取得经过验证的、可持续的结果后，我们将改进措施推广到整个NICU患者群体。
经过4个变革周期后，患者现在平均在采集新的实验室检查样本前14.2小时接受TPN。在这个项目的整个过程中所采取的干预措施产生了具有统计学意义的结果，将患者的输注时间增加了61.4%（P<0.001），改善了葡萄糖稳态，并缩短了平均住院时间。
总之，通过渐进式变革和迭代的PDSA循环创造流程能力产生了持续的效果。
