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THE PRACTICE OF PARENTERAL NUTRITION
IN MALAYSIAN HOSPITALS
RIYADH ABDULLAH OMAR ALBATANI
UNIVERSITI SAINS MALAYSIA
2008
THE PRACTICE OF PARENTERAL NUTRITION IN MALAYSIAN
HOSPITALS
by
RIYADH ABDULLAH OMAR ALBATANI
Thesis submitted in fulfillment of the requirements for the degree of Doctor of Philosophy
June 2008
ii
ACKNOWLEDGEMENTS
I am extremely grateful to Dr.Mohd Baidi Bahari (School of pharmaceutical Sciences,
Universiti Sains Malaysia) for introducing me to scientific research and helping me
establish my overall direction. His advice and constructive criticism have been
invaluable in the fruition of this doctoral thesis for maintaining my focus and for his
insight guidance in picking up key findings that I may have overlooked. For his kinds of
introducing me to the “hands-on” practical work of clinical research and for his help in
conducting the studies which formed part of this doctoral thesis, I am thankful to his
constant encouragement and support, his warm presence and for consistently reminding
me to “Keep smiling”. I am also thankful to Pn. Zalila Ali (USM Mathmatic School) for
introducing me to new approaches in analysing data, also thanks to Dr.A.F
Shammsuddin (Field-supervisor, HUKM Pharmacy Department), Mr. Amrahi Buang
(UMMC) and Mr. Dellimin Che Abdullah (HUSM). Thanks to Dr. Mohd Izham Mohd
Ibrahim (USM Social and Administrative Pharmacy) for assisting me in statistics. I am
especially appreciative of the Yemen Government and specifically University of Sana’a
for granting me this opportunity to gain experience in a foreign country and to broaden
my horizons. I have been fortunate to have a large number of friends and colleagues who
have had a profound effect on me and on my research. Last, but not least, I would like
to dedicate this thesis to my family, especially to my parents for providing me with the
essential tools, during my formative years, to pursue and realise my dreams, my brothers
Fatima, Sefan and Mohd and my wife Amina for her support and endless patience when
I most needed it. They will always remain the guiding light in my life as I look forward
to new challenges in the near future.
iii
TABLE OF CONTENTS
Acknowledgements
ii
Table of contents
iii
List of tables
xi
List of abbrevations
xiv
Abstrak
xvi
Abstract
xviii
Part 1 Survey of TPN practice in Malaysian hospital
1
1.1 Introduction and literature review
1
1.1.1 Background
1
1.1.2 Practices of PN
3
1.1.3 Problem statement
8
1.1.4 Rationale of the study
10
1.1.5 Objectives
11
1.1.6 Justification of the study
12
1.2
Methodology 13
1.2.1 Introduction
13
1.2.2 Parenteral nutrition practice in Malaysian hospitals
13
1.2.3 Study design of survey of evaluation of PN Practice in Malaysian hospital
14
1.2.4 Determination the sample size
14
1.2.5 Subjects (hospitals) 16
iv
1.2.5 (a) Selection of hospitals
16
1.2.5 (b) Inclusion criteria
17
1.2.5 (c) Exclusion criteria
17
1.2.6 Data Analysis
17
1.3 Results and discussion
19
1.3.1 Response rate
19
1.3.2 Classification of hospitals
20
1.3.3 PN services in Malaysian hospital
21
1.3.4 Hospital size
22
1.3.5 Availability of PN services
23
1.3.5 (a) PN services and mean of pharmacist and pharmacist assistant
23
1.3.5 (b) Mean of preparation per day
24
1.3.6 Type of specialties
25
1.3.7 Type of Clinical Pharmacy services offered
26
1.3.8 Clinical services offered pharmacy department according to type of hospitals.
27
1.3.9 Year started parenteral nutrition services
28
1.3.10 Ward with PN services
29
1.3.11 Places for preparation of PN
30
1.3.12 Type of services related to PN
31
1.3.12 (a) Individualization
32
1.3.12 (b) Standard formulas
33
1.3.12 (c) Computer program 33
v
1.3.13 Extent of pharmacist involved in PN
34
1.3.13 (a) PN pharmacist compounding 34
1.3.13 (b) PN monitoring and nutrition support team
35
1.3.14 Quality control of PN compounding
36
1.3.15 The use of commercially available standard product
39
1.3.16 Suggestions of services offered by PN pharmacists
40
1.3.17 Type of solution used in PN
41
1.4 Summary and conclusion
43
1.4.1 PN Practices in Malaysian Hospital
43
1.4.2 The extend of the PN services
43
1.4.3 The personnel involve in PN services
43
1.4.4 The load of pharmacist
44
1.4.5 The role of pharmacist
44
Part 2 Compare service provided in four hospitals 45 2.1
Introduction and literature review
45
2.1.1 Indication
45
2.1.1.1 Parenteral nutrition in malnutrition
46
2.1.1.2 (a) Parenteral nutrition in premature
47
2.1.1.2 (b) Special considerations in premature nutritional supplement
47
2.1.1.3 Parenteral nutrition in children
48
2.1.1.4 Parenteral nutrition in surgical case 49
2.1.1.5 Parenteral nutrition in cancer 49
vi
2.1.2 Nutrient and substrate requirments for PN
50
2.1.2. (a ) Protien 51
2.1.2 (b) Carbohydrate 53
2.1.2. (c) Fat 54
2.1.2(d) Electrolytes, vitamin and trace elements
55
2.1.2 (e) Energy requirments 57
2.1.2 (f) Fluid requirment 57
2.1.3 The parenteral nutrition product in Malaysian hospitals 58
2.1.4 Route of parenteral nutrition
59
2.1.5 Outcomes of parenteral nutrition 60
2.1.6 Complication of parenteral nutrition
61
2.1.6 (a) Mechanical
62
2.1.6 (b) Infection 63
2.1.6 (c) Metabolic 65
2.1.7 Monitoring of parenteral nutrition
66
2.1.8 Cost of parenteral nutrition
66
2.1.9 Problem statement
68
2.1.10 Rationale of the study
69
2.1.11 Objectives
70
2.1.12 Scope (contribution) of the study
70
2.1.13 Justification of the study
70
2.2
Methodology
72
2.2.1 Introduction
72
vii
2.2.2 Development of data collection form
72
2.2.3 The pilot study
73
2.2.3 (a) Data analysis of the pilot study
73
2.2.3 (b) Result of the pilot study
73
2.2.3 (c) Discussion of pilot study
75
2.2.3 (d) Conclusion
76
2.2.4 The cost of solutions 2.2.5 Study design of the comparative study
76 79
2.2.6 Sites of the comparative study
79
2.2.7 Determination of sample size of comparatve study
79
2.2.8 Calculation of power and sample size of HPP
80
2.2.8 (a) Power calculation
80
2.2.8 (b) Calculation of power and sample size of HUSM
82
2.2.8 (c) Calculation of power and sample size of HUKM
84
2.2.8 (d) Calculation of power and sample size of UMMC
86
2.2.9 Subjects
87
2.2.10 Inclusion criteria
87
2.2.11 Execlusion criteria
88
2.2.12 Data analysis
88
2.2.12 (a) Two way ANOVA
88
2.2.12 (b) Pearson chi square
89
2.3 Results and discussions
91
2.3.1 Introduction 91
2.3.2 Characterstics of PN patients according to hospital 91
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2.3.3 Diagnosis of PN patients
92
2.3.4 Reasons of PN patients
93
2.3.5 Diagnosis and reasons.
93
2.3.6 Outcome of PN patients
96
2.3.7 Complications due to PN
97
2.3.8 Type of complications & factors associated with complications
98
2.3.9 The route of PN
106
2.3.10 The cost per day
107
2.3.11 The duration of PN
108
2.3.12 Energy requirements of PN
109
2.3.13 Volume prepared of PN
110
2.3.14 Macronutrient requirement
112
2.3.14 (a) Glucose supplement of PN
112
2.3.14 (b) AA supplement of PN
113
2.3.14 (c) Lipid supplement of PN
115
2.3.15 Vitamin requirements of PN
118
2.3.16 Trace elements requirements of PN
120
2.3.17 Electrolyte requirements of PN
121
2.3.17 (a) Sodium requirement of PN
121
2.3.17 (b) Potassium requirement of PN
123
2.3.17 (c) Magnesium requirement of PN
125
2.3.17 (d) Calcium requirement of PN
127
2.3.17 (e) Phosphate requirement of PN 128
2.3.17 (f) Chloride supplement in PN 130
ix
2.3.18 Monitoring of body temperature
132
2.3.19 The monitoring of fluid input and output
133
2.3.20 The monitoring of fluid output in ml
135
2.3.21 The monitoring of fluid balance in ml
136
2.3.22 Monitoring of PCO2
137
2.3.23 Monitoring of PO2
138
2.3.24 Monitoring of O2 saturation
139
2.3.25 Monitoring of base excess BE
140
2.3.26 Monitoring of WBC
141
2.3.27 Monitoring of HB
143
2.3.28 Monitoring of platelet
144
2.3.29 The monitoring of PT
146
2.3.30 Monitoring of INR
147
2.3.31 Monitoring of APTT
148
2.4 Summary and conclusions
150
2.4.1 The outcomes of PN in four studied hospitals
150
2.4.2 Type of complication of PN patients
150
2.4.3 The cost per day and duration of PN patients
151
Bibliography
152
List of appendices
171
List of publications and seminars
186
x
LIST OF TABLES Page
Table 1.1.1 Total number of government hospitals providing PN
Services
3
Table 1.2.2 The total number of government and private hospitals
15
Table 1.2.3 The total number of government and private hospitals
16
Table 1.3.4 The classification of the hospitals
20
Table1.3.5 PN services in Malaysian hospital
21
Table 1.3.6 Hospital size in relation to hospital type
23
Table 1.3.7 Availability of PN services according to class of hospital
23
Table 1.3.8 The specialties type offered by the Malaysian hospital
26
Table 1.3.9 Type of clinical pharmacy services offered pharmacy department
27
Table 1.3.10 Clinical pharmacy services offered by pharmacy department according to hospital type
28
Table 1.3.11 Year of PN service started
29
Table 1.3.12 Ward with PN services
30
Table 1.3.13 Places for preparation of PN
31
Table 1.3.14 Parenteral nutrition services offered by pharmacy department
34
Table 1.3.15 Pharmacist involvement in parenteral nutrition services
36
Table 1.3.16 Monitoring of quality control during PN compounding
37
Table 1.3.17 The use of commercially available standard product
40
Table 1.3.18 Type of recommendation by pharmacist 40
xi
Table 1.3.19 Components of solutions
42
Table 2.2.1 The group
73
Table 2.2.2 Gender of pilot study
74
Table 2.2.3 Race of pilot study
74
Table 2.2.4 Diagnosis of pilot study
74
Table2.2.5 Reason for PN of pilot study
74
Table 2.2.6 Outcomes of PN of pilot study
75
Table 2.2.7 Complication due to PN of pilot study
75
Table 2.2.8 Type of complications of pilot study
75
Table 2.2.9 The cost of PN per day of pilot study
75
Table2.2.10 The prices of the contents of the bags in each hospitals
77
Table 2.2.11 Number of PN patient in PPH
80
Table 2.2.12 Values of ( )22/ Β+ ZZα for frequently used
combinations of significance level and power
82
Table 2.2.13 Number PN patient in HUSM
83
Table 2.2.14 Number of PN patients in HUKM
84
Table 2.2.15 Number of PN patients in UMMC
86
Table 2.3.16 Demography of PN patient
92
Table 2.3.17 Diagnosis of PN patients
92
Table 2.3.18 Reasons for PN 93
Table 2.3.19 Outcomes of PN patients
96
Table 2.3.20 Relation of diagnosis with death in each hospital
97
Table 2.3.21 Complication due PN
97
xii
Table 2.3.22 Type of complication
98
Table 2.3.23 Complication of premature in each hospital
100
Table 2.3.24 Route of PN
106
Table 2.3.25 Cost per day
108
Table 2.3.26 Duration of PN
109
Table 2.3.27 Energy requirement
110
Table 2.3.28 Volume prepared of PN
111
Table 2.3.29 Glucose requirement in gm/kg/day
112
Table 2.3.30 The monitoring of RBS
113
Table 2.3.31 AA requirement of PN in gm/kg/day
114
Table 2.3.32 The monitoring of BUN
114
Table 2.3.33 The monitoring of serum creatinine
115
Table 2.3.34 Lipid requirement in gm/kg/day
116
Table 2.3.35
The monitoring of total bilirubin 117
Table 2.3.36 The monitoring of ALT (U/L)
117
Table 2.3.37 The monitoring of ALP (U/L)
118
Table 2.3.38 Multivitamin requirement of PN
119
Table 2.3.39 Trace elements requirement of PN
120
Table 2.3.40 Sodium requirement of PN (meq/day)
122
Table 2.3.41 The monitoring of Na
123
Table 2.3.42 Potassium requirement (mEq/day)
124
Table 2.3.43 The monitoring of potassium
124
Table 2.3.44 Magnesium requirement of PN (meq/day)
126
Table 2.3.45 Monitoring of Mg (mMol/kg/day) 126
xiii
Table 2.3.46 Calcium requirement of PN (meq/day)
128
Table 2.3.47 The monitoring of Ca
128
Table 2.3.48 Phosphate requirement of PN (mmol/day)
129
Table 2.3.49 The monitoring of PO4
130
Table 2.3.50 Chloride requirement of PN (qs meq/day)
131
Table 2.3.51 The monitoring of PH
131
Table 2.3.52 The monitoring of HCO3
132
Table 2.3.53 The monitoring of body temperature
133
Table 2.3.54 Daily fluid requirement for patients
134
Table 2.3.55 The monitoring input in ml
135
Table 2.3.56 The monitoring output in ml
136
Table 2.3.57 The monitoring fluid balance in ml
137
Table 2.3.58 The monitoring of PCO2
138
Table 2.3.59 The monitoring of PO2
139
Table 2.3.60 The monitoring of O2 saturation
140
Table 2.3.61 The monitoring of BE kpa
141
Table 2.3.62 The monitoring of WBC per mm3 of blood
143
Table 2.3.63 The monitoring of HB mmol/L
144
Table 2.3.64 The monitoring of platelet 10 raise9/L
145
Table 2.3.65 The monitoring of PT
147
Table 2.3.66 The monitoring of INR
148
Table 2.3.67 The monitoring of APTT
149
xiv
LIST OF ABBREVATIONS The abbreviation
The Title
APTT Activated partial thromboplastin time A Adult ALB Albumin A/G Albumin/globulin ratio AA Amino acids ALT Amino alanine transferase ANOVA Analysia of variance ADU Aseptic dispensing unit AST Aspartate amino transferase ALP Aspartate aminoransferase BE Base excess HCO3 Bicarbonate BUN Blood urea nitogen test BW Body wieght £ British pound Ca2+ Calicium CRB Catheter related bacteremia CRBSI Catheter related blood stream infection CVC Centeral venous catheter CPN Central parenteral nutrition Cl Chloride OTC Drugs prescribed without physcicians NEC Enterocolitis ECF Extracellular fluid GLB Globulin g/l Gram/liter Hb Hemoglobin HCB Hospital compounded bags HPN Hospital parenteral nutrition HUSM Hospital Universiti Sains Malaysia HUKM Hospital University Kebangsaan Malaysia INR International normalized ratio IFALD Intestinal failure associated liver disease ICF Intracellular fluid LFT Liver function test LCT Long chain triglyceride LBW Low birth wieght Mg2+ Magnisium MCT Medium chian triglyceride umol/l Micromol/liter MMol/d Milli mol/day
xv
Ml Milliliter
NG Naso gastric N Neonate NPCTON Non protein calories to nitrogen NBM Nothing by mouth NST Nutrition support team O2 Sat. Ogygen saturation PN Parenteral nutrition PDA Patent ductus arteriolus P Pediatric pH Hydrogen ion concentration PICU Pediatric intensive care unit % O2 Sat Percent oxygen saturation PCO2 kPa Peripheral arterial carbon dioxide content PO2 kPa Peripheral arterial oxygen content PICC Peripheral intravenous catheter PPN Peripheral parenteral nutrition PO4
3- Phosphate
Plt Platelet K+ Potassium Prem Premature PT Prothrombin time PPH Pulau Pinang Hospital RBS Random blood sugar RM Ringgit Malaysian SB Separate bottles Scr Serium creatinine Na+ Sodium SVC Superior vena cava TCB Three compartment bags TB Total bilirubin TBW Total body water TCO2 Total carbon dioxide TPN Total parenteral nutrition TP Total protein U/L Unit/liter USD United state dollar UMMC University Malaya Medical Centre WBC White blood cells Wt Wieght (The Clinican’s Ultimate Reference)
xvi
PRAKTIS NUTRISI PARENTERAL DI HOSPITAL DI MALAYSIA
ABSTRAK
Nutrisi Parenteral (PN) telah diamalkan di Malaysia semenjak tahun 1986. Satu tinjauan
terdiri daripada 41 soalan tentang perkhidmatan PN telah dijalankan untuk menilai
amalan nutrisi parenteral di hospital di Malaysia. Keputusan daripada tinjauan itu
menunjukkan perkhidmatan nutrisi parenteral diamalkan di sebanyak 17.3% hospital-
hospital di Malaysia, 55.6% diamalkan di hospital tertier manakala 44.6% diamalkan di
hospital sekunder. Purata bilangan sediaan nutrisi parenteral adalah sebanyak 10±11
sehari di hospital tertier dan 4±2 bagi hospital sekunder. Produk nutrisi parenteral
disediakan oleh pegawai farmasi di 88.9% hospital manakala pembantu farmasi di
66.7% hospital. Pasukan bantuan nutrisi (NST) boleh didapati di 33.3% hospital
manakala 88.9% mempunyai ahli farmasi yang bergiat didalam penyediaan sediaan PN
dan 66.7% meggunakan borang piawai memantau pesakit.
Bahagian ke dua dari kajian ini merupakan kajian retrospektif terhadap dapatan,
komplikasi, dan kos terhadap perkhidmatan PN. Kajian dijalankan di 4 hospital
pendidikan, ia itu Hospital Pulau Pinang (PPH), Hospital Universiti Sains Malaysia
(HUSM), Hospital Universiti Kebangsaan Malaysia (HUKM), dan Pusat Perubatan
Universiti Malaya (UMMC). Sejumlah 890 kes PN dari tahun 2003 hingga 2005 dinilai.
Dapatannya termasuk toleransi terhadap pemberian oral sebanyak 90.7%, 98.7%, 50.3%,
dan 22% kes serta kematian sebanyak 5.7%, 1.3%, 7.2%, dan 15% kes. Diantara
komplikasinya ialah sepsis sebanyak 6.7%, 0.7%, 0%, dan 0% kes, metabolik (asid base
xvii
tidak seimbang) sebanyak 6.7%, 6.2%, 0% dan 0.8% kes, komplikasi buah pinggang
sebanyak 22.5%, 14.4%, 44.4%, dan 11.6% kes, komplikasi hati sebanyak 33.7%,
12.3%, 0%, dan 5.8% kes, elektrolit tidak seimbang sebanyak 27%, 56.2%, 55.6%, dan
81.8% kes masing-masing di PPH, HUSM, HUKM, dan UMMC. Komplikasi mekanikal
hanya berlaku sebanyak 3.4% di PPH dan 0.5% di HUSM. Laluan administrasi adalah
laluan sentral sebanyak 31.7%, 69.2%, 50.9%, 57.2% kes dan laluan periferi sebanyak
68.3%, 30.8%, 49.1%, dan 42.8% bagi semua kes di PPH, HUSM, HUKM, dan UMMC.
Kos per hari bagi prematang kes adalah sebanyak (RM) 181±41, 99±46, 189±86 dan
73±16 manakala bagi kanak-kanak adalah sebanyak 223±126, 210±121, 242±109, dan
147±91, bagi dewasa adalah sebanyak 236±45, 398±103, 840±229, dan 406±112 di
PPH, HUSM, HUKM, dan UMMC dimana perbezaan ketara adalah sebanyak
(P=0.001). Kajian menunjukkan perkhidmatan PN ditawarkan terutamanya oleh hospital
tertier dan sekunder. Kajian juga menyimpulkan kadar penglibatan pegawai farmasi
dalam penyediaan PN adalah berbeza antara hospital. Kajian juga mendapati kadar
komplikasi yang tinggi mungkin disebabkan oleh penggunaan sistem secara persendirian
berbanding sistem piawai. Kos nutrisi parenteral juga meningkat seiring dengan
peningkatan umur pesakit dan perbezaannya adalah ketara. Perbezaannya mungkin
disebabkan peningkatan keperluan terhadap nutrisi terhadap umur.
Kata kunci : Nutrisi Parenteral, Praktis, Kos, Hasil, Komplikasi, Malaysia
xviii
THE PRACTICE OF PARENTERAL NUTRITION IN MALAYSIAN
HOSPITALS
ABSTRACT
Parenteral Nutrition (PN) has been practiced in Malaysian hospitals, since 1986. A
survey compised of 41 questions on PN practice was developed to evaluate the practice
of PN in Malaysian hospitals. The results show that PN services is practiced in 17.3%
of Malaysian hospitals. 55.6% were practiced in tertiary hopitals and 44.6% were
practiced in secondary hospital. The average number of PN preparations per day was
10± 11 in tertiary hospital and 4 ± 2 in secondary hospitals. PN solution were prepared
by pharmacist in 88.9% of hospitals and by Pharmacist assisstants in 66.7% of
hospitals. Nutritional support team (NST) existed in 33.3% hospitals while 88.9% have
pharmacists participating in PN compounding and 66.7% used standard Patient
Monitoring Forms.
The second part of the study was a retrospective study on the outcome, complications
and cost of PN services. The study was carried out at 4 teaching hospitals namely,
Hospital Pulau Pinang (PPH), Hospital Universiti Sains Malaysia (HUSM), Hospital
University Kebangsaan Malaysia (HUKM) and University Malaya Medical Centre
(UMMC). A total of 890 PN cases from the years 2003 to 2005 were evaluated. The
outcome included tolerating feeding 90.7%, 98.7%, 50.3% and 22%, Death 5.7%, 1.3%,
7.2% and 15%. Among the complication were sepsis 6.7%, 0.7%, 0% and 0%,
metabolic (acid -base) 6.7% ,6.2%, 0% and .8%, renal complication were 22.5%,
14.4%, 44.4% and 11.6%, liver complication 33.7%, 12.3%, 0% and 5.8%, electrolyte
xix
imbalances 27%, 56.2%, 55.6%, 81.8% PPH, HUSM, HUKM and UMMC respectively.
Mechanical complication only occurred 3.4% in PPH and 0.5% in HUSM. The cost per
day for premature cases was (RM) 181±41, 99±46, 189±86 and 73±16 while for
pediatrics 233±126, 210±121, 242±109 and 147±91, for adults 236±45, 398±103,
840±229 and 406±112 at PPH, HUSM, HUKM and UMMC and the differences were
significant (P=.001). The study concluded that the PN services were offered mainly by
tertiary and secondary hospitals. The study also concluded that the the extend of
pharmacist involvement in PN varies from hospital to another, the study also found that
the high rate of complication could be due to the use of individualization system rather
than the use of standard system. The cost of PN also increased with a patient’s age and
the differences were significant. The differences could be due to increasing nutritional
requirements with age.
Keywords: Parenteral Nutrition, Practice, Cost, Outcome, Complication, Malaysia
1
Part 1 SURVEY OF TOTAL PARENTERAL NUTRITION PRACTICE IN MALAYSIAN HOSPITALS 1.1 INTRODUCTION AND LITERATURE REVIEW 1.1.1 Background The history of intravenous infusion of fluids can be traced back to the sixteenth century.
However, Dudrick and colleagues introduced the infusion of modern nutrients only 35
years ago when he successfully administered long-term PN to an infant. Since then
parenteral nutrition has become an important adjunctive therapy in the management of
patients unable to utilize the gastrointestinal tract (Dudrick et.al. 1969).
Parenteral nutrition formulation is a complex admixture of standard solutions containing
nutrients. There are more than 40 different components including both macronutrients
(carbohydrates, lipids, amino acids) and micronutrients (electrolytes, trace minerals and
vitamins). These nutrients are mixed into a bag and infused simultaneously into the
blood circulation through the peripheral or central vein. Parenteral nutrition may be
partial in nature i.e. one that provids supplementary nutrients to that provide orally or
enterally, or total (TPN, total parenteral nutrition or hyperalimentation) i.e. one that
provides total energy and nutrient intakes for patients, (Maisonneuve et.al 2004).
Parenteral nutrition is usually infused over 24 hours at a rate of 25 to 50 mL/h ( Koss
2003).
2
Since parenteral nutrition involves a complex process, its provision usually involves a
multidisciplinary team (Nutritional support teams, NST) consisting of doctors, nurses,
nutritionists, pharmacists and other related health care providers. The nutrition support
team evaluates the patient’s metabolic needs, prescribes appropriate nutritional support,
prepares nutritional admixture, administers the parenteral nutrition and monitors the
patient (Harbans 1994) and (Ramanujam 1994). Generally serum levels of electrolytes
should be checked daily, glucose levels must be checked at least three times per day to
achieve euglycemia while calcium, magnesium and phosphorus should be cheked
weekly. Parenteral nutrition improves wound healing, enhances immune system
function, improves gastrointestinal structure and function and improves clinical
outcomes through a reduction in complication rates and length of stay with
accompanying cost savings (Shikora 2001).
Prior to early eighties, parenteral nutrition in Malaysia was provided conventially.
Multiple nutritional solutions were hung over the patient’s bed and administered by a
multiple intravenous line. The indication for PN is mainly fluid therapy rather than as
nutritional supplement (Bahari 1993). Parenteral nutrition in Malaysia was first started
at the Kuantan General Hospital in 1986, followed by the Penang Hospital, Kuala
Lumpur Hospital and Universiti Sains Malaysia Hospital (Bahari 1994), (Shamsuddin
et.al 1994) and (Bahari et.al 1996).
The School of Pharmaceutical Sciences, Universiti Sains Malaysia being the only
School of Pharmacy in Malaysia at that time contributed tremendously to the
development of the parenteral nutrition programme. For instance, in 1985, the School
3
introduced a PN programme as a part of its final year curriculum, which was expanded
to include a practice session in compounding PN in 1986 (Bahari, 1993). Table 1.1.1
shows total number of government hospitals providing PN Services (Bahari, 1993)
Table 1.1.1: Total number of government hospitals providing TPN Services
Adapted from MB Bahari 1993 with permission. 1.1.2 Practices of PN
Since it was introduced by Dudrick and his colleague parenteral nutritional therapy has
been accepted as a mode of therapy in many medical areas such as surgery, pediatrics,
gastroenterology and others (Dudrick et.al 1969). In fact standard PN guidelines have
been developed to assist practitioners through out the world (A.S.P.E.N 1996)
(Guideline on Pediatric, 2005) and (Pennington 1996). Studies on the effect of PN
support showed that appropriate nutritional intervention has been shown to improve
clinical outcomes and shorten length of stay as well as patients quality of life beside
financial savings (Imad 2002) and (Bozzetti 2001). However, there is still a need to
promote optimal nutrition care as a core component of patient management (Ravasco
et.al. 2004) and (Guglielmi et.al 2003).
Year Number of hospital initiating PN services
Cumulative no
1986 1 1 1987 3 4 1988 6 10 1989 4 14 1990 4 18
4
The role of pharmacists in the provision of PN services in Malaysian hospitals prior to
1986 has been very minimal. In fact, their main role was limited to the procurement and
distribution of the nutritional solutions. In 1986 PN services were started in Kuantan,
Penang and Kuala Lumpur hospitals and followed by HUSM in 1987. HUSM provided
the PN services initially to the pediatric wards and later expanded the services to include
adult wards especially to surgical patients. In order to improve the role of pharmacists,
HUSM started an Aseptic Dispensing Unit (ADU) within the Pharmacy Department in
1991 to provide a centralized PN service. The pharmacists from the ADU worked
together with physicians, nurses and dietitians as a team known as PN Team (Bahari
1993).
The data in 1993 showed that the mean PN preparation rate was 2.38 per day (634
preparations for 266 days, ranging from 1 to 7 preparations per day). Of those, only one
preparation (0.16%) encountered complications. The average duration of PN for each
patient was 8.8 days (ranging from 1 day to 32 days; n=62 patients). Fifteen (24.2%) of
the patients were adults (Shamssudin et.al 2003).
The quality of PN services is evaluated based on their availability, the range of services
offered, staff load, rate of complications, outcomes and costs. A survey in hospital
pharmacists practices in France (F), Switzerland (CH), and Belgium (B) showed that
NST were present in 32% to 45% of hospitals. Standard formulas were used in adult
patients (F, 79%; CH, 86%; B, 86%), whereas approximately 50% of tailor-made PN
bags were used for children. Most standard formulas were provided by industry as tailor-
made formulas produced exclusively for hospital pharmacies. Quality controls were
5
mostly visual in 75% to 95% of hospitals surveyed (Maisonneuve et.al. 2004). Another
study in Portugal showed that NST was reported in 34% of hospitals, 40% of which
were teaching hospitals. The composition of NSTs included physicians, pharmacists,
dietitians/nutritionists in 25% of all hospitals, physicians and dietitians/nutritionists
(30%), physicians and pharmacists (5%) and dietitians/nutritionists only (16%), only 9%
of NST covered the whole hospital population and 16% acted on a consultation basis.
While 30% were only involved in purchasing nutrition products. Only 18% of the NSTs
were involved in teaching/training (Ravasco et.al. 2004). A study in UK to determine
the progress of PN practices since 1988 to 1992 showed that 32.5% of respondents had
access to nutrition support teams, compared with 27% in 1988. Of these, 33% provided
enteral nutrition and 53% parenteral nutrition. However, since 1988, the number of
respondents using peripheral parenteral nutrition had doubled to 15% (James et.al. 1992).
A study in Latin America showed that malnutrition was present in 50.2% of the patients.
However, nutritional therapy was used only in 8.8% of these patients (6.3% enteral
nutrition and 2.5% parenteral nutrition) (Correia and et.al. 2003). A study in the Von
Hauner Children's Hospital at the University of Munich on the type of prescription
showed that 68% used standard PN and 32% individualized PN. The standard PN were
used more often in the pediatric intensive care unit with modifications of standard PN
solutions performed in 54% of all cases. While, macronutrients and electrolytes
contents were similar in both individual and standard PN solutions, calcium and
phosphate intakes were lower in individual PN. Electrolyte imbalances occurred slightly
more often in individualised PN than in standard PN (34% vs. 26%, respectively).
(Krohn et.al. 2005). Another study evaluated the use of individualized PN prescriptions
in neonates. It revealed that 20% of PN strictly followed the computer programmed
6
generated projections while 80% of PN prescriptions contained higher carbohydrate,
sodium and phosphate content ( Beecroft et.al. 1999). In another study (Villares et.al.
2002) found that the prescription was customized to each individual patient in 87% of
the 48 centres. The centres used MCT and mixture of MCT/LCT for the fat and 50% of
the centres using all-in-one mixtures. Most centers used inorganic phosphate (78%),
daily vitamins and trace elements (65%), heparin (50%) and carnitine (27%). The study
also found that only 40% of the centers indicated that the solution had to be used within
24 hours.
A study on the competency of physicians in prescribing parenteral nutrition support
showed that the mean total score was 48.6±20.8. Total score differed according to the
number of nutrition lectures attended during residency, specialty area and experience in
prescribing parenteral nutrition (Vanek 1997). Another study involving dietitians in
1993 found that only 5% assumed total responsibility for the formulation of parenteral
nutrition regimens. By 1995 this figure had risen to 14%. However, 83% of nutrition
support dietitians wanted to increase their involvement in PN ( Fisher et.al 1996).
Results from a 1995 survey showed that 42% of dietitians felt that education at
undergraduate level was inadequate, while 58% felt education at postgraduate level
could be improved (Gilmour 1998).
A study in Swiss hospitals found that multi-disciplinary nutritional support teams were
present in 52% of hospitals. 83% of adult PN used commercially prepared products in
multicompartment bags. However, pediatric PN still used in house individualized
admixtures because of the absence of commercial products. While 57% of home PN
7
were provided by hospital pharmacists (Pichard et.al 2001). A study into the effects of
PN prescribing practice on patients by ( Porcelli 2004) reported an average of 182 Very
low birth weight (VLBW) infant admissions and involved the preparation 4810
parenteral nutrition orders per year. PN were prescribed by experienced neonatal
nutrition staff in 5 centers of 8 centers surveyed, six centers with using paper parenteral
nutrition order forms. All the centers provided some guidance such as recommended
ordering dose range and self-reported medical mistakes such as incorrect parenteral
nutrition additive dilutions and incorrect supplementation of parenteral nutrition
additives.
Seres et.al (2003) in his survey found that there was no consistent method of prescribing
PN. He noted that 45% of responders reported adverse events directly related to PN that
required intervention. Of these events, 25% caused temporary or permanent harm, and
4.8% resulted in a near-death event or death. Another study by Schloreb et.al. (1998)
showed the amounts of glucose given in PN were high ( more than 4.48 mg/kg per
minute) and produced a respiratory quotient greater than 1.0 in a standard PN formula
of 4.25% amino acids, 15% dextrose, and 20% fat emulsion. Monitoring of fifty-three
patients on PN found that nutritional requirements were reached in 67.6% of the patients
within 2.9 ± 0.7 days. The mean duration of parenteral nutrition was 7.2 ± 6.6 days.
Pain at the venipuncture site occurred in 17.1% of the cases, pain and fever in 20% and
pain, hyperthermia and edema in 2.8%. No patient developed an abscess (Correia et.al.
2003).
8
Surveys to evaluate the current status of parenteral nutritional management in Malaysian
hospital are crucial to offer a critical perspective of routine practices. In Malaysia, the
practice of PN was introduced in the late 1980s and many the initiatives launched by
tertiary and secondary hospitals to train health professionals have led to its widespread
use. The current academic survey was undertaken in January 2007 in order to evaluate
the practice of clinical nutrition in Malaysian hospitals, and identify those that might be
receptive to teaching and training initiatives. The survey developed a set of
questionnaires for the relevant hospitals (Appendix 1). Questions focused on various
indicators concerning parenteral nutrition (PN): these included adult special sties type
offered, (b) The no of pharmacists and pharmacist assistants, (c) Type of clinical
services offered by the pharmacy department, (d) services in Malaysian hospitals, (e)
services in Malaysian hospitals according to hospital type, (f) years of hospital service,
(g) Ward with PN services, (h) Average number of preparation per day for adult and
pediatric, (i) Places for the preparation of PN, (j) The practices of patient on PN, (k)
Services of PN offered by pharmacists, (l) The addition of the component , (m)
Information about compatibility, (n) Monitoring of quality control during compounding,
(o) Product quality and improvement to its stability, (q) The use of commercially
available standard product and (r) Components of the solutions.
1.1.3 Problem Statement
PN is an essential component of care for those who are unable to tolerate adequate oral
or enteral feeding. However, it is not complications free due to the danger of
9
biochemical abnormalities, sepsis, thrombosis, extravasations, and death (Ahmed et.al
2004).
A prospective study carried in children with diarrhea of more than 14 days’ duration
(University of Malaya Medical Centre, Kuala Lumpur from 1 January 1996 to 31
December). Twenty-seven patients (14 boys and 13 girls) were studied. The result was
nine cases required parenteral nutrition ( Lee et.al. 1999).
The Straits Times of Malaysia (May 13, 1977-Editorial) estimated that there were about
200,000 squatters around the city of Kuala Lumpur. The size of this disadvantaged group
of urban dwellers suggests that there may be many other urban children who are
potentially vulnerable to the development of malnutrition (George et.al 1981).
Micronutrient malnutrition is a serious problem to the health and productivity of more
than 2 billion people worldwide. Iron, Vitamin and Iodine were the major three
micronutrient deficiencies elements (Hesham et.al 2003) and (Cheah 2006).
After more than a decade of PN introduction in Malaysia, there is no comprehensive
report on the evaluation of PN practice. There is also no report about the extend of PN
services offered, the total number of hospitals offering the service, the range of services
offered, workload, manpower training and other related information to the provision of
PN services in Malaysia. Such information is very important for policy makers as it
serves as a guide for them to prepare policy related to the provision of PN services (Al-
batani et.al 2006).
10
Literature also shows that the provision of PN services by pharmacists vary from
hospital to another. As such, these variations need to be addressed and minimized so
that a standard guideline for pharmacists involved in the provision of PN services can be
formulated.
1.1.4 Rationale of the study The information necessary to address the above problem is still not available. Although
the PN service have been introduced for more than 20 years, the data on the number of
hospitals offering the service, the extend of pharmacists involvement, the availability of
standard solution and other related information are not available in a comprehensive
manner: (Bahari 1999), (Shamsuddin et.al 1994), (Bahari 1998), ( Bahari 1990),
( Harbans1994) and (Ramanujam 1994).
This study will be able to provide information related to the extend of PN practice
among Malaysian hospitals, the role of pharmacists and the scope of PN service. The
study will also provide an evaluation of the types of cases commonly on PN, the types of
solution of various PN services in the most established hospitals in Malaysia.
The data from the study will provide the information for the hospitals and policy makers
for the planning and providing of PN services. In addition, the information related to the
availability of PN services is also useful for the future planning of PN. Moreover, the
geographical location of hospitals who offer PN service will allow physician to refer
patients for PN more efficiently.
11
The information related to of PN solution used by the hospitals such as standard
solutions, individualized solutions or premixed solutions is useful for the future planning
of PN service. As the data can be used as guideline in selecting the type of service to
offer and in selecting type of solutions to use.
This part of the study will highlight the PN services in Malaysian hospitals including the
number of hospitals providing the services, the type and extend of clinical pharmacy
services, the facilities available, the staff load, quality assurance, the availability of
standard formula and computer programmed for PN calculations. The study will also
look into the methods used by hospitals without PN services i.e. the use of ready made
commercially available PN solution or purchase from other hospitals.
1.1.5 Objectives The general objectives of the study is to: 1. explore PN practice in Malaysian hospitals. The specific objectives of the study are to: a. determine the extend of PN services offered by Malaysian hospitals.
b. determine the personnel involved in the provision of PN services.
c. determine the load of PN services
e. document the role of pharmacists in the provision of PN services
12
1.1.6 Justification of the study The study provides information related to the provision of PN services in Malaysia. The
information is very useful as in devising plans to the provision of PN services.
The result of the study is also useful to provide information in the development of
protocol and procedures to improve the current PN practice. The result also provides
insight information various PN practices in Malaysian hospitals. Remedial steps could
be developed to improve the weakness of the current practice.
The justification of this study lie in the fact that there is not much information or
knowledge about PN practices in Malaysia. The study was done to answer, enlighten,
and evaluate the practice of PN in Malaysian hospitals. There is no informations about
the types of clinical services offered by pharmacy department.
The study also justified because it will provide information about the number of
hospitals offering PN service, the date PN services started in Malaysian hospitals, the
extend of PN service and the load of PN service. The types of quality assurance carried
out by the PN services such as aseptic techniques, frequency of microbial counts and
maintenance of facilities in the clean room. The type of PN solutions used in the PN
service such as standard formula or individualization for adults and Pediatrics. The
personnel involved in the preparation of PN solution, the duration of PN service and the
supply during the weekend and public holidays. The involvement of pharmacists in the
estimation of PN requirement, PN monitoring and nutrition support team.
13
1.2 METHODOLOGY 1.2.1 Introduction
This part of study comprises a survey for the evaluation of PN practice in Malaysian
hospitals. The survey was carried out among all hospitals in Peninsular Malaysia. A
total of 100 hospitals were selected by stratified random selection according to the states
in Malaysia. The list of hospitals was downloaded from website which includes public
and private hospitals in peninsular Malaysia in the year of 2007.
1.2.2 Parenteral nutrition practice in Malaysian hospitals
The questionnaire of the PN practice in Malaysian hospitals was developed based on a
study done by Shamsuddin (2003) in Malaysia and other surveys conducted on PN
practices in hospital pharmacies in Switzerland, France, and Belgium by Maisonneuve
et.al (2004). The content of the questionnaire was discussed with faculty and staff
working in parenteral nutrition services. All the questions were designed to attain the
objectives of this study. This section evaluated the practice of PN in Malaysia, based on
the following aspects. Type of clinical services offered by the pharmacy department, the
presence of PN services in Malaysian hospitals, the year the provision of PN services
commenced in Malaysian hospitals, the provision of PN supplement to other wards, the
preparations per day, the place of PN solutions prepared, the type and frequency of
quality control processes such as prescription checks, calculation, microbial counts,
particle counts and microbiological tests for final PN solutions. The use of standard
formula and individualised prescriptions for adults and pediatrics. The evaluation also
14
looking into aspects of personnel involved in the preparation of PN, additional services
such as 24 hour PN services, weekend and holiday services, the use of computer
programs for PN calculation and checking the compatibility between drug-drug and
drug-PN. The use of standard patient monitoring devices by pharmacists or the PN team
and the use of commercially available PN solution or those ordered from other hospitals
(Smith 1997) and (Passmore 2002).
1.2.3 Study design of survey of Practice PN in Malaysian Hospitals
The survey utilized a structured questionnaires (Appendix 1). A pretest was carried out
to evaluate the validity using three voluntered pharmacist. The survey questionnaire was
sent to the pharmacy director in each hospital. It was accompanied by a letter explaining
the objectives of the study and a self address post-paid envelope. Responses were
expected within a 30 days time frame.
1.2.4 Determination of the sample size.
The sample size was determined using to the following procedure: First, the total
number of hospitals in Malaysia was determined as follow:
122 (Government) + 93 (Private) = 215 hospitals
Then the sample size was determined using the following equation formula.
n = 2
2/⎥⎦⎤
⎢⎣⎡
EZ α )1( PP −
15
P =15:200= 0.075 (MOH Annual Report, 2002).
q = (1-p) = 0.925
n = sample size
Z = standard normal deviate usually 1.96
E= The degree of accuracy desired, usually set at 0.05.
Determination of sample size n =
2
05.96.1
⎥⎦
⎤⎢⎣
⎡ 0.075 (0.925)
= 100 hospitals were selected by stratified random selection method. Table 1.2.2: The total number of hospitals in both government and private hospitals Hospital Governments Private Johor 11 14 Kedah 9 Kelantan 9 8 Melaka 3 Negeri sembilan 6 5 Pahang 8 Perak 14 9 Perlis 1 Pulau Pinang 6 14 Selangor 10 19 Sarawak 14 8 Sabah 22 2 Terengganu 6 WP Kuala Lumpur 2 14 WP Putrajaya 1 WP Labuan Total 122 93
16
Table 1.2.3: The total number of government and private Hospitals in participated in the study (100). Hospital Governments Private Johor 5 7 Kedah 4 Kelantan 4 4 Melaka 1 Negeri sembilan 3 2 Pahang 4 Perak 7 4 Perlis 1 Pulau Pinang 3 7 Selangor 5 9 Sarawak 7 4 Sabah 11 1 Terenggannu 3 WP Kuala Lumpur 1 7 WP Putrajaya 1 Total 60 45
1.2.5 Subjects (hospitals)
In order to evaluate the parenteral nutrition practice in Malaysian hospitals, a
survey was carried out among all hospitals including private and public hospitals in
peninsular Malaysia. The list of hospitals according to geographical site was obtained
from the Ministry of Health website which includes public and private hospitals in
peninsular Malaysia.
1.2. 5 (a) Selection of hospitals
A total of 215 hospitals from public and private hospitals were listed in ministry of
health website. Hundred (100) of hospitals were selected by stratified random selection
according to the states in Malaysia.
17
1.2.5 (b) Inclusion criteria
All the government and private hospitals in Malaysia.
1.2.5 (c) Exclusion criteria
There were 29 small clinics were excluded from the study.
1.2.6 Data Analysis
The data was analyzed using SPSS version 11 and descriptive statistic was used as
appropriate. Contingency tables were used for the following:
1. The classification of the hospitals.
2. PN services in Malaysian hospital.
3. Hospital size with relation to hospital type.
4. Availability of PN services according to class of hospital.
5. The Specialties type offered by the Malaysian’s hospital.
6. Type of Clinical Pharmacy Services offered Pharmacy Department.
7. Clinical Pharmacy Services offered by Pharmacy Department according to hospital
type.
8. Year of PN service started.
9. Ward with PN services.
10. Places for preparation of PN.
11. Parenteral Nutrition Services Offered by Pharmacy Department.
18
12. Pharmacist Involvement in Parenteral Nutrition Services.
13. Monitoring of quality control during PN compounding.
14. The use of commercially available standard product.
15. Type of recommendation by Pharmacist.
16. Components of solutions.
19
1.3 RESULTS AND DISCUSSION
1.3.1 Response rate
The response rate of the survey was 52% (52 out of 100 selected hospitals). This finding
is comparable to other Malaysian health related studies using the questionnaires survey
which is between 24.25% to 85% (Mohamad et.al 1997 and Marnoch et al 2002). The
response rate from studies among doctors were lower (24.25%) than Pharmacists (52%)
and nurses (85%). The differences could be due to the differenence in workload of each
profession and time available. However, the finding on response rate was comparable to
other studies on PN done outside Malaysia such as in Switzerland which was 55.6%,
France 30.5%, and Belgium 24.5% (Maisonneuve et.al. 2004). A study in Portugal
showed that the response rate was 44%, reaching (60%) in primary care (Ravasco et.al.
2004) while in the United Kingdom about 61.2% of questionnaires distributed were
completed and returned (James 1992).
The study also showed that most of Malaysian pharmacists were aware about the PN
services even though their hospital did not offer PN services.
20
1.3.2 Classification of hospitals
Table 1.3.4 shows the number of hospitals according the classification such as tertiary
(15.4%), secondary (67.3%) and primary (17.3%) hospitals that responded to the
questionnaires. The classification was based on the facilities, the level of training of
medical staff, size and professionalism. The number of primary hospitals did not
represent the actual number of primary hospitals selected for the study because most of
them did not respond to the questionnaire. Another reason was the increase in the
number of private hospitals in 2007. This is due to the compulsory registration of all
private practitioners and hospitals in Malaysia which was implemented in 2007 (Chee
2007), (Association of private hospitals) and (Charles 2002).
Table 1.3.4: The classification of the hospitals Hospitals Hospital type n % Tertiary hospitals teaching referral
8 (15.4)
Secondary hospitals general district nucleus
35 (67.3)
Primary hospitals private Public clinic HPN organization
9 (17.3)
Total 52(100)
21
1.3.3 PN services in Malaysian hospital
There were 9 (17.3%) Malaysian hospitals participated in the study offered PN service.
Among the reasons for this low rate were:
1. The cost of setting PN services is very expensive and smaller
hospitals do not have enough cases for PN and therefore it is not cost
effective.
2. Small hospitals have the choice to purchase the PN solution from
other hospitals.
3. The system that allows small hospital to transfer patients who
require PN support to another hospitals with PN services.
4. Smaller hospitals have the choice to use ready made solution,
which can be purchased from the pharmaceutical companies.
Studies from other countries showed that nutritional therapy was used in 8.8% of
patients (6.3% enteral nutrition and 2.5% parenteral nutrition) in Latin America (Correia
et.al. 2003) However, an other study showed that Standard PN solutions were
prescribed in 68% of cases (Krohn et.al 2005).
Table 1.3.5: PN services in Malaysian hospital
n (%) PN service 9(17.3) No PN service 43(82.7) Total 52(100)
22
1.3.4 Hospital size
Table 1.3.6 shows the size of the hospitals that participated in the study. Majority of the
hospitals (68.2%) had less than 250 beds and the relation between hospitals type and the
hospital size was significant (P=0.024). All the primary hospitals had less than 250 beds
and 68.6% of secondary hospitals also had less than 250 beds while 22.8% had between
250 to 500 beds. However, tertiary hospitals had more than 1000 beds. The study found
that tertiary hospitals with 1000-1250 beds capacity have a higher number of pharmacist
and pharmacist assistant. Therefore they could handle more preparation per day (Table
1.3.7). In addition, tertiary hospital also could offer wider types of pharmacy service
( Raymond 2005) and (Starkweather 1970).
1. Tertiary hospitals had larger beds number than secondary and primary because they
received referral patients from larger geographical areas. For example, the Penang
hospital used to receive patients from other hospitals such as those from Perlis, Kedah
and Perak.
2. Tertiary hospitals also had wider number of specialties.
3. Tertiary hospitals also cater to chronic and severe cases that required prolong hospital
stay.
4. Tertiary hospitals had latest and sophisticated equipments such as MRI, etc.
23
Table 1.3.6: Hospital size in relation to hospital type. Less
than 250 beds
250-500 beds
500-750 beds
750-1000 beds
1000-1250 beds
More than 1250 beds
Total
Hospital type Tertiary hospitals
2(25) 4(50) 0(0) 0(0) 1(12.5) 1(12.5) 8(15.4)
Secondary hospitals
24(68.6) 8(22.8) 2(5.7) 1(2.8) 0(0) 0(0) 35(67.3)
Primary hospitals
9(100)
0(0) 0(0) 0(0) 0(0) 0(0) 9(17.3)
Total 35(67) 12(23) 2(4) 1(2) 1(2) 1(2) 52(100) 1.3.5 Availability of PN services Table 1.3.7: Availability of PN services. Hospital type Mean no of
pharmacist Mean no of assistant pharmacist
PN services Total mean no of preparation/day for adult and pediatric
Tertiary hospitals 13±12 27±46 55.5 % 10±11 Secondary hospitals 5±6 9±6 44.4 % 4±2 Primary hospitals 1±1 4±3 0% 0
1.3.5 (a) PN services and mean of pharmacist and pharmacist assistant
Table 1.3.7 shows that PN is available in 55.5 % of tertiary, 44.4 % in secondary and 0%
in primary hospitals. All primary hospitals did not have PN services because the
hospitals did not manage complicated cases and patients that require PN service were
referred to the either secondary or tertiary hospitals. Similarly not all secondary hospital
24
had PN services, as most small secondary hospital referred complicated cases to tertiary
hospitals for further management.
The other reason was the load of pharmacist in the pharmacy department. The number
of pharmacists was 13± 12, 5± 6, and 1±1 in tertiary, secondary and primary hospitals
respectively. In addition the number of pharmacist assistant was 27± 46, 9 ± 6, and 4±3
in tertiary, secondary and primary hospitals respectively. The differences were
significant (P=.001 and P= .021 respectively). Most tertiary hospitals had higher number
of pharmacists and pharmacy assistants, and therefore could afford to offer a labor
intensive service such as PN. This is supported by Krishnan et.al (2001) that showed
higher number of pharmacist in tertiary hospitals was due to the load of the hospitals.
1.3.5 (b) Mean preparation per day
Table 1.3.7 shows the mean no of PN preparation per day were 10±11 and 4±2 in
tertiary and secondary hospitals respectively. The relation between mean average no of
preparation per day total and type of hospital was not significant P = 0.310.
The higher mean number of PN in tertiary hospitals could be due to the differences in
1. the number of patients
2. the type of specialties offered.
3. the facilities available
4. the number of trained staff.