20. Identifying Safe Patients for Home Initiated Parenteral Nutrition: An App-Based Screening Tool

Background: Home initiated parenteral nutrition (HIPN) is a growing method to start patients on parenteral nutrition (PN). HIPN can minimize healthcare costs and improve quality of life by avoiding hospitalization. However, not all patients are appropriate for HIPN. Determining suitable HIPN patients consists of several factors highlighted in the American Society for Parenteral and Enteral Nutrition (ASPEN) consensus Recommendations. According to ASPEN, establishing organizational policies and procedures to determine safe and clinically appropriate HIPN patients includes assessing the patient’s overall medical, clinical, and psychosocial status. To standardize this procedure, an app-based screening tool was developed and implemented throughout the organization to provide a streamlined approach from the start of the HIPN referral process.

Purpose: The dietitian-led, app-based HIPN screening tool pilot program aims to identify safe and clinically appropriate patients for HIPN with the goal of improving patient safety and adherence to HIPN best practice recommendations.

Methods: Patients referred to KabaFusion for HIPN from November 1, 2023, to September 30, 2024, were selected for this pilot program. The Registered Dietitian (RD) completed the “Home Initiated PN Dietitian Screening” (HIPDS), a screening tool in an app-based platform. The 28-question HIPDS adapted from the ASPEN Consensus Recommendations and Newton AF, DeLegge MH 2007 Home Initiation of Parenteral Nutrition. A team of dietitians completed implementation and covers 4 categories (clinical, patient/caregiver home initiation education process/agreement, environment, and RD confirmation/approval) to help determine if the patient is a HIPN candidate. The screening was completed by collecting data from clinical documents and performing a telephonic assessment with the patient or caregiver. Exclusion criteria included patients less than 18 years old, patients deemed appropriate for HIPN but did not initiate PN at home, and patients who did not have a HIPDS completed before the first dose of PN.

Results: A total of 36 patients were reviewed by a RD for HIPN of which 30 met the inclusion criteria and the HIPDS was completed. Six patients were excluded from the study, three due to initiating PN in a hospital and three did not have the HIPDS completed prior to the first dose. For the 30 patients that had HIPDS completed, 23 were deemed appropriate and safe for HIPN and seven were not a candidate for the following reasons: uncorrectable electrolytes (57%), appropriate for enteral nutrition (14%), patient refused PN, (14%), and psychosocial discrepancy (14%). Of the 23 patients that had HIPN, no patients required hospitalization related to the clinical management of PN. However, one patient was hospitalized for a line infection within 30 days of initiating therapy. No patients had electrolytes that were uncorrectable; no patients had an adverse drug reaction; and 18 patients (78%) reached goal PN within 30 days of therapy initiation. To evaluate if the use of the HIPDS helped to enforce best practice recommendations, thiamine usage, and lab draw within 24-48 hours, post-initiation was reviewed retrospectively; 21 patients (91%) received intravenous thiamine with PN initiation, and 20 patients (86%) had labs drawn within 24-48 hours post-initiation.

Discussion: The HIPDS helped identify clinically stable patients for HIPN by reviewing medical history, laboratory values, allergies, and ensured a patient had adequate social support and a safe home environment prior to initiating therapy. The study revealed no patients had uncorrectable electrolytes after HIPN, and only a small number of patients were hospitalized, but none related to PN clinical management showed a positive correlation between screening with the HIPDS and safe HIPN outcomes. Most patients’ PN included intravenous thiamine and had labs drawn 24-48 hours after initiation indicating the HIPDS encouraged adherence to best practice recommendations. Most patients that were deemed inappropriate to initiate PN at home were due to having abnormal electrolytes that would make HIPN unsafe. Completion of the HIPDS increased patients’ knowledge of PN and allowed them to make an informed decision on initiating the therapy. Potential limitations of the study include limited sample size and reliance on patient reported information during telephonic assessments. There are limited recent studies on HIPN, and future research in this area is needed.

Conclusions: The use of an app-based screening tool by RDs is effective in identifying safe and clinically appropriate patients for HIPN. All patients in the pilot that received HIPN avoided hospitalizations related to PN management, adverse drug reactions, uncorrectable electrolyte abnormalities, and advanced PN to goal without complications.