Aims To assess the level of adherence with current local guidelines for the initiation, prescribing, and administering of SCAMP¹ in the neonatal intensive care unit (NICU) and special care baby unit (SCBU) in a district general hospital.^2–4

Method All patients in NICU/SCBU across both sites of the local Trust during 1st April 2021 to 31st March 2022, were listed via BadgerNet retrospectively, and filters were applied to screen patients who would fit the parenteral nutrition (PN) initiation criteria -

1. All infants born < 31/40

2. All infants with birth weight < 1.5 kg

3. All infants born ≤ 37/40 with intra-uterine growth restriction and absent/reversed end diastolic flow

4. All infants with any form of feed intolerance

5. All infants with any surgical problems

6. All infants that had received PN during local admission

99 patients were selected after the filters were applied. The patient profiles were first reviewed via BadgerNet and 10 patients were excluded from the audit as PN was initiated in another hospital, or transfer to another hospital occurred within 6 hours of life. 89 patients were then selected for the audit. The population size was run through a sampling calculator and 73 patients had to be audited in order for a confidence interval of ≥ 95% and a ≤5% margin of error; this would have fit research paper standards, however sampling was not necessary given the relative small patient population. A pilot study was completed with 10 patients using the data collection tool, which was found to be adequate and therefore used to audit all 89 patients selected. Medical notes for patients were requested from Medical Records and examined. The results were recorded on a Microsoft Excel spreadsheet for analysis.

Results There was poor compliance to all standards - none of which reached 100% - but most notably with the initiation of PN within the timeframe where the compliance rate was 12.7%. Other criteria included initiation of PN within neonates that fulfilled the criteria, documentation of party which made decisions, total fluid requirement, glucose side arms and administration timings. A lack of documentation was apparent throughout the project from all aspects which contributed to the poor compliance rate.

During the audit 32.1% of prescriptions were found to have errors, most of which were around wrong calculations of volumes and rates. These were amended by a pharmacist prior to administration. It highlighted the importance of a neonatal pharmacist but also the need to ensure calculations are done correctly.

There was a difference in practice cross site as seen in the difference in compliance to standards 1, 3, 4, and 5. In particular, the 11.2% of patients not started on PN when it was indicated were mostly from Site 2, suggesting clinician preference and therefore a need to align practice across sites.

Conclusions In summary, most PN prescriptions were not initiated, prescribed, and/or administered as per guidelines. There were differences in practice cross-site but no identifiable trend across corrected gestation at birth.

References

1. Morgan C, Herwitker S, Badhawi I, et al. SCAMP: standardised, concentrated, additional macronutrients, parenteral nutrition in very preterm infants: a phase IV randomised, controlled exploratory study of macronutrient intake, growth and other aspects of neonatal care. BMC Pediatr 2011;11:53.

2. Lewisham and Greenwich NHS Trust. Clinical Guideline – Parenteral Nutrition for Infants on NICU/SCBU. [Online publication] 2019. https://lgnet.lewishamandgreenwich.nhs.uk/download.cfm?ver=22635 (Accessed 20 September 2022).

3. London Core Neonatal Nutrition Group for London ODN. Guideline for use for Standard Parenteral Nutrition: SCAMP. 14th May 2018.

4. National Institute of Health and Care Excellence. Neonatal Parenteral Nutrition. [Online publication]. 2020. https://www.nice.org.uk/guidance/ng154 (Accessed 27 October 2022).