Optimizing Parenteral Nutrition: A Pharmacist-Led Quality Improvement Initiative

Parenteral nutrition (PN) is a complex, high-alert compounded nutritional therapy utilized when oral or enteral feedings are not appropriate for a patient.¹ Formulas are intricate, containing dozens of ingredients, and may pose complications during compounding and administration due to the delicate admixture’s stability.² Despite ongoing improvements in training and standardization to optimize cost, quality, and patient safety, PN is still linked to errors and subsequent patient harm.^1,2

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In a study published in Nutrition in June 2025, a team of researchers investigated the impact of a pharmacist-led quality improvement program on the appropriate use of PN. A retrospective analysis of 400 cases determined PN therapy rationale and workflow efficiency between interdisciplinary team members.²

Results revealed that a pharmacist-led, multidisciplinary team approach enabled the successful integration of a comprehensive clinical nutrition management program within the hospital’s information system.This clinical collaboration significantly improved the appropriate use and administration of PN therapies and enhanced medical staff workflow efficiency.²

Traditionally, PN macronutrients (amino acids, carbohydrates, and fats) were infused from separate bottles, a process known as multibottle system (MBS) infusions, tailoring doses to meet individual patient needs.^1,3 However, because this method requires multiple intravenous (IV) lines, MBS infusions are associated with higher costs, increased infusion times, and greater risk for metabolic complications and infections.^1,3 An all-in-one system, also known as a total nutrient admixture (TNA), is completely customizable and allows IV preparation staff to mix all PN components and clinical staff to infuse it from 1 bag.³ Another convenient option is a multichamber bag (MCB), a commercially available bag that contains a preset dose of constituents in sealed separate compartments. Staff can prepare MCBs quickly by breaking the individual compartment seals and adding additional nutrients or electrolytes based on patient needs.³

Under the improved system, PN administration became more standardized. As a result of the study, MBS infusion use decreased over 97% and TNA orders increased 4-fold, simplifying the infusions, minimizing patient complications, and improving personalized patient nutrition needs.MCB use increased from 7.5% to 23.5% and incorrect use, such as remixing MCBs with other macronutrients, drastically decreased to 0%, suggesting improved work efficiency and cost reduction.In addition, patients received more appropriate doses of amino acids and nutrient proportions to meet recommended daily intakes, optimizing patient outcomes.²

Furthermore, time spent on PN prescriptions significantly decreased and, accordingly, improved work efficiency.Physician time to create and save a PN order was cut by almost 50% from 5.8 minutes to 3 minutes, and pharmacist time to review an order decreased by 60% from 1.75 minutes to 0.69 minutes.²

With these positive findings, the researchers advocate for enhanced quality and consistency of nutrition education and training for clinical providers. Offering flexible training opportunities (e.g., online versus on-site, continuing education) alongside continuous quality improvement initiatives can expand clinician participation and ultimately lead to better patient health outcomes.

Pharmacists should be employed to lead quality improvement efforts since they can significantly influence complex therapies like PN. Streamlining multifaceted processes benefits both multidisciplinary team members and patients, saving time and reducing error potential. Additionally, these programs promote invaluable pharmacist integration in clinical teams.

REFERENCES

1. Wischmeyer PE, Klek S, Berger MM, et al. Parenteral nutrition in clinical practice: international challenges and strategies. Am J Health Syst Pharm. 2024;81(Supplement_3):S89-S101. doi:10.1093/ajhp/zxae079

2. Shan H, Hu W, Hong Y, et al. Optimizing parenteral nutrition practices: impact of a pharmacist-led quality improvement program on prescription patterns and work efficiency. Nutrition. 2025;140:112888. doi:10.1016/j.nut.2025.112888

3. Berlana D. Parenteral nutrition overview. Nutrients. 2022;14(21):4480. doi:10.3390/nu14214480