THE PRACTICE OF PARENTERAL NUTRITION IN MALAYSIAN HOSPITALS

by

RIYADH ABDULLAH OMAR ALBAT ANI

Thesis submitted in fulfillment of the requirements for the degree of

Doctor of Philosophy

June 2008

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

l

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.

II

TABLE OF CONTENTS

Acknowledgements

Table of contents

List of tables

List of abbrevations

Abstrak

Abstract

Part 1 Survey ofTPN practice in Malaysian hospital

1.1 Introduction and literature review

1.2

1.1.1 Background

1.1.2 Practices of PN

1.1.3 Problem statement

1.1.4 Rationale ofthe study

1.1.5 Objectives

1.1.6 Justification of the study

Methodology

1.2.1 Introduction

11

Ill

xi

XIV

xvi

xviii

3

8

10

11

12

13

13

1.2.2 Parenteral nutrition practice in Malaysian hospitals 13

1.2.3 Study design of survey of evaluation of PN Practice in 14

Malaysian hospital

1.2.4 Determination the sample size 14

1.2.5 Subjects (hospitals) 16

111

1.3

1.2.5 (a) Selection of hospitals

1.2.5 (b) Inclusion criteria

1.2.5 (c) Exclusion criteria

1.2.6 Data Analysis

Results and discussion

1.3.1 Response rate

1.3.2 Classification of hospitals

1.3.3 PN services in Malaysian hospital

1.3.4 Hospital size

1.3.5 Availability of PN services

1.3.5 (a) PN services and mean of pharmacist and

pharmacist assistant

1.3.5 (b) Mean of preparation per day

1.3.6 Type of specialties

1.3.7 Type of Clinical Pharmacy services offered

1.3.8 Clinical services offered pharmacy department

according to type of hospitals.

1.3.9 Year started parenteral nutrition services

1.3.1 0 Ward with PN services

1.3.11 Places for preparation ofPN

1.3.12 Type of services related to PN

1.3.12 (a) Individualization

1.3.12 (b) Standard formulas

1.3.12 (c) Computer program

IV

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23

23

24

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1.4

Part 2

2.1

1.3.13 Extent of pharmacist involved in PN

1.3.13 (a) PN pharmacist compounding

1.3.13 (b) PN monitoring and nutrition support team

1.3.14 Quality control of PN compounding

1.3.15 The use of commercially available standard product

1.3.16 Suggestions of services offered by PN

pharmacists

1.3.17 Type of solution used in PN

Summary and conclusion

1.4.1 PN Practices in Malaysian Hospital

1.4.2 The extend of the PN services

1.4.3 The personnel involve in PN services

1.4.4 The load of pharmacist

1.4.5 The role of pharmacist

Compare service provided in four hospitals

Introduction and literature review

2.1.1 Indication

34

34

35

36

39

40

41

43

43

43

43

44

44

45

45

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 4 7

supplement

2.1.1.3 Parenteral nutrition in children

2.1.1.4 Parenteral nutrition in surgical case

2.1.15 Parenteral nutrition in cancer

v

48

49

49

2.12 Nutrient and substrate requirments for PN 50

2.12.(a) Protien 51

2.12 (b) Carbohydrate 53

2.12.(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 1he 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

Vl

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 76

2.2.5 Study design of the comparative study 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 ofHUSM 82

2.2.8 (c) Calculation of power and sample size ofHUKM 84 l

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 ANOV A 88

2.2.12 (b) Pearson chi square 89

2.3 Results and discussions 91

2.3.1 Introduction 91

2.3.2 Characterstics ofPN patients according to hospital 91

Vll

2.3.3 Diagnosis of PN patients

2.3 .4 Reasons of PN patients

2.3.5 Diagnosis and reasons.

2.3.6 Outcome of PN patients

92

93

93

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

2.3.1 0 The cost per day

2.3.11 The duration ofPN

2.3.12 Energy requirements ofPN

2.3.13 Volume prepared ofPN

2.3.14 Macronutrient requirement

2.3.14 (a) Glucose supplement ofPN

2.3.14 (b) AA supplement of PN

2.3.14 (c) Lipid supplement ofPN

2.3.15 Vitamin requirements ofPN

2.3.16 Trace elements requirements ofPN

2.3.17 Electrolyte requirements of PN

2.3.17 (a) Sodium requirement of PN

2.3.17 (b) Potassium requirement of PN

2.3.17 (c) Magnesium requirement ofPN

2.3.17 (d) Calcium requirement ofPN

2.3.17 (e) Phosphate requirement ofPN

2.3.17 (f) Chloride supplement in PN

Vlll

106

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112

112

113

115

118

120

121

121

123

125

127

128

130

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 m1 135

2.3.21 The monitoring of fluid balance in ml 136

2.3.22 Monitoring of PC02 137

2.3.23 Monitoring of P02 138

2.3.24 Monitoring of 02 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

IX

LIST OF TABLES Page

Table l.l.l Total number of government hospitals providing PN 3

Services

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 ofthe 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 ofPN 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 27

department

Table 1.3.1 0 Clinical pharmacy services offered by pharmacy 28

department according to hospital type

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 34

department

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

X

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

Table2.2.7 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 ofPN per day of pilot study 75

Table2.2.1 0 The prices of the contents of the bags in each hospitals 77

Table 2.2.11 Number ofPN patient in PPH 80

Table 2.2.12 Values of (Za 12 + Z8 Y for frequently used

82

combinations of significance level and power

Table 2.2.13 Number PN patient in HUSM 83

Table 2.2.14 Number ofPN patients in HUKM 84

Table 2.2.15 Number ofPN patients in UMMC 86

Table 2.3.16 Demography ofPN patient 92

Table 2.3.17 Diagnosis ofPN 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

XI

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 ofRBS 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 (UIL) 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 ofPN 120

Table 2.3.40 Sodium requirement ofPN (meq/day) 122

Table 2.3.41 The monitoring ofNa 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 ofMg (mMol/kg/day) 126

Xll

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 P04 130

Table 2.3.50 Chloride requirement ofPN (qs meq/day) 131

Table 2.3.51 The monitoring of PH 131

Table 2.3.52 The monitoring of HC03 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 PC02 138

Table 2.3.59 The monitoring of P02 139

Table 2.3.60 The monitoring of 02 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

XJll

The abbreviation

APTT A ALB AIG AA ALT ANOVA ADU AST ALP BE HC03 BUN BW £ Ca2+

CRB CRBSI eve CPN Cl OTC NEC ECF GLB g/1 Hb HCB HPN HUSM HUKM INR IFALD ICF LFT LCT LBW Mg2+

MCT umol/1 MMol/d

LIST OF ABBREVATIONS

The Title

Activated partial thromboplastin time Adult Albumin Albumin/globulin ratio Amino acids Amino alanine transferase Analysia of variance Aseptic dispensing unit Aspartate amino transferase Aspartate aminoransferase Base excess Bicarbonate Blood urea nitogen test Body wieght British pound Calicium Catheter related bacteremia

.. ·

Catheter related blood stream infection Centeral venous catheter Central parenteral nutrition Chloride Drugs prescribed without physcicians Enterocolitis Extracellular fluid Globulin Gram/liter Hemoglobin Hospital compounded bags Hospital parenteral nutrition Hospital Universiti Sains Malaysia Hospital University Kebangsaan Malaysia International normalized ratio Intestinal failure associated liver disease Intracellular fluid Liver function test Long chain triglyceride Low birth wieght Magnisium Medium chian triglyceride Micromol/liter Milli mol/day

XIV

Ml

NG N NPCTON NBM NST 02 Sat. PN PDA p

pH PICU %02 Sat PC02 kPa P02 kPa PICC PPN Pol-Pit K+

Prem PT

PPH RBS RM SB Scr Na+

svc TCB TB TBW TC02 TPN TP U/L USD UMMC WBC Wt

Milliliter

Naso gastric Neonate Non protein calories to nitrogen Nothing by mouth Nutrition support team Ogygen saturation Parenteral nutrition Patent ductus arteriolus Pediatric Hydrogen ion concentration Pediatric intensive care unit Percent oxygen saturation Peripheral arterial carbon dioxide content Peripheral arterial oxygen content Peripheral intravenous catheter Peripheral parenteral nutrition Phosphate Platelet Potassium Premature Prothrombin time Pulau Pinang Hospital Random blood sugar Ringgit Malaysian Separate bottles Serium creatinine Sodium Superior vena cava Three compartment bags Total bilirubin Total body water Total carbon dioxide Total parenteral nutrition Total protein Unit/liter United state dollar University Malaya Medical Centre White blood cells Wieght

(The Clinican's Ultimate Reference)

XV

PRAKTIS NUTRISI PARENTERAL Dl HOSPITAL Dl 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 l 0± 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 me man tau 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

XVI

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 mendapaii. 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

XVII

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 ofPN 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

XVlll

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=.OOI). 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

XlX

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 modem 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).

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 m Malaysia was provided conventially. l

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.a/1994) and (Bahari et.a/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

2

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 l.l.l: Total number of government hospitals providing TPN Services

Year Number of hospital Cumulative no initiating PN services

1986 1 1 1987 3 4 1988 6 10 1989 4 14 1990 4 18

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 surg~ry, 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.a/2003).

3

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 l

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.a/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

4

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% ofthe patients.

However, nutritional therapy was used only in 8.8% of these patients (6.3% enteral l

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

5

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

6

were provided by hospital phannacists (Pichard et.a/2001). A study into the effects of

PN prescribing practice on patients by (Porcelli 2004) reported an average of 182 Very

low birth weight (VLB W) 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 fonns. 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) l

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).

7

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)

l

Services of PN offered by pharmacists, (I) 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

8

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.a/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.a/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 (AI-

batani et.a/2006).

9

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. a! 1994), (Bahari 1998), ( Bahari 1990),

( Harbans1994) and (Ramanujam 1994).

This study will be able to provide information related to the extend ofl 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.

10

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 phannacy

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:

I. explore PN practice in Malaysian hospitals.

The specific objectives of the study are to:

a. determine the extend ofPN 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

11

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.

12

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 of2007.

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 apd staff·

working in parenteral nutrition services. All the questions were designed to attain the

objectives of this study. This section evaluated the practice ofPN 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

13

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,(Govemment) + 93 (Private)= 215 hospitals

Then the sample size was determined using the following equation formula.

n = [ z ~~ 2 r P(l- P)

14

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

0.075 (0.925) .05

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

Johor Kedah Kelantan Mel aka Negeri sembilan Pahang Perak Perl is Pulau Pinang Selangor Sarawak Sa bah Terengganu WP Kuala Lumpur WP Putrajaya WP Labuan Total

Governments

11 9 9 3 6 8 14 1 6 10 14 22 6 2 1

122

15

Private

14

8

5

9

14 19 8 2

14

93

Table 1.2.3: The total number of government and private Hospitals in participated in the study (I 00).

Hospital Governments Private

Johor 5 7 Kedah 4 Kelantan 4 4 Mel aka I Negeri sembilan 3 2 Pahang 4 Perak 7 4 Perl is I Pulau Pinang 3 7 Selangor 5 9 Sarawak 7 4 Sa bah 11 1 Terenggannu 3 WP Kuala Lumpur I 7 WP Putrajaya 1 Total 60 45

1.2.5 Subjects (hospitals)

In order to evaluate the parenteral nutrition practice in Malaysi.an 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.

12.5 (a) Selection of hospitals

A total of 215 hospitals from public and private hospitals were listed in ministry of

health website. Hundred (1 00) of hospitals were selected by stratified random selection

according to the states in Malaysia.

16

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 ofPN.

11. Parenteral Nutrition Services Offered by Pharmacy Department.

17

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.

18

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.a/ 1997 and Mamoch eta/ 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.

19

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 ofthe hospitals

Hospitals Hospital type n%

Tertiary hospitals teaching 8 (15.4) referral

Secondary hospitals general 35 (67.3) district nucleus

Primary hospitals private 9 (17.3) Public clinic HPN organization

Total 52(100)

20

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 us~d 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.a/2005).

Table 1.3.5: PN services in Malaysian hospital

PN service No PN service Total

n (%)

9(17.3) 43(82.7) 52(1 00)

21

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 I 000 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 lPerlis, 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.

22

Table 1.3.6: Hospital size in relation to hospital type.

Less 250- 500- 750- 1000- More Total than 250 500 750 1000 1250 than beds beds beds beds beds 1250

beds

Hospital type Tertiary 2(25) 4(50) 0(0) 0(0) 1(12.5) 1 (12.5) 8(15.4) hospitals Secondary 24(68.6) 8(22.8) 2(5.7) 1(2.8) 0(0) 0(0) 35(67.3) hospitals Primary 9(100) 0(0) 0(0) 0(0) 0(0) 0(0) 9(17.3) hospitals 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 ofPN services.

Hospital type Mean no of Mean no of PN services Total mean

Tertiary hospitals Secondary hospitals Primary hospitals

pharmacist

13±12 5±6 1±1

assistant pharmacist

27±46 9±6 4±3

55.5% 44.4% 0%

no of preparation/day for adult and pediatric

10±11 4±2 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

23

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 l±l 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 ofthe hospitals.

1.3.5 (b) Mean preparation per day

Table 1.3.7 shows the mean no of PN preparation per day were 1.0±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 = 0.31 0.

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.

24