Discharge Planning for Parenteral Nutrition Patients
By Jennifer Doley, MBA, RD, CNSC, FAND
Vol. 25 No. 4 P. 22
RDs are poised to take on the challenges to ensure optimal patient outcomes.
Clinical dietitians know that parenteral nutrition (PN) is a life-saving therapy for hospitalized patients who can’t ingest or absorb enough nutrients via the oral or enteral route due to gastrointestinal (GI) dysfunction. PN provides amino acids, lipids, dextrose, vitamins, minerals, trace elements, and electrolytes to patients who may suffer from paralytic or prolonged ileus, mesenteric ischemia, small bowel obstruction, short bowel syndrome, other malabsorptive conditions, and GI fistulas.1 Some patients on home PN (HPN) may be able to transition to enteral or oral nutrition; however, others may have a life-long dependence on HPN.
The number of patients on HPN is difficult to determine. A 2017 study estimated that more than 20,800 adult patients in the United States received HPN in 2013.2 In order for patients on PN, which typically is initiated/administered in the hospital, to transition to the home setting, comprehensive discharge planning is necessary to reduce risk of complications and readmission.
Discharge planning considerations include the patient’s home environment, patient and caregiver education, insurance coverage, and availability of home health or home infusion companies to provide HPN solutions. Clinical considerations such as the type of IV line used for HPN infusion and blood glucose and electrolyte management also are important.
To ensure patients have a smooth transition home, RDs should take an active role in the discharge planning process.
Central IV Access
Often, the need for HPN is unanticipated during admission. HPN dependence may occur as a result of medical conditions or complications patients experience during their hospital stay. In these cases, patients often are started on PN with the intent to discontinue it before discharge. The type of central IV access initially placed isn’t ideal in the home environment, making it necessary to place a more permanent access device before discharge.
Because a high concentration of PN can cause vascular damage, especially in smaller peripheral veins, central IV access is necessary. The choice of an IV access device depends on the expected duration of HPN, whether it be short term, generally defined as less than three months, or long term. For short-term HPN, a peripherally inserted central catheter (PICC) often is the choice. PICCs, which trained nurses can place at bedside, are easily removed, making them a more economical choice. However, PICCs may be more problematic for active individuals. With PICC use, the catheter exits the body at mid arm, creating a greater risk of dislodgement. It’s also challenging to maintain dressings at the exit site.3
For long-term HPN, more permanent catheters, including tunneled or implanted devices, are preferable. Although surgical placement is required—which results in higher risk of placement complications—long-term catheters have many benefits. For example, they’re easier to care for, they lower the risk of infectious complications and blood clots, and are more secure. Implanted devices have the added benefit of being easy to hide, helping minimize negative changes in body image.3
When choosing an IV access device, the number of lumens should be determined. If the patient needs additional medications, such as IV antibiotics or chemotherapy, a device with more than one lumen may be required. Also consider the insertion site. Some insertion sites have a higher risk of infection. Access to certain sites also may be limited by the patient’s anatomy, risk of thrombosis, or the presence of other implanted devices.3
PN Infusion Schedule
In most cases, PN is initiated at a lower rate and increased to goal when tolerance has been established. Once this is achieved and blood sugar and labs are stable, the PN can be changed to a cyclic schedule in which it’s run at a higher rate for a shorter time period (ie, 10 to 14 hours), typically overnight so the patient can be free of the infusion pump during the day. This transition should occur during the hospital stay to ensure the patient is stable before discharge. While most patients prefer cyclic HPN, stability with the regimen may be a challenge. Infusion of large amounts of dextrose over a shorter time period may make blood sugar control particularly difficult in patients with diabetes. Large volume infusions overnight can disrupt sleep if it results in the patient needing to urinate frequently. Large volume infusions in smaller time frames also may be inadvisable in patients with heart failure or renal disease.
Calculating nutrition needs of patients transitioning to home can be challenging, especially when considering the duration of HPN. Prolonged HPN administration, particularly in patients with complete bowel rest (lack of GI stimulation), can lead to serious and sometimes life-threatening conditions. Of great concern is PN-associated liver disease, which can progress to cirrhosis. While it’s the responsibility of the home health clinical team and primary care provider to monitor for PN-related complications, it’s important that RDs managing the PN in the hospital take these factors into consideration before the patient’s discharge.
A balance of calories from dextrose and IV lipid emulsions, as well as avoiding overfeeding, can help prevent PN-associated liver disease. Hospitalized patients probably are acutely ill, malnourished, and have undergone surgery. Therefore, their energy and protein needs initially are higher. However, discharge may be delayed significantly for some patients, resulting in a prolonged hospitalization. By the time the patient is discharged on PN, they may no longer be acutely ill.
RDs should consider the patient’s long-term nutritional needs for maintenance of nutrition status and consider adjusting the PN macronutrients before discharge, if appropriate, to avoid overfeeding.
Before discharge with PN, patients must be medically stable. Blood glucose management is important, particularly in patients with diabetes. IV dextrose infusion can make blood glucose difficult to control, especially if the PN is cycled. Dextrose from other IV solutions should be removed or minimized. The amount of dextrose in the PN can be reduced, but it’s important to ensure that patients are discharged on a PN regimen that provides sufficient energy and a balance of dextrose and lipids. Insulin can be added to the PN, but adjustments to the patient’s usual diabetes medication regimen may be necessary. RDs should work with physicians to help determine the best course of action for blood glucose management.
In a hospital setting, blood sugar measurements via finger sticks typically are monitored four to six times per day. However, they likely won’t be monitored after discharge if the patient doesn’t have diabetes. Therefore, it’s important to ensure blood glucose is well managed before discharge.
Moreover, many patients who require PN are malnourished and at risk of refeeding syndrome. Refeeding occurs when a patient is fed after a prolonged period of inadequate intake. The dextrose from the PN will be rapidly absorbed by the body’s cells, along with thiamin and electrolytes needed for energy metabolism, including potassium, magnesium, and phosphorus. As a result, serum levels of these electrolytes and thiamin can drop significantly, which can be life-threatening in severe cases. In a hospital setting, electrolytes are initially checked daily, but that’s not the case in home settings. Patients shouldn’t be discharged until refeeding has resolved and electrolytes are stable.
It’s important to know whether the company providing the HPN has any requirements regarding a patient’s clinical status before discharge; for example, some demand that the PN not require changes for at least 24 hours before discharge.
Keeping these complexities in mind, it’s important to note that HPN is expensive, making it important for hospital case management teams to work with primary care providers and home health and/or home infusion companies to ensure that HPN will be covered by insurance. Thorough documentation in the medical record is vital to ensure that the patient’s insurer will cover HPN.
If the beneficiary has a condition that significantly impairs the absorption of nutrients and/or their transport through the GI tract, Medicare may cover HPN. The impairment must be considered “permanent.” However, this doesn’t mean there’s no possibility the GI condition will improve in the future. Permanence is defined as “long and indefinite duration.” Past Medicare guidelines defined long term as greater than three months; however, new policies don’t stipulate a specific time frame.4
For Medicare coverage, HPN also must be considered “reasonable and necessary.” To meet this definition, EN should have been considered but ruled out, been ineffective, or shown to have worsened the patient’s GI dysfunction. An HPN solution considered “reasonable and necessary” provides 20 to 35 kcal/kg/day to achieve and maintain body weight. Any special nutrient formulas, a dextrose concentration of less than 10%, and protein outside the range of 0.8 to 2 g/kg/day must be documented by the provider as medically necessary to be covered by Medicare.5
Other insurer requirements for HPN coverage will vary depending on the patient’s insurance company and individual plan. Many follow Medicare guidelines for coverage. It’s important that coverage is ensured before patients are discharged. Out-of-pocket costs should be accurately determined and communicated to patients.
To avoid insurance denials for HPN, thorough and specific documentation is necessary. Documentation required from the medical provider includes the patient’s GI impairment resulting in the need for HPN, the anticipated duration of HPN, and failed attempts to use EN or reasons why EN isn’t feasible. RDs should identify and document malnutrition, nutritional needs, contraindications to EN, and the PN prescription.
Communication of the Discharge Plan
Both verbal and written/electronic communication with the home infusion provider is ideal. Some companies have RDs on staff that manage HPN, but some may employ only pharmacists or nurses. Hospital RDs should communicate with home infusion providers to ensure they receive the patient’s current HPN prescription, including nutrient base, electrolytes, other additives, volume, and infusion schedule. Units of measure are especially important to communicate. The American Society for Parenteral and Enteral Nutrition recommends that PN labels display contents “per day.”6 However, some facilities may use “per liter” units. Some electrolytes, such as phosphorus, may be displayed as millimoles instead of milliequivalents.
These details are important to communicate to avoid HPN-related complications after discharge.
As part of discharge planning, the patient’s home environment must meet certain requirements to safely administer HPN. For example, there must be adequate refrigeration space to store a week’s worth of HPN solutions. To avoid infections, running water and sanitary conditions are a necessity to safely administer HPN.
Assessment of the ability and level of care available to patients for both HPN administration and general activities of daily living also is critical. Case management can survey patients and caregivers to determine whether patients are candidates for HPN from the perspective of the home environment and level of care available.1,3
Patient and Caregiver Education
To ensure HPN can be safely infused to avoid complications and readmission to the hospital, proper education for patients, families, and any other caregivers is vital. Topics to cover include storage, handling, and infusion. Because IV vitamin solutions become unstable in HPN after 24 hours, patients or caregivers must safely add the vitamin solution to the HPN directly before infusion. Furthermore, patients or caregivers must be able to program the IV pump. General sanitation and hand hygiene also are vital.1,3
While home health teams will provide initial assistance and education immediately after discharge, education also should occur before discharge. For example, the patient’s nurse should provide education on proper catheter care and hygiene. RDs also should take an active role in education. The patient’s nutrition goals should be communicated, including advice on weight gain or maintenance, correcting malnutrition or micronutrient deficiencies, and the potential transition to enteral or oral intake.
Consultation with the physician is important so all members of the health care team understand the overarching goals for patients, namely the expected duration of HPN and the ability to transition to enteral or oral intake. The physician should inform patients of their predicted course of care and associated risks. In many cases, there’s some uncertainty regarding these questions.
Despite the great complexities involved in preparing PN patients to receive HPN, RDs are an important part of the health care team, as they’re well equipped to take on the associated tasks of discharge planning. Dietitians play an integral role in achieving optimal nutrition status of patients, educating patients and caregivers, and ensuring patients are well prepared medically and nutritionally to achieve full recovery and optimal health in the comforts of their own homes.
— Jennifer Doley, MBA, RD, CNSC, FAND, has been an RD for 28 years and is currently a malnutrition program manager for Morrison Healthcare. Previous roles include nutrition support specialist, regional clinical nutrition manager, and dietetic internship director.
1. Mueller CM, ed. Adult Nutrition Support Core Curriculum. 3rd ed. American Society of Parenteral and Enteral Nutrition Press; 2017.
2. Mundi MA, Pattison A, McMahon MT, et al. Prevalence of home parenteral and enteral nutrition in the United States. Nutr Clin Pract. 2017;32(6):799-805.
3. Bering J, DiBaise JK. Home parenteral and enteral nutrition. Nutrients. 2022;14:2558.
4. Centers for Medicare and Medicaid Services. Parenteral Nutrition: Local Coverage Article. CMS.gov. Accessed January 26, 2023 at Article - Parenteral Nutrition (A58836) (cms.gov)
5. Local coverage determination: parenteral nutrition. Centers for Medicare and Medicaid Services website. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=38953. Accessed January 26, 2023.6. Ayers P, Adams S, Boullata J, et al. ASPEN Parenteral nutrition safety consensus recommendations. J Parenter Enteral Nutr. 2014;389(3):296-333.