tpn policy

7/31/2019 TPN Policy

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UNIVERSITY OF KENTUCKY HOSPITAL POLICY NUMBER: PH-06-16

CHANDLER MEDICAL CENTER FIRST ISSUED: 4/94

Department of Pharmacy Policy CURRENT AS OF: 6/26/05

SUBJECT: Neonate and Pediatric PPN/TPN Orders

PURPOSE: To insure that all neonatal and pediatric TPN/PPN orders are

properly written, interpreted, and carried out.

To establish consistency of ordering, preparation, and delivery of

the neonatal and pediatric TPN/PPN solutions.

To alleviate neonatal and pediatric TPN/PPN preparation during

shifts which are not staffed to accommodate preparation of these

labor intensive solutions (i.e., second and third shifts).

To eliminate the need for pharmacy to specifically prepare "stat"TPN/PPN solutions.

To utilize current technology by preparing a 24 hour supply of

patient-specific TPN/PPN solutions.

INFORMATION:

1. The Neonate/Pediatric Order Form must be completed and signed by the

physician. Neonatal TPN orders must be rewritten every day. PPN/TPN orders

written on a physician's order sheet will not be accepted by the pharmacy.Changes in rate, formula, electrolytes, and any other additives must also be

written on a PPN/TPN order form. Prior to signing the TPN form, the physician

must complete the calcium phosphorus compatibility calculation. The calcium

and phosphorus values need to be adjusted to ensure compatibility based on the

guideline provided on the form. If the prescribing physician does not check the

calcium phosphorus compatibility box, he or she will not be contacted by the

pharmacy with the calcium and/or phosphorus adjusted values. The pharmacist

may make the appropriate changes in calcium and/or phosphorus values to ensure

that the final product will be in solution.

2. All PPN/TPN orders must be received in the central pharmacy no later than11:00am.

3. All neonate and pediatric orders received in the IV room before 11:00am should

be processed and sent to the patient care area by 3:00pm and hung at 4:00pm.

4. Pediatric patients on home PPN/TPN who are admitted after 11:00am shall be

permitted to finish the PPN/TPN that is infusing unless it is a source of concern.


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Subsequent PPN/TPN will be prepared by the pharmacy. If PPN/TPN orders are

received outside of the normal preparation period, then an appropriate dextrose

and electrolyte solution will be hung until the new solution is available.

5. Changes in current solution orders received in the pharmacy after 11:00am will be

processed and sent to the patient care area by 3:00pm and hung at 4:00pm, thefollowing day. The current PPN/TPN solutions will continue until the new

solution is sent the following day. If the continuation of the current PPN/TPN

solution is unacceptable due to a critical situation (i.e. hyperkalemia), the current

solution should be discontinued and an appropriate dextrose and electrolyte

solution hung until the new solution is available.

6. The pharmacy will send a 24 hour supply of PPN/TPN by 3pm. The neonate and

pediatric universal hang time is 4:00pm.

Setting up AutoMix and MicroMix CompoundersEach day the technician responsible for preparing TPN/PPN products is also responsible

for setting up the compounders. This begins with a removal of all products hanging from

the day before, including the removal of the tubing. All previously hanging products

must be discarded every 24 hours. The technician then replaces the existing tubing with

new tubing and calibrates both machines. All additives are then hung on the machine

according to pre-programmed protocol. The technician records the date, name of

additive, lot number, concentration, and expiration date for each additive hung. The

responsible pharmacist then checks each line, hanging additive, and recorded data before

compounding begins. Both the technician and pharmacist are responsible for initialing

the data log to indicate their initial verification of set-up accuracy. Upon emptying an

additive container, the technician replaces the empty container with a full vial ofadditives. The lot number and expiration date of replacement vials should also be

recorded on the data log.

Order Processing

1. Upon receipt of a new order, the responsible pharmacist should review the order

for completeness and accuracy. The pharmacist should calculate the

calcium/phosphate compatibility equation as well as assure that the individual

electrolyte concentration do not exceed the normal range (i.e. K meq/L Na

meq/L). The order is then given to a technician for entry in to the pharmacy

computer system for billing purposes. This order will appear on the medication

administration record and used by the nurse for documentation of administration.The technician then enters the order into the Multi-Task Operating System

(MTOS) software for compounding purposes. Once the order is entered into the

MTOS software program, labels are printed separated according to the order of

compounding. The pharmacist then checks the order against the labels; once

checked and initialed by the pharmacist, compounding can begin. The

compounding begins first with the technician matching the patient identification

number to the LCD display on the AutoMix with the patient identification number


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printed on the patient specific label. This procedure is repeated for orders

requiring products delivered by the MicroMix. Additives that are not on the

MicroMix must be manually added to the bag. This is done by the technician

drawing into a syringe the correct amount of an additive that is listed on the

patient specific label. The syringe and vial form which the additive is obtained

should be placed next to final TPN container. Following a review by thepharmacist, the technician will manually add the additive to the correct patient's

bag. Both the pharmacist and technician are responsible for initialling the label of

all products they prepare. Upon completion of adding all additives, the

pharmacist checks the final container for particulate matter, proper labeling, etc.

As a double check for accuracy, the pharmacist must weigh the final container for

accurate fluid volume. Any bag that varies more than 5% of calculated

compounding volume should be discarded and remade. See addendum for

compounding process.

2. Pending the computer software update, the TPN label listing the contents in

meq/kg and meq/L information will be attached to the individual TPN. The labelmay be used by the nurse to verify the tpn contents against the order.

Endorsed by TPN Committee 2/20/90

Clinical Board 2/27/90

Approved:___________________ Authorized:_____________________

Kimberley Hite, MS, PharmD John Armitstead, MS, FASHPAssociate Director Director of Pharmacy

Inpatient Pharmacy


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Addendum for policy PH-06-16

Neonatal and Pediatric PPN/TPN Procedures

Purpose: To provide consistency in compounding and a guideline for training new

employees in the TPN compounding process.

1.) The TPN technician is responsible for taking down and setting up the Automix

and Micromix compounders at the beginning of each compounding shift.

a) Discarding all used source containers and tubing form the prior day.

b) Clean both automated compounders as well as the hood itself.

c) Hang new source containers and new sterile tubing on each compounder.

d) Calibrate pumps as per instructions.

e) Record and initial appropriate data on daily log.

2.) Faxing a list of the prior days TPN patients to both the Pediatric Pharmacy

Satellite and to the NICU unit clerk.

a) Assuring that a new order or D/C order has been received for each Neonate

b) Pediatric patients receive current formula unless change or D/C order is received

prior to cut off time.

3.) After each order has been approved by a Pharmacist, the technician will enter the

new daily formula in the Multi-Task Operating System (TPN) computer and

print labels.

4.) The IV Pharmacist will check the label against the physicians order for accuracy

and completeness prior to compounding.

5.) TPN technician will pump each patients bag according to protocol, as well as ,

make any necessary manual additions to the bag.

6.) All manual additions should be checked by a Pharmacist prior to being added to

the TPN bag.

7.) Each neonatal TPN bag should be weighed after the addition of any manual adds

and the weight of the bag recorded on the compounding label.

8.) As a quality assurance measure, the IV Pharmacist should determine that the

actual weight of the bag is within 5% of the predicted final weight.

9.) After QA has been completed, convey each TPN along with a copy of the


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compounding label to the Pediatric Satellite for delivery to patients.

10.) In addition to the TPN bags, lipid emulsion syringes should also be conveyed to

the Pediatric Satellite for delivery to patients.


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