Enhancing Economic Efficiency Through the Implementation of Home Parenteral Nutrition SOP with a Novel Training Module

Enhancing Economic Efficiency Through the Implementation of Home Parenteral Nutrition SOP with a Novel Training Module | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Enhancing Economic Efficiency Through the Implementation of Home Parenteral Nutrition SOP with a Novel Training Module Jaw-Yuan Wang, Wei-Chih Su, Tsung-Kun Chang, Yen-Cheng Chen, Ching-Wen Huang, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4622390/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Home parenteral nutrition (HPN) is essential in providing nutrition and hydration to appropriately selected patients who cannot receive adequate oral or enteral nutrition. This study investigated the implementation of HPN at our institution, following our standardized operating procedures (SOP) and the utilization of the Port-A auxiliary device model. Methods This was a retrospective observational study that enrolled adult and pediatric patients undergoing HPN. The patients were supervised by the Nutrition Therapy Team of a single institution from January 2020 to December 2022. Results Results indicated substantial improvements in operational efficiency and patient outcomes. Specifically, the integration of our hospital’s SOP and the use of the auxiliary device led to a notable reduction in nursing workload hours in terms of providing HPN education (mean reduction of 36.2 hours) and shortened patient hospital stays (mean reduction of 2.9 days), suggesting that these interventions can lead to a streamlined, efficient, and safe HPN administration. Furthermore, the HPN protocol of our institution led to significant direct and indirect cost savings, signifying its potential to alleviate the financial burden of Taiwan’s healthcare system. Lastly, HPN at our institution is safe, with the incidences of adverse events of special interest generally showing a decreasing trend during the study period. Conclusions The study demonstrates that integrating the SOP of Kaohsiung Medical University Hospital and using the Port-A auxiliary device for HPN therapy substantially enhances operational efficiency, cost savings, and patient outcomes. auxiliary device cost-effectiveness home parenteral nutrition Figures Figure 1 Figure 2 Figure 3 Introduction Home parenteral nutrition (HPN) is an adaptation of the in-hospital parenteral nutrition (PN) that encompasses both total PN and supplemental PN. HPN aims to provide nutrition and hydration to patients unable to maintain an adequate nutritional status through oral feeding or enteral nutrition [ 1 ]. The prevalence of HPN varies globally, with Europe and the USA having 6–34 and 75 cases per million, respectively [ 2 ]. HPN epidemiological data from Taiwan and other Asian countries is scarce, with studies conducted at individual institutions, rather than at the national level [ 3 – 5 ]. The most comprehensive and up-to-date data is from Singapore, which included 41 adults (2002–2017) and 8 pediatric patients (2011–2017) who received HPN at the country’s largest PN centers [ 3 ]. In this study, the mean age is 53 years for adult patients and 8 years for pediatric patients. For appropriately selected patients with terminal cancer and malnutrition, HPN is an integral part of palliative care, intending to increase survival and improve quality of life (QoL) [ 6 – 8 ]. As a life-saving therapy, HPN is especially indicated for patients with inoperable gastrointestinal (GI) cancers, short bowel syndrome, GI fistulas with high flow, post-operative bowel anastomosis leak, and hypercatabolic states due to sepsis, polytrauma, and major fractures. Furthermore, by helping treat malnutrition through the efficient delivery of nutrients and fluids, HPN can prevent death from starvation and dehydration. It can also reduce in-hospital stays and increase the proportion of care in outpatient settings [ 7 , 9 ]. While HPN may be costly, studies found that it is more cost-effective compared to in-hospital PN [ 10 ]. Earlier studies classified the cost of illness as either direct, indirect, intangible, or personal costs [ 11 – 15 ]. The direct costs include both healthcare and non-healthcare costs [ 12 , 13 , 16 ]. Included in the healthcare costs are medical expenditures such as institutional inpatient and outpatient care, healthcare professional (HCP) fees, medication, laboratory tests, patient training, etc. Conversely, the non-healthcare costs encompass the transportation and supply expenditures of patients, as well as household expenses associated with HPN, and so forth [ 12 , 13 ]. Indirect costs include diminished productivity due to morbidity and mortality, impairment, and reduction in workdays. Intangible costs are those related to the psychological discomfort of the patients and are often omitted from the cost of illness studies due to challenges in measurement [ 12 , 15 ]. Lastly, the personal costs are those shouldered by the patient or their family for consultations with HCPs, medications, laboratory tests, home adjustments, transportation, and the necessity for home care [ 13 , 14 ]. Shifting to HPN can result in cost savings by circumventing several factors associated with the high cost of in-hospital PN. While HPN has the potential to improve the patient’s QoL and clinical outcomes, setting it up comes with challenges, as patients often find the procedure overwhelming due to its complexity and demanding nature of the procedure. These challenges include requiring specialized medical techniques, (e.g., aseptic techniques) patient and family training, parenteral nutrition solution preparation, and accounting for patient factors such as age, learning ability, family support, presence of active malignancy, etc. [ 1 ]. Furthermore, HPN requires intensive medical case management by practitioners with expertise in the provision of nutrition support [ 17 ] as well as specialized nursing care and materials such as intravenous (IV) lines, HPN fluids, needles, pumps, IV medication, and other disposable [ 17 ]. Patients undergoing HPN may also experience central venous line complications, liver disease, metabolic complications, and fluid/electrolyte disorders which should require prompt and effective management [ 18 ]. Given the relative complexity of preparing for HPN and possible complications, inadequate preparation and medical stability before discharge may lead to early hospital readmissions due to HPN-related complications. Therefore, adopting a multifaceted approach is essential for mitigating problems associated with HPN implementation. To address these issues, this study has a dual objective. Firstly, to present the implementation experience of the HPN protocol of the Kaohsiung Medical University Hospital (KMUH), highlighting the use of an auxiliary device for setting up an HPN. Secondly, to evaluate the cost-saving potential of HPN implementation to provide valuable insights into the economic impact of HPN therapy which can guide HCPs in optimizing resource allocation for patients requiring HPN. With these objectives, this paper can serve as a reference for HCPs, as well as patients and their caregivers engaged in HPN regarding its implementation, cost-effectiveness, and overall impact on patient care and management. Subjects and Methods Subjects This was a retrospective observational study conducted with the approval of the Ethics Committee of KMUH under Institutional Review Board number KMUH-IRB-20130256. The study enrolled adult and pediatric patients undergoing HPN under the supervision of the Nutrition Therapy Team (NTT) of KMUH, Kaohsiung, Taiwan from January 2020 to December 2022. Patients eligible for HPN therapy were selected based on stable disease status, adequate motivation and self-care ability, having a caregiver, consideration of economic burden, and eligibility for reimbursement, excluding sterilization supplies, according to Taiwan’s National Health Insurance (NHI) payment guidelines. Patients and their primary caregivers who had not received complete HPN care training as per the KMUH’s protocol, and patients and their families who were unwilling to receive HPN were excluded from the study. The evaluation of the patient's medical condition was conducted by HCPs or by one of the members of the NTT, ensuring adherence to rigorous criteria. Patients were ideally discharged in a stable condition, maintaining a stable infusion regimen, electrolyte levels, hematocrit, blood sugar, and blood gas, and with a documented balanced fluid intake/output. Patient and caregiver education Both patients and their primary caregivers received a comprehensive education in administering HPN effectively. The educational program covered various topics essential for the safe, efficient, and effective execution of HPN. This included instruction on HPN solution preparation and administration, proper use of the Port-A auxiliary device, and access to QR code-linked instructional videos. Training also covered hand hygiene, changing nutrition bags, vitamin supplementation, infusion rate adjustment, wound care, and monitoring of vital signs. Patients were also educated on emergency protocols and complication prevention and evaluation. Data collection The data collected included baseline patient characteristics, including their age, gender, disease types, and cancer types. The reasons for discontinuing HPN were also recorded. This study also documented the number of patients undergoing HPN therapy, the number of HPN patient days, and the average HPN days per patient during the study period. To evaluate the economic benefits of HPN, several key metrics were also documented. In particular, HPN education hours provided by nurses to patients and caregivers were categorized before and after the implementation of the auxiliary device to determine their correlation with the pharmacoeconomics of HPN in KMUH. Additionally, the length of hospital stay was analyzed to establish whether using the auxiliary device substantially reduced hospital stays. The cost savings of HPN, calculated as annual direct cost savings in KMUH were also assessed. Lastly, the adverse events of special interest (AESI) reported by both physicians and patients or their caregivers during the study period were collected. RESULTS Study population Between 2020 and 2022, a total of 306 patients underwent HPN, with the majority (n = 298, 97.4%) being adults, while the remaining were pediatric patients (n = 8, 2.6%). Most patients were male (55.7%), with females accounting for a smaller proportion (44.3%). The male patients’ average age was 64.5 years, while that of the females was slightly lower at 61.8 years. Over 90% of patients had cancer, while the remaining had non-cancerous conditions. Among patients with cancer, the most prevalent type was colorectal cancer (57.9%), followed by gastric cancer (17.7%), hepatobiliary and pancreatic cancers (15.5%), esophageal cancer (2.2%) and other unspecified types 6.6% ( Table 1 ). In terms of the number of patients receiving HPN, records showed that the year 2020 had the greatest number of HPN patients (n = 113), while 2021 had the least number (n = 92) (Supplementary Table 1) . Table 1 Baseline characteristics of patients receiving HPN at KMUH (2020–2022) Characteristics N = 306 Groups, n (%) Adult Pediatric 298 (97.4%) 8 (2.6%) Gender, n (%) Male 166 (55.7%) Female 132 (44.3%) Mean age, years (SD) Male 64.5 ± 12.6 Female 61.8 ± 12.9 Disease, n (%) Cancer 271 (90.9%) Non-cancer 27 (9.1%) Cancer type, n (%) Colorectal cancer 157 (57.9%) Gastric cancer 48 (17.7%) Hepatobiliary and pancreatic cancer 42 (15.5%) Esophageal cancer 6 (2.2%) Others 18 (6.6%) HPN, home parenteral nutrition; KMUH, Kaohsiung Medical University Hospital; SD, standard deviation. During the study period, a total of 24,922 HPN patient days were recorded, with adult patients accounting for 23,328 days, and pediatric cancer patients accounting for 1,594 days. Notably, HPN patient days for non-cancer cases were minimal, with 4,671 adult and 1,588 pediatric HPN patient days recorded (Supplementary Table 1) . In general, non-cancer patients received HPN for a longer duration than cancer patients. Over the study period, a total of 580 HPN days per non-cancer adult patient and 794 HPN days per non-cancer pediatric patient were observed. Particularly, an average of 193 HPN days per non-cancer adult patient and 265 HPN days per non-cancer pediatric patient were recorded. On the other hand, among cancer patients, a total of 205 HPN days per adult patient and 6 HPN days per pediatric patient were noted. Specifically, the average HPN days per patient were 68 days for adult patients and 6 days for pediatric patients. Table 2 details the total and average HPN days of adult and pediatric patients over the study period. Implementation of HPN in KMUH The standard operating procedure (SOP) for HPN at KMUH outlines a straightforward but systematic approach to the management of HPN ( Fig. 1 ) . Firstly, the initiation of HPN begins with a request from the patient’s attending physician who evaluates if there is a clear indication for HPN administration. If so, the process proceeds to the next step wherein the HPN team comprised of a nutritionist and nurses plans and conducts algorithm-based instruction and training on the efficient, safe, and effective administration of HPN to both the patient and their primary caregiver ( Fig. 2 ) . This step ensures that all necessary preparations are made, and that the patient and caregivers are adequately trained in the skills required for HPN administration. Once the requirements for this step are sufficiently met as assessed by the patient’s attending physician, the patient is discharged and HPN is initiated at the patient’s residence or care facility. The next consideration is whether a home visit for HPN therapy is warranted based on the patient’s needs and circumstances. If the patient can be managed effectively through regular outpatient department (OPD) visits or follow-up consultations either in person or via phone calls, then a home visit may not be necessary. Finally, if the decision is made to terminate HPN therapy for the patient, the case is closed following appropriate procedures. Figure 1 outlines the steps in the implementation of HPN at KMUH. HPN education and training In the process of HPN education and training, several key steps are undertaken to ensure that the patient and caregiver are sufficiently trained and informed. Firstly, materials and supplies related to HPN are prepared. Patient education is facilitated with a healthcare instructional booklet and a demonstration of accessing an instructional video via a QR code. This video provides detailed instructions in guiding patients and their primary caregivers in utilizing the auxiliary device to administer the HPN. Subsequently, the primary caregiver administers HPN under the supervision of the evening nursing staff, who then verifies the accuracy of execution and records the caregiver’s HPN implementation skills in the shift endorsement notes. Health education sessions continue the next day wherein the primary caregivers are further educated using the "HPN Care eBook" to enhance their comprehension of care procedures. On the third day, using a checklist, the nursing staff evaluates the primary caregiver's proficiency in HPN skills and assesses their skills and knowledge. Finally, the attending physician is briefed on the primary caregiver's learning progress to facilitate discharge preparation. Figure 2 shows the detailed algorithm for patient and caregiver education and training on HPN. HPN educational content For the proper implementation of HPN, comprehensive educational content is essential in providing patients and caregivers with the necessary knowledge and skills. The KMUH’s HPN program includes instructional materials that cover a wide range of areas including the SOP of HPN, proper use of the Port-A auxiliary device, and proper waste disposal. a. SOP of HPN : Patients and caregivers are provided with detailed instructions on the preparation and administration of HPN solutions. Figures 1 and 2 illustrate the SOP of HPN setup and administration, and the algorithm on the training of patients and caregivers, respectively. b. Port-A auxiliary device model : Patients and caregivers are also educated on the proper use of the Port-A auxiliary device model, designed to facilitate HPN therapy. Supplementary Fig. 1 shows the auxiliary device model (patent no.: TW I595458 B). c. QR code : A QR code linking to instructional videos is provided to enhance patient and caregiver understanding of HPN, including its benefits, potential complications, and management strategies. The videos also provide step-by-step instructions for administering an HPN. d. Proper hand-washing techniques and understanding of aseptic technique : Patients and caregivers receive training on a proper hand-washing technique and knowledge of aseptic techniques to minimize the risk of infections during HPN administration. e. Changing parenteral nutrition using IV cassettes : Education is provided on the safe and correct procedure for changing parenteral nutrition bags using intravenous cassettes to maintain sterility and prevent contamination. f. Addition of parenteral vitamin : Patients and caregivers are educated on the importance of parenteral vitamin supplementation and the proper method for its administration. g. Adjustment of infusion rate : Training is provided on adjusting the infusion rate of HPN solutions as per HCP instructions to ensure appropriate delivery and avoid complications. h. Injection site wound care and evaluation : Patients and caregivers receive guidance on proper wound care and regular evaluation of injection sites to monitor for signs of infection or other complications. i. Body weight measurement and fluid intake/output record : Education includes instructions on accurately measuring body weight and keeping records of fluid intake and output to monitor hydration status and treatment efficacy. j. Body temperature/blood pressure measurement record : Patients and caregivers are trained to measure and record body temperature and blood pressure regularly to detect any abnormalities that may indicate complications. k. Finger and urine sugar measurement : Instruction is provided on monitoring blood glucose levels through fingerstick measurements and urine sugar tests to manage and monitor glucose levels effectively during HPN therapy. l. Medical waste disposal : Patients and caregivers are educated on the proper disposal of medical waste generated during HPN therapy to ensure environmental safety and infection control. m. Emergency situations and contact person : Patients are provided with information on whom to contact in case of emergencies or concerns regarding their HPN therapy, ensuring prompt assistance and management. n. Prevention and evaluation of complications : Education emphasizes the importance of preventing complications associated with HPN therapy and equips patients and caregivers with the knowledge to recognize and evaluate potential complications, enabling timely intervention and management. Cost savings from using the auxiliary device In the pilot implementation of the Port-A auxiliary device for HPN (before 2020), involving approximately 10 adult cancer patients, several positive outcomes were observed that reflected indirect cost savings. In this analysis, the data from the patients in whom the auxiliary device was used was compared with historical data. In particular, the workload burden of the nursing staff was substantially reduced in terms of hours spent in providing HPN education to patients and their caregivers. Prior to the utilization of the auxiliary device, nurses typically spent an average of 67.5 hours in providing HPN education. However, with the integration of the auxiliary device into practice, the time spent on this task was markedly reduced to an average of 31.3 hours, a substantial decrease of 36.2 hours ( Fig. 3 a ) . This alleviation in workload could be due to the device’s feature that allows it to be initially practiced in a model before actual patient use. Subsequently, repeated practice resulting in skill refinement led to the efficient execution of HPN, saving time and reducing the need for manpower. Furthermore, the integration of the auxiliary device for HPN resulted in a reduction in hospital stays. Before the implementation of the auxiliary device, patients undergoing HPN therapy experienced an average hospital stay of 5.4 days. In contrast, with the introduction of the auxiliary device into the HPN regimen, the average hospital stay was considerably reduced to 2.5 days, a reduction of 2.9 days ( Fig. 3 b ) . This substantial decrease underscored the efficacy of the auxiliary device in facilitating efficient HPN therapy management, thereby expediting patient recovery and promoting timely discharge from the hospital. Direct cost-savings from HPN The study demonstrated the cost-saving potential of HPN therapy across various patient demographics. In Taiwan, NHI daily coverage for in-hospital PN is approximately USD 67 (data source: 1,946 New Taiwan Dollar [NTD], converted to USD using the three-year average NTD to USD exchange rate), which also reflects the amount saved per day when the patient shifts to HPN. During the three-year study period, considering the average HPN days and the total number of HPN patients, HPN yielded a total of USD 1,665,272 in cost savings. Notably, adult cancer patients emerged as the subgroup with the most substantial savings, with a total of USD 1,246,251 saved over the three-year study period. Conversely, HPN resulted in USD 392 in cost savings in pediatric cancer patients. HPN resulted in lower cost savings among non-cancer adult patients with total savings of USD 312,306. On the other hand, among pediatric non-cancer patients, HPN resulted in total savings of USD 106,323. Table 2 details the cost savings resulting from KMUH’s HPN protocol. Safety During the study period, the recorded AESIs were categorized as device-related, metabolic, and infection-related. Device-related issues during the study period primarily arose from catheter obstruction (n = 2) and catheter detachment (n = 3). Metabolic AESIs in patients undergoing HPN therapy commonly included electrolyte imbalances (n = 73) and hyperglycemia (n = 40). In 2020, the highest incidence density was observed for catheter-related infections at 3.0‰, and the highest incidence for vascular infections leading to hospital readmissions at 7.0%. Table 3 details the AESIs in patients undergoing HPN throughout the study period, under the supervision of KMUH. Table 3 AESIs associated with HPN during the study period, supervised by KMUH AESI type AESI 2020 2021 2022 Device-related, n (%) catheter obstruction 2 (1.8) 0 (0) 0 (0) catheter detachment 3 (2.7) 0 (0) 0 (0) Metabolic, n (%) hypercholesterolemia 17 (15.0) 6 (6.5) 2 (2.0) hyperglycemia 22 (19.5) 7 (7.6) 11 (10.9) electrolyte imbalance 46 (40.7) 17 (18.5) 10 (9.9) hypoglycemia 6 (5.3) 0 (0) 1 (1.0) Infection-related catheter-related infections n (‰ * ) 29 (3.0) 11 (1.1) 17 (1.8) vascular infections leading to hospital readmission n (%) 8 (7.0) 2 (2.2) 3 (2.9) *The calculation is based on incidence density with the following formula: incidence density = (no. of infections / patient-days) × 1000 AESI, adverse event of special interest; HPN, home parenteral nutrition; KMUH, Kaohsiung Medical University Hospital. DISCUSSION This study highlighted the benefits and cost-saving implications of HPN, particularly following the SOP of KMUH and the use of the Port-A auxiliary device model. As per the SOP of the KMUH, patients, and caregivers were educated and trained on the proper use of the auxiliary device for the safe and efficient administration of HPN. This auxiliary device, developed at KMUH, was specifically designed to streamline and facilitate the ease of administering HPN ( Supplementary Fig. 1 ). Its innovative and user-friendly design expedites skill acquisition with correct practice to ensure optimal therapeutic outcomes and enables caregivers to administer HPN themselves. One of the benefits resulting from the incorporation of the auxiliary device for HPN was the considerable alleviation in the workload burden of the nursing staff, as shown in the reduction in working hours. With the use of the auxiliary device, the nurses’ working hours were substantially reduced to an average of 31.3 hours, from an average of 67.5 hours — a decrease of 36.2 hours. Furthermore, the integration of the auxiliary device in HPN resulted in a reduction in hospital stays. Patients undergoing HPN therapy typically have an average hospital stay of 5.4 days, which, with the introduction of the auxiliary device into the HPN regimen, was shortened to an average of 2.5 days — a reduction of 2.9 days. These results underscored the effectiveness of the Port-A auxiliary device in facilitating efficient, effective, and safe administration of HPN, leading to the amelioration of the nurses’ workload as well as reducing patient hospital stays. The results of the present study support the conclusions of previous reports examining the cost-saving implications of HPN [ 7 , 9 , 19 ]. Notably, the integration of HPN with the use of the auxiliary device at KMUH generated significant direct cost savings, as evidenced by a notable reduction in NHI in-hospital PN fees amounting to USD 482,432 in 2022 alone. This observation corroborates the conclusion of prior studies demonstrating the cost-effectiveness of HPN over traditional in-hospital PN modalities [ 10 ]. Findings from this study offer novel insights into the potential nationwide impact of widespread HPN adoption. Drawing from KMUH's experience, the implementation of HPN therapy across 22 medical centers in Taiwan is projected to result in an estimated annual savings of USD 12,212,002 in NHI hospitalization fees. These projected savings demonstrate that HPN implementation can lead to economic advantages not only for patients and the hospital but also on a larger scale such as at a healthcare system level. The implementation of HPN, particularly with the use of the auxiliary device, also resulted in substantial indirect cost savings. The reduction in the nurses’ working hours in providing HPN education translates to minimized productivity losses associated with unnecessary time spent setting up a typical in-hospital PN without the auxiliary device. This reduction in working hours not only enhances productivity and efficiency among staff, but also ensures optimal utilization of healthcare resources, mitigating the indirect costs attributed to workforce-related issues. Moreover, incorporating the auxiliary device led to decreased hospital stays for patients undergoing HPN therapy, which could potentially translate to fewer missed workdays for patients, as well as reduced caregiver burden and associated psychological discomfort. Consequently, by minimizing the duration of hospitalization and facilitating the ease of administering HPN, the auxiliary device contributes to intangible cost savings associated with patient well-being and QoL. Despite these economic advantages resulting from direct and indirect cost savings, the use of HPN in appropriately selected patients remains substantially lower in Taiwan than in countries such as Germany and the USA [ 2 ]. Moreover, in Taiwan, there is an increased trend in home medical care due to several factors such as the coronavirus disease-19 pandemic and an aging population, suggesting an increased demand for HPN in the country in the coming years. Given that Taiwan has already transitioned into an aged society in 2018 and is projected to become a super-aged society by 2025 [ 20 ], the implementation of HPN could help alleviate the strain on Taiwan’s healthcare system. The KMUH’s HPN protocol, using the Port-A auxiliary device is not only efficient and effective in producing cost-savings, but is also safe. Although AESIs were recorded during the study period, except for hyperglycemia and infection-related AESIs, the incidences of these AESIs generally demonstrated a decreasing trend, with the lowest incidences observed in 2022. This decreasing trend can be attributed to several factors, including improved patient and caregiver education and skills, enhanced compliance leading to the efficient and safe execution of HPN, and the refinement of the protocol considering unique patient needs. This study has several limitations. Firstly, there is a lack of universally accepted standards in executing HPN with the existing literature showing diverse practices [ 21 , 22 ]. This study, using the experience of KMUH, lacks systematic comparisons with the HPN practices of other institutions. Without a basis for comparison, the HPN protocol in KMUH lacks points of reference for areas needing improvement. Because of the diverse HPN protocols across hospitals and institutions, and the complex nature of multidisciplinary team involvement [ 23 , 24 ], further exploration is necessary to establish specific indications, criteria, and standards for HPN application. Secondly, the accurate assessment of cost savings associated with HPN in this study presents challenges. Although the economic savings were calculated by considering the reduction in hospital stay days, numerous indirect costs need to be accounted for [ 12 , 15 ], which could potentially over- or underestimate the cost-saving benefits of HPN implementation. Moreover, the possibility of HPN leading to higher medical costs due to adverse events or complications associated with PN is a factor that warrants consideration. Lastly, this study did not include assessments in QoL or patient and caregiver satisfaction. Although these are essential aspects of patient care, the data collected were insufficient to analyze these metrics. Future research should include these measurements for a more comprehensive understanding of the impact of HPN on patient well-being and their family or caregivers. In conclusion, this study highlights the multiple benefits and implications of HPN therapy, particularly within the framework of KMUH’s HPN protocol. By integrating KMUH’s SOP and using the Port-A auxiliary device model for HPN administration, significant improvements in operational efficiency, cost-saving potential, and patient outcomes were demonstrated. Particularly, the reduction in nursing workload hours and shortened patient hospital stays show the efficacy of the auxiliary device in streamlining HPN administration and enhancing patient care. However, the lack of standardized protocols, comprehensive cost analysis, and QoL assessments should be addressed in future research to refine HPN protocols. These improvements will prove crucial for the imminent widespread adoption of HPN in the fast-changing healthcare landscape in Taiwan. Declarations Data Availability Statement The data that support the findings of this study are available on request from the corresponding authors. Acknowledgments The writing of this article and other related activities were funded by Baxter, Taiwan. The funding agency had no role whatsoever in formulating the scientific content. The authors would like to thank Lance Chen of Baxter for his helpful comments on this study and manuscript preparation. English editorial assistance for the manuscript were provided by EMD Asia Scientific Communication (Taiwan branch) Co., Ltd. Author Contributions All authors contributed to the conceptualization of the present study. WCS and LCS conducted the statistical analyses, prepared the tables and figures, and wrote the first draft of the paper. WCS and TKC contributed to the planning of the statistical analyses, interpretation of the data, and writing of the paper. YCC, CWH, YSY, PJC, TCY, and HLT supervised the conduct of statistical analyses. All authors contributed to the interpretation of the data and writing of the paper. All authors have read and approved the final paper. Funding This work was supported by grants through funding from the National Science and Technology Council (MOST 111-2314-B-037-070-MY3, NSTC 112-2314-B-037-090, NSTC 112-2314-B-037-050-MY3) and the Ministry of Health and Welfare (12D1-IVMOHW02). Funding was also obtained from the Health and Welfare Surcharge on Tobacco Products, the Kaohsiung Medical University Hospital (KMUH102-M218, KMUH112-2R37, KMUH112-2R38, KMUH112-2R39, KMUH112-2M27, KMUH112-2M28, KMUH112-2M29, KMUH-SH11207), and Kaohsiung Medical University Research Center (KMU-TC112A04). In addition, this study was supported by grants from the Taiwan Precision Medicine Initiative and Taiwan Biobank, Academia Sinica, Republic of China (Taiwan). Ethical Approval This retrospective observational study was approved by the Ethics Committee of Kaohsiung Medical University Hospital (KMUH) with Institutional Review Board number KMUH-IRB-20130256. Competing Interest Authors declare no competing interests. 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Home Parenteral Nutrition: a direct costs study in the approved centres of Montpellier and Strasbourg. Gastroen Clin Biol. 2006; 30:574-579. Curtas S, Hariri R, Steiger E. Case management in home total parenteral nutrition: a cost‐identification analysis. J Parenter Enteral Nutr. 1996; 20:113-119. Howard L, Ashley C. Management of complications in patients receiving home parenteral nutrition. Gastroenterol. 2003; 124:1651-1661. Witteveen P, Van Groenestijn M, Blijham G, Schrijvers A. Use of resources and costs of palliative care with parenteral fluids and analgesics in the home setting for patients with end-stage cancer. Ann Oncol. 1999; 10:161-166. National Development Council. Population Aging [https://www.ndc.gov.tw/en/Content_List.aspx?n=85E9B2CDF4406753] Accessed June 11, 2024 Johnson T, Sexton E. Managing children and adolescents on parenteral nutrition: challenges for the nutritional support team. Proc Nutr Soc. 2006; 65:217-221. Martí‐Bonmatí E, Cervera P, Mínguez A, Perez-Serrano MD. A parametric description of the parenteral nutrition protocols of 19 American hospitals. Nutr Hosp. 1989; 4 1:23-30. Kim H, Spaulding R, Werkowitch M, Yadrich D, Piamjariyakul U, Gilroy R et al . Costs of multidisciplinary parenteral nutrition care provided at a distance via mobile tablets. JPEN J Parenter Enteral Nutr. 2014; 38:50S-57S. Sangster AG. Home parenteral nutrition: a multi-professional approach. British Journal Community Nur. 2015; 20 Suppl 6a:S24, S26-27. Additional Declarations There is NO conflict of interest to disclose. Supplementary Files SupplementaryFigure1.tif Supplementary Fig 1. Auxiliary device model used in the administration of HPN. The device features a body designed for needle insertion, an injection part with a compartment, and a guiding tube that connects to the compartment and discharges fluid. This setup allows the user to verify proper needle insertion and depth by checking if the hypodermic fluid flows out of the second end of the tube. HPN, home parenteral nutrition. SupplementaryTable1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4622390","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":326556099,"identity":"6c5c4922-11f8-468c-b3a6-f3ca08b27e43","order_by":0,"name":"Jaw-Yuan Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIie3QMUvEMBQH8HcEziVSxyfKLX6BBwWtk1+lR4dbqtyY4dCbdBFuLdyXEPwCrwS8pbMUTvCkcHM/QBFf6uSQ6uiQ/5A8kvx4SQBCQv5lFDMSTiIpGYH1H8h4ysk8iY+XMOKkJ8ot0wDRZ2xaM31i6WeA4VcSFTlwTTh6ft3suIa304uDFau56bwE62suC0J1vs2pLGCvLx8tqKLydyG8Sa08fywELILVVGegDu+HSE62I9TxeraznSPvjZDPYeI+GekklaLvooQs/QSrfeoI4ba3QqpMxpfYS6KHzLbY3d6t1rOmRWOvaFN+NHox8RI4Sn/c83ti/3nXZng7JCQkJATgCybTWVN3U7QpAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-7705-2621","institution":"Kaohsiung Medical University Hospital, Kaohsiung Medical University","correspondingAuthor":true,"prefix":"","firstName":"Jaw-Yuan","middleName":"","lastName":"Wang","suffix":""},{"id":326556100,"identity":"6318b99b-fa6f-4f2e-9cd4-04ef0f18a812","order_by":1,"name":"Wei-Chih Su","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Wei-Chih","middleName":"","lastName":"Su","suffix":""},{"id":326556101,"identity":"6e967d51-2a75-4bab-ada4-07b6a1cae73c","order_by":2,"name":"Tsung-Kun Chang","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Tsung-Kun","middleName":"","lastName":"Chang","suffix":""},{"id":326556102,"identity":"f0cbce48-b69a-46ad-a462-65a1eec3d098","order_by":3,"name":"Yen-Cheng Chen","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Yen-Cheng","middleName":"","lastName":"Chen","suffix":""},{"id":326556103,"identity":"164832ee-1fb7-413f-8cc4-4e3304ea59c0","order_by":4,"name":"Ching-Wen Huang","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Ching-Wen","middleName":"","lastName":"Huang","suffix":""},{"id":326556104,"identity":"ed5eccb1-b79c-4c45-9486-38fd0a8a5420","order_by":5,"name":"Yung-Sung Yeh","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Yung-Sung","middleName":"","lastName":"Yeh","suffix":""},{"id":326556105,"identity":"c5762535-0eb2-4724-8ad2-72042c4a90fc","order_by":6,"name":"Po-Jung Chen","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Po-Jung","middleName":"","lastName":"Chen","suffix":""},{"id":326556106,"identity":"89c512c0-1486-44b3-a3fb-729d9965cd2f","order_by":7,"name":"Tzu-Chieh Yin","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Tzu-Chieh","middleName":"","lastName":"Yin","suffix":""},{"id":326556107,"identity":"36c90d07-a871-41d3-b9cf-4bb26d649c8d","order_by":8,"name":"Hsiang-Lin Tsai","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Hsiang-Lin","middleName":"","lastName":"Tsai","suffix":""},{"id":326556108,"identity":"0ecb3174-d247-4464-96da-d3c5743f87aa","order_by":9,"name":"Li-Chu Sun","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Li-Chu","middleName":"","lastName":"Sun","suffix":""}],"badges":[],"createdAt":"2024-06-22 14:55:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4622390/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4622390/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62221704,"identity":"2481345b-f4ca-43ac-8c4d-ef8fb4ee3646","added_by":"auto","created_at":"2024-08-11 12:32:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":61548,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eProtocol for the implementation of HPN in KMUH.\u003c/strong\u003e HPN initiation begins with a request from the patient’s attending physician, who determines if HPN is indicated. If there are valid indications, the NTT team provides an HPN plan and HPN training to the patient and their primary caregiver. Once the caregiver and patient are adequately trained, the patient is discharged, and HPN starts at home or a care facility. Home visits for HPN are considered based on the patient's needs; if manageable through OPD visits or follow-ups, home visits are unnecessary. When warranted, HPN therapy is terminated with proper case closure procedures.\u003c/p\u003e\n\u003cp\u003eHPN, home parenteral nutrition; KMUH, Kaohsiung Medical University Hospital; NTT, Nutrition Therapy Team; OPD, outpatient department.\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4622390/v1/520c542897e977dbed50e8b0.png"},{"id":62221705,"identity":"f5860b56-7301-4948-9d1d-8f6086307ef5","added_by":"auto","created_at":"2024-08-11 12:32:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":50014,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAlgorithm-based education on the proper implementation of HPN for the patient and caregiver.\u003c/strong\u003e Firstly, materials and supplies for HPN are prepared, followed by patient education through a healthcare instructional booklet and an instructional video accessed via a QR code. The primary caregiver administers HPN under the supervision of the nursing staff, verifying and recording the caregiver’s HPN implementation skills. Health education sessions continue the next day with the \"HPN Care eBook\" to enhance caregiver knowledge. On the third day, the nursing staff evaluates the caregiver's proficiency in HPN skills using a checklist, and the attending physician is briefed on the caregiver's learning progress to facilitate discharge preparation.\u003c/p\u003e\n\u003cp\u003eHPN, home parenteral nutrition; QR, quick response (code).\u003c/p\u003e","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4622390/v1/c98142dccafbfc8d0745de93.png"},{"id":62221707,"identity":"6c572b42-1c18-490d-a053-bae76238fe47","added_by":"auto","created_at":"2024-08-11 12:32:55","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":182342,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDecreased workload of nurses and patient hospital stay.\u003c/strong\u003eAfter the implementation of the Port-A auxiliary device, the HPN education hours provided by nurses to patients and their caregivers decreased from 67.5 hours to 31.3 hours, a decrease of 36.2 hours \u003cstrong\u003e(A)\u003c/strong\u003e. After the implementation of the Port-A auxiliary device, patient hospital stay markedly decreased from 5.4 days to 2.5 days, a decrease of 2.9 days \u003cstrong\u003e(B). \u003c/strong\u003eThe data was collected during the pilot implementation of the Port-A auxiliary device before 2020, where the outcomes in approximately 10 adult cancer patients were compared with historical data.\u003c/p\u003e","description":"","filename":"figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4622390/v1/a929c480c1b0a657975e2f67.png"},{"id":75651842,"identity":"3f5d7aee-b01d-489a-88c4-5b6fd0574e83","added_by":"auto","created_at":"2025-02-06 18:09:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1268787,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4622390/v1/3a9ec968-0573-4733-84de-a4ef9fd79d67.pdf"},{"id":62223308,"identity":"f7e504e4-19f6-4734-a20a-c0abce02b76a","added_by":"auto","created_at":"2024-08-11 12:48:55","extension":"tif","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":562290,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary Fig 1. Auxiliary device model used in the administration of HPN. \u003c/strong\u003eThe device features a body designed for needle insertion, an injection part with a compartment, and a guiding tube that connects to the compartment and discharges fluid. This setup allows the user to verify proper needle insertion and depth by checking if the hypodermic fluid flows out of the second end of the tube.\u003c/p\u003e\n\u003cp\u003eHPN, home parenteral nutrition.\u003c/p\u003e","description":"","filename":"SupplementaryFigure1.tif","url":"https://assets-eu.researchsquare.com/files/rs-4622390/v1/4dc92a80630cd2ca5770b0a8.tif"},{"id":62222933,"identity":"380939ff-9f54-48e3-8f39-f437f2ca9aad","added_by":"auto","created_at":"2024-08-11 12:40:55","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":13712,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4622390/v1/497029cbd431dbee0180adcd.docx"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose.","formattedTitle":"Enhancing Economic Efficiency Through the Implementation of Home Parenteral Nutrition SOP with a Novel Training Module","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHome parenteral nutrition (HPN) is an adaptation of the in-hospital parenteral nutrition (PN) that encompasses both total PN and supplemental PN. HPN aims to provide nutrition and hydration to patients unable to maintain an adequate nutritional status through oral feeding or enteral nutrition [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The prevalence of HPN varies globally, with Europe and the USA having 6\u0026ndash;34 and 75 cases per million, respectively [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. HPN epidemiological data from Taiwan and other Asian countries is scarce, with studies conducted at individual institutions, rather than at the national level [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The most comprehensive and up-to-date data is from Singapore, which included 41 adults (2002\u0026ndash;2017) and 8 pediatric patients (2011\u0026ndash;2017) who received HPN at the country\u0026rsquo;s largest PN centers [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In this study, the mean age is 53 years for adult patients and 8 years for pediatric patients.\u003c/p\u003e \u003cp\u003eFor appropriately selected patients with terminal cancer and malnutrition, HPN is an integral part of palliative care, intending to increase survival and improve quality of life (QoL) [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. As a life-saving therapy, HPN is especially indicated for patients with inoperable gastrointestinal (GI) cancers, short bowel syndrome, GI fistulas with high flow, post-operative bowel anastomosis leak, and hypercatabolic states due to sepsis, polytrauma, and major fractures. Furthermore, by helping treat malnutrition through the efficient delivery of nutrients and fluids, HPN can prevent death from starvation and dehydration. It can also reduce in-hospital stays and increase the proportion of care in outpatient settings [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile HPN may be costly, studies found that it is more cost-effective compared to in-hospital PN [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Earlier studies classified the cost of illness as either direct, indirect, intangible, or personal costs [\u003cspan additionalcitationids=\"CR12 CR13 CR14\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The direct costs include both healthcare and non-healthcare costs [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Included in the healthcare costs are medical expenditures such as institutional inpatient and outpatient care, healthcare professional (HCP) fees, medication, laboratory tests, patient training, etc. Conversely, the non-healthcare costs encompass the transportation and supply expenditures of patients, as well as household expenses associated with HPN, and so forth [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Indirect costs include diminished productivity due to morbidity and mortality, impairment, and reduction in workdays. Intangible costs are those related to the psychological discomfort of the patients and are often omitted from the cost of illness studies due to challenges in measurement [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Lastly, the personal costs are those shouldered by the patient or their family for consultations with HCPs, medications, laboratory tests, home adjustments, transportation, and the necessity for home care [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Shifting to HPN can result in cost savings by circumventing several factors associated with the high cost of in-hospital PN.\u003c/p\u003e \u003cp\u003eWhile HPN has the potential to improve the patient\u0026rsquo;s QoL and clinical outcomes, setting it up comes with challenges, as patients often find the procedure overwhelming due to its complexity and demanding nature of the procedure. These challenges include requiring specialized medical techniques, (e.g., aseptic techniques) patient and family training, parenteral nutrition solution preparation, and accounting for patient factors such as age, learning ability, family support, presence of active malignancy, etc. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Furthermore, HPN requires intensive medical case management by practitioners with expertise in the provision of nutrition support [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] as well as specialized nursing care and materials such as intravenous (IV) lines, HPN fluids, needles, pumps, IV medication, and other disposable [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Patients undergoing HPN may also experience central venous line complications, liver disease, metabolic complications, and fluid/electrolyte disorders which should require prompt and effective management [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Given the relative complexity of preparing for HPN and possible complications, inadequate preparation and medical stability before discharge may lead to early hospital readmissions due to HPN-related complications. Therefore, adopting a multifaceted approach is essential for mitigating problems associated with HPN implementation.\u003c/p\u003e \u003cp\u003eTo address these issues, this study has a dual objective. Firstly, to present the implementation experience of the HPN protocol of the Kaohsiung Medical University Hospital (KMUH), highlighting the use of an auxiliary device for setting up an HPN. Secondly, to evaluate the cost-saving potential of HPN implementation to provide valuable insights into the economic impact of HPN therapy which can guide HCPs in optimizing resource allocation for patients requiring HPN. With these objectives, this paper can serve as a reference for HCPs, as well as patients and their caregivers engaged in HPN regarding its implementation, cost-effectiveness, and overall impact on patient care and management.\u003c/p\u003e"},{"header":"Subjects and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSubjects\u003c/h2\u003e \u003cp\u003e This was a retrospective observational study conducted with the approval of the Ethics Committee of KMUH under Institutional Review Board number KMUH-IRB-20130256. The study enrolled adult and pediatric patients undergoing HPN under the supervision of the Nutrition Therapy Team (NTT) of KMUH, Kaohsiung, Taiwan from January 2020 to December 2022. Patients eligible for HPN therapy were selected based on stable disease status, adequate motivation and self-care ability, having a caregiver, consideration of economic burden, and eligibility for reimbursement, excluding sterilization supplies, according to Taiwan\u0026rsquo;s National Health Insurance (NHI) payment guidelines. Patients and their primary caregivers who had not received complete HPN care training as per the KMUH\u0026rsquo;s protocol, and patients and their families who were unwilling to receive HPN were excluded from the study.\u003c/p\u003e \u003cp\u003eThe evaluation of the patient's medical condition was conducted by HCPs or by one of the members of the NTT, ensuring adherence to rigorous criteria. Patients were ideally discharged in a stable condition, maintaining a stable infusion regimen, electrolyte levels, hematocrit, blood sugar, and blood gas, and with a documented balanced fluid intake/output.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePatient and caregiver education\u003c/h2\u003e \u003cp\u003eBoth patients and their primary caregivers received a comprehensive education in administering HPN effectively. The educational program covered various topics essential for the safe, efficient, and effective execution of HPN. This included instruction on HPN solution preparation and administration, proper use of the Port-A auxiliary device, and access to QR code-linked instructional videos. Training also covered hand hygiene, changing nutrition bags, vitamin supplementation, infusion rate adjustment, wound care, and monitoring of vital signs. Patients were also educated on emergency protocols and complication prevention and evaluation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eThe data collected included baseline patient characteristics, including their age, gender, disease types, and cancer types. The reasons for discontinuing HPN were also recorded. This study also documented the number of patients undergoing HPN therapy, the number of HPN patient days, and the average HPN days per patient during the study period. To evaluate the economic benefits of HPN, several key metrics were also documented. In particular, HPN education hours provided by nurses to patients and caregivers were categorized before and after the implementation of the auxiliary device to determine their correlation with the pharmacoeconomics of HPN in KMUH. Additionally, the length of hospital stay was analyzed to establish whether using the auxiliary device substantially reduced hospital stays. The cost savings of HPN, calculated as annual direct cost savings in KMUH were also assessed. Lastly, the adverse events of special interest (AESI) reported by both physicians and patients or their caregivers during the study period were collected.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec7\"\u003e\n \u003ch2\u003eStudy population\u003c/h2\u003e\n \u003cp\u003eBetween 2020 and 2022, a total of 306 patients underwent HPN, with the majority (n\u0026thinsp;=\u0026thinsp;298, 97.4%) being adults, while the remaining were pediatric patients (n\u0026thinsp;=\u0026thinsp;8, 2.6%). Most patients were male (55.7%), with females accounting for a smaller proportion (44.3%). The male patients\u0026rsquo; average age was 64.5 years, while that of the females was slightly lower at 61.8 years. Over 90% of patients had cancer, while the remaining had non-cancerous conditions. Among patients with cancer, the most prevalent type was colorectal cancer (57.9%), followed by gastric cancer (17.7%), hepatobiliary and pancreatic cancers (15.5%), esophageal cancer (2.2%) and other unspecified types 6.6% \u003cstrong\u003e(\u003c/strong\u003eTable \u003cspan\u003e1\u003c/span\u003e\u003cstrong\u003e).\u003c/strong\u003e In terms of the number of patients receiving HPN, records showed that the year 2020 had the greatest number of HPN patients (n\u0026thinsp;=\u0026thinsp;113), while 2021 had the least number (n\u0026thinsp;=\u0026thinsp;92) \u003cstrong\u003e(Supplementary Table\u0026nbsp;1)\u003c/strong\u003e.\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eBaseline characteristics of patients receiving HPN at KMUH (2020\u0026ndash;2022)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;306\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroups, n (%)\u003c/p\u003e\n \u003cp\u003eAdult\u003c/p\u003e\n \u003cp\u003ePediatric\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e298 (97.4%) 8 (2.6%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGender, n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e166 (55.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e132 (44.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean age, years (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e64.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e61.8\u0026thinsp;\u0026plusmn;\u0026thinsp;12.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisease, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e271 (90.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCancer type, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eColorectal cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e157 (57.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGastric cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e48 (17.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHepatobiliary and pancreatic cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42 (15.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEsophageal cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6 (2.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18 (6.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003eHPN, home parenteral nutrition; KMUH, Kaohsiung Medical University Hospital; SD, standard deviation.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eDuring the study period, a total of 24,922 HPN patient days were recorded, with adult patients accounting for 23,328 days, and pediatric cancer patients accounting for 1,594 days. Notably, HPN patient days for non-cancer cases were minimal, with 4,671 adult and 1,588 pediatric HPN patient days recorded \u003cstrong\u003e(Supplementary Table\u0026nbsp;1)\u003c/strong\u003e. In general, non-cancer patients received HPN for a longer duration than cancer patients. Over the study period, a total of 580 HPN days per non-cancer adult patient and 794 HPN days per non-cancer pediatric patient were observed. Particularly, an average of 193 HPN days per non-cancer adult patient and 265 HPN days per non-cancer pediatric patient were recorded. On the other hand, among cancer patients, a total of 205 HPN days per adult patient and 6 HPN days per pediatric patient were noted. Specifically, the average HPN days per patient were 68 days for adult patients and 6 days for pediatric patients. Table \u003cspan\u003e2\u003c/span\u003e details the total and average HPN days of adult and pediatric patients over the study period.\u003c/p\u003e\n \u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/122228_c8a1650c59388082/122228_custom_files/img1723011283.png\"\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cdiv\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\"\u003e\n \u003ch2\u003eImplementation of HPN in KMUH\u003c/h2\u003e\n \u003cp\u003eThe standard operating procedure (SOP) for HPN at KMUH outlines a straightforward but systematic approach to the management of HPN \u003cstrong\u003e(\u003c/strong\u003eFig. \u003cspan\u003e1\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e. Firstly, the initiation of HPN begins with a request from the patient\u0026rsquo;s attending physician who evaluates if there is a clear indication for HPN administration. If so, the process proceeds to the next step wherein the HPN team comprised of a nutritionist and nurses plans and conducts algorithm-based instruction and training on the efficient, safe, and effective administration of HPN to both the patient and their primary caregiver \u003cstrong\u003e(\u003c/strong\u003eFig. \u003cspan\u003e2\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e. This step ensures that all necessary preparations are made, and that the patient and caregivers are adequately trained in the skills required for HPN administration. Once the requirements for this step are sufficiently met as assessed by the patient\u0026rsquo;s attending physician, the patient is discharged and HPN is initiated at the patient\u0026rsquo;s residence or care facility. The next consideration is whether a home visit for HPN therapy is warranted based on the patient\u0026rsquo;s needs and circumstances. If the patient can be managed effectively through regular outpatient department (OPD) visits or follow-up consultations either in person or via phone calls, then a home visit may not be necessary. Finally, if the decision is made to terminate HPN therapy for the patient, the case is closed following appropriate procedures. Figure \u003cspan\u003e1\u003c/span\u003e outlines the steps in the implementation of HPN at KMUH.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\"\u003e\n \u003ch2\u003eHPN education and training\u003c/h2\u003e\n \u003cp\u003eIn the process of HPN education and training, several key steps are undertaken to ensure that the patient and caregiver are sufficiently trained and informed. Firstly, materials and supplies related to HPN are prepared. Patient education is facilitated with a healthcare instructional booklet and a demonstration of accessing an instructional video via a QR code. This video provides detailed instructions in guiding patients and their primary caregivers in utilizing the auxiliary device to administer the HPN. Subsequently, the primary caregiver administers HPN under the supervision of the evening nursing staff, who then verifies the accuracy of execution and records the caregiver\u0026rsquo;s HPN implementation skills in the shift endorsement notes. Health education sessions continue the next day wherein the primary caregivers are further educated using the \u0026quot;HPN Care eBook\u0026quot; to enhance their comprehension of care procedures. On the third day, using a checklist, the nursing staff evaluates the primary caregiver\u0026apos;s proficiency in HPN skills and assesses their skills and knowledge. Finally, the attending physician is briefed on the primary caregiver\u0026apos;s learning progress to facilitate discharge preparation. Figure \u003cspan\u003e2\u003c/span\u003e shows the detailed algorithm for patient and caregiver education and training on HPN.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\"\u003e\n \u003ch2\u003eHPN educational content\u003c/h2\u003e\n \u003cp\u003eFor the proper implementation of HPN, comprehensive educational content is essential in providing patients and caregivers with the necessary knowledge and skills. The KMUH\u0026rsquo;s HPN program includes instructional materials that cover a wide range of areas including the SOP of HPN, proper use of the Port-A auxiliary device, and proper waste disposal.\u003c/p\u003e\n \u003cp\u003e\u003cspan\u003e\u003cstrong\u003ea. SOP of HPN\u003c/strong\u003e: Patients and caregivers are provided with detailed instructions on the preparation and administration of HPN solutions. Figures \u003cspan\u003e1\u003c/span\u003e and\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e illustrate the SOP of HPN setup and administration, and the algorithm on the training of patients and caregivers, respectively.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e\u003cstrong\u003eb. Port-A auxiliary device model\u003c/strong\u003e: Patients and caregivers are also educated on the proper use of the Port-A auxiliary device model, designed to facilitate HPN therapy.\u0026nbsp;\u003cstrong\u003eSupplementary Fig.\u0026nbsp;1\u003c/strong\u003e shows the auxiliary device model (patent no.: TW I595458 B).\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e\u003cstrong\u003ec. QR code\u003c/strong\u003e: A QR code linking to instructional videos is provided to enhance patient and caregiver understanding of HPN, including its benefits, potential complications, and management strategies. The videos also provide step-by-step instructions for administering an HPN.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e\u003cstrong\u003ed. Proper hand-washing techniques and understanding of aseptic technique\u003c/strong\u003e: Patients and caregivers receive training on a proper hand-washing technique and knowledge of aseptic techniques to minimize the risk of infections during HPN administration.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e\u003cstrong\u003ee. Changing parenteral nutrition using IV cassettes\u003c/strong\u003e: Education is provided on the safe and correct procedure for changing parenteral nutrition bags using intravenous cassettes to maintain sterility and prevent contamination.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e\u003cstrong\u003ef. Addition of parenteral vitamin\u003c/strong\u003e: Patients and caregivers are educated on the importance of parenteral vitamin supplementation and the proper method for its administration.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e\u003cstrong\u003eg. Adjustment of infusion rate\u003c/strong\u003e: Training is provided on adjusting the infusion rate of HPN solutions as per HCP instructions to ensure appropriate delivery and avoid complications.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e\u003cstrong\u003eh. Injection site wound care and evaluation\u003c/strong\u003e: Patients and caregivers receive guidance on proper wound care and regular evaluation of injection sites to monitor for signs of infection or other complications.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e\u003cstrong\u003ei. Body weight measurement and fluid intake/output record\u003c/strong\u003e: Education includes instructions on accurately measuring body weight and keeping records of fluid intake and output to monitor hydration status and treatment efficacy.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e\u003cstrong\u003ej. Body temperature/blood pressure measurement record\u003c/strong\u003e: Patients and caregivers are trained to measure and record body temperature and blood pressure regularly to detect any abnormalities that may indicate complications.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e\u003cstrong\u003ek. Finger and urine sugar measurement\u003c/strong\u003e: Instruction is provided on monitoring blood glucose levels through fingerstick measurements and urine sugar tests to manage and monitor glucose levels effectively during HPN therapy.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e\u003cstrong\u003el. Medical waste disposal\u003c/strong\u003e: Patients and caregivers are educated on the proper disposal of medical waste generated during HPN therapy to ensure environmental safety and infection control.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e\u003cstrong\u003em. Emergency situations and contact person\u003c/strong\u003e: Patients are provided with information on whom to contact in case of emergencies or concerns regarding their HPN therapy, ensuring prompt assistance and management.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e\u003cstrong\u003en. Prevention and evaluation of complications\u003c/strong\u003e: Education emphasizes the importance of preventing complications associated with HPN therapy and equips patients and caregivers with the knowledge to recognize and evaluate potential complications, enabling timely intervention and management.\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003eCost savings from using the auxiliary device\u003c/h2\u003e\n \u003cp\u003eIn the pilot implementation of the Port-A auxiliary device for HPN (before 2020), involving approximately 10 adult cancer patients, several positive outcomes were observed that reflected indirect cost savings. In this analysis, the data from the patients in whom the auxiliary device was used was compared with historical data. In particular, the workload burden of the nursing staff was substantially reduced in terms of hours spent in providing HPN education to patients and their caregivers. Prior to the utilization of the auxiliary device, nurses typically spent an average of 67.5 hours in providing HPN education. However, with the integration of the auxiliary device into practice, the time spent on this task was markedly reduced to an average of 31.3 hours, a substantial decrease of 36.2 hours \u003cstrong\u003e(\u003c/strong\u003eFig. \u003cspan\u003e3\u003c/span\u003ea\u003cstrong\u003e)\u003c/strong\u003e. This alleviation in workload could be due to the device\u0026rsquo;s feature that allows it to be initially practiced in a model before actual patient use. Subsequently, repeated practice resulting in skill refinement led to the efficient execution of HPN, saving time and reducing the need for manpower. Furthermore, the integration of the auxiliary device for HPN resulted in a reduction in hospital stays. Before the implementation of the auxiliary device, patients undergoing HPN therapy experienced an average hospital stay of 5.4 days. In contrast, with the introduction of the auxiliary device into the HPN regimen, the average hospital stay was considerably reduced to 2.5 days, a reduction of 2.9 days \u003cstrong\u003e(\u003c/strong\u003eFig. \u003cspan\u003e3\u003c/span\u003eb\u003cstrong\u003e)\u003c/strong\u003e. This substantial decrease underscored the efficacy of the auxiliary device in facilitating efficient HPN therapy management, thereby expediting patient recovery and promoting timely discharge from the hospital.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\"\u003e\n \u003ch2\u003eDirect cost-savings from HPN\u003c/h2\u003e\n \u003cp\u003eThe study demonstrated the cost-saving potential of HPN therapy across various patient demographics. In Taiwan, NHI daily coverage for in-hospital PN is approximately USD 67 (data source: 1,946 New Taiwan Dollar [NTD], converted to USD using the three-year average NTD to USD exchange rate), which also reflects the amount saved per day when the patient shifts to HPN. During the three-year study period, considering the average HPN days and the total number of HPN patients, HPN yielded a total of USD 1,665,272 in cost savings. Notably, adult cancer patients emerged as the subgroup with the most substantial savings, with a total of USD 1,246,251 saved over the three-year study period. Conversely, HPN resulted in USD 392 in cost savings in pediatric cancer patients. HPN resulted in lower cost savings among non-cancer adult patients with total savings of USD 312,306. On the other hand, among pediatric non-cancer patients, HPN resulted in total savings of USD 106,323. Table \u003cspan\u003e2\u003c/span\u003e details the cost savings resulting from KMUH\u0026rsquo;s HPN protocol.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\"\u003e\n \u003ch2\u003eSafety\u003c/h2\u003e\n \u003cp\u003eDuring the study period, the recorded AESIs were categorized as device-related, metabolic, and infection-related. Device-related issues during the study period primarily arose from catheter obstruction (n\u0026thinsp;=\u0026thinsp;2) and catheter detachment (n\u0026thinsp;=\u0026thinsp;3). Metabolic AESIs in patients undergoing HPN therapy commonly included electrolyte imbalances (n\u0026thinsp;=\u0026thinsp;73) and hyperglycemia (n\u0026thinsp;=\u0026thinsp;40). In 2020, the highest incidence density was observed for catheter-related infections at 3.0\u0026permil;, and the highest incidence for vascular infections leading to hospital readmissions at 7.0%. Table \u003cspan\u003e3\u003c/span\u003e details the AESIs in patients undergoing HPN throughout the study period, under the supervision of KMUH.\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eAESIs associated with HPN during the study period, supervised by KMUH\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAESI type\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAESI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2020\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2021\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eDevice-related, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ecatheter obstruction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ecatheter detachment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003eMetabolic, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ehypercholesterolemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17 (15.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ehyperglycemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22 (19.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (10.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eelectrolyte imbalance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e46 (40.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (9.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ehypoglycemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eInfection-related\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ecatheter-related infections n (\u0026permil;\u003csup\u003e*\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29 (3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003evascular infections leading to hospital readmission n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8 (7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (2.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e*The calculation is based on incidence density with the following formula:\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003eincidence density = (no. of infections / patient-days) \u0026times; 1000\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003eAESI, adverse event of special interest; HPN, home parenteral nutrition; KMUH, Kaohsiung Medical University Hospital.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study highlighted the benefits and cost-saving implications of HPN, particularly following the SOP of KMUH and the use of the Port-A auxiliary device model. As per the SOP of the KMUH, patients, and caregivers were educated and trained on the proper use of the auxiliary device for the safe and efficient administration of HPN. This auxiliary device, developed at KMUH, was specifically designed to streamline and facilitate the ease of administering HPN (\u003cb\u003eSupplementary Fig.\u0026nbsp;1\u003c/b\u003e). Its innovative and user-friendly design expedites skill acquisition with correct practice to ensure optimal therapeutic outcomes and enables caregivers to administer HPN themselves. One of the benefits resulting from the incorporation of the auxiliary device for HPN was the considerable alleviation in the workload burden of the nursing staff, as shown in the reduction in working hours. With the use of the auxiliary device, the nurses’ working hours were substantially reduced to an average of 31.3 hours, from an average of 67.5 hours — a decrease of 36.2 hours. Furthermore, the integration of the auxiliary device in HPN resulted in a reduction in hospital stays. Patients undergoing HPN therapy typically have an average hospital stay of 5.4 days, which, with the introduction of the auxiliary device into the HPN regimen, was shortened to an average of 2.5 days — a reduction of 2.9 days. These results underscored the effectiveness of the Port-A auxiliary device in facilitating efficient, effective, and safe administration of HPN, leading to the amelioration of the nurses’ workload as well as reducing patient hospital stays.\u003c/p\u003e \u003cp\u003eThe results of the present study support the conclusions of previous reports examining the cost-saving implications of HPN [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Notably, the integration of HPN with the use of the auxiliary device at KMUH generated significant direct cost savings, as evidenced by a notable reduction in NHI in-hospital PN fees amounting to USD 482,432 in 2022 alone. This observation corroborates the conclusion of prior studies demonstrating the cost-effectiveness of HPN over traditional in-hospital PN modalities [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Findings from this study offer novel insights into the potential nationwide impact of widespread HPN adoption. Drawing from KMUH's experience, the implementation of HPN therapy across 22 medical centers in Taiwan is projected to result in an estimated annual savings of USD 12,212,002 in NHI hospitalization fees. These projected savings demonstrate that HPN implementation can lead to economic advantages not only for patients and the hospital but also on a larger scale such as at a healthcare system level.\u003c/p\u003e \u003cp\u003eThe implementation of HPN, particularly with the use of the auxiliary device, also resulted in substantial indirect cost savings. The reduction in the nurses’ working hours in providing HPN education translates to minimized productivity losses associated with unnecessary time spent setting up a typical in-hospital PN without the auxiliary device. This reduction in working hours not only enhances productivity and efficiency among staff, but also ensures optimal utilization of healthcare resources, mitigating the indirect costs attributed to workforce-related issues. Moreover, incorporating the auxiliary device led to decreased hospital stays for patients undergoing HPN therapy, which could potentially translate to fewer missed workdays for patients, as well as reduced caregiver burden and associated psychological discomfort. Consequently, by minimizing the duration of hospitalization and facilitating the ease of administering HPN, the auxiliary device contributes to intangible cost savings associated with patient well-being and QoL.\u003c/p\u003e \u003cp\u003eDespite these economic advantages resulting from direct and indirect cost savings, the use of HPN in appropriately selected patients remains substantially lower in Taiwan than in countries such as Germany and the USA [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Moreover, in Taiwan, there is an increased trend in home medical care due to several factors such as the coronavirus disease-19 pandemic and an aging population, suggesting an increased demand for HPN in the country in the coming years. Given that Taiwan has already transitioned into an aged society in 2018 and is projected to become a super-aged society by 2025 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], the implementation of HPN could help alleviate the strain on Taiwan’s healthcare system.\u003c/p\u003e \u003cp\u003eThe KMUH’s HPN protocol, using the Port-A auxiliary device is not only efficient and effective in producing cost-savings, but is also safe. Although AESIs were recorded during the study period, except for hyperglycemia and infection-related AESIs, the incidences of these AESIs generally demonstrated a decreasing trend, with the lowest incidences observed in 2022. This decreasing trend can be attributed to several factors, including improved patient and caregiver education and skills, enhanced compliance leading to the efficient and safe execution of HPN, and the refinement of the protocol considering unique patient needs.\u003c/p\u003e \u003cp\u003eThis study has several limitations. Firstly, there is a lack of universally accepted standards in executing HPN with the existing literature showing diverse practices [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This study, using the experience of KMUH, lacks systematic comparisons with the HPN practices of other institutions. Without a basis for comparison, the HPN protocol in KMUH lacks points of reference for areas needing improvement. Because of the diverse HPN protocols across hospitals and institutions, and the complex nature of multidisciplinary team involvement [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], further exploration is necessary to establish specific indications, criteria, and standards for HPN application. Secondly, the accurate assessment of cost savings associated with HPN in this study presents challenges. Although the economic savings were calculated by considering the reduction in hospital stay days, numerous indirect costs need to be accounted for [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], which could potentially over- or underestimate the cost-saving benefits of HPN implementation. Moreover, the possibility of HPN leading to higher medical costs due to adverse events or complications associated with PN is a factor that warrants consideration. Lastly, this study did not include assessments in QoL or patient and caregiver satisfaction. Although these are essential aspects of patient care, the data collected were insufficient to analyze these metrics. Future research should include these measurements for a more comprehensive understanding of the impact of HPN on patient well-being and their family or caregivers.\u003c/p\u003e \u003cp\u003eIn conclusion, this study highlights the multiple benefits and implications of HPN therapy, particularly within the framework of KMUH’s HPN protocol. By integrating KMUH’s SOP and using the Port-A auxiliary device model for HPN administration, significant improvements in operational efficiency, cost-saving potential, and patient outcomes were demonstrated. Particularly, the reduction in nursing workload hours and shortened patient hospital stays show the efficacy of the auxiliary device in streamlining HPN administration and enhancing patient care. However, the lack of standardized protocols, comprehensive cost analysis, and QoL assessments should be addressed in future research to refine HPN protocols. These improvements will prove crucial for the imminent widespread adoption of HPN in the fast-changing healthcare landscape in Taiwan.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003eData Availability Statement\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding authors.\u003c/p\u003e\n\u003cp\u003eAcknowledgments \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe writing of this article and other related activities were funded by Baxter, Taiwan. The funding agency had no role whatsoever in formulating the scientific content. The authors would like to thank Lance Chen of Baxter for his helpful comments on this study and manuscript preparation. English\u0026nbsp;editorial assistance for the manuscript were provided by EMD Asia Scientific Communication (Taiwan branch) Co., Ltd.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAuthor Contributions\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the conceptualization of the present study. WCS and LCS conducted the statistical analyses, prepared the tables and figures, and wrote the first draft of the paper. WCS and TKC\u0026nbsp;contributed to the planning of the statistical analyses, interpretation of the data, and writing of the paper.\u0026nbsp;YCC, CWH, YSY, PJC, TCY, and HLT supervised the conduct of statistical analyses. All authors contributed to the interpretation of the data and writing of the paper. All authors have read and approved the final paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis work was supported by grants through funding from the National Science and Technology Council (MOST 111-2314-B-037-070-MY3, NSTC 112-2314-B-037-090, NSTC 112-2314-B-037-050-MY3) and the Ministry of Health and Welfare (12D1-IVMOHW02). Funding was also obtained from the Health and Welfare Surcharge on Tobacco Products, the Kaohsiung Medical University Hospital (KMUH102-M218, KMUH112-2R37, KMUH112-2R38, KMUH112-2R39, KMUH112-2M27, KMUH112-2M28, KMUH112-2M29, KMUH-SH11207), and Kaohsiung Medical University Research Center (KMU-TC112A04). In addition, this study was supported by grants from the Taiwan Precision Medicine Initiative and Taiwan Biobank, Academia Sinica, Republic of China (Taiwan). \u0026nbsp;Ethical Approval\u003c/p\u003e\n\u003cp\u003eThis retrospective observational study was approved by the Ethics Committee of Kaohsiung Medical University Hospital (KMUH) with Institutional Review Board number KMUH-IRB-20130256.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Competing Interest\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDetsky AS, Mclaughlin JR, Abrams HB, Whittaker JS, Whitwell J, L\u0026apos;Abb\u0026eacute; K \u003cem\u003eet al\u003c/em\u003e. A cost‐utility analysis of the home parenteral nutrition program at Toronto General Hospital: 1970\u0026ndash;1982. 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Gastroenterol. 2003; 124:1651-1661.\u003c/li\u003e\n\u003cli\u003eWitteveen P, Van Groenestijn M, Blijham G, Schrijvers A. Use of resources and costs of palliative care with parenteral fluids and analgesics in the home setting for patients with end-stage cancer. Ann Oncol. 1999; 10:161-166.\u003c/li\u003e\n\u003cli\u003eNational Development Council. Population Aging [https://www.ndc.gov.tw/en/Content_List.aspx?n=85E9B2CDF4406753] Accessed June 11, 2024\u003c/li\u003e\n\u003cli\u003eJohnson T, Sexton E. Managing children and adolescents on parenteral nutrition: challenges for the nutritional support team. Proc Nutr Soc. 2006; 65:217-221.\u003c/li\u003e\n\u003cli\u003eMart\u0026iacute;‐Bonmat\u0026iacute; E, Cervera P, M\u0026iacute;nguez A, Perez-Serrano MD. A parametric description of the parenteral nutrition protocols of 19 American hospitals. Nutr Hosp. 1989; 4 1:23-30.\u003c/li\u003e\n\u003cli\u003eKim H, Spaulding R, Werkowitch M, Yadrich D, Piamjariyakul U, Gilroy R\u003cem\u003e et al\u003c/em\u003e. Costs of multidisciplinary parenteral nutrition care provided at a distance via mobile tablets. JPEN J Parenter Enteral Nutr. 2014; 38:50S-57S.\u003c/li\u003e\n\u003cli\u003eSangster AG. Home parenteral nutrition: a multi-professional approach. British Journal Community Nur. 2015; 20 Suppl 6a:S24, S26-27.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"auxiliary device, cost-effectiveness, home parenteral nutrition ","lastPublishedDoi":"10.21203/rs.3.rs-4622390/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4622390/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHome parenteral nutrition (HPN) is essential in providing nutrition and hydration to appropriately selected patients who cannot receive adequate oral or enteral nutrition. This study investigated the implementation of HPN at our institution, following our standardized operating procedures (SOP) and the utilization of the Port-A auxiliary device model.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a retrospective observational study that enrolled adult and pediatric patients undergoing HPN. The patients were supervised by the Nutrition Therapy Team of a single institution from January 2020 to December 2022.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResults indicated substantial improvements in operational efficiency and patient outcomes. Specifically, the integration of our hospital’s SOP and the use of the auxiliary device led to a notable reduction in nursing workload hours in terms of providing HPN education (mean reduction of 36.2 hours) and shortened patient hospital stays (mean reduction of 2.9 days), suggesting that these interventions can lead to a streamlined, efficient, and safe HPN administration. Furthermore, the HPN protocol of our institution led to significant direct and indirect cost savings, signifying its potential to alleviate the financial burden of Taiwan’s healthcare system. Lastly, HPN at our institution is safe, with the incidences of adverse events of special interest generally showing a decreasing trend during the study period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study demonstrates that integrating the SOP of Kaohsiung Medical University Hospital and using the Port-A auxiliary device for HPN therapy substantially enhances operational efficiency, cost savings, and patient outcomes.\u003c/p\u003e","manuscriptTitle":"Enhancing Economic Efficiency Through the Implementation of Home Parenteral Nutrition SOP with a Novel Training Module","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-11 12:32:50","doi":"10.21203/rs.3.rs-4622390/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"080a0dd7-d96b-49b4-a905-a10a00050f74","owner":[],"postedDate":"August 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-06T18:00:58+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-11 12:32:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4622390","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4622390","identity":"rs-4622390","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}