Process Management
Process Management tests the systems that turn a nutrition order into safe, traceable delivery: order verification, compounding, labeling, hang time, monitoring, transitions, and quality improvement.
Build a complete, verified order
An EN or PN order must include patient identifiers, formula or PN composition, route, rate, volume, duration, and monitoring plan. Pharmacists verify PN orders for compatibility, osmolarity, electrolyte limits, and glucose infusion rate. High-alert components-insulin, potassium, calcium, and phosphate-warrant an independent double-check. Label the bag with beyond-use date and time, storage conditions, and patient-specific identifiers.
Compounding and hang time
Follow USP <797> for sterile compounding and USP <800> for hazardous drugs. Assign beyond-use dates from the compounded preparation, not from the day it is hung. For enteral formula, a closed system commonly has a 24–48 hour hang time; an open system is typically 4–8 hours, per manufacturer and policy. Do not decant formula into unlabeled containers.
Worked example
A 70 kg patient has a PN order with 25% dextrose at 80 mL/h. Dextrose delivered = 0.25 × 80 = 20 g/h = 20,000 mg/h. Glucose infusion rate = 20,000 ÷ 70 ÷ 60 = 4.76 mg/kg/min. That is near the usual upper limit of 4–5 mg/kg/min; check glucose and consider reducing the rate or dextrose concentration. Also confirm central access, because 25% dextrose is hyperosmolar.
Transitions and quality
Plan discharge early: train the patient or caregiver, arrange home infusion, and document the tapering plan. Transition from PN to EN or oral intake when intake consistently meets at least 60% of needs. Track line infections, tube misconnections, formula errors, and unplanned interruptions; report incidents and use them for improvement.
Traps
Missing rate or composition on an order, using the wrong hang time, failing to reconcile drugs that interact with EN (phenytoin, warfarin, levothyroxine), and documenting monitoring only after an adverse event all cost marks.