Advanced Practice of Total Parenteral Nutrition by Physicians in Saudi Arabia

Objectives: To explore the physician’s advanced practice of Total Parenteral Nutrition in Saudi Arabia. Methods: It analyzes a cross-sectional survey that discussed advanced physician practice of Total Parenteral Nutrition services (TPNs) in Saudi Arabia. The survey consisted of respondents’ demographic information about physicians and Advanced Practice Total Parenteral Nutrition services (TPNs) by Physicians, the types of prescribing, preparations


INTRODUCTION
Over the years, nutrition support services have advanced significantly, including the development of enteral or parenteral nutrition, which has evolved from simple onecomponent preparations to multiple contents. [1][12] However, to ensure that the role of healthcare providers is well-documented based on international guidelines, [1,[7][8][9] various developments and methods are required to clarify physicians' job descriptions when prescribing TPN order forms for neonates, pediatrics, and adults.Physicians are crucial in designing patient safety systems during parenteral nutrition therapy, from prescribing to administering TPN contents and monitoring patients for complications and nutrition-related problems. [7]espite the availability of new technologies and developments, there is a lack of research on the advanced practice of physicians in nutrition support therapy. [7,12,18]There is a need to explore International Journal of Pharmacology and Clinical Sciences, Vol 12, Issue 3, Jul-Sep, 2023 the advanced practice of parenteral nutrition by physicians in Saudi Arabia, where standardized and customized parenteral nutrition and outsourcing are widely used. [19,20]This crosssectional study aims to fill this gap and explore the actual advanced practice of physicians in parenteral nutrition therapy in Saudi Arabia.The study aims to shed light on using premixed parenteral nutrition or outsourcing and physicians using standardized or customized parenteral nutrition therapy. [13,14]Ultimately, the study's findings will provide insights into the current advanced practice of physicians in nutrition support therapy and help improve patient care and outcomes.The overall aim of this study is to investigate the advanced practice of Total Parenteral Nutrition by physicians in Saudi Arabia by exploring their utilization of standardized or customized TPN prescribing, premixed parenteral nutrition or outsourcing, identifying challenges they face, and providing recommendations for improving their practice, emphasizing Specific objectives that include investigating the current advanced practice of physicians in Total Parenteral Nutrition (TPN) therapy locally, examining the utilization of standardized or customized TPN prescribing by physicians, and assessing the utilization of pre-mixed parenteral nutrition or outsourcing by physicians in Saudi Arabia.Besides, identify the challenges physicians face in TPN therapy, and provide recommendations for improving the advanced practice of physicians in TPN therapy in Saudi Arabia.

METHODS
This study employed a cross-sectional survey design to explore the advanced practice of Total Parenteral Nutrition (TPN) by physicians in Saudi Arabia.An electronic survey utilizing a 5-point Likert response scale system with closed-ended questions was self-reported by physicians ranging from internship to consultant levels across various specialties in Saudi Arabia.Non-physicians, students, and incomplete or unqualified surveys were excluded from the study.The survey consisted of questions on the respondents' demographic information, advanced practice of TPN by physicians, types of TPN prescribing, preparations and administrations, and responsibility of TPN services.[23][24] The response rate required for the calculated sample size is at least 60-70% and above. [23,24]he survey was distributed through social media platforms such as WhatsApp and Telegram groups of physicians, and a reminder message was sent every 1-2 weeks.The survey was validated through expert review and pilot testing, and various reliability tests were conducted.Data was analyzed using the SurveyMonkey system, the Statistical Package for Social Sciences (SPSS), Jeffery's Amazing Statistics Program (JASP), and Microsoft Excel Sheet Version 16.The analysis included descriptive and frequency analysis, goodness of fitness analysis, correlation analysis, and linear regression analysis was used to determine factors affecting the advanced practice of TPN by physicians and the responsibility of TPN services.The study followed the STROBE (Strengthening the reporting of observational studies in epidemiology statement: guidelines for reporting observational studies) guidelines for reporting observational studies in epidemiology. [25,26]

Factors affecting the practice responsibility of the Total Parenteral Nutrition services (TPNs) at the institution
Factors affecting the perception were analyzed.We adjusted the significant values using the independent samples Kruskal-Wallis test and the Bonferroni correction for multiple tests.before, and the number of patients needed for TPN) out of twelve were non-significant differences (p>0.05).However, multiple regression analysis confirmed that one factor (i.e., gender) explained 20.2% of the negative relationship to the variation in practice, with a statistically significant difference (p=0.000).

Practice responsibility of the
The bootstrap model was also confirmed.Furthermore, the relationship was verified by the non-existence of multicollinearity with a Variance Inflation Factor (VIF) of 1.359, less than three or five as a sufficient number of VIF.Besides, three factors (physician qualifications, physician specialties, and Number of TPN orders) explained 18.1%, 20.5%, and 28.8%, respectively of the positive relationship to the variation in practice, with a statistically significant difference (p=0.000),(p=0.000), and (p=0.000),respectively.The bootstrap model was also confirmed.[29] (Table 7).

DISCUSSION
][9] The use of standardized physician orders and electronic prescribing of TPN has also made the process easier and prevented prescribing errors by physicians. [9,20]lectronic prescribing of TPN is an additional new development that physicians need to practice daily. [2,7]30,31] The physicians must know all ready-made content and the appropriate prescribing for individual patients.However, adopting these new procedures and techniques in TPN requires the cooperation of healthcare professionals such as physicians, pharmacists, and nutritionists.A recent crosssectional study of physicians revealed that the average advanced practice of physicians in TPN was acceptable.Most physicians practiced a patient safety system for TPN, which is expected since international and national quality management standards and accreditation agencies require it.The present research consists of a wide range of physicians' demographic characteristics that can reflect the physician's culture, similar to previous studies. [2,15,14]The findings showed that the average advanced practice by physicians was acceptable.
Most physicians practice a patient safety system for TPN; that has expected because international and national quality management standards and accreditation agencies require it.Thus, there is no previous investigation to compare with the current findings.
The second most common practice item by physicians was using a pediatric TPN form and a clean room for TPN preparation.Using the pediatric form for prescription makes life easier and prevents unnecessary mistakes.However, the adult form of TPN was less found in practice, possibly due to its unavailability at some healthcare facilities.A clean room area is required for the aseptic TPN preparation technique, although physicians do not prepare the TPN.The TPN services are managed by the pharmacy department or administered by nurses in the ward.The lowest practice item among physicians was electronic prescribing of TPN, which is expected because the physician's order entry system was unavailable for most local healthcare organizations. [32,33]Additionally, implementing IV admixture emphasizing TPN services is not widely available at most local hospitals. [32,33]The study showed that most pediatrics and adults used customized TPN, Most physicians prefer the TPN responsibility were pharmacy technicians and physicians.While not choosing the clinical pharmacist or pharmacist to be responsible for TPN.That is related might most physicians deal with the pharmacy technicians who prepare TPN in the pharmacy department.Various factors affect the perception of responsibility for TPN services.The location affected physicians' perception; the northern and southern areas had the lowest agreement with physician's responsibilities for TPN, while the central area had a higher deal of physician's duties but did not agree with clinical pharmacists.That has related might more educated physicians in TPN in the central region than in southern and northern areas.The northern area is more agreed for clinical pharmacists for TPN responsibility might relate to available TPN clinical pharmacists.The working sites like the Military, national guard, and university hospitals were lower agreements of physician's responsibilities for TPN, which might be related to the availability of clinical pharmacists to take care of TPN services.Thus, The military and national guard hospitals agreed more with clinical pharmacists for TPN responsibilities.The female gender disagrees with physician's responsibilities for TPN because most involved in the TPN process were female physicians, which might show the difficulties of TPN services.However, they still disagree with the clinical pharmacist for TPN responsibility; it might deal with pharmacy technicians.Thus, there is no previous investigation to compare with the current findings.The academic qualifications might affect physicians' perception of TPN responsibilities; the resident agreed little with the physician's duties, while the consultant agreed with responsibilities related to inadequate clinical pharmacists early and took care of TPN responsibilities.In contrast, today, general practitioners found that pharmacists taking care of them decreases the physician's work and responsibilities.The physician specialties might have the perception of responsibility, such as emergency physicians highly disagree with TPN responsibilities for TPN because of the high workload in the emergency and might difficulties educating TPN services.While they prefer the physician responsible for TPN, it might contradict with pharmacist's responsibility for TPN because most patients used only four TPN administrations, which was not the preferred indication.The physician's experience might affect the physician responsible for TPN; less experienced physicians disagree with responsibility because they might find difficulties in the TPN prescribing alone, and available pharmacists can do the job without any problems.Thus, most with 1-3 years of experience prefer the clinical pharmacist for TPN responsibility.Most physicians did not agree with the physician's TPN responsibility with the presence of TPN services at healthcare facilities or physicians prescribing TPN most physicians disagree with TPN responsibility by physicians.With The high number of patients required for TPN or the number of TPN orders, the physician disagrees with the TPN's responsibility.The most dependable factor was female gender affected physician's responsibilities negatively for TPN, as explored earlier.However, other factors, such as the physician's qualifications, specialty, and number of TPN, disagree with the physician's responsibilities for TPN services.Thus, there is no previous investigation to compare with the current findings.

LIMITATIONS
Despite there are advantages of current research of advanced practice of TPN and reflecting the accurate picture in medical care.There are various disadvantages, such as the samplings method was not randomized and included a wide range of demographic characteristics of subjects.Besides, the reliability test was not optimal.Future research about advanced TPN with randomized sampling techniques and high-reliability results is highly suggested.

CONCLUSION
The physician's practice of advanced total parenteral nutrition was adequate.The physicians practice common elements of TPN, such as patient safety and using TPN ordering forms.In contrast, the physician's lease practice of an electronic prescribing of TPN or automated preparation of TPN.Various factors might be affected positively of practice, such as age, gender, and the number of patients.In contrast, other factors, like location and physician qualifications, might negatively affect the practice.One of the physician's responders did not practice a new model of prescribing TPN.Most physicians agreed that the TPN services take care of by physicians and pharmacy technicians, with negative approval with pharmacist or clinical pharmacist responsibilities in parenteral nutrition.Various factors might negatively affect the duties, such as physician's qualifications, specialties, and the number of TPN prescriptions.Other factors might positively influence gender.The advanced practice of TPN with the model of prescribing should be reviewed thoughtfully with TPN teams emphasizing the pharmacist Parenteral Nutrition services (TPNs) at the institution.Factors affecting the perception were analyzed.We adjusted the significant values using the independent samples Kruskal-Wallis test and the Bonferroni correction for multiple tests.Advanced practicing Total Parenteral Nutrition services (TPNs) at the institution International Journal of Pharmacology and Clinical Sciences, Vol 12, Issue 3, Jul-Sep, 2023 Total Parenteral Nutrition services (TPNs) at the institution includes location, worksite, gender, Physician qualification, Physician specialties, years of experience, and current position.In addition International Journal of Pharmacology and Clinical Sciences, Vol 12, Issue 3, Jul-Sep, 2023

Table 2 : Demographic, social information. Physician Qualifications Response Count Response Percent p-value (X2)
International Journal of Pharmacology and Clinical Sciences, Vol 12, Issue 3, Jul-Sep, 2023

Table 4 : The types of prescribing, preparations, and administrations of the Total Parenteral Nutrition services (TPNs) system. No Items Neonates Pediatric Adolescent Adults Geriatrics I do not know how to calculate it
SkippedInternational Journal of Pharmacology and Clinical Sciences, Vol 12, Issue 3, Jul-Sep, 2023

of practicing Total Parenteral Nutrition services (TPNs) at the institution. Physicians
levels (p=0.000).Six levels of work experience affected the institution's advanced practicing Total Parenteral Nutrition services (TPNs).The lowest score (3.0952) was obtained for those with work experience of >12 years, with a statistically significant difference between all levels (p=0.008).Five levels of the position

Table 6 : Multiple regression of Factors with the Advanced Practice Total Parenteral Nutrition services (TPNs) by Physicians.
a. Dependent Variable: Advanced practice Total Parenteral Nutrition services (TPNs) by Physicians, Predictors: (Constant), location, worksite, gender, Physician qualification, Physician specialties, years of experience, current position, Present of the Parenteral Nutrition services (TPNs) at the institution, Requisitions of any Parenteral Nutrition services (TPNs) before, Number of TPN orders, and Number of patients needed for TPN.International Journal of Pharmacology and Clinical Sciences, Vol 12, Issue 3, Jul-Sep, 2023

Table 6 : Multiple regression of Factors with the Advanced Practice Total Parenteral Nutrition services (TPNs) by Physicians.
Dependent Variable: the responsibility of the Total Parenteral Nutrition services (TPNs), Predictors: (Constant), location, worksite, gender, Physician qualification, Physician specialties, years of experience, current position, Present of the Parenteral Nutrition services (TPNs) at the institution, Requisitions of any Parenteral Nutrition services (TPNs) before, Number of TPN orders, and Number of patients needed for TPN.
International Journal of Pharmacology and Clinical Sciences, Vol 12, Issue 3, Jul-Sep, 2023 International Journal of Pharmacology and Clinical Sciences, Vol 12, Issue 3, Jul-Sep, 2023