Prealbumin testing leads to PN feeding savings

Pharmacy-led team saves $1.3 million per year

An aggressive prealbumin testing regime, parenteral nutrition (PN) protocols, and oversight by a hospitalwide nutrition support team has turned a once-lofty goal of decreasing patient stays through nutrition into an estimated $1.3 million annual savings for Bridgeport (CT) Hospital.

The hospital’s pharmacy developed nutrition testing and feeding protocols that — together with dietary, lab, medical, and nursing staffs — make up the nutritional support team concept. A one-page PN protocol chart includes the tasks of the various departments from admission through the initial weeks of PN intravenous feeding. (See chart, p. 139.)

"We’re looking at critically ill and problem patients with the dietitians, nurses, and a GI fellow," says senior clinical pharmacist Teresa Papstein, RPh, BCNSP. "During rounds, the pharmacists recommend the types of solutions and concentrations related to protein or caloric intake or any electrolyte changes if necessary," she says.

Prealbumin testing is done upon admission to detect levels of malnutrition. Then it’s repeated twice a week on Mondays and Thursdays following the first week of PN feeding, along with related lab work such as a chemistry profile, magnesium, phosphorous, and blood sugar levels.

Prealbumin and albumin are transport proteins produced in the plasma of the liver. With a 21-day half-life, prealbumin flows only in the vascular space and remains in the circulation longer than albumin, allowing for increased examination to determine the level of patient malnutrition, explains Bridgeport’s chief of chemistry, Larry Bernstein, MD. Half-life refers to the rate of the protein’s degradation vs. its creation. With a half-life of just one or two days, albumin flows throughout the extravascular space, making it harder to track and evaluate for malnutrition levels, Bernstein says.

In terms of treatment following prealbumin testing, the hospital’s specific protocol calls for an automatic 500 ml of 20% fat emulsions for patients on peripheral parenteral nutrition (PPN) feeding, using a shorter catheter that can be in place longer. Patients on total parenteral nutrition (TPN) feeding who need a longer catheter receive a 10% fat emulsion unless either percentage is changed by a physician, pharmacist, or dietitian.

"Basically we found inappropriate use of fat. Our PPN patients were not getting enough calories. We’re getting more fat calories under the protocol, which should help caloric intake and in turn their prealbumin testing," Papstein says. Under-taking prealbumin testing, developing a protocol with standard nursing compliance charts, and creating the nutrition team concept have been a decade in the making at Bridgeport.

Prealbumin testing is eliminating inappropriate use of PN feeding and allowing an earlier transition from parenteral to enteral tube or oral feeding based on prealbumin results, Papstein says. And that, in turn, is leading to shorter patient stays and greater financial savings.

Bernstein estimated the length of stay savings by calculating the percentage of patients with severe or moderate malnutrition that could be better identified with prealbumin testing. Papstein notes that pharmacists, charged with ensuring lab work compliance, work directly with the nursing staff on any blood work oversight.

In the nutrition program, nutritional testing criteria include all admissions who are unable to swallow or eat for up to five days before admission, those with a history of weight loss of more than 20%, those with specific diseases such as AIDS, those with a serum albumin level below 3.2 mg, and those placed on PPN, TPN, or enteral support. Earlier criteria included patients 65 or older, but that requirement was dropped upon review.

In the 425-bed facility, part of the Yale-New Haven Health System, an average of 10 to 20 patients are on PN feeding at any one time, Papstein says.

As chief of chemistry, Bernstein has been a long-time champion of prealbumin as a quicker and more effective means of nutritional testing, based again on its longer half-life, even though the prealbumin testing can cost more than albumin testing. However, he argues, by establishing proper nutritional feeding based on prealbumin testing, the patient’s chances for a shorter hospital stay and the resulting savings outweigh the higher cost. Bernstein predicts prealbumin testing eventually will replace albumin testing as the test kits advance or become compatible with current albumin test kits.

"In the acute care setting it’s important because when a patient becomes malnourished, the liver stops producing prealbumin. We identify high-risk patients as soon as possible, in the first 24 hours, then have the dietitians come in," he says. Patients given a level-three status are the highest risk because they are malnourished or will become so. "The most severely malnourished patients benefit from intervention, but it’s in the moderate patients where the disagreement is," he says.That debate centers not on which testing is better but on how patient feeding can make patients better, he says.

"The Joint Commission wants patients identified early then put on a feeding plan within 48 hours, so the relationship with this [prealbumin] process is best. With the 21-day half-life of albumin testing, it may take a week to see a patient’s change depending on metabolic reserve," he says.

Burn or trauma patients or those with gastrointestinal diseases benefit greatly from prealbumin testing, he says. In the burn unit, a prealbumin test is necessary because skin grafting won’t hold unless the score level is at least 8.5. Determining a satisfactory level as quickly as possible is an obvious need, Bernstein argues, adding that albumin testing alone can’t determine it as fully or as fast.

The hospital deems a prealbumin score of 11 to 16 as mild malnutrition, with anything less than 11 as medically significant. Based on differing patient risk categories, length of stay financial savings at Bridgeport have been estimated at $200,000 for mild-risk patients, $727,135 for moderate-risk, and $339,330 for severe-risk patients. The hospital’s pharmacy chipped in an estimated $50,000 in savings for an annual total of $1,316,465.

Meanwhile, Bernstein and his colleagues still debate which test is better. Although prealbumin tests are done to confirm albumin tests, he says prealbumin tests alone would suffice. "Like many things, it will require a change in thinking and acceptance," he says, a process he believes will take a few years. "People who’ve seen prealbumins say, ‘Why do we do albumins?’ and my only response to that is it’s been around for so long."

[Editor’s note: For more details, contact Teresa Papstein, RPh, BCNSP, Bridgeport Hospital, 267 Grant St., Bridgeport, CT 06610. Telephone: (203) 384-3797. Or contact Larry Bernstein, MD. Telephone: (203) 384-3208. E-mail:]