The Basic Practice of Total Parenteral Nutrition by Physicians in Saudi Arabia

Objectives: To explore the essential practice of Total Parenteral Nutrition services (TPNs) by the physician in Saudi Arabia. Materials and Methods: The study is a cross-sectional survey highlighting the essential practice of Total Parenteral Nutrition services (TPNs) by a Saudi Arabian physician. The survey consisted of respondents’ demographic information about the essential practice of Total Parenteral Nutrition services (TPNs) by the physician at the institution, including the availabilities of Parenteral Nutrition services (TPNs) at the institution, physician prescribing TPN, the number of patients who need TPN, and the number of TPN orders. The 5-point Likert response scale system was used with closed-ended questions. The survey was validated through the revision of expert reviewers and pilot testing. Besides, various tests of the reliability of McDonald’s ω , Cronbach


INTRODUCTION
Physicians, during their undergraduate education journey, make various clinical rotations.As included medical, surgical, obstetrics, gynecology, pediatric, and other disciplines in medical practice.There is a need for the physician to be familiar with nutrition support, either enteral or parental feeding, at specific rotations such as pediatrics and surgical rotations.To focus more, the physician should prescribe parenteral nutrition according to internal enteral and parental feeding guidelines.Besides, the job description and competency requirements for nutrition support.[3] Those competencies recommendations to prevent enteral or parental nutrition support-related problems.Enteral and parental nutrition-related concerns had critical consequences that should be considered such as impact on patients, and economic burden on healthcare systems. [4][7][8][9] The authors were unaware of any publication about the current topic locally or in Gulf and Arabic International Journal of Pharmacology and Clinical Sciences, Vol 12, Issue 1, Jan-Mar, 2023 countries. [10,11]The cross-sectional study aims to illustrate the primary practice of TPN by physicians in Saudi Arabia.

MATERIALS AND METHODS
An across-sectional survey that investigated the physician's basic knowledge about Total Parenteral Nutrition services (TPNs) in Saudi Arabia.The survey was a self-administered questionary that was designed electronically.The physician samples include all physicians, from interns to consultants, and physician specialties, in all regions of Saudi Arabia.The excluded criteria were all non-physician or students, non-completed, non-qualified surveys.The survey consisted of 3 parts that included respondents' demographic information and the essential practice of Total Parenteral Nutrition services (TPNs) by the physician at the institution.[8][9]12] The essential practice of Total Parenteral Nutrition services (TPNs) by the physician at the institution consists of 13 items assessed by a 5-point Likert response scale system with closed-ended questions.According to the previous litterateur with an unlimited population size, the sample was calculated as a cross-sectional study, with a confidence level of 95% with a z score of 1.96 and a margin of error of 5%, a population percentage of 50%, and a drop-out rate 10%.[15] The response rate required for the calculated sample size is at least 60-70% and above. [15,16]The physician recruitment process by snowball sampling techniques was used by distributing the survey via social media of what's applications and telegram groups of a physician.The reminder message had been sent every 1-2 weeks.The survey was validated through the revision of expert reviewers and pilot testing.Besides, various tests of the reliability of McDonald's ω, Cronbach alpha, Gutmann's λ2, and Gutmann's λ6 been done with the study.The data analysis of the physician practice of some items for Total Parenteral Nutrition services (TPNs) at the institution is done through the survey monkey system.Besides, the Statistical Package of Social Sciences (SPSS) version xx, Jeffery's Amazing Statistics Program (JASP), and Microsoft Excel sheet version 16.It included a description and frequency analysis, good of fitness analysis, and correlation analysis.Besides, inferential analysis of factors affecting the essential practice of Total Parenteral Nutrition services (TPNs) by the physician with linear regression.The STROBE (Strengthening the reporting of observational studies in epidemiology statement: guidelines for reporting observational studies) guided the reporting of the current study. [17,18]
The estimated total number of TPN prescriptions was (21,  3).The average score of practice items for Total Parenteral Nutrition services (TPNs) at the institution was (3.31).The element "Mission of Total Parenteral Nutrition services (TPNs) system" obtained the highest score (3.61).The element "Nutrition Support Team services: was (3.56).In contrast, the lowest score was obtained for the element "The vision of reporting Total Parenteral Nutrition services (TPNs)" (2.59).The score for the element "education and training program of Total Parenteral Nutrition services (TPNs)" was (3.11), with a statistically significant difference between the responses (p<0.000).All aspects of the practice of pharmacists about of practice items for Total Parenteral Nutrition services (TPNs) at the institution were statistically significant between responses (p<0.000)(Table 4).The score for single-test reliability analysis of McDonald's ω was 0.685, Cronbach's α was 0.678, Gutmann's was λ2, 0.718, Gutmann's λ6 was 0.885, and Greater Lower Bound was 0.957 with statistically significant (p<0.05).

Factors affecting the essential practice of Total Parenteral Nutrition services (TPNs) by the physician at the institution
Factors affecting physician practice were analyzed.We adjusted the significant values using the independent samples Kruskal-Wallis test and the Bonferroni correction for multiple tests.The essential practice of Total Parenteral Nutrition services (TPNs) by the physician at the institution includes location, worksite, gender, Physician qualification, Physician specialties, years of experience, current position, presence 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.The result showed that the central region displayed the highest scores (3.3757) of TPN prescription, with statistically significant differences between regions (p=0.000).Regarding the workplace site, the study revealed that ten worksites affected the essential practice of (TPNs) by the physician at the institution.Moreover, the lowest scores (3.1213) were obtained from MOH hospitals with statistically significant differences among all sites (p=0.004).Regarding the physician gender and TPN practice, the result showed that females (3.4670) were more affected the essential practice of (TPNs) by the physician at the institution than males (3.3283) with a statistically significant difference (p=0.001).Also, the age of the responders affected The essential practice of (TPNs) by the physician at the institution.Additionally, physicians aged more than 55 years old showed the lowest score (2.8681), with a statistically significant difference between all age groups (p=0.000).
Five levels of academic qualifications also affected the essential practice of (TPNs) by the physician at the institution.The lowest score (3.0654) was obtained for the consultants, with a statistically significant difference between all levels (p=0.000).Five levels of the physician specialties affected the essential practice of (TPNs) by the physician at the institution, with the lowest score (3.0124) obtained for the pediatrics with a statistically significant difference between all levels (p=0.000).The levels of work experience affected the essential practice of (TPNs) by the physician at the institution.The lowest score (3.0816) 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 affect the essential practice of Total Parenteral Nutrition services (TPNs) by the physician at the institution, with the highest score (3.7619) of physician staff with a statistically significant difference between all levels (p=0.000).The presence of the Parenteral Nutrition services (TPNs) at the institution with the highest score (3.5244) affected The essential practice of Total Parenteral Nutrition services (TPNs) by the physician at the institution, with a statistically significant difference between all answers (p=0.000).The physician did not request any (TPNs) before, with the highest score (3.5674) affected The essential practice of Total Parenteral Nutrition services (TPNs) by the physician at the institution, with a statistically significant difference between all answers (p=0.000).The total number of patients needed for TPN orders (81-100) daily had the highest score (3.5608), which affected The essential practice of (TPNs) by the physician at the institution, with a statistically significant difference between all answers (p=0.000).The total number of TPN orders (16-20) and (6-10) daily had the highest score (3.8413) and (3.5868), respectively, affected The essential practice of Total Parenteral Nutrition services (TPNs) by the physician at the institution, with a statistically significant difference between all answers (p=0.000).(Table 5).
The relationship between the physician practice of some items for Total Parenteral Nutrition services (TPNs) at an institution and factors such as location, worksite, age (years), gender, qualifications, specialties, years of experience, position held, the availability of 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.The multiple regression analysis considered perception as the dependent variable and factors affecting it as an expletory variable.There was a medium relationship (R=0.661 with p=0.000) between the physician practice of Total Parenteral Nutrition services (TPNs) and its factors.Six factors (worksite, physician qualifications, experiences, position, requisitions of any Parenteral Nutrition services (TPNs) before, and the number of patients needing TPN) out of twelve were non-significant differences (p>0.05).However, multiple regression analysis confirmed that four factors (i.e., locations, physician specialties, presence of the Parenteral Nutrition services (TPNs) at the institution, and the number of TPN orders) explained 18.0%, 18.5%, 49.8.2%, and 26.3% respectively of the negative relationship to the variation in knowledge, with a statistically significant difference (p=0.000),(p=0.000),(p=0.000) and (p=0.000).The bootstrap model was also confirmed.Furthermore, the relationship was verified by the non-existence of multicollinearity with a Variance Inflation Factor (VIF) of 1.288, 1.430, 1.836, and 1.408, respectively, less than three or five as a sufficient number of VIF.Besides, two factors (age and gender) explained 19.5%, and 36.7%, of the positive relationship to the variation in knowledge, with a statistically significant difference (p=0.000) and (p=0.000),respectively.The bootstrap model was also confirmed.21] (Table 5).

DISCUSSION
The nutrition support program consisted of an oral diet, which is a dietitian's or nutritionist's responsibility. [1]The second type of enteral feeding is a ready-made fluid diet given through a tube by nasal or oral route.Enteral feeding is most the responsibility of dietitians or nutritionists and sometimes by physicians or pharmacists. [1]The third practice of nutrition is parental nutrition which is primarily the responsibility of pharmacists or physicians and sometimes by dietitians or nutritionists.All those previous types required various practice issues related to knowledge and skills.The current cross-sectional study will focus on parental nutrition.The electronic self-administered survey was distributed to multiple types of physicians with different age levels and specialties.It reflected physician's culture to demonstrate their practice of parental nutrition in Saudi Arabia.7] The findings showed that less than half of respondent's organizations had parenteral nutrition services.However, most organizations were hospitals, indicating that intravenous administration services might not exist, as shown in previous research.The findings showed few respondents had only requested TPN before, which might reflect the inadequate practice of parenteral nutrition.Generally, the results showed a considerable number of more than twenty thousand TPN prescriptions for more than nine hundred patients daily.The average TPN prescription was almost four days, which most patients might undergo for surgical purposes, which was not an appropriate TPN duration. [8]The findings showed that physicians intermediate practice of TPN.The most practice element was the mission of TPN, and TPN teams existed in hospitals which was a good advantage.However, the lowest practice element was the vision of TPN services and the lack of education and training for TPN.That's expected because the majority of hospitals do not have TPN services.TPN Educational support will improve the practice of TPN by physicians. [12]Furthermore, some practice elements are always non-available in the hospital, such as quality management of TPN services, ADR of TPN documentation, and Medication errors of TPN, which was very important to monitor all TPN-related problems.Besides, TPN competency, policy, and procedures are not fully implemented at hospitals which might lead to difficulties in physician's practice.For more explanation, several factors affected the physician's essential practice of TPN in Saudi Arabia.Regarding the practice pattern, the highest practice of TPN was located among central region physicians.That's anticipated because most available the advanced hospital had TPN services.The study revealed that the MOH hospitals had the lowest physician's practice for the working sites because most did not have TPN services.Concerning gender, female physicians had more TPN practice than male physicians, who might be more involved in TPN prescribing.Regarding the physician experience, the study concluded that the older physicians and consultants with high years of experience had the lowest TPN practice.They might be busy with administrative issues or leave TPN practice to younger staff physicians for education and to gain more practice and experience.According to the physician specialist, the study revealed that the pediatric physician had the lowest practice of TPN, which might be related to insufficient knowledge to prescribe TPN and no standardized system for TPN services.The presence of TPN services at healthcare facilities, a high number of TPN orders, and the high number of patients requiring TPN had much practice TPN.The most dependable factors that might affect TPN practice by physicians were positive, such as gender and age.To

The number of TPN orders prescribed daily Response Count Response Percent
International Journal of Pharmacology and Clinical Sciences, Vol 12, Issue 1, Jan-Mar, 2023

Table 5 : Multiple regression of Factors with the physician's knowledge of Total Parenteral Nutrition services (TPNs) adjusted based on diseases.
Dependent Variable: the basic practice of Total Parenteral Nutrition services (TPNs) by the physician at the institution, 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 1, Jan-Mar, 2023