Advance knowledge of Physician about Total Parenteral Nutrition in Saudi Arabia

Objectives: To explore the physician’s advanced knowledge about Total Parenteral Nutrition in Saudi Arabia. Materials and Methods: It analyzes a cross-sectional survey that discussed the physician’s basic knowledge of some items for Total Parenteral Nutrition services (TPNs) in Saudi Arabian. The survey consisted of respondents’ demographic information about Physician knowledge of Total Parenteral Nutrition services (TPNs) calculations. Besides, the physician’s understanding of Total Parenteral Nutrition services (TPNs) adjusts based on diseases, Physician knowledge of Total Parenteral Nutrition services (TPNs) components for various populations. 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 alpha, Gutmann’s λ 2, and Gutmann’s λ 6 were done with the study. Furthermore, the data analysis of the Pharmacist practice of Cardiopulmonary Resuscitation (CPR) medications is done through the survey monkey system. Besides, the Statistical Package of Social Sciences (SPSS), Jeffery’s Amazing Statistics Program (JASP), and Microsoft Excel sheet version 16. Results: A total number of 409 physicians responded to the questionnaire. Of them, almost one-half responded from the Northern region (186 (45.48%)), and one Quarter responded from the central area (106 (25.92%)), with statistically significant differences between the provinces ( p =0.000). Females responded more than males (268 (65.53%)) versus 141 (34.47%)), with statistically significant differences between all levels ( p =0.001). Most of the responders were in the age group of 36-45 years (198 (48.41%)) and 46-55 years (109 (26.65%)), with statistically significant differences between all age groups ( p =0.000). Almost one-half of responders, 176 (43.03%), worked at an organization that had Parenteral Nutrition services (TPNs) services, with only 86 (21.03%) had been ever requested any Parenteral Nutrition services (TPNs) with statistically significant differences between all answers ( p =0.000). The average score of knowledge calculation of Total Parenteral Nutrition services components was (3.41). The element “Total daily requirement of the protein” obtained the highest score (3.81). The aspect “Total daily requirement of the electrolytes” was (3.77). The average score of knowledge the Total Parental Nutrition services (TPNs) adjust with various diseases was (3.70). The element “Hepatic Failure” obtained the highest score (4.30). The aspect “Renal failure” was (4.22). Conclusion: The advanced knowledge of physicians about parenteral nutrition calculations or adjusting parenteral nutrition based on the current disease was inadequate. Therefore, targeting undergraduates and postgraduate education and training is highly in the medical care.


INTRODUCTION
Various types of patients (adults, pediatrics, neonates, and geriatric) admit to the hospital with different cor morbidity conditions such as cardiovascular problems, hepatic disorders, or kidney problems. [1]Those patients are sometimes admitted to the hospital for surgical procedures, have complications of their disease, or have any concern that leads to stopping feeding by regular diet by month. [2]The testing doctor will switch them to enteral feeding.If he fails, they switch to parenteral feeding, called partial parenteral nutrition, which can give part of their feeding by intravenous administration. [2,3]ometimes the patient needs complete nutrition provided by intravenous administration called total parenteral nutrition. [2,3]Various nutritional societies set up the contents of TPN.Such as fluid, carious, carbohydrates, protein, lipids, electrolytes, multivitamins, and trance elements. [4,5]Every component had specific calculations for neonates, pediatricians, adults, and geriatricians. [4,5]Furthermore, if the patient had additional medical concerns such as hepatics or renal problems, each component should have been adjusted accordingly to guidelines.Any health care professionals, including physicians, pharmacists, nurses, and nutritionists who deal with such patients, should be familiar with all related parenteral nutrition.That knowledge of parenteral nutrition and it assumed as advanced knowledge of parenteral nutrition.8][9][10] The authors are not familiar with any studies locally or in Gulf and Arabic countries published about the current topic. [11,12]The present study International Journal of Pharmacology and Clinical Sciences, Vol 12, Issue 2, Apr-Jun, 2023 aims to demonstrate the physician's advanced knowledge of parenteral nutrition in Saudi Arabia,

MATERIALS AND METHODS
It analyzes a cross-sectional survey discussing physicians' advanced knowledge of Total Parenteral Nutrition services (TPNs) in Saudi Arabia.It self-reported an electronic survey of the physician, including a physician from internship to consultant, physician specialties, and Saudi Arabia.All non-physician or students, non-completed, non-qualified surveys will be excluded from the study.The survey consisted of respondents' demographic information about the physician's knowledge of Total Parenteral Nutrition services (TPNs) calculations.Besides, the physician's understanding of Total Parenteral Nutrition services (TPNs) adjusts based on diseases.9][10]13] The 5-point Likert response scale system was used with closedended 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 drop-out rate 10%.[16] The response rate required for the calculated sample size is at least 60-70% and above. [16,17]The survey was distributed through 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 reliability 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  [18,19]

Factors affecting the physician's advanced knowledge of Total Parenteral Nutrition services (TPNs) calculations
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.physician knowledge of Total Parenteral Nutrition services (TPNs) calculations includes location, worksite, gender, Physician qualification, Physician specialties, years of experience, current position, Present of the ) was obtained for the consultants, with a statistically significant difference between all levels (p=0.000).Nine levels of the physician specialties affected the physician knowledge of Total Parenteral Nutrition services (TPNs) calculations, with the lowest score (3.0124) obtained for the pediatrics with a statistically significant difference between all levels (p=0.000).Six work experience levels affected the physician's knowledge of Total Parenteral Nutrition services (TPNs) calculations.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 did not affect the physician's knowledge of Total Parenteral Nutrition services (TPNs) calculations, 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 physician knowledge of Total Parenteral Nutrition services (TPNs) calculations, with a statistically significant difference between all answers (p=0.000).The physician did not request any Parenteral Nutrition services (TPNs) before, with the highest score (3.5674) affected physician knowledge of Total Parenteral Nutrition services (TPNs) calculations, 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 physician knowledge of Total Parenteral Nutrition services (TPNs) calculations, with a statistically significant difference between all answers (p=0.000).[22] Besides, three factors (worksite, gender, and the number of patients needed for TPN) explained 20.8%, 32.3%, and 15.3% of the positive relationship to the variation in knowledge, with a statistically significant difference (p=0.000)(p=0.000), and (p=0.020)respectively.The bootstrap model was also confirmed.[22] (Table 6).

Factors affecting physician's knowledge of Total Parenteral Nutrition services (TPNs) adjust based on diseases
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.22] (Table 6).[22] Besides, two factors (worksite and gender) explained 21.5%, and 18.6%, of the positive relationship to the variation in knowledge, with a statistically significant difference (p=0.000),(p=0.000), and (p=0.020),respectively.The bootstrap model was also confirmed.[22] (Table 7).

DISCUSSION
[4][5] The next very critical step is calculating of daily requirements of the seven components of TPN.That included fluid, energy, carbohydrates, protein, lipid, electrolytes, vitamins, and trance elements.All those elements should be calculated according to patient conditions and comorbid diseases.Besides, the calculation of total requirements according to the types of patients neonates, pediatric, adults, and geriatric disorders. [4,5]All those knowledge elements are required for any clinician prescribing parenteral nutrition.The current cross-sectional study for physicians to assess the of parenteral nutrition explores the updated knowledge level of TPN calculation.The study had various ages, academic qualifications, experience, working sites, and positions and jobs.That's reflected in the culture of the medical field.8] The study's findings showed that physicians' average score knowledge general calculation was medium similar to previous study. [8]Most physicians are familiar with the requirements of protein and electrolytes daily.That's related to the physicians dealing with general nutrition that needs protein and electrolytes.
In contrast, the slightest knowledge of fluid and trance elements.The litter knowledge of trance element calculation might be expected because they rarely used them in practice.In contrast, the lowest understanding of daily fluid was storage because most responders had an emergency and surgical specialties, which was essential knowledge.
The findings showed the average knowledge of calculating per population all components for the total parental nutrition average.Most physicians can calculate the daily energy, protein, and lipid for adults and geriatrics patients.That's related to whether physicians deal with surgery for adults and geriatrics, not pediatrics or neonates.However, most physicians are familiar with calculating daily fluid for geriatrics and pediatrics.That's related high demand for fluid during an emergency or surgical condition, and physicians deal more with fluid.Variable factors might affect the knowledge of adjusting TPN for specific diseases.Locations and the working site might affect the knowledge with the lowest level related non the availability of patient's needs for adjusting TPN or the facilities of TPN not existing.The female physician might deal with adjusting TPN for specific patients and gain more information than make.Older physicians with high academic qualifications, such as consultants who do not deal with comorbid conditions, require parental nutrition.Thus, the knowledge will decrease over time.The female physician is more familiar with Adjusted TPN than the male physician; might the female physician more involved in patients requiring adjusted TPN.With the higher age and high academic qualifications, such consultants had the lowest knowledge of adjusting TPN.That might be related to most of them not prescribing TPN and specialists being more involved than consultants in adjusting TPN.The internal medicine and pediatrics had higher knowledge of adjusting TPN because most patients had comorbid symptoms treated by them.Not enough experience within 4-6 years had the lowest understanding of adjusting TPN because they were more experienced and educated to be experts in adjusting TPN.The availability of TPN in healthcare organizations and the medium number of TPN had more knowledge than others that related to the daily practice of TPN increase the understanding of TPN.In contrast, a higher number of patients might affect the ability to adjust TPN because of workload and properly got mistakes in TPN.The knowledge of adjusting TPN did affect by the previous prescribing of TPN without clear reasons.As mentioned earlier, the most dependable factors that negatively affected the knowledge modified of TPN were physician qualifications, specialties, and the presence of TPN services.In contrast, working sites and gender might have been affected positively with the adjustment of TPN knowledge, as discussed before.Thus, there is no previous investigation to compare with the current findings.

Limitaions
The current study showed beneficial information about physician's knowledge of calculation and adjustments of TPN for various patients.However, it included several limitations, such as non-randomized techniques used for sampling methods, Leads a wide range of demographic characteristics, and the reliability test reaching optimal level.Figure study with randomized sampling methods and high-reliability test scores were warranted.

CONCLUSION
The average knowledge of physicians about parenteral nutrition calculation was insufficient.Some essential parts were more deficit knowledge, such as fluid and trance element calculations.In addition, the average understanding of adjusting TPN for various conditions was inadequate.For example, most physicians had a deficit of knowledge of changing calculations for people with diabetes and burn patients.Multiple factors, such as physician qualifications and specialties, might negatively affect the calculation knowledge and adjustment of TPN for disease.In contrast, other factors such as working site and gender might positively affect understanding TPN calculations and adjusted TPN knowledge.Therefore, a review of physician's curricula for undergraduate and postgraduate education to include parenteral nutrition education and training is highly recommended in Saudi medical practice.
The relationship between the physician knowledge of Total Parenteral Nutrition services (TPNs) calculations and factors such as location, worksite, age (years), gender, qualifications, specialties, years of experience, position held, 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.The multiple regression analysis considered perception as the dependent variable and factors affecting it as an expletory variable.There was a medium relationship (R=0.687 with p=0.000) between the physician's knowledge of Total Parenteral Nutrition services (TPNs) calculations and its factors.Five factors (age, experience, position, Present of the Parenteral Nutrition services International Journal of Pharmacology and Clinical Sciences, Vol 12, Issue 2, Apr-Jun, 2023

physician's knowledge of Total Parenteral Nutrition services (TPNs) calculations. The
. The female (3.4670) affected the physician knowledge of Total Parenteral Nutrition services (TPNs) calculations more than the male (3.3283) with a statistically significant difference (p=0.001).The age of the responders affected the physician's knowledge of Total Parenteral Nutrition services (TPNs) calculations.Physicians aged >55 showed the lowest score (2.8681), with a statistically significant difference between all age groups (p=0.000).Five levels of academic qualifications affected the physician's knowledge of Total Parenteral Nutrition services (TPNs) calculations.The lowest score (3.0654

Table 5 : Physician knowledge of Total Parenteral Nutrition services (TPNs) adjusted based on diseases. No Items No knowledge Little knowledge Partial knowledge Incomplete knowledge Complete knowledge Total Weighted Average p-value (X2)
knowledge of Total Parenteral Nutrition services (TPNs) adjusted based on diseases than the male (3.6434) with a statistically significant difference (p=0.000).The age of the responders affected the physician's knowledge of Total Parenteral Nutrition services (TPNs) adjusted based on diseases.Physicians aged >55 showed the lowest score (3.5478), with a statistically significant difference between all age groups (p=0.000).Five levels of academic qualifications affected the physician knowledge of Total Parenteral Nutrition services (TPNs) adjusted based on diseases, with the lowest score (3.4838) obtained for the consultants with a statistically significant difference between all International Journal of Pharmacology and Clinical Sciences, Vol 12, Issue 2, Apr-Jun, 2023

Table 6 : Multiple regression of Factors with the physician's knowledge of Total Parenteral Nutrition services (TPNs) calculations.
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.

physician knowledge of Total Parenteral Nutrition services (TPNs) adjusted based on diseases, with
a statistically significant difference between all answers (p=0.000

Table 7 : Multiple regression of Factors with the physician's knowledge of Total Parenteral Nutrition services (TPNs) adjusted based on diseases.
Dependent Variable: physician knowledge of Total Parenteral Nutrition services (TPNs) adjust based on diseases, Predictors: (Constant), 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.adjustment of TPN.Besides, burn patients might be indicated, but it is not common in practice.Thus, the results overestimated knowledge of TPN in various diseases.Thus, there is no previous investigation to compare with the current findings.Various factors might affect the adjusted TPN for different diseases.The location factor might affect the modified TPN knowledge.Such as, the southern region had the lowest knowledge related to insufficiently educated TPN physicians, non-availability of TPN services, no clinical pharmacist specialized in TPN, or the number of patients with comorbid conditions needing TPN.The working site factor might have affected the knowledge of adjusting TPN.For instance, the MOH hospitals and National Guard Hospitals might have related to un-available TPN services at most MOH hospitals and non-available patients required to adjust for TPN for National Guard hospitals.
International Journal of Pharmacology and Clinical Sciences, Vol 12, Issue 2, Apr-Jun, 2023 International Journal of Pharmacology and Clinical Sciences, Vol 12, Issue 2, Apr-Jun, 2023