Mo2116 Development of Institutional Guidelines for the Identification and Management of Refeeding Syndrome Among Acutely Admitted Patients

Abstract

Refeeding Syndrome refers to biochemical and physical abnormalities, arising as a result of shifts in electrolytes and fluid balance in malnourished individuals following the initiation of feeding. This is an acute complication of malnutrition among hospitalised patients with the potential for significant morbidity and mortality. We audited the percentage of patients admitted over 6 days at a tertiary referral centre at high risk of Refeeding Syndrome. Analysis of identification and management centred on NICE (National Institute of Clinical Excellence) Guidelines, CG32. 102 patients were included and 22 (21.5%) patients were at a high risk for developing Refeeding Syndrome. 8 patients from the high risk group did not have electrolyte levels monitored. Of the 14 high-risk patients who had bloods assayed, their treating physician prescribed only 7 patients thiamine. Only 32% of patients at high risk of Refeeding Syndrome were managed according to best practice, and 9% of the patients at high risk progressed to develop Refeeding Syndrome with one mortality. Following these findings, we formed amultidisciplinary committee comprisingmembers from the Department of Gastroenterology and Hepatology, Department of Nutrition and Dietetics, Department of Pharmacy and Nursing Administration. We developed institutional guidelines derived from literature review and NICE Guidelines for the identification and management of Refeeding Syndrome. We also developed guidelines for repletion of electrolytes with specific reference to formulations and doses appropriate to the levels of repletion required. A programme of education for nursing and clinical staff alike was undertaken, with the addition of regular patient weights applied to nursing charts and more streamlined dietician referral practices applied throughout the hospital. Flowcharts for expedient clinical intervention were available on all wards and the accident and emergency department, as were the above-mentioned electrolyte repletion guidelines. We are pleased to report that a repeated audit after initial implementation of these guidelines revealed that 11/54 patients (20%) were at high risk of Refeeding Syndrome. 45.5% of these patients were managed according to the guidelines, receiving both thiamine and appropriate blood investigations, which is comparable to 32% in the initial audit. This demonstrates progress after only 2months of widespread implementation of these guidelines at our institution. This audit cycle highlights the importance of identification and management of patients at risk of Refeeding Syndrome. The application of formal guidelines generated in a multidisciplinary manner as demonstrated at our institution yields improvements in patient management, giving clear recommendations and improving clinical education and awareness of malnutrition.