Audit of the dietetic management of patients at risk of refeeding syndrome in an acute Dublin hospital and subsequent implementation of a hospital policy.
- Cathy O’ Neill, Senior Dietitian Upper GI Surgery, Beaumont Hospital, Dublin, Ireland (2011)
Currently: Gráinne Corrigan, Dietitian in Gastroenterology, Beaumont Hospital, Dublin, Ireland.
What was the problem you were trying to address?
It was noted among the research group of the dietetic department that there was a considerable variation in practice with regards to the dietetic management of patients at risk of refeeding syndrome.
An enteral feeding audit within the dietetic department showed 21% of patients (n = 17) commenced on enteral feeds (n=80) over a month period, were deemed at risk of this syndrome. Our departmental parenteral nutrition (PN) audit showed 58% of patients (n=127) commenced on PN (n=220) over one year were at risk of refeeding syndrome. Concomitantly, the gastroenterology department highlighted a poor awareness and management of refeeding syndrome among the medics through an audit of emergency admissions. From this audit 42% percent of patients (n=102) were deemed at some risk of refeeding, of which only 32% were managed appropriately. Only 9% of the high risk patients were referred to the dietetic department. Consensus was the need for assessment of current dietetic practice and a more uniform and evidence based, multidisciplinary guideline for the management of these patients.
How did you create your project plan?
The dietetic research group completed a literature review of the management of refeeding syndrome and sourced an existing audit of dietetic practice in refeeding syndrome. This questionnaire was adapted and completed anonymously by each dietitian in the department to assess the current management of patients deemed at risk of refeeding syndrome. The results were summarised by the research group and presented at a journal club meeting of the dietetic department for discussion.
A working group was formed with representation from the dietetic, nursing, pharmacy and gastroenterology departments and regular meetings were held to discuss the actions needed to implement a hospital policy on the management of refeeding syndrome, e.g. the need for nutritional screening. The roles and responsibilities of the various professions were highlighted and summarised in the refeeding syndrome guideline document.
- The results of the practice audit were compared to the recommendations made by The National Institute for Health and Clinical Excellence (NICE) in their guideline “Nutrition Support in Adults (2006)” and presented at journal club.
- The policy working group have submitted the final draft of a comprehensive Guideline on the Prevention & Treatment of Refeeding Syndrome, to be available on the hospital intranet for reference. A 2-page summary document with an algorithmic model for the management of patients at risk of refeeding syndrome (NICE, 2006) and micronutrient / electrolyte supplementation was developed as a quick reference guide on the wards.
- Awareness and education on refeeding syndrome was achieved through presentations to medical and nursing students, grand round presentations and hopefully, once approved there will be further education at ward-level.
- There was considerable variation in the dietetic practices regarding refeeding syndrome management and their consistency with the NICE guidelines.
- In particular, there was a significant difference in the micronutrient supplementation recommended by the dietitian, despite clear guidance on this from NICE.
- It was also noted that a considerable number of patients are identified at risk of refeeding syndrome following dietetic assessment.
- Many at- risk patients are likely not identified due to the absence of nutritional screening in the hospital at present. It is hoped this will be implemented in the near future to optimise the number and appropriateness of dietetic referrals.
- The dietetic department, as a whole now follow the NICE guidelines 2006 for the management of patients at risk of refeeding and will refer to the policy document for guidance once approved. Scope for clinical judgement remains for all cases.
- The availability of a comprehensive guideline for the management and treatment of refeeding syndrome will be invaluable at ward level and ensure safety and uniformity in the medical management of these patients.
- The development and communication of this policy has greatly increased the awareness and knowledge of refeeding syndrome among the medical and nursing staff, which helps facilitate best practice in the nutritional care of these patients, e.g. completion of blood levels requested by the dietitian, electrolyte supplementation etc.
How are you going to maintain the improvement?
A follow up audit of the dietetic practice on refeeding syndrome will be completed to ensure an improvement and uniformity in evidence based management of this patient group. Regular education through presentations, grand rounds and ward updates will maintain the greater awareness of refeeding syndrome now achieved.
Tips for others planning similar projects
- Form a smaller working group to co-ordinate the project if involving a large group. The subgroup of dietitians (research group) worked well in terms of assigning tasks, attendance at meetings etc.
- The multidisciplinary approach to the development of the guidance document worked extremely well and regular meetings provided a platform to discuss any changes / improvements needed.
- The absence of hospital-wide nutritional screening was the main barrier to the implementation of a refeeding policy and the establishment of this in the future is hoped to greatly enhance the project goals.
“What’s all this about refeeding syndrome?” – Consultant Nephrologist
“This patient is at high risk of refeeding so we are monitoring his electrolytes daily” – Medical Senior House Officer
“Can we have a copy of the refeeding guideline for the ward- I never knew anything about this before now” – Clinical Nurse Manager