Refeeding syndrome consists of metabolic changes that occur on the reintroduction of nutrition to in those who are malnourished or in the starved state (Figure 1). The consequences of untreated re-feeding syndrome can be serious; causing hematologic abnormalities and result in death (1). However, it is often a ‘forgotten about’ condition (2).
The risk can be reduced by preventing rapid reintroduction of nutrition alongside supplementation and monitoring/correction of electrolytes (1). Dietitians rely on doctors to prescribe vitamins, replacement medication and monitor the appropriate bloods. Prior to 2017, St George’s Hospitals’ refeeding guidelines (Figure 2/Figure 3) were not in line with NICE's ‘Nutrition Support for Adults’ guidelines (CG32).
This audit included patients from January – November 2017 whereby 51 patients were identified as ‘high risk or ‘extremely high risk’ and 3 were classed as ‘at risk’. Practice was compared to NICE guidelines and also aimed to capture how closely doctors followed the dietitian’s plans.
Aims and objectives
- To gain an understanding of compliance with ‘Nutrition Support for Adults’ guidelines by doctors and dietitians.
- To understand how many patients were being discharged with refeeding medications unnecessarily.
- To identify key learning areas for the hospital to lead to safer and cost effective care when treating Refeeding Syndrome in line with the NICE guidelines.
Reasons for implementing your project
St George’s Hospital is a large teaching hospital in South London, with nearly 1000 beds (acute medical, surgical, cardiac and neurosciences specialities). Change/audit was needed as:
- The trust’s refeeding guidelines were out of date and not following NICE recommendations
- The knowledge and management of refeeding syndrome needs to be improved in doctors (2).
- The old guideline flow chart was limited to tube fed patients
- It was not cost effective and in orally fed patients £4.68 was being wasted over three days due to IV medications being recommended
Therefore this audit assessed baseline practice against the ‘Nutrition Support for Adults’ guidelines.
Checking the appropriate biochemistry is a key element of managing refeeding syndrome; it had been noted in a previous audit that the appropriate refeeding bloods were not being checked on the weekend. Due to this, dietitians often have to request via biochemistry to add on phosphate and magnesium, thus highlighting doctors were not following dietetic plans to test and replace.
How did you implement the project
Dietetics worked collaboratively with pharmacy to update the Trust’s nutrition support policy, this included NICE's ‘Nutrition Support for Adults’ guidelines along with a flow chart of actions (Figure 5). To audit the compliance of the new guideline, we created an extensive excel sheet with drop down boxes to limit typing errors and to assist with analysing the results.
The excel document was divided into sections:
Specific Patient Information:
- Patients route of nutrition
- Date identified at risk
- Level of refeeding risk
- Length of stay.
- Specific refeeding medication prescriptions (Thiamine, Vitamin B co strong and Multivitamin)
- Name, duration and frequency
- Frequency of checking relevant biochemistry (Magnesium, Phosphate and Potassium)
- Documentation of verbally informing the doctors.
- Were relevant baseline bloods checked?
- Were the relevant bloods checked for the first three days post baseline bloods?
- Were the relevant bloods then checked three times a week for two weeks?
- When the baseline bloods were low, were they replaced correctly within 24 hours?
- Was Pabrinex/Thiamine was given prior to feeding/ prescribed within 24 hours?
- Were the medications (Thiamine, Pabrinex, Vitamin B co strong and Multivitamin) prescribed as per the Dietitian’s plan?
- Were the correct frequencies and dose’s prescribed? - Were the replacement of the baseline bloods correct?
- Were the Refeeding medications on the Discharge summary post completing the 10 day course? Dietitians collected data from their caseloads once patients were identified as at risk. The results were then analysed and translated into graphs.
The challenges were:
- The amount of data that needed to be collected for one patient.
- Having to obtain and sort through previous paper notes as some wards used electronic documentation and some used paper notes.
- Determining if Pabrinex/thiamine was given immediately before feeding started. This was overcome by an organised and methodical approach along with managerial support. It is unknown if Pabrinex/thiamine was given before feeding started however we did audit if it was prescribed within 24 hours.
The project did not incur costs and all resources were able to be provided by the hospital free of charge.
The initial aims and objectives were achieved. It was clear to see that the ‘Nutrition Support for Adults’ guidelines are not being followed by doctors (96% out of 51 patients) and dietitians (90% out of 51 patients). Refeeding medication was also being inappropriately put on the patient’s discharge medications (see below).
It was noticed areas whereby cost savings could occur;
- Intravenous Pabrinex, partly due to the old guidelines, was being prescribed to patients who could have cheaper oral medication. In this audit, when all the patients were grouped together, it found that there would have been a £78 per day saving if the NICE CG32 guidelines had been followed.
- 8 out of 54 patients also had their refeeding medications put onto their discharge medications despite having completed the 10 day prescription resulting in further costs in the community.
Further improvements are needed in encouraging dietitian’s to be more specific with their recommendations for refeeding medications to prevent prescribing errors. We found that 45% of the dietitian’s medical note plans requested the correct medication names however did not document specific guidelines as per NICE CG32 recommendations. Within the 45%, only 20% of dietitian’s requested the correct (dose, frequency and duration).
In the 10 out of 51 patients whereby the dietitian’s plan was correct, 7 doctors mirrored the recommendations. It is advised that Pabrinex/thiamine should be given ‘immediately before’ feeding. Whilst this was unable to be obtained, we did audit if it was prescribed in the first 24 hours. The dietitian recommended for Pabrinex/thiamine to be prescribed to 48 patients and it was found that 62% of patients received this within this time frame (Figure 6).
Checking baseline bloods is an important part of the refeeding syndrome pathway to determine if the patient has low potassium, magnesium or phosphate. In total, 70% of patients had their phosphate and magnesium checked within 24 hours of being identified as at risk and potassium was checked in 91% of cases.
Correct replacement of biochemistry when a patient is in Refeeding Syndrome is an area that needs further education to the doctors. For example, out of the 12 cases whereby the patient’s magnesium was low, it was incorrectly replaced in 9 patients (Figure 7). Being identified as 'at risk' and potassium checked occured in 91% of cases.
Key learning points
- The key, unexpected, learning was that when following the NICE ‘Nutrition Support in Adults’ guidelines correctly as opposed to the old trust guidelines, cost savings can be made. This work also created a great opportunity to liaise with pharmacy and work together to create positive change and build better relationships for future work.
- This audit provides a baseline forum for discussion with doctors to improve practice; the results will be presented at trust audit days, dietetic department meetings and care group meetings. Doctors have fed back that for ease of reference they would prefer the flowchart stipulating the NICE guidelines to be inserted into their ‘grey reference book’, which is now electronic and accessible on mobile devices.
- A key point from this audit is that updating and auditing dietetic guidelines results in improved dietetic practice:
- 5th January – 13th September: 7/33 doctors were advised to use the old guidelines
- 20th September – 8th November: 1/18 doctors were advised to use the old guidelines. It is also important to share resources to prevent recreating documents and wasting time.
Our data also shows that 10 out of 54 patients were discharged prior to finishing their refeeding medication. This would correlate with data which shows that length of hospital stay has decreased and there is more pressure to discharge earlier due to capacity pressures. Therefore, is it efficient to expect GPs to manage refeeding syndrome in the community, particularly to reduce unnecessary continuation of thiamine. Overall, it was a successful audit and another audit will be conducted on one year to see if practice has improved.
- Crook M, Hally V & Panteli J. The importance of the refeeding syndrome. Nutrition. 2001; 17, 632-7.
- Harrison W, Haddick R.A. Knowledge of refeeding syndrome amongst foundation year doctors. Gut 2015; 64: 0017-5749.
- Europa. Average length of stay for hospital in-patients 2010 and 2015. Available from: http://ec.europa.eu/eurostat/statisticsexplained/images/5/57/Average_length_of_stay_for_hospital_in-patients%2C_2010_and_2015_%28days%29_HLTH17.png). [Accessed: 23rd January 2018]