From the 2022 HVPA National Conference
Miyabi Saito B.S (University of Virginia School of Medicine), Andrew Burns MD, Kelsey Berry MD, Eva Manthe RDN, CSP, Julia Taylor MD MA, Susan Gray MD, Joanne Mendoza MD
Background
Adolescent mental health has worsened internationally during the COVID-19 pandemic. Admissions for nutritional rehabilitation to our pediatric hospital medicine service due to an eating disorder (ED) have doubled annually over the last 3 years. Recent data suggest that protocols advancing nutritional support more quickly can be implemented safely.
Objective
This study describes our quality improvement (QI) initiative to increase the calories at initiation on hospital day one to at least 1500kcal/day, from 40% to 80% of the population by June 30, 2022, without increasing risk of refeeding syndrome, and to implement empiric electrolyte supplementation for all admitted patients.
Methods
A retrospective review of patients admitted to our children’s hospital for nutritional rehabilitation from January 2017 to May 2021 was performed. Our children’s hospital is contained within a hospital without a dedicated ED or pediatric psychiatry unit. Baseline demographics, clinical presentation, therapeutic interventions, and outcomes were described (N=49). Our multidisciplinary team compared current practices with best practices to identify opportunities for improvement. Phase 1 outcomes include initiating calories at ≥1500kcal/day and empirically supplementing electrolytes to prevent refeeding syndrome. Safety outcomes include rates of hypophosphatemia/refeeding syndrome, need for nasogastric tube feeding, and length of stay. We used the Model for Improvement to design iterative PDSA cycles to implement interventions, beginning in June 2021, addressing both educational and systemic interventions (N=26, ongoing).
Results
Baseline data showed variability in calories and electrolyte supplementation. Presenting percent median body mass index (%mBMI) was lower during the COVID-19 pandemic, indicating increased severity of malnutrition at presentation. We achieved calories at initiation of at least 1500kcal/day in more than 80% of patients without negatively impacting patient safety. There was no change in time to lowest phosphorus level, or measured level, readmission and NGT placement rates decreased, and empiric electrolyte supplementation was successfully implemented in all patients during the intervention period. Average days until medical stabilization was stable, although overall length of hospitalization was increased during the intervention period. Possible explanations include a statewide higher demand for in-patient treatment facilities or greater degree of malnutrition at presentation.
Conclusions
Updated evidence-based data stimulated a multidisciplinary team to examine current practice and implement a QI initiative to improve the care of adolescents with an ED without compromising patient safety. PDSA cycles have achieved our initial outcomes of higher starting calories and empiric electrolyte supplementation. We did not adversely affect time to medical stabilization by increasing calories at initiation, despite increased severity at presentation during the intervention period. Next steps will include a high value care approach to reducing unnecessary electrolyte testing and developing a sustainability plan for long-term maintenance of evidence-based practices.
Clinical Implications
By practicing more evidence-based standard of care, we aim to improve the care of these vulnerable adolescents without compromising patient safety. With initiation of higher calorie count on admission, we hope to shorten length of stay and ultimately decrease hospital costs.
