315 - Food as Medicine: Developing a Standardized Inpatient Pathway for Medical Stabilization of Patients with Disordered Eating

Poster Number: 315
Publication Number: 315.322

Irene Kocolas, University of Utah School of Medicine, Salt Lake City, UT, United States; Lisa Giles, University of Utah School of Medicine, Salt Lake City, UT, United States; Rebecca Hurst-Davis, Primary Children's, Salt Lake City, UT, United States; Laura Bennett-Murphy, University of Utah School of Medicine, Salt Lake City, UT, United States; Mouna Ayoub Bahsoun, Intermountain Healthcare, Salt Lake City, UT, United States; Aaron Porter, Primary Children's Hospital, Grantsville, UT, United States; Bryan Stone, University of Utah, Salt Lake City, UT, United States

Background: Disordered eating describes a range of maladaptive eating behaviors that increase psychosocial and medical risk.  Prevalence rates in children and adolescents range from 1.4-14%. Medical complications are common. The requirement for medical stabilization and initial intensive nutritional rehabilitation is based on established markers of physical and psychological health. Yet, there are no standard protocols to guide inpatient medical stabilization. Providers at our hospital largely varied in care approaches, leading to high rates of nasogastric tube (NG) use without oral nutrition.

Objective: To implement a standardized pathway for inpatient medical stabilization at Primary Children’s Hospital and set criteria for follow up care.

Design/Methods: Based on culture of continuous improvement and an established operating model, our multidisciplinary team utilized SWOT analysis (Figure 1). A comprehensive model focused on medical, nutritional and psychiatric stabilization that addresses all dimensions of quality (Figure 2). We conducted daily and monthly improvement cycles. Results are reported with point estimates, 95% confidence intervals and p-values. Data for 29 patients in 18 months pre-implementation were compared to 197 patients in 33 months post-implementation.

Results: NG tube feedings declined during medical admission from 79.3% (63.6-95%) to 42% (24.9-49%) (p < 0.00) following implementation. When NG feeds were required, hours of use decreased from 86.4 (64.3-108.5) to 48.9 (34.6-63.1) (p=0.05). Total patients discharged with NG decreased from 65.5% (47.1-83.9%) to 18.7% (13.1-24.2%) (p < 0.00). BMI was not different in the two groups (16.2 (15.3-17) to 16.8 (16.3-17.3)(p= 0.378). Length of stay (LOS) increased from 121 to 183 hours (p=0.01). Re-admission rates were not significantly different (14% (0-31%) vs 25% (13-36%), p=0.30), although time to readmission was longer with the standardized pathway (23 (9-36) days vs 86 (29-143) days, p=0.31). Compared to the pre- pathway year (2018), admissions increased 2.24-fold in 2019 (p < 0.00), 2.83-fold in 2020 (p < 0.00) and 3.31-fold in 2021 (p < 0.00). Conclusion(s): In creating a standardized pathway, care shifted focusing on oral nutrition over enteral feeding. Through role clarity in multi-disciplinary care, most patients discharged solely on oral nutrition. Although LOS lengthened, time to readmission was longer in a population with similar BMI. The increase in admissions may reflect community utilization of medical stabilization and the need for a standardized program. We look forward to longitudinally following patients to monitor long term progress.
SWOT (Strength-Weakness-Opportunity-Threat) analysisFigure 1
Key components of medical inpatient pathway: medical, nutrition and psychiatric stabilizationFigure 2