title: Outcomes of an inpatient medical nutritional rehabilitation protocol in children and adolescents with eating disorders.
abstract: BACKGROUND
  Medical stabilization through inpatient nutritional rehabilitation is often necessary for patients with eating disorders (EDs) but includes the inherent risk of refeeding syndrome. Here we describe our experience of implementing and sustaining an inpatient nutritional rehabilitation protocol designed to strategically prepare patients with EDs and their families for discharge to a home setting in an efficient and effective manner from a general adolescent medicine unit. We report outcomes at admission, discharge, and 4-weeks follow-up.
  
  
  METHODS
  Protocol development, implementation, and unique features of the protocol, are described. Data were collected retrospectively as part of a continuous quality improvement (QI) initiative. Safety outcomes were the clinical need for phosphorus, potassium, and magnesium supplementation, other evidence of refeeding syndrome, and unexpected readmissions within one month of discharge. The value outcome was length of stay (LOS). Treatment outcomes were the percentage median BMI (MBMI) change from admission to discharge, and from discharge to 4-weeks follow-up visit.
  
  
  RESULTS
  A total of 215 patients (88% F, 12% M) were included. Patients averaged 15.3 years old (5.8-23.2y); 64% had AN, 18% had atypical anorexia (AtAN), 6% bulimia nervosa (BN), 5% purging disorder (PD), 4% avoidant-restrictive food intake disorder (ARFID), and 3% had an unspecified food and eating disorder (UFED). Average LOS was 11 days. Initial mean calorie level for patients at admission was 1466 and at discharge 3800 kcals/day. Phosphorus supplementation for refeeding hypophosphatemia (RH) was needed in 14% of inpatients; full-threshold refeeding syndrome did not occur. Only 3.8% were rehospitalized in the thirty days after discharge. Patients averaged 86.1% of a median MBMI for age and gender, 91.4% MBMI at discharge, and 100.9% MBMI at 4-weeks follow-up. Mean percentage MBMI differences between time points were significantly different (admission-discharge: 5.3%,p<0.001; discharge-follow-up: 9.2%,p<0.001).
  
  
  CONCLUSIONS
  Implementation of the CHOP inpatient nutritional rehabilitation protocol aimed at rapid, efficient, and safe weight gain and integration of caregivers in treatment of patients with diverse ED diagnoses led to excellent QI outcomes in percentage MBMI at discharge and 4-weeks follow-up, while maintaining a short LOS and low rates of RH phosphorus supplementation.
authors.affiliation: The Children's Hospital of Philadelphia, Department of Pediatrics, Division of Adolescent Medicine, Philadelphia, Pennsylvania USA.|The University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania USA.
authors.forename: Rebecka
authors.identifier: 0000-0001-9360-8434
authors.initials: R
authors.lastname: Peebles
authors.affiliation: The Children's Hospital of Philadelphia, Department of Pediatrics, Division of Adolescent Medicine, Philadelphia, Pennsylvania USA.
authors.forename: Andrew
authors.initials: A
authors.lastname: Lesser
authors.affiliation: The Children's Hospital of Philadelphia, Department of Pediatrics, Division of Adolescent Medicine, Philadelphia, Pennsylvania USA.
authors.forename: Courtney Cheek
authors.initials: CC
authors.lastname: Park
authors.affiliation: The Children's Hospital of Philadelphia, Department of Clinical Nutrition, Philadelphia, Pennsylvania USA.
authors.forename: Kerri
authors.initials: K
authors.lastname: Heckert
authors.affiliation: The University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania USA.|The Children's Hospital of Philadelphia, Department of Child and Adolescent Psychiatry and Behavioral Sciences, Philadelphia, Pennsylvania USA.
authors.forename: C Alix
authors.initials: CA
authors.lastname: Timko
authors.affiliation: The Children's Hospital of Philadelphia, Department of Pediatrics, Division of Adolescent Medicine, Philadelphia, Pennsylvania USA.|The University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania USA.
authors.forename: Eleni
authors.initials: E
authors.lastname: Lantzouni
authors.affiliation: The University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania USA.|The Children's Hospital of Philadelphia, Department of Child and Adolescent Psychiatry and Behavioral Sciences, Philadelphia, Pennsylvania USA.
authors.forename: Ronald
authors.initials: R
authors.lastname: Liebman
authors.affiliation: The University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania USA.|The Children's Hospital of Philadelphia, Department of Child and Adolescent Psychiatry and Behavioral Sciences, Philadelphia, Pennsylvania USA.
authors.forename: Laurel
authors.initials: L
authors.lastname: Weaver
keywords: Adolescents; Anorexia nervosa; Bulimia nervosa; Eating disorders; Malnutrition; Nutritional rehabilitation; Refeeding syndrome