# Implementation of an Electronic Medical Record-Embedded Refeeding Risk Order Set and Its Impact on Refeeding Syndrome Among Adults Receiving Enteral Nutrition: A Retrospective Cohort Study in an Inpatient Hospital Setting

## TL;DR

This study evaluated an electronic medical record tool to prevent refeeding syndrome in hospitalized patients receiving nutrition, finding it improved workflow but did not reduce syndrome occurrence.

## Contribution

The study demonstrates the feasibility and immediate adoption of an EMR-based refeeding risk order set in an inpatient setting.

## Key findings

- RROS implementation did not significantly reduce refeeding syndrome occurrence or severity.
- Post-RROS patients received more electrolyte boluses and had a lower starting enteral nutrition rate.
- The tool improved workflow efficiency and reduced errors in electrolyte monitoring and feeding initiation.

## Abstract

Background/Objectives: Refeeding syndrome (RFS) is challenging to prevent and manage in hospitalized patients receiving enteral nutrition (EN). Nebraska Medicine implemented an Electronic Medical Record (EMR) Refeeding Risk Order Set (RROS) to standardize prevention measures, including structured electrolyte monitoring, thiamine supplementation, and conservative EN initiation. This study evaluated whether RROS implementation reduced RFS occurrence or severity and assessed its operational impact. Methods: In this retrospective cohort study, adults receiving EN before and after RROS implementation were compared. Primary outcomes were RFS occurrence and severity; secondary outcomes included EN initiation and advancement rates, electrolyte trends, lab frequency, and electrolyte repletion. Results: RFS occurrence did not differ significantly between groups (92.3% vs. 91.3%, p = 0.694), nor did severity (p = 0.535). The post-RROS group received more electrolyte boluses on EN Day 0 (p = 0.027) and had a lower EN starting rate (15.7 vs. 18.3 mL/h, p = 0.045). Conclusions: Although the RROS did not reduce RFS occurrence or severity, integrating American Society for Parenteral and Enteral Nutrition (ASPEN)-based guidance into the EMR was highly feasible and adopted immediately. Automating electrolyte monitoring, micronutrient supplementation, and conservative feeding initiation reduces the risk of errors and promotes consistent care. These benefits improve workflow efficiency and support providers during high census periods, limited staffing, or when experience varies. Future research should explore combining EMR tools with predictive analytics to optimize early risk identification and individualized management.