Development, implementation, and preliminary evaluation of an evidence-based risk management program for refeeding syndrome in critically ill patients receiving nutritional support: a sequential multiphase study

Background Refeeding syndrome (RFS) is a potentially life-threatening metabolic complication in critically ill patients receiving nutritional support. Despite its clinical importance in the ICU, standardized risk management strategies for RFS remain limited, potentially hindering early recognition and timely prevention. This study aimed to develop an evidence-based RFS risk management program and preliminarily evaluate its effects on RFS incidence, nutritional and electrolyte outcomes, and ICU length of stay in critically ill patients receiving nutritional support. Methods A sequential multiphase study was conducted, comprising the development and refinement of an evidence-based RFS risk management program followed by a quasi-experimental evaluation with historical controls in the ICU of Jingzhou Hospital Affiliated to Yangtze University, China. The program was developed based on evidence synthesis and refined through two rounds of Delphi expert consultation. Eligible participants were adults (≥ 18 years) receiving enteral or parenteral nutritional support and expected to remain in the ICU for at least 5 days. Baseline nutritional risk and disease severity were assessed using NRS-2002 and APACHE II, respectively. Patients admitted from March to May 2025 received routine care (control group), while those admitted from June to October 2025 received an evidence-based RFS risk management program (intervention group), including early risk screening, individualized nutrition support, dynamic electrolyte monitoring, thiamine supplementation, and multidisciplinary collaboration. The primary outcome was the incidence of RFS. Secondary outcomes included serum electrolyte levels, nutritional indicators, and ICU length of stay. Results A total of 64 patients were included, with 32 patients in the intervention group and 32 in the control group. The incidence of RFS was lower in the intervention group compared with the control group (18.8% vs. 59.4%; RR = 0.32, 95% CI: 0.15–0.69; p = 0.001). Significant between-group differences were observed in serum potassium, magnesium, calcium, and phosphorus levels on day 5 of nutritional support (all p < 0.05), while serum albumin and prealbumin levels were higher in the intervention group (both p < 0.001). ICU length of stay was shorter in the intervention group compared with the control group (9.0 [7.0–12.0] vs. 12.0 [9.0–18.5] days; p = 0.001). Conclusions Implementation of an evidence-based risk management program was associated with a reduced incidence of RFS and improved short-term nutritional and biochemical outcomes, as well as shorter ICU length of stay in critically ill patients. Clinical trial number Not applicable.