Frequency and Predictors of Fasting Orders in Inpatients with Ulcerative Colitis: The Audit of Diet Orders - Ulcerative Colitis (ADORE-UC) Study: 712

Introduction: Studies have demonstrated that physicians may contribute to malnutrition by ordering bowel rest inappropriately. Practice guidelines recommend that patients hospitalized with UC be offered a normal diet or enteral nutrition unless such a diet is not tolerated. There are no published studies assessing compliance with this recommendation. This study aims to assess the frequency of unnecessary bowel rest in hospitalized UC patients and to identify predictors of prolonged bowel rest. Methods: We conducted a retrospective cohort study of ulcerative colitis patients who were admitted to the gastroenterology (GI) service or the general internal medicine (GIM) service at an academic hospital between January 2009 and December 2014, with a length of stay of 2 or more and 30 or fewer days. The frequency and duration of bowel rest orders and the number of meals missed because of these orders were assessed. Bowel rest orders were considered necessary if the patient had intractable nausea or vomiting, pancreatitis, bowel obstruction, toxic megacolon or were awaiting endoscopy. Prolonged bowel rest was defined as being NPO (nil per os) or on a CFD (clear fluids diet) for over 25% of the duration of the admission, and absence of an appropriate indication. Predictors of prolonged bowel rest were assessed using logistic regression. Results: A total of 187 admissions in 158 UC patients were identified during the study period. The median length of stay was 8 days ([IQR] = 4 - 12). Prolonged bowel rest orders were encountered in 82 (43.9%) admissions. The mean duration of prolonged bowel rest was 2.27 days (SD = 1.2) or 36% of admission length (SD = 26). Prolonged bowel rest was encountered in 52 (27.8%) admissions. Significant (p< 0.05) predictors of prolonged bowel rest in the final model were: NPO or CFD diet ordered at admission, odds ratio [OR] 19.5 (95% confidence interval [CI] 7.75 - 49.0); more than one admission during the study period, 8.86 (95% CI 2.16 - 36.27); biologic therapy initiation during admission, 4.25 (95% CI 1.40 - 12.85); and admission to non-GI service 2.64 (1.30 - 6.72). Conclusion: There is a high burden of prolonged bowel rest among hospitalized UC patients. Our findings also suggest that targeted interventions, possibly directed early in admission, are needed to decrease the frequency of inappropriate bowel rest among hospitalized UC patients. Further studies are needed to assess the nutritional impact of prolonged bowel rest on UC patients.