Eating Disorders Anorexia Nervosa Paediatric Inpatient ...



Canberra Health ServicesClinical Guideline Eating Disorders – Anorexia Nervosa Paediatric Inpatient Management (Paediatric Wards)Contents TOC \h \z \t "Heading 1,1" Contents PAGEREF _Toc5374917 \h 1Guideline Statement PAGEREF _Toc5374918 \h 2Scope PAGEREF _Toc5374919 \h 3Section 1 – Principles of Inpatient treatment of Anorexia Nervosa PAGEREF _Toc5374920 \h 3Section 2 – Criteria for Admission PAGEREF _Toc5374921 \h 4Section 3 – Admission and Initial Medical Management PAGEREF _Toc5374922 \h 5Section 4 – Nutritional Management PAGEREF _Toc5374923 \h 8Section 5 – Psychological Management PAGEREF _Toc5374924 \h 10Section 6 – Nursing Management PAGEREF _Toc5374925 \h 11Section 7 – Discharge Planning PAGEREF _Toc5374926 \h 14Section 9 – Transition to Adult Services PAGEREF _Toc5374927 \h 15Implementation PAGEREF _Toc5374928 \h 16Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc5374929 \h 16References PAGEREF _Toc5374930 \h 16Definition of Terms (if applicable) PAGEREF _Toc5374931 \h 17Search Terms PAGEREF _Toc5374932 \h 17Attachments PAGEREF _Toc5374933 \h 17Guideline StatementAnorexia Nervosa is a serious psychiatric condition that is associated with significant physical consequences and has the highest mortality rate of any psychiatric condition. It is recognised that timely and appropriate care improves the likelihood of positive outcomes for young people with Anorexia Nervosa This guideline is designed to provide current evidence based guidance on the inpatient treatment of young people with Anorexia Nervosa. BackgroundThere have been ongoing improvements in the evidence base for the treatment of eating disorders with new recommendations coming through clinical practice guidelines such as the Royal Australian and New Zealand College of Psychiatrists (RANZCP) clinical practice guidelines for the treatment of eating disorders1. This CHS clinical guideline has been written to reflect these recommendations and guide the management of patients who require admission due to becoming medically unstable secondary to their eating disorder (e.g. Anorexia Nervosa). There is a lack of high quality evidence to guide inpatient treatment of young people with Anorexia Nervosa with most recommendations being based on expert consensus. This guideline has been written using the RANZCP guideline and other international clinical practice guidelines as well as expert information from the Eating Disorder Toolkit2 (put out by Hunter New England NSW Health) and the Sydney Children’s Hospital Network Westmead Eating Disorder Service Overview3. Key ObjectiveTo ensure that young people with Anorexia Nervosa receive consistent evidence based treatment when they are admitted to the Paediatric wards of the Centenary Hospital for Women and Children To provide smooth transition of care for young people with Anorexia Nervosa to outpatient services Alerts Anorexia Nervosa is a serious disorder with life-threatening physical and psychological complications Re-feeding syndrome is a potential complication of initiating nutrition (re-feeding) after a period of poor intake or starvation and may be fatal. Back to Table of ContentsScopeThis guideline applies to the management of patients with Anorexia Nervosa on the Paediatric Wards at the Centenary Hospital for Women and Children For the purpose of this document the patient aged under 16 will be referred to as a young person. Please note - For management of patients admitted to the adult wards refer to the ‘Adults with Eating Disorders – Management of (Inpatients)’ clinical guideline.This guideline applies to the following staff working within their scope of practice:Medical OfficersRegistered and Enrolled NursesAllied Health StaffStudents with direct supervision.Back to Table of ContentsSection 1 – Principles of Inpatient treatment of Anorexia NervosaReview of current evidence indicates that outpatient care should be the first-line treatment of Anorexia Nervosa in young people. However, hospitalisation for young people with Anorexia Nervosa for the management of acute medical instability is thought to be essential in preventing mortality associated with Anorexia Nervosa 1. 1) Multidisciplinary treatment approach Anorexia Nervosa is a complex illness that is best managed using a multidisciplinary approach. A consistent team approach is essential where the team hold the same values and treatment goals. The team provides a united front which ensures effective communication with the young person and their family as well as providing assurance in a period of crisis and distress for the family3. The Multidisciplinary team includes: Paediatric Medical staff, Child and Adolescent Mental Health Service (CAMHS) Consultation Liaison Psychiatry team, Nursing Staff, Dietitian, Social Worker, Psychologist, Hospital School teachers and the child’s parents. 2) Engagement with the young personA young person with Anorexia Nervosa generally has an intense fear of putting on weight and most of the difficult behaviours that are associated with this illness are driven by this fear. An admission to hospital is highly stressful for the young person and an empathetic, non-judgemental approach is necessary to facilitate engagement. The young person requires a containing but caring approach that ensures safety but also focuses on providing positive experiences for the young person2. 3) Engaging the young person’s family in treatment is essentialThe young person’s family should be involved in all aspects of care of the young person and be considered part of the treating team. A young person’s parents are an essential resource whose ongoing support and encouragement is necessary to support the young person’s recovery. The young person’s parents require support and guidance to build their confidence and competence in re-feeding their child and should be provided with opportunities to practice in differing contexts such as meals on the ward and during gate leave3. 4) Aims for Admission The purpose of an inpatient admission of the young person is to provide a safe and therapeutic environment where the young person is supported to move towards a healthy weight and re-establish normal eating patterns. The aims for admission are:Medical and psychological stabilisationContainment of eating disorder behaviours (including compensatory behaviours such as vomiting and over exercising)To establish a trajectory of weight gain.Back to Table of Contents Section 2 – Criteria for Admission1) Medical instability The young person is medically unstable secondary to Anorexia Nervosa and requires inpatient treatment. Indicators of medical instability requiring admission for a young person are presented in table 1.Table1: Indicators for admission. Indicators for admission Medical StatusHeart rate < 50 bpmCardiac arrhythmiaQTc>450 msecPostural Tachycardia> 20/minBlood Pressure<80/50 mmPostural hypotension>20mmTemperature <35.5oCHypokalaemiaNeutropaeniaWeight<75% of expected body weight, i.e. <75% median Body Mass Index (BMI) (% median BMI = actual BMI ÷ BMI on 50th centile for age x 100)Rapid weight loss: 1kg per week over several weeks or grossly inadequate nutritional intake (<100kcal daily) or continued weight loss despite community treatmentRisk Moderate to High Suicidal IdeationActive Self-HarmTable based on the Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the treatment of eating disorders 12) Failure to respond to outpatient treatmentWhere possible admissions related to failure to respond to outpatient treatment are planned admissions. If a service such as the Eating Disorder Program (EDP) feels that an admission is warranted for a young person, they are to contact CAMHS Consultation Liaison Psychiatry to arrange an admission to hospital. The young person, their parents and clinicians from the outpatient service will be invited to a meeting with the inpatient multidisciplinary team where the admission will be discussed and treatment/management, such as activity level, use of Nasogastric tube (NGT) feeding and behaviour management, is negotiated and agreed upon. After the meeting, the young person’s treating psychiatrist calls the paediatric consultant on-call to provide details of the in-depth management plan and to ask the on-call paediatrician to accept the young person for admission under a joint bed card. Preference in planned admissions is given to those young people who have already engaged with specialised outpatient eating disorder services such as the EDP. In cases where the young person is rapidly deteriorating and there are concerns regarding physical wellbeing and medical instability, the young person should be directed to present to the emergency department for assessment and triage. 3) Co-morbid medical or psychiatric problems that interfere with treatmentCo-morbid medical or psychiatric problems that complicate the outpatient management of Anorexia Nervosa can include conditions such as; Type 1 Diabetes, Cystic Fibrosis, Major Depression, Obsessive Compulsive Disorder or severe family dysfunction.4) Aged under 16 years: for a young person to be admitted to the paediatric inpatient service they must be aged under 16 years. Young persons over the age of 16 (and under the age of 18) may be considered for admission if they have had a recent inpatient admission in Paediatrics for Anorexia Nervosa. Back to Table of Contents Section 3 – Admission and Initial Medical ManagementAssessment of the young person on admissionHistory of the young person’s presenting illness Duration of illnessDescription of eating disorder symptoms (onset, triggers and maintaining factors)Weight control behaviours (restricting intake, vomiting, laxative use, etc)Current eating patternExcessive exercise behavioursPremorbid weight and growth patternDate of menarcheAmenorrhoeaBody Distortion, fear of potential weight gainInsight into illness and motivation for changeImpact on schoolPast and co-existing psychiatric history Social and Family history Physical Assessment of the young personWeight and heightCalculate BMIPulseBlood pressureTemperatureAssess for dehydrationSkin inspection – acrocyanosis, calloused knuckles, lanugo hair etcPubertal statusUrinalysisInvestigationsElectrocardiogram (ECG) Blood tests – Full blood count, Electrolytes, liver function tests, glucose, calcium, magnesium, and phosphate. Thyroid stimulating hormone, Tri-iodothyronine, Serum thyroxine, Follicle stimulating hormone, Luteinising hormone and oestradiol. Bone densityConsider risk of re-feeding syndrome. Young persons are at an increased risk with: Very low weight for height, i.e., % median BMI (%mBMI) is < 70%No nutritional intake for >3-4 days (on background of being underweight)>1kg weight loss/week for more than 2 weeksgreater than 15% weight loss in 3 monthsabnormal electrolyte blood test results before feeding has commenced4.Notify the following staff of the young person’s admission: On call Consultant Paediatrician, via switch 40000On call Consultant CAMHS Consultation Liaison Psychiatrist, via switch Dietitian for nutrition assessment, extension: 42567Paediatric Social Work Intake Team, mobile: 0401075 911Paediatric Psychologist, pager: 50210Initial Medical Management of the young personMedical Stabilisation The maintenance of the young person’s vital signs, including heart rate >50/min, temperature > 35.5 C, systolic BP > 80mmHg, diastolic BP > 40mmHg. For young persons who are not medically stable on admission nasogastric tube re-feeding is indicated (with continuous NGT feeding started as per Nutrition Management Protocol in section 4). Note: As medical instability is considered necessary for admission (see criteria for admission) it is expected that the majority of young persons will have NGT feeding Daily bloodsElectrolytes, urea and creatinine (EUC) and Comprehensive Metabolic Panel (CMP) for the first week of admission (if very low %mBMI and medically unstable the young person may require twice daily biochemistry monitoring initially).Monitoring of biochemistry should be continued into the second week if electrolyte levels have been abnormal. Supplementation Thiamine 100mg/dayPhosphate Sandoz 500mg BDFactors to consider regarding NGT feeding If the young person is not considered medically unstable enough to warrant NGT feeding discharge to outpatient treatment should be considered. Where possible treatment for eating disorders should be conducted in the least restrictive environment. The exception would be where the admission is planned (and no NGT was agreed on prior to admission) or the admission is due to increased risk of self-harm, suicidal ideation or other behaviours that are interfering with treatment. Generally parents have the primary responsibility in providing consent for the young person. Engagement with the young person’s whole family is therefore essential and ongoing treatment on the ward can only be undertaken when the parents give informed consent. Parents require clear information regarding the seriousness of Anorexia Nervosa and the treatment options available to them so that they are supported in their decision making. If the young person is refusing treatment where their physical health is at serious risk and they lack capacity, then parents or carers are able to consent on their behalf. If there are difficulties with obtaining parental consent, then consider using appropriate legal frameworks such as “duty of care provisions”, the Mental Health Act 2015 or the Children and Young People Act 20085 (please see ‘Consent and Treatment’ Policy). Often parents and the young person request of few days ‘trial’ without a NGT. Delaying NGT insertion for this type of trial is inappropriate for the following reasons: It unnecessarily increases the health risk to the young person, as the young person is likely to continue to lose weight and it limits the ability to ensure that the young person is being re-fed safely. It unnecessarily increases length of stay. It undermines the assertion that the young person is medically unstable and that Anorexia Nervosa is a serious life threatening condition. Back to Table of ContentsSection 4 – Nutritional ManagementThe aim is for the young person to gain around 0.5kg to 1 kg per week while gradually returning to a normal healthy eating pattern. NGT feeding is generally only a short term measure. Young persons are provided with meals and encouraged to eat while they have the NGT in place. On admission, all young persons should be referred to a Dietitian. Nutritional management for the young person is delivered by the dietitian in consultation with the young person’s medical and psychiatric team. The information below provides details of the usual nutrition care process and options for nutritional management, however this may be individualised in collaboration with the Multidisciplinary Team (MDT) and young person. If the young person is admitted outside of business hours:If the young person has an NGT inserted outside of business hours, commence interim enteral feeding protocol of Nutrini 10mL/hr for 24 hours until the young person assessed by a dietitian to determine goal rate – see below Note: – the goal is to ensure that the young person does not remain at this rate for longer than 1 business day.Dietitian assessment and management prior to the MDT meeting:conduct a complete nutrition assessment of the young person and then liaise with the MDT to identify severity of risk of re-feeding syndrome and nutrition intervention recommendations. ensure medical management of risk of re-feeding syndrome (see details in initial medical management) is in place before starting the oral or enteral feeding plan.determine the standardised meal plan for the young person, considering the appropriateness of dislikes and determines the enteral feeding rate.calculate the young person’s BMI and % median BMI (%mBMI) (actual BMI ÷ BMI on 50th %ile for age x 100) as a marker of malnutrition. If %mBMI is < 70% then the young person is at a higher risk of developing re-feeding syndrome and requires a more cautious introduction of calories and close monitoring. Young persons with other indicators for risk of re-feeding syndrome should also be identified and managed accordingly.Goal is for all young persons to be fed to at least the calorie level of their intake prior to admission. A young person who has never been admitted previously are to commence on an Anorexia Admission Diet in DietPAS (~3500kJ) + enteral feeds (if NGT inserted). If not for NG feeding to consider starting the young person on a higher calorie meal plan to match pre-admission intake. The following is to be taken into consideration when formulating the nutrition plan:If the young person’s %mBMI > 70% - commence on total energy intake of 7000 kJ (1675kcal). Intake will consist of NGT feeds and oral intake, estimated energy intake to be determined by dietitian.If the young person’s %mBMI < 70% - commence on total energy intake of 5000kJ (1200kcal). Intake will consist of NGT feeds and oral intake, estimated energy intake to be determined by dietitian.The young person is allowed 2 dislikes (can only be single foods, not entire food groups, and not allowed to request low fat, vegetarian or vegan options unless a clear history of this eating pattern exists pre-dating the onset of the eating disorder).The young person is to receive meals and encouragement to eat during first 3 days of the admission but no boluses are to be given if meals are not completed.Dependant on the timing of the initial MDT meeting and completion of dietitian assessment, typical management may be as follows: Prior to the MDT meeting:The young person is to be commenced on Enteral feeds (Nutrini) to run continuously (over 24 hours) at rate determined by dietitian until next MDT meeting (a maximum of 3 days) where they are usually changed to overnight feeds to coincide with a change to a larger meal plan.After the first MDT meeting:At the first MDT meeting (held Monday/Thursday) or after approximately 3 days of admission, the NGT feeds are to change to overnight feeds (to provide approximately 2500kJ as 50mL/hr over 12 hours, 1kcal/mL feed) and progress to a higher calorie meal plan (with either half or full boluses to be given if meals are not completed).Standard Meal plans:Anorexia admission meal plan (3500kJ)Meal plan 1- Red (5000kJ) Meal plan 2 – Orange (7000kJ) Meal plan 3 – Green (9,000kJ) Meal plan 4 – Blue (11,000kJ)Meal plan 5 – Purple (13,000kJ) Bolus feeds (nutrition supplements) are to be given when the meal plan is not able to be consumed as specified. The young person is to be offered an opportunity to drink the bolus first, with NGT use only if the young person refuses or is unable to consume the volume required. Full and half bolus volumes for main meals (depending on amount of meal consumed) are specified in each meal plan. Only full bolus option is provided for midmeals.If young person consumes <50% of the main meal, they are to be given a full bolus.If young person consumes >50% of the main meal, they are to be given a half bolus.If young person consumes <100% of midmeal, they are to be given a full bolus.Boluses may be slightly larger than the energy content of some meals/midmeals (not necessary to match the bolus volume to each individual meal’s energy profile) as they are intended to act as an incentive for the young person to meet their nutrition needs orally.The decision to cease overnight feeds is made in collaboration with the MDT and is dependent on the young person’s compliance with meal plans, rate of weight gain and in relation to ideal body weight/goal weight. Nasogastric tubes may remain in place for a period of time to avoid unnecessary reinsertion (if feeds are required to recommence). Prior to discharge: The dietitian will provide general recommendations to the young person and their family on eating after discharge and facilitate transfer of nutrition care to an outpatient service if required. Back to Table of ContentsSection 5 – Psychological ManagementA psychiatric assessment of the young person and their family is conducted by the CAMHS Consultation Liaison Psychiatry team as soon as possible after admission. The aim of this assessment is to confirm diagnosis of Anorexia Nervosa and identify any co-existing psychiatric conditions such as depression, anxiety, post-traumatic stress disorder etc. The CAMHS Consultation Liaison Psychiatry team is responsible for all decisions regarding psychotropic medication. The CAMHS Consultant Psychiatrist leads the ward MDT meetings. Initial intervention consists of containing the young person’s anxiety to allow re-feeding to begin, with further aims of containing eating disordered behaviours, normalising eating patterns, developing better coping skills and to treat other co-existing psychiatric conditions 3. Psychological Intervention Clinical Psychology services provide supportive psychotherapy to the young person while they are an inpatient. This support is designed to facilitate treatment and manage distress. It provides the young person with an opportunity to verbalise their concerns and problem solve situations on the ward that may be contributing to their distress. There may be times where the young person requires more targeted therapeutic support and will require time-limited psychological treatment. This often occurs when the young person presents with co-existing psychiatric conditions. Psychological intervention is designed and implemented in consultation with the CAMHS Consultation Liaison Psychiatric team. Where family dynamics and family issues are affecting the young person’s engagement and progress Social Work will provide support and brief family therapy intervention to assist the young person. Family Assessment, Engagement and EducationDuring the admission Social Work and Clinical Psychology will conduct a family assessment. The purpose of this assessment is to understand the context in which the young person lives and how the illness has impacted on the family. It also provides further opportunity to engage the family and help them understand Anorexia Nervosa. This psychological education provides an opportunity to discuss outpatient treatment options with the young person and their family. The majority of young persons will be discharged to either the Eating Disorder Program (ACT residents) or NSW CAMHS (NSW residents). Both of these services utilise Maudsley Family Based Therapy (MFBT) as their main treatment modality. The psychological education provided to parents while the young person is an inpatient is designed to inform them about MFBT and what will be required from the family. The Eating Disorder Program aims to engage with the family prior to the young person being discharged from hospital. This is typically facilitated through the Eating Disorder Program clinicians attending the Multidisciplinary Team meetings and arranging a family assessment. Multidisciplinary Team Meetings The purpose of the multidisciplinary team (MDT) meeting is to review the young person’s progress and plan treatment. The management plan is discussed and denotes what progress level (attachment A) the young person is on and will include what their activity level is, meal plans and enteral feeding, leave passes, etc. The management plan is documented in the young person’s clinical record medical notes and via the Anorexia Nervosa Management Plan form, available on the clinical forms register, which is filled out at each meeting. The meeting also provides an opportunity for the young person and their parents to be involved in the decision making regarding their care. Discharge planning is an ongoing process within the MDT meetings. These meeting occur twice weekly:Monday 10.30 am Thursday 10.30 am Attendance: All members of the young person’s MDT are expected to attendThe young person and their parents/guardians are invited to attendClinicians from The Eating Disorder Program and NSW CAMHS attend where appropriate Back to Table of ContentsSection 6 – Nursing ManagementInpatient management for a young person with anorexia nervosa consists of a level system (see attachment A) where progression through the levels is based on medical stabilisation, weight gain and improvement in eating patterns. Ward management of the young person is guided by their progress level and the individual Anorexia Nervosa Management Plan which is placed on the front of the young person’s clinical record and is updated at the MDT meeting. It can be useful to make young person aware that all decisions regarding their management plan are made in the MDT meetings. This can help in reducing splitting type behaviours, avoiding negotiations and ensure consistency in management. The young person can experience high levels of distress particularly around meal times and at weigh ins. A firm but compassionate, non-judgemental approach is necessary in supporting the young person at these times. Validating the young person’s distress, directing and supporting them in using distraction and other distress tolerance skills are useful strategiesMonitoring of the young person:Daily blood tests for first week of admission and continues into second week if levels not returned to normal.4 hourly vital sign observations including lying and standing BP until medically stable Continuous cardiac monitoring if the young person has been admitted to the High Dependency Unit Urinalysis on admission and before every weight recording of the young person Documentation of bowel habits on a Bowel chart Documentation of the food eaten by the young person on a Food chart Nutritional management of the young person: As per management plan/progress level. The young person’s progress level is determined at MDT meetingAs per Adolescent Eating Disorder Nutrition Management Protocol in section 4The young person’s NGT needs to be flushed every 4 hours, check the placement of the NGT each shift. Do not leave syringes in the young person’s room.Set limits around the length of time for each meal. 30 minutes for eating of main meals and 15 minutes for eating of snacks. Managing weight control behaviours of the young person: The bathroom is to be locked and the young person can only use bathroom 5 times per day and then they must use bed pan. The young person is not to use the toilet for 60 minutes after meals. Nursing staff are to stop and disconnect continuous feeds from the NGT before the young person goes to the bathroom Bolus feeds given as per section 4 if their meal plan is not consumed. This includes when the young person has hidden food or when eating of the food is excessively messy. Nursing staff are to make sure that the young person is provided with a warning about the behaviour and the consequences. If the behaviour continues the young person is to receive a bolusThe young person is to be on bed rest after meals Slow weight gain or weight loss for the young person may result in an increase in meal plan and/or a reduction in activity (i.e. change in progress level) Activity Levels of the young person:As per management plan/progress level determined at MDT meetingShowering is limited to one per day and for a total of 5 minutes without supervision. Weigh ins of the young person:Mondays and Thursdays before breakfast after the young person empties their bladder fully and a urinalysis is performedNeed to be weighed in hospital gown and underpants onlyWe do not prevent the young person from seeing the weight. Limits of Visitors for the young person:There are no restrictions to immediate family (parents and siblings) visiting the young person in the first 24 hours of their admissionAfter the first 24 hours visitors are restricted to immediate family. Initially they can visit for two hours after 3 pm on week days and up to six hours between 8.30am to 9 pm on Saturday and Sunday.To begin with visits are not to occur at meal times. Once the young person has progressed the young person’s parents can start to visit at meal times and the young person can also have day leave passes (please see attachment one: progress levels). The young person is able to have other visitors e.g. friends, cousins, or teachers visit when they reach level 4 as per agreement at the MDT meeting. Limits on phone calls for the young person:The young person can receive an incoming call from immediate family outside of school hours (9am to 4 pm). The calls are not to interfere with the young person’s meal time. The young person may make one outgoing phone call per day. Parents are to take the young person’s mobile phone home when they are first admitted and future mobile phone use for the young person will with discussed with the MDT team When the young person is first admitted they are not able to have internet access. Internet access for the young person will be negotiated as the young person progresses. Back to Table of ContentsSection 7 – Discharge PlanningDischarge planning should start as soon as possible after the young person’s admission and planning should include determining agreed upon indicators for discharge. The main criteria for discharge is that the young person is physically stable and their remaining clinical issues are able to be managed safely in the community. The decision to discharge a young person is made at the MDT meetings in consultation with the team. The young person and their parents will be included in the discussions regarding discharge planning at the MDT meetings. Factors to consider in determining discharge 2 are the young person’s:Medical Status Nutritional status (were the young person has demonstrated that they are able to consume adequate nutrition orally)Psychological functioning Family functioning The majority of young persons will be discharged to either the EDP (ACT residents) or NSW CAMHS (NSW residents). The young person’s General Practitioner (GP) is essential in the outpatient management and it is recommended that the young person attends GP follow up appointments fortnightly. It is recommended that those clinicians who will be providing follow up are invited to discharge planning MDT meetings. A discharge summary of the young person’s admission should be sent to the young person’s GP with copies of the discharge summary provided to the young person’s parents and where appropriate to the EDP, case manager at NSW CAMHS or private clinicians providing follow up. The discharge summary should include the young person’s discharge weight and BMI as well as criteria for readmission of the young person. In the ACT, the EDP is able to provide continuity of care as they have access to the young person’s mental health records via the MAJICeR system, however the EDP team do still require handover documentation from the allied health team members of the young person’s MDT. The handover documentation should include Nutrition Transfer of Care documents (such as meal plans) and the family assessment conducted by Social Work and Psychology. This handover information is to be sent to the EDP generic email inbox Eatingdisordersprogram@.au. Back to Table of ContentsSection 8 – Ongoing monitoring of Physical Health The young person’s GP plays an essential role in the outpatient management of the young person. It is recommended that the young person has GP follow up appointments fortnightly following discharge. The ongoing frequency of contact with outpatient treatment services will need to be negotiated with the respective service. If the young person has not reached puberty, they will need ongoing GP appointments to monitor their growth and development.Low bone mineral density If the young person has been underweight for one year or longer consider a bone mineral density scan. The scan may be performed earlier if they have bone pain or have experienced recurrent fractures5. Consider referring the young person to the Paediatric Endocrinology team for review, treatment and ongoing monitoring of bone mineral density. Back to Table of ContentsSection 9 – Transition to Adult ServicesIt is essential that transition to adult services is part of the care planning for young people with Anorexia Nervosa as it is with any other young person with a chronic illness. Transition can be a high risk time for young person with Anorexia Nervosa. This is in part due to the cultural differences between paediatric and adult services where paediatrics emphasise parental responsibility and adult services emphasise individual responsibility and decision making. This change in approach can be very confusing and difficult for the young person and their family, particularly when the young person’s capacity for making decisions regarding treatment is not well understood by the receiving adult services team4.The Eating Disorder Program in the ACT is a service that provides care from childhood into adulthood and can offer young people already engaged with them continuity of care as they transition into adult services. However, the young person and their family need to be prepared for if/when the young person needs to be admitted to an adult ward the paediatric treating team should familiarise themselves with the Adults with Eating Disorders – Management of (Inpatients) Clinical Guideline so that they can prepare the young person and their family for what to expect. In those patients with severe Anorexia Nervosa, and who are expected to require further inpatient admissions, the family and young person will need to be clearly informed when their next presentation will result in an admission to an adult ward. It is recommended that the adult eating disorders inpatient team be invited to the discharge MDT meeting to assist with the transition process and handover of the young person’s care. Back to Table of ContentsImplementation This guideline will be available to all staff on the CHS policy register.It will also be used for training of staff on the Paediatric and Adolescent wards including nursing, medical and allied health staff.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPoliciesNursing and Midwifery Continuing Competence Patient Identification and Procedure Matching Consent and Treatment, Child Protection Emergency Detention in the Inpatient Setting and a Person’s Rights under the Mental Health Act 2015ProceduresNasogastric Tube ManagementHealthcare Associated Infections Patient Identification and Procedure Matching Care of Persons Subject to Psychiatric Treatment Orders Guidelines Adults with Eating Disorders – Management of (Inpatients)LegislationHuman Rights Act 2004Mental Health Act 2015Children and Young People Act 2008Health Records (Privacy and Access) Act 1997Guardianship and Management of Property Act 1991Back to Table of ContentsReferencesHay, P. Chinn, D., Forbes, D., Madden, S., Newton, R., Sugenor, L., Touyz, S. & Ward, W (2014)., Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the treatment of eating disorders. Australian & New Zealand Journal of Psychiatry Vol. 48 (11) 1 – 62Eating Disorder Toolkit - a Practice–Based guide to the Inpatient Management of Adolescents with Eating Disorders, with Special Reference to Regional and Rural Areas. (2008) MH-Kids, Hunter New England, NSWHealthWallis, A., Titterton, J., Madden, S,. & Kohn, M. (Eds.) (2012). Eating Disorder Service The Children’s Hospital, Westmead: Service Overview.MARSIPAN (2012) Junior MARSIPAN: Management of really sick patients under 18 with Anorexia Nervosa. Royal College of Psychiatrists LondonEating Disorders: Recognition and treatment, NICE Guideline UK, 2017 Sydney Children’s Hospital Network (2013). Re-feeding Syndrome: Prevention and Management – SCH Practice Guideline. Accessed at: on 16/04/2019Back to Table of ContentsDefinition of Terms (if applicable) Re-feeding Syndrome – an adverse metabolic response that can occur with the initiation of nutrition after a period of poor intake or starvation. It involves the confusion of serum electrolytes, vitamin deficiencies and sodium and fluid retention. It can be life threatening and can lead to cardiac, neurological and haematological complications, in particular cardiac failure, arrhythmia, delirium, seizures and anaemia. Splitting - a psychological defence mechanism characterised by the person holding polarising beliefs of good feelings and bad feelings, of attachment and rejection. This can lead to destructive behaviours that are damaging to their personal relationships. In a hospital setting this can disrupt team functioning where the patient idolizes some staff and disparages others.Back to Table of ContentsSearch Terms Anorexia Nervosa, Anorexia, Eating Disorder, Enteral feeding, Nasogastric tube, NGT, Re-feeding syndrome, paediatric, adolescent, young personBack to Table of ContentsAttachmentsAttachment One – Progress LevelsDisclaimer: This document has been developed by Canberra Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Canberra Health Services assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval This document supersedes the following: Document NumberDocument NameAttachment One: Progress LevelsProgress LevelsLevel 5Walking to hospital school Walking to adolescent lounge under supervision No enteral feeds Parents are able to start selecting meals for the young person with Dietitian supervision30 minute rest after meals, are able to have dinner with parentsAble to have overnight leave passes Can leave ward with parental supervision for 30 minutes per day (not able to leave hospital grounds)Level 4 Walking to hospital school Requirement for+/- enteral feeds to be determined at MDT meetings Meal plan as per dietitian 30 minute rest after meals Are able to have dinner with Parents Can access day leave passes (see note) Can leave ward with parental supervision for 30 minutes per day in wheelchair but are not able to leave hospital grounds Level 3 Wheel chair to hospital school Walk to bathroomOvernight feeds 30 minutes rest after meals Can leave ward with parental supervision for 30 minutes per day in wheelchair, but are not able to leave hospital grounds Level 2 (usually for the first 3 days)Wheel chair to hospital schoolWalk to bathroom 30 minutes rest after meals, Continuous NGT feeds Admission meal plan No leave passes Level 1 First 24 hours (medical stabilisation)Complete Bed rest Continuous NGT feeds Admission meal planNo access to internet or mobile phone (Restrictions may continue past 24 hours if patient remains medically unstable) Based on the Children’s Hospital Westmead Eating Disorder Service Program 3 Note: Day leave passes and overnight leave passes relate to leaving the hospital grounds with parental supervision. Depending on their progress the young person may also have permission to leave the ward under parental supervision to visit other parts of the hospital ................
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