Highland eating disorder service (HEDS) & Medical Emergency Eating Disorder (MEED)

Dear colleagues

As a team we continue to work to provide safe and effective treatment for patients across Highland with Eating Disorders in line with SIGN and NICE guidelines. 

In order to ensure that we are able to adequately assess risk and provide appropriate treatment, we require the following minimum information on all referrals to our service

Essential referral information

• BMI / rate of weight loss
• BP / pulse / temperature if BMI ˂ 17.5
• Baseline blood tests, including: FBC, U+Es, LFTs, Ca, PO4, Mg, Glc, TFTs
• ECG if low BMI (below 15) / significant electrolyte imbalance / compulsive exercise
• Details of eating disorder behaviours (e.g. restricting diet, binge eating, vomiting, laxative use, compulsive exercise)
• Other relevant info (e.g. co-morbidities, pregnancy, prescribed medication)
• List of other professionals involved
• Details of any risk, e.g: suicide, harm to others, child protection, self-neglect, vulnerable adult
• If aged 16 to 18, clarify if left school (refer to CAMHS if <18 or aged 16-18 in school)

Highland Eating Disorder Service will not be able to accept any referrals that do not contain the required data. The referral will be returned to Referrer requesting the information to be completed.

If there is any doubt about or difficulty obtaining the required information, or concerns about risk to individual patients, please contact Highland eating Disorder Service on 01463 253667 and a member of the team will be happy to discuss the referral.

Thank you for your assistance in providing us with this information, Highland Eating Disorder Service

Refeeding risk assessment for referrers

NICE guidelines 2017: Criteria for determining people at high risk of developing refeeding problems.  

The MEED guidelines can be found here: RCPSYCH medical emergencies in eating disorders

Ideally admissions of MEED patients should be planned so that Dr H. Younger (or another GI Consultant in her absence), Eating Disorders team, Dietitian and nursing teams are prepared prior to admission. If they are admitted out with hours when these staff are not available then the Consultant looking after them would decide on initial care until Dr Younger and her team are available.

Please refer to the MEED Checklist for guidance on admission.  

Aim of Increased Level of care i.e. 1-1 nursing is to ensure safe and sensitive monitoring of patient’s health and well-being

Resources Funding has been agreed by Raigmore hospital managers for additional staff to provide 1:1 input to MEED patients. Requests can be made to the nursing bank.

Care Management plan 

1. Should be written and reviewed regularly
2. Should ensure that patient is aware of the level of care and understands need for it – where possible this should be discussed by HEDS prior to admission to hospital, but this is not always possible  - see also Patient and carers Information Leaflet
3. Should include -
   • Risk assessment
   • Level of care e.g. 1-1 nursing
   • Level of privacy e.g. can they shut toilet door
   • Who can be delegated to undertake observations e.g. family / friends / AHPs
   • In what circumstances can they leave ward environment e.g. in wheelchair/ with family/ with staff
   • What criteria when met may allow level of care to be reduced?
   • When level of care will be reviewed and by whom (In New Craigs reviewed every 24 hours by Consultant )

Carrying out increased levels of care

1. Usually involves a number of staff with care being passed over at regular intervals due to the intense nature of 1-1 care
2. Nurse in charge would inform staff of levels of care and why
3. Staff should be aware of patient history and be made aware by reading the care plan of current needs etc (See MEED checklist for behaviours that patient may display that need to be monitored)
4. Staff should be aware of any triggers that are likely to cause distress e.g. after initial stages of re-feeding when feeling physically better but still enmeshed in ED thoughts, on introduction of oral foods
5. Staff should be approachable to patients and relatives but should also be aware of maintaining professional limits
6. Engagement with patient should be therapeutic including silence which can also be therapeutic. Patient is unlikely to want to talk all day and may appreciate some silent observation to allow them to read, watch TV etc
7. Any change in presentation should be reported to nurse in charge to give access to full information for review of levels of care

Care management plan

1. Should be written and reviewed regularly
2. Should ensure that patient is aware of the level of care and understands need for it – where possible this should be discussed by Highland Eating Disorder Service (HEDS) prior to admission to hospital, but this is not always possible - see also Patient and carers Information leaflet
3. Should include:
   • Risk assessment
   • Level of care e.g. 1 to 1 nursing
   • Level of privacy e.g. can they shut toilet door
   • Who can be delegated to undertake observations e.g. family / friends / Allied Health Professionals (AHPs)
   • In what circumstances can they leave ward environment e.g. in wheelchair/ with family/ with staff
   • What criteria, when met, may allow level of care to be reduced?
   • When level of care will be reviewed and by whom (In New Craigs reviewed every 24 hours by Consultant) 

Increased levels of care

1. Usually involves a number of staff with care being passed over at regular intervals due to the intense nature of 1 to 1 care.
2. Nurse in charge would inform staff of levels of care and why.
3. Staff should be aware of patient history and be made aware by reading the care plan of current needs, etc. See MEED checklist for behaviours that patient may display that need to be monitored.
4. Staff should be aware of any triggers that are likely to cause distress e.g. after initial stages of re-feeding when feeling physically better but still enmeshed in eating disorder (ED) thoughts, on introduction of oral foods.
5. Staff should be approachable to patients and relatives but should also be aware of maintaining professional limits.
6. Engagement with patient should be therapeutic including silence which can also be therapeutic. Patient is unlikely to want to talk all day and may appreciate some silent observation to allow them to read, watch TV, etc.
7. Any change in presentation should be reported to nurse in charge to give access to full information for review of levels of care

The Dietetic care plan provided is not punitive in intent, but aims to protect the patient from the devastating effects of the illness. Dietitians, as part of the multi-disciplinary team, need to validate the actions of colleagues and to repeatedly and kindly emphasise the protective intent to patients and their families/other carers.

Dietitians do not have a checklist within this Protocol, as they keep their own records. However, their role is frequently invoked in the checklists provided here for the use of Nurses and Medical staff, so expectations and responsibilities are summarised here for completeness and to acknowledge the crucial role of this staff group within the overall care plan.

Initial assessment and recommendation of nutrition

A Specialist Gastroenterology Dietitian will be contacted as soon as it is known that the admission of a patient with anorexia is intended, and/or as soon as the patient is admitted to the ward. When a Specialist Eating Disorder Dietitian has already been involved, they will be contacted to provide a full dietetic handover.

The Dietitian will consult with the senior doctor involved to ascertain what form nutritional delivery should take (whether as food, oral supplement, tube feed, or – in exceptional cases – Total parenteral nutrition (TPN)). Nasogastric (NG) feeding is the preferred starter mode of nutrition on the ward, unless there is prior agreement from the Multidisciplinary Team (MDT) regarding the primary use of food/oral supplements. Plans will also be made for how nutrition is to be delivered if the patient has difficulty complying with, or fails to gain weight on the initial feeding route. The patient’s legal state should be discussed and acknowledged, and may need to be reviewed frequently.

Where the patient reports gastrointestinal (GI) conditions, allergies or intolerances and/or special diets (eg vegetarian), there should be investigation to explore whether these are medically validated, and whether any restrictive diets pre-date the onset of the eating disorder. This information will usually be included in the handover provided by Specialist Eating Disorder Dietitian. Other complicating conditions which may require particular care and further consultation with other specialities include diabetes, coeliac disease, pregnancy, breast-feeding and substance misuse.

The Dietitian will formulate a plan for sufficient nutrition to avoid the risks of both refeeding syndrome on one hand, and underfeeding on the other. In liaison with the Senior Doctor, a decision will be made regarding fluid balance, and the volume of oral fluids allowed will be calculated on an individual basis and documented. The Dietitian will stipulate which fluids are acceptable to be included in the patient’s oral fluid intake.

Nasogastric Tube Feeding Protocol

The Dietitian will prescribe the enteral feed volume, rate of infusion and duration of the feed. This should not be altered by any member of the wider MDT without consultation with the Dietitian or Senior Doctor. The Dietitian will recalculate nutritional requirements and amend feed provision as often as is deemed necessary.

If an NG tube becomes displaced for any reason, this should be replaced without delay and feeding recommenced. In the case of multiple intentional tube removals by patient. The use of nasal bridles in NG feeding should not be considered as standard practice, as they do not fit within Mental Health Acts principles of least restrictive practice. There are reported cases of bridles being pulled out by patients causing damage to the nasal septum. If a team is considering the use of this restrictive intervention, then it is vital that appropriate observations are in place, that it is utilised for the shortest possible time and that it forms part of a comprehensive treatment approach to facilitate recovery.

Arrangements for weighing the patient

The Dietitian will take responsibility for the twice weekly weighing of the patient unless otherwise stated. If patient is admitted “out of hours” or the Dietitian requests a member of the nursing team to weigh the patient, this should be done in hospital gown, in the morning after passing urine.

If the Dietitian asks in advance for a patient to be weighed, this should not be communicated with the patient so as to safeguard them from any attempt to alter their weight or jeopardise this opportunity.

Prescribing

In consultation with doctors, dietitians generally advise the prescribing of

• Oral thiamine 300mg (100mg three times daily) for 10 days, then reduce to 200mg (100mg twice daily). A full daily dose of Thiamine (300mg) to be given prior to initiating feeding on first occasion
• If unable to swallow, recommend IV Pabrinex I+II once daily for 10 days
• Forceval 1 capsule daily oral
• Supplements of Potassium, Phosphate and Magnesium are prescribed as indicated by blood monitoring.

Ongoing dietetic review on ward

For continuity, the same Specialist Gastroenterology Dietitian will review the patient for the duration of their admission (unless exceptional circumstances dictate otherwise).

Once a patient is medically stable and nutrition has been fully established, the Specialist Eating Disorder Dietitian will be contacted to seek input regarding onward meal planning for the period the patient remains on the ward.

Necessary ongoing observations at ward level:

• Monitor fluid intake and ensure not exceeding the calculated fluid restriction. Ensure patient is not over drinking, or taking excessive caffeine intake. Complete fluid balance chart.
• When/if a patient is eating food, they must be directly supervised for 30 to 60 minutes following the meal
• Monitor activity levels on the ward and document

Discharge/transition plan:

Dietitians communicate in good time with their counterparts in the service to which the patient is to be transferred.

For patients transferring to the Eden Unit it is helpful for any feeding tube to be left in place and for 2 days of feed to be sent with patient. Patients who are returning home should be supplied with an interim meal plan until any modifications can be discussed with outpatient clinicians.

Prior to admission 

Which room?

Where the patient is located in the ward should be considered prior to admission. This should be discussed with Dr Younger. Preferably a single room should be used but this may be dependent on whether there is difficulty getting one-to-one staffing.
If a single room is not possible then they should be located in a cohort room where there is a nurse in attendance at all times, so they can be observed.

Staffing

Staff who have had extra training in looking after MEED patients should ideally be allocated to look after these patients. Extra staffing will need to be arranged as normally these patients require one-to-one nursing. The Nurse Manager/Charge nurse for the hospital should be made aware of these patients so they know about the extra staffing needs. If the patient is to be on telemetry they should have a one-to-one nurse looking after them and they must be a Registered Nurse.

Telemetry

The need for this may be known prior to admission, if it is planned, but if not, staff still need to prepare in case it is required. Inform CCU and ensure telemetry is available. A mobile phone will be used for communication between ward 7C and CCU. There is a dedicated mobile phone for MEED patients in Ward 7C, Charge Nurse office. The staff nurse looking after the patient should carry the mobile phone and, when the phone needs charged, it should be charged beside the member of staff who has been allocated the one-to-one input with the patient.

On Admission 

If it is an unplanned admission ensure Dr H Younger and the Specialist Gastroenterology Dietitian, and Highland Eating Disorder Service are informed when they are next available.

NEWS:

On admission must be done 4 hourly minimum or as per NEWS, whichever is most frequent.
The GI Consultant will then decide when/if NEWS can be done less or more frequently.

BM’s:

• On admission minimum 4 hrly.
• Dr H Younger will then decide when/if they need be done less or more frequently.

Weight:

• The Dietitian will take responsibility for weighing the patient. However, if the admission is out with hours a Staff Nurse should take the patients initial weight
  as per MUST protocol (wearing a hospital gown only).
• After this the weight should be done in the morning, after passing urine and wearing a hospital gown only.
• The Dietitian will clearly document the frequency and arrangements for when/how the patient is weighed within their initial assessment.

Tissue viability:

• Often need a repose mattress due to low BMI.
• Skin should be inspected and Skin bundle commenced.

Mobility:

• This has to be decided by Dr H Younger but if out of hours then bed rest should be advocated, up to commode only until seen by Dr H. Younger.

Washing:

• This is to be decided by Dr H Younger. E.g. basin wash at bedside or up to shower, etc, but must be wheeled through.
• Out of hours, if Dr Younger is not available, they should have a supervised basin wash at bedside only.

Nutrition:

• Decisions regarding this will be made by the dietician and Consultant.
• If NG feeding is commenced, then often this is all they are allowed orally as their nutrition is calculated very carefully.
• If they have a food plan made up by the Dietitian then this must be followed fully with no deviation from it, unless authorized by Dietitian/Consultant.
• The use of nasal bridles in NG feeding should not be considered as standard practice, as they do not fit within the Mental Health Act principles of least restrictive practice. There are reported cases of bridles being pulled out by patients causing damage to the nasal septum. If a team is considering the use of this restrictive intervention, then it is vital that appropriate observations are in place, that it is utilised for the shortest possible time and that it forms part of a comprehensive treatment approach to facilitate recovery.

Observation:

• Patients should be supervised at all times, even when going to toilet or washing/showering.
• They must also be observed for signs of exercise in a bid to burn calories e.g. swinging their legs if sat on bed/chair, walking around their bed.
• If they do not have one-to-one nursing, then the most important times to observe them is during eating and 30 to 60 mins after, and when going to the
  toilet.

Fluids: 

• Patients should be observed in case they are fluid loading i.e. drinking a lot of water in a bid to keep their weight up but not taking in calories, or taking excessive amounts of caffeine.
• Ensure a fluid balance chart is kept; check with Consultant/Dietitian regarding permitted total volume and fluid types.

Support services

Beat: Beating Eating Disorders

• www.b-eat.co.uk (see resources)

Help and support:

• Scotlandhelp@beateatingdisorders.org.uk (see resources) 0808 801 0432 
  Helplines are open 365 days a year from 9am to midnight during the week, and 4pm to midnight on weekends and bank holidays.

Recommended Reading

Anorexia Nervosa:

• Graham, P and Fairburn, C. (2019) Overcoming Anorexia Nervosa 2nd Edition: A self-help guide using cognitive behavioural techniques. Robinson publishing
• Schmidt, U., Startup, H., et al (2018) A Cognitive-Interpersonal Therapy Workbook for Treating Anorexia Nervosa: The Maudsley Model. Routledge.
• Treasure, J. (2013) Anorexia Nervosa: A Recovery Guide for Sufferers, Families and Friends 2nd Edition. Routledge

Bulimia Nervosa:

• Cooper, P.J (2009) Overcoming Bulimia Nervosa and Binge-Eating: A self-help guide using cognitive behavioural techniques. Robinson publishing
• Fairburn, C. (2013) Overcoming Binge Eating: The Proven Program to Learn Why You Binge and How You Can Stop 2nd Edition. Guilford Press
• Schmidt, U., Treasure, J. and Alexander, J. (2015). Getting Better Bite by Bite: A Survival Kit for Sufferers of Bulimia Nervosa and Binge Eating Disorders 2nd Edition. Routledge

For Carers

• Lock, J. (2015) Help Your Teenager Beat an Eating Disorder 2nd Edition. Guilford Press
• Treasure, J. and Smith, G. (2016) Skills-based Caring for a Loved One with an Eating Disorder: The New Maudsley Method 2nd Edition. Routledge
• Eating Disorder: The New Maudsley Method 2nd Edition. Routledge