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Title Page 2
Purpose 3
Definition of Medically Unstable Eating Disorder Patient 3
Goals of Medical Hospitalization 3
Initial evaluation 3
Protocol 3
BIDMC EATING DISORDER FLOWSHEET 3
Legal Issues 3
Disposition/Resources 3
SHORT FORM: ROLES AND RESPONSIBILITIES 3
MEDICAL HOUSE OFFICER, HOSPITALIST 3
NUTRITION AND FOOD SERVICE 3
NURSING 3
CASE MANAGEMENT 3
PSYCHIATRIC CONSULTANT 3
SOCIAL WORK 3
INFORMATION FOR PATIENT CARE OBSERVERS 3
PATIENT INFORMATION 3
References 3
Title Page
Beth Israel Deaconess Medical Center
Multidisciplinary Guideline for the Management of Medically Unstable Eating Disorder Patients in the General Hospital
December 2008
Multidisciplinary Committee for Medically Unstable Eating Disorder Patients
Rohn S. Friedman, M.D., Chair and Contact ( or (617) 632-8404); Johanna Klein, M.D.; Suzanne Gleysteen, M.D.; Richard Wolfe, M.D.; Patricia Samour, R.D. Claire Shoaie, R.D., Joanne Devine, R.N.; Leslie Ajl, R.N.; Catherine Mahoney, J.D.; Marie Huppuch, R.N.; Barbara Sarnoff Lee, LICSW
The intent of this guideline is to educate clinicians in the evaluation and management of eating disorder patients and to optimize treatment in this particular general hospital setting. The recommendations contained in this guideline are based on current recommendations as published in the cited references as well as upon the clinical experience of the Committee in terms of this institution. Ultimate decision –making should be based on multidisciplinary assessment of individual patients.
Purpose
1. To establish criteria for medical instability in eating disorder patients. This is a particularly important area, since many of these patients are young, healthy-appearing individuals. In the absence of a gross abnormality, the extreme precariousness of a patient’s medical status is often not appreciated. We have seen patients with a bradycardia of 29 or at 62% of lean body mass “medically cleared”.
2. By establishing some guidelines for “medical instability” we also clarify criteria that would justify seeking guardianship and involuntary treatment (whether medical or psychiatric hospitalization or NG tube placement and involuntary medical treatment)
3. By establishing a guideline for medical and nutritional evaluation and management of these patients, we will avoid the phenomenon of reinventing the wheel each time such a case presents.
4. The guideline provides consistency in treatment and reduces miscommunication between patients and staff in treating patients who characteristically enact their conflicts in ways that manipulate and divide staff and foster miscommunication and disagreement. It focuses on weight, caloric intake, and medical monitoring and tries to avoid engaging in struggles or endless negotiations over extraneous issues.
Definition of Medically Unstable Eating Disorder Patient
1. Electrolyte abnormality including Ca, PO4, Mg
2. Arrhythmia, prolonged QTc
3. Pulse <40, temperature < 97, blood pressure < 90/60, orthostatic change in pulse or pressure > 20
4. Weight <75% ideal body weight. A rough approximation of ideal body weight for women is 100 lbs/60 inches + 5 lbs/inch above that; for men 107 lbs/60 inches + 6 lbs/in above that.
5. Glucose < 60 or high glucose in diabetic undertreating self to control weight
6. Medical complication (cardiovascular, renal, hepatic, pancreatitis, pancytopenia, diet pill toxicity, ipecac cardiotoxicity, aspiration pneumonitis/Mallory Weiss tear from vomiting)
Goals of Medical Hospitalization
1. To achieve weight gain and medical stabilization
2. To transfer to appropriate eating disorder treatment as soon as an appropriate disposition is available
a. inpatient eating disorder program
b. inpatient psychiatry unit
c. outpatient eating disorder program (including PCP, nutritionist, psychiatrist, psychotherapist, partial hospitalization, and residential programs as appropriate)
3. To provide optimal care consistent with the setting.
a. The patient deserves the best care possible, and we are committed to providing the best care.
b. We work on treatment PLANS not treatment CONTRACTS; we will be held to our commitment to provide the best care, but we will not be held to a particular plan if it is not serving the interests of the patient.
c. In this phase of treatment in the acute general hospital, the goals are not to treat the eating disorder per se, to reeducate about eating patterns, to conduct psychotherapy, to do family therapy, or to provide other components that are part of the longer term treatment plan. In the general hospital setting dietitians cannot offer extensive nutritional counseling and education, social workers and psychiatrists cannot do intensive psychotherapy, and nurses cannot conduct milieu therapy—NOR SHOULD THEY TRY, because this fosters unrealistic expectations that are a set up for failure and frustration on everyone’s part and blur the clarity of treatment goals.
Initial evaluation
1. Weight after voiding in johnny only
2. Vital signs with orthostatic blood pressure and pulse
3. Laboratories including Chem 20, CBC with diff, EKG, amylase, TSH,U/A, CXR
4. Immediate nutrition consult in POE for “Eating Disorder.” The dietician (RD) or diet technician (DT) will meet with the patient within 24 hours.
5. Ask about binging, purging, LMP (and weight at LMP), laxatives, diuretics, diet pills, emetics, exercise
6. Search possessions according to Medical Center Protocol PR-08 for laxatives, emetics, Gatorade, diet pills, diuretics, etc.
7. Psychiatric consultation (may occur in ED or on floor, but should be contacted ASAP)
8. Case management consultation to alert case management to likely need for disposition
9. Social work consultation for an evaluation of family and support system
10. Admitting diagnosis should be a medical diagnosis such as hypokalemia or other medical complication, Malnutrition, Other Protein-Calorie Malnutrition, Other Protein-Energy Malnutrition , Unspecified protein-calorie malnutrition, Nutritional Marasmus, Kwashiorkor, Malnutrition of moderate degree (wt for age 60% to < 75% of standard) and Malnutrition of mild degree (wt for age 75 to < 90% of standard). The last 2 are more pediatric. Anorexia Nervosa and Eating Disorder generate Psych DRGs and may not cover a medical admission.
Protocol
1. House officer should order the “eating disorder protocol diet” (as well as the nutrition consult if it has not yet occurred), a daily multivitamin with mineral supplement, 2 packets (500 mg) Neutraphos bid (unless contraindicated by hyperphosphatemia, hyperkalemia, or renal failure; the dose should be adjusted daily according to labs), and thiamine supplementation of 100 mg po qd for 3 doses.
2. House officer and RN should go over the “Patient Information” Handout with the patient, summarizing the medically unstable eating disorder protocol.
3. Nutrition services will calculate (and document in chart) % ideal body weight, BMI (weight in kg/(height in meters)2), basal energy expenditure (BEE) and refeeding schedule to produce 2-3 lb/week (1-1.5 kg/wk) weight gain during inpatient stay. Nutrient levels will start at BEE to BEE x 1.2 for calories, and at 1.2 to 1.5 g protein/kg/d. Calorie level will be increased up to daily as determined by the RD in increments of ~250 kcal/d until the goal daily average weight gains (on average, a minimum of 0.15 kg per day) are achieved. The RD will monitor appropriate lab results and weights, and advance the calorie level as needed to allow weight gain but avoid refeeding complications. The RD or DT will meet with the patient after receiving the initial consult on admission, and review the hospital menu choices. The patient will be shown a menu and asked about his/her general food preferences (up to a maximum of 10 menu items that he/she does not want to receive and 10 menu items he/she would prefer to be served.) The list of food preferences will not be subject to revision except at the weekly meeting with nutrition staff. The patient will not select each meal; no menus will be sent to the patient. A meal from the regular diet menu (or therapeutic menu if indicated for other medical problems) containing approximately the calculated number of calories will be delivered by food services staff. The patient should be reassured that he/she will receive meals in the correct amount to make sure that the patient gains weight at the appropriate rate and is not overfed; that the meals will be nutritionally complete, and that every effort will be made to respect the patient’s food preferences as initially determined. No carbonated beverages will be provided; the patient may have one 8 oz caffeinated beverage a day. The patient may have water or other noncaloric, noncarbonated, noncaffeinated beverages during the day unless there is a need to restrict them due to water-loading or hyponatremia. The patient will not be allowed to go to the floor kitchen or refrigerator or have food brought in by visitors at any time. No cafeteria passes will be provided, and visitors/staff will not be allowed to bring food to the patient from the cafeteria. Three meals a day will be served; no snacks are allowed. Calorie counts will not be completed on eating disorder patients.
4. The patient will have 30 minutes to consume the entire meal. No delays, substitutions, reheating, or saving foods for later will be allowed.
5. Patient should have direct observation (either with 1:1 nursing observer or in observed common area of floor) during meal and for one hour after to prevent vomiting. If the setting is the observed common area, the patient will be allowed only a hospital gown and appropriate robe which will be searched after meal; no other objects will be allowed into the room. If eating in his or her room, the patient will initially be attired in a gown and robe until weight gain is established, at which point the issue of attire may be considered at the weekly team meeting. The patient may not use the bathroom unobserved during the observation period. The observer will report to the staff who will also document in the chart either that the patient consumed the entire meal or did not consume the entire meal in the allotted 30 minutes.
6. If the patient fails to consume the entire meal in the time limit for any reason, nursing staff will immediately put a nutrition consult into the computer system (POE) stating the reason for the consult (failure to complete 100% of last meal). All subsequent meals, starting with the next scheduled mealtime if possible, will be delivered as cans of liquid nutritional supplement (type and amount to be determined by the RD or DT) unless and until a minimum of three consecutive liquid meals have been consumed in their entirety and a team decision is made to resume solid meals. Patient will have 30 minutes to consume the supplement; if the patient is unable to drink the entire amount in the time allotment, the nurse will call the medical house staff to place a nasogastric feeding tube and verify its position by Xray. Unless there is reason to suspect an unusually small stomach capacity, the remaining supplement will be bolused into the tube over twenty minutes if the volume is less than 250 cc; if it is more, equal portions of 250 cc or less will be bolused every 30 minutes until the entire volume has been delivered. If the initial bolus is well-tolerated, subsequent boluses can be given over 10 minutes. The patient will be monitored through the procedure, and for 1 hour after, checking for nausea or distension and to prevent surreptitious vomiting. See also Nursing Manual Policy 900-3 “Using an Enteral Feeding Tube.”
7. If the patient refuses NGT or feeding, capacity to refuse treatment will be evaluated by psychiatry.
8. Patient must remain in hospital (not necessarily the general hospital) until no longer medically unstable. If the patient asks to leave AMA, psychiatry should evaluate the patient’s competence to decide to leave AMA if the patient needs to remain on a medical unit or commitability to a psychiatric unit if the patient does not need to be on a medical unit.
9. Patient will be weighed in a.m. after voiding, before eating or drinking anything, in hospital gown qd, on a standing scale (not the bed scale). For consistency the same scale should be used each time. For standardization, the baseline weight will be the weight obtained on the first morning after admission. Patient will also have I & O, VS with orthostatics q shift; lytes, Ca, PO4, Mg followed daily (until stable); cardiac telemetry if arrhythmia or severe bradycardia. Patient will be monitored for edema and too rapid weight gain. Patient will be monitored for refeeding complications including cardiovascular collapse, pancreatitis, acute gastric dilatation, bloating, constipation, hypophosphatemia, and seizures. The eating disorder flowsheet should be used to monitor these items.
10. Initially patient will be restricted to the floor; (s)he may be restricted to bedrest to avoid excess exercise; if there is a question of purging or water-loading, the patient may be restricted to use of a bedside commode; patient may require 1:1 constant observation; privileges will gradually be increased once weight gain established.
11. The target weight of treatment (not necessarily inpatient) is 90% ideal body weight (in women, the weight at which normal menstruation occurred is an alternative target if known; or a BMI > 18.5).
12. Psychiatry will facilitate a weekly team meeting of medicine, nursing, dietary, social work, legal, and case management to discuss and coordinate treatment and disposition. The first team meeting should be within 72 hours, the sooner the better, given the importance of establishing a consistent plan. Social work will coordinate the scheduling of the meeting; it is important for all disciplines to respond to scheduling requests in a timely fashion to facilitate the team meeting. Weight gain and compliance will be evaluated at the weekly team meeting and a decision about advancing the diet or privileges will be made at that time only.
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BIDMC EATING DISORDER FLOWSHEETdate / date / date / date / date / date / date / date / date / date
time / time / time / time / time / time / time / time / time / time
Weight
Temp
Pulse lying
BP lying
Pulse standing
BP standing
Intake
Output
Urine S.G.
Na
K
CL
CO2
BUN
glucose
Ca
PO4
Mg
edema
bloating
constipation
abd pain (consider acute gastric dilatation and pancreatitis)
QTc
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