Eating Disorders Care Pathway - GP Portal (PDF)

- 1 - Solent West CAMHS Eating Disorder Care Pathway November 2021 Solent West (Southampton) CAMHS Team Care Pathway For Eating Disorders: A Guide for GPs  - 2 - Solent West CAMHS Eating Disorder Care Pathway November 2021 Contents Introduction...............................................................................................................3 Key Points..................................................................................................................4 Diagnostic Classification...........................................................................................6 Flow Charts.......................................................................................................... (1) Primary healthcare eating disorders care pathway………………………………7 (2) CAMHS eating disorders care pathway……………..…………………………………8 Appendix 1 Contact details.................................................................................9 Appendix 2 Junior MARSIPAN Physical assessment...........................................10 Appendix 3 Junior MARSIPAN Risk Assessment Framework…………………………..12 Appendix 4 Junior MARSIPAN Management in general practice.......................16 Appendix 5 Suspected Eating Disorder – Quick Guide for GPs……………………..…18 Appendix 6 Physical Observations Monitoring Form…………..………………………….20 Appendix 7 Refeeding Syndrome – A guide for Clinicians……………………………….22 Appendix 8 Helpline and Resources....................................................................23  - 3 - Solent West CAMHS Eating Disorder Care Pathway November 2021 Introduction This Eating Disorders Care Pathway has been developed by a variety of professionals with experience in working with young people with eating disorders; within this group of professionals there is variation of clinical expertise and backgrounds. This pathway aims to ensure that young people who present with a suspected eating disorder in Southampton are responded to in a timely fashion by services and clinicians who have the skills and experience in assessing and treating individuals with an eating disorder. The pathway aims to ensure that all people with an eating disorder and their parents or carers have equal access to treatments for eating disorders, regardless of: age, gender or gender identity, sexual orientation, socioeconomic status, religion, belief, culture, family origin or ethnicity, where they live and who they live with, any physical or other mental health problems or disabilities. The Care Pathway is presented in the form of flow charts to ensure that it is user-friendly and that it can be used in clinical practice efficiently. However, it is recognised that further information at times will be required; the appendices attached to this document offer a detailed appraisal of the steps required to assess and safely manage this complex client group. Contact details for Solent West CAMHS Team are also included. This Care Pathway will be reviewed regularly to ensure that it remains in line with current research and good practice. We recommend considering the following key points before using the Care Pathway.  - 4 - Solent West CAMHS Eating Disorder Care Pathway November 2021 Key Points 1. Children and adolescents become physically compromised more quickly than adults with the same weight loss. Therefore, they can move from low risk to high risk in a short space of time and need regular monitoring. 2. Anorexia Nervosa, Bulimia Nervosa and Other Specific Feeding and Eating Disorders (OSFED) are complex and challenging illnesses that can require a long period of treatment from a wide range of professionals. 3. Early identification and intervention are key to the management of complex eating disorders. Young people with suspected eating disorders should be referred early to Solent West CAMHS team or Paediatrics if physical health is of high concern; continued monitoring by primary care is paramount whilst awaiting a specialist assessment. Consultation should be sought as required from specialists (such as Paediatric team, CAMHS) during this period. 4. BMI (Body Mass Index) is only a proxy measure of medical risk and has limitations, particularly in children and adolescents. Plotting weight, height and BMI on percentile charts, or using a Weight4Height calculation is a more accurate way of detecting failure to thrive and comparing development to normal growth patterns. Some young people may be within a healthy range but still at risk physically e.g. with bulimia nervosa or with rapid weight loss. Junior MARSIPAN recommends the use of % Median BMI (see Junior MARSIPAN pages 19- 20 for further detail). 5. Changes in a young person’s behaviour, personality, social functioning; inability to eat and drink normally, which may emerge in a dramatic or subtle presentation, are good indicators of a developing eating disorder. 6. Eating disorders often have complex presentations. It is important to take into consideration various sources of information when making an assessment. School or college may be able to offer useful information on the behaviour of the young person both in general and around mealtimes. Every professional involved with the client has a responsibility to facilitate smooth transitions between settings and professionals, as well as to work in a multi-disciplinary manner. 7. All services that have responsibility for a young person whilst in their care, such as education, should be informed of any risks and care plans, and given guidance on maintaining the young person’s safety whilst under their care. This would generally be done with parental and young person’s consent, but if there is sufficient concern about the young person’s safety, it can be done under the appropriate safeguarding legislation without consent. 8. Having awareness and understanding of the impact an eating disorder has on a family is crucial in evaluating the level of support the family can offer a young person in managing and recovering from their eating disorder. Where there are concerns that those caring for a young person are unable to support/engage in a safe treatment plan, safeguarding should become a consideration. This includes persistent non- attendance of appointments or engagement with physical monitoring, due to the potential medical risk posed. The Solent NHS Trust Was Not Brought policy is to be followed. If any clinician has safeguarding concerns, they should seek advice via their line manager and Solent Safeguarding team or from Child Protection Team (UHS). They should contact MASH to share information and discuss whether a referral is appropriate. 9. Due to the impact an eating disorder has on the systems around a young person, good communication is essential. Review meetings with written care plans is necessary in all cases, utilising the Care Programme Approach (CPA) process where appropriate, and will be shared with Primary Care.  - 5 - Solent West CAMHS Eating Disorder Care Pathway November 2021 10. Where a young person is seriously ill with an eating disorder and issues of refusal of treatment arise, appropriate agencies should be consulted to consider any necessary legal steps to be taken. Due to the nature of these illnesses, there is often a need to clarify consent to treatment. (See ‘Legal aspects – guiding principles’ Appendix 5 on page 23 for further details) 11. The young person’s view (or demeanour suggesting a view) should always be taken into account in case management. It may vary from that of the parents and should be recorded regularly. 12. The appointment of a lead clinician and named GP in each case is critical for safe management. 13. Be aware that people with an eating disorder and their families may find it difficult or distressing to discuss it with healthcare professionals, staff and other service users. They may be vulnerable to stigma and shame and they may need interventions and information tailored to their age and level of development.  - 6 - Solent West CAMHS Eating Disorder Care Pathway November 2021 Diagnostic Classification Classification of Anorexia Nervosa* For a definitive diagnosis, all the following are required:- A) Weight loss or, in younger children, a lack of weight gain, leading to a body weight at least 15% below that expected for age and height. (Please note Atypical Anorexia Nervosa can present at a healthy weight) B) Weight loss is self-induced by avoidance of ‘fattening foods’. One of more of the following may be present: self-induced purging via vomiting or laxative use; excessive exercise; use of appetite suppressants and/or diuretics. C) Self-perception of being too fat, with an intrusive dread of fatness, which leads to a self-imposed low weight threshold. D) Widespread endocrine disorder involving the hypothalamic-pituitary-gonadal axis is manifest in older females as amenorrhoea and in older males as a loss of sexual interest and potency. (An apparent exception is the persistence of vaginal bleeds in anorexic females who are on replacement hormonal therapy, most commonly taken as a contraceptive pill). If onset is pre-pubertal, the sequence of pubertal events is delayed or even arrested (growth ceases; in girls the breasts do not develop and there is primary amenorrhoea; in boys the genitals remain juvenile). With recovery puberty is often completed normally, but menarche is late. Classification of Bulimia Nervosa A) Recurrent episodes of overeating (at least twice a week over a period of 3 months) in which large amounts of food are consumed in short periods of time and an associated loss of control B) Persistent preoccupation with eating, and a strong desire or a sense of compulsion to eat (craving) C) Attempts to counteract the ‘fattening’ / ‘ calorific’ effects of food by one or more of: self-induced vomiting; self-induced purging; alternating periods of starvation; use of drugs such as appetite suppressants, thyroid preparations or diuretics; neglect of insulin treatment in diabetics. D) Self-perception of being too fat, with an intrusive dread of fatness. OSFED Commonly young people do not fulfil the ICD 10 diagnosis for anorexia nervosa but fit into the category of atypical eating disorder also known as OSFED (Other specific feeding and eating disorders). This classification of an eating disorder is equally serious and should be managed as with a young person who fulfils a diagnosis of anorexia nervosa or bulimia nervosa. *NB: ICD-10 classification is most relevant for adults and older adolescents who have stopped growing. Prepubertal and peripubertal children and growing adolescents do not easily fit this classification.  - 7 - Solent West CAMHS Eating Disorder Care Pathway November 2021 Suspected eating disorder by Tier 1-2 Universal Services 1) Primary Health Care – Eating Disorders Care Pathway Referral to Solent West CAMHS GP – medical assessment using Junior MARSIPAN Risk Assessment Framework (see appendices 3+4) GREEN: Minimal risk to physical or psychological health RED: Immediate risk to physical health Use CAMHS Duty Line for advice or make routine referral to Solent West CAMHS [email protected] Phone: 0300 1236661 Referral to Paediatrics - contact on call Paediatrician to discuss/arrange paediatric review Simultaneous referral to Solent West CAMHS Await CAMHS assessment Pre-assessment letter sent from CAMHS to GP Maintain regular monitoring of young person and contact with family until seen by CAMHS Paediatric admission pathway AMBER: Moderate risk to physical or psychological health  - 8 - Solent West CAMHS Eating Disorder Care Pathway November 2021 (2) CAMHS Intervention – Eating Disorders Care Pathway Ongoing care with Solent West CAMHS The Eating Disorder Service within Solent West CAMHS is a provision of care offered within the community CAMHS team and is not a stand-alone service. The professionals within the Eating Disorders Service comprise of a mixed group of professional groups including psychology, psychiatry, nursing, occupational therapy, dietetics, family therapy. For regular observations we have a weekly weights clinic at CAMHS. Very occasionally in low risk patients we may ask the GP to monitor physical observations if patient preference indicates. (See Appendix 6 for physical obs monitoring form) External Referral received by SPA Team Suspected Eating Disorder SPA to triage, checking medical assessment has been completed (height and weight essential) Send task to ED team on S1 If urgent contact ED worker and Duty Dr on same working day ED service review referral (including re- referrals) and attempt to contact family by telephone based on level of urgency Referral not indicating an eating disorder Specialist assessment offered Liaison with and referral to Paediatrics for urgent cases if not already done simultaneously by GP Assessment in Clinic or on Paediatric ward GREEN: Routine 4 weeks RED: Emergency Within 48 hours AMBER: Urgent 1 week Immediate Assessment Liaison with and referral to Paediatrics if not already done simultaneously by GP (contact on call Paediatrician/Consultant of the Week (COW) to discuss/arrange paediatric review OR Paediatric Mental Health Liaison Team using SBAR tool) Internal CAMHS referral: Clinician to gather detailed information including height, weight, pattern of weight loss and food/fluid intake, then contact ED team to discuss urgency and refer Letter to GP requesting bloods, observations and vitamins  - 9 - Solent West CAMHS Eating Disorder Care Pathway November 2021 Appendix 1 Contact details Solent West CAMHS Team Horizon, Western Community Hospital Site, William Macleod way, Millbrook, Southampton SO16 4XE Tel: 02380 030061 Fax: 02380 698510 Email: [email protected] CAMHS Single Point of Access Address and contact details as above  - 10 - Solent West CAMHS Eating Disorder Care Pathway November 2021 Appendix 2 – Junior MARSIPAN Physical Assessment Check for/measure What to look for When to be concerned (amber or red in Junior MARSIPAN risk assessment framework) Specific management Heart rate Bradycardia, postural tachycardia <50 bpm or symptomatic postural tachycardia Nutrition, ECG ECG (especially if bradycardic or any other cardiovascular complication) Other cause for bradycardia (e.g. heart block), arrhythmia, check QTc interval, check electrolytes Prolonged QTc, heart rate <50 bpm, arrhythmia associated with malnutrition and/or electrolyte disturbances Nutrition and correct electrolyte abnormalities, increased QTc – bed rest, discuss with cardiologist; medication for arrhythmia or bradycardia likely to be unhelpful unless symptomatic or tachycardic; should correct with nutrition and correct level of electrolytes Blood pressure Hypotension – refer to standardised charts for age and gender Systolic, diastolic or mean arterial pressure below the 0.4th centile for age and gender, and/or postural drop of more than 15 mmHg Nutrition, bed rest until postural hypotension improved; echo likely to be abnormal while malnourished Hypothermia Temperature <36°C will usually be accompanied by other features; beware of <35°C Nutrition, blankets Assess for dehydration Hypotension and bradycardia usually related to malnutrition, not acute dehydration Significant dehydration and malnutrition Oral rehydration salts orally or via a nasogastric tube preferred treatment unless there is hypovolaemia; beware of giving fluid boluses unless in hypovolaemia – cardiac compromise or hyponatraemia may occur; check electrolytes and renal function Hypovolaemia Tachycardia or inappropriate normal heart rate in undernourished young person, hypotension and prolonged capillary refill time Senior paediatric review. Normal saline 10 ml/kg bolus, then review. If IV fluids are used then these should usually be normal saline with added KCl, with added electrolytes, e.g. phosphate, as required; consider other factors, e.g. intercurrent sepsis, as contributors Other features of severe Malnutrition Lanugo hair, dry skin, skin breakdown and/or pressure sores Nutrition; if skin breakdown or pressure sores present, seek specialist wound care advice Evidence of purging Low K, metabolic alkalosis or acidosis, enamel erosion, swollen parotid glands, calluses on fingers Hypokalaemia as below, uncontrolled vomiting with risk of oesophageal and other visceral tears Specialist nursing supervision to prevent vomiting  - 11 - Solent West CAMHS Eating Disorder Care Pathway November 2021 Hypokalaemia Likely to be due to Purging. Normal electrolyte level does not exclude medical compromise <3 mmol/l – admit; consider an HDU, PICU or ICU if <2–2.5 mmol/l Correction; IV initially if <3 mmol/l (oral supplements may still be vomited); ECG Hyponatraemia or Hypernatraemia Less common but important; consider water-loading <130 mmol/l – admit; consider an HDU, PICU or ICU if <120– 125 mmol/l If IV correction, proceed with care Other electrolyte Abnormalities Check PO4, magnesium, calcium Hypoglycaemia Hypoglycaemia is a relatively rare finding at presentation and implies poor compensation or coexisting illness (e.g. infection) – admit Once re-feeding is established, brief hypoglycaemia can be found after meals but should normalise rapidly Oral or nasogastric correction where possible (sugar drink, hypostop); IV bolus if severe (altered conscious or mental state; seizures): 2ml/ kg of 10% glucose followed by ongoing infusion containing glucose, e.g. 5ml/ kg/h of 10% glucose with 0.45% saline to minimise the risk of rebound hypoglycaemia after IV dextrose bolus; glucagon in malnourished patients may not be effective as glycogen stores are likely to be low Mental health risk or safeguarding/ family issues Suicidality, evidence of self-harm, family not coping Admit for comprehensive psychosocial assessment as per NICE self-harm guidance; admit for place of safety if necessary in safeguarding context CAMHS involvement, apply local self-harm and safeguarding procedures as needed  - 12 - Solent West CAMHS Eating Disorder Care Pathway November 2021 Appendix 3 – Junior MARSIPAN Risk Assessment Framework Junior MARSIPAN PHYSICAL RISK ASSESSMENT FRAMEWORK FOR YOUNG PEOPLE WITH EATING DISORDERS RED (High risk) AMBER (Alert to high concern) GREEN (Moderate risk) WEIGHT Weight for Height <70% Weight for Height 70-80% Weight for Height 80-85% Result Result Result Recent weight loss of 1kg or more/week for two consecutive weeks Recent weight of 0.5-1kg/week for two consecutive weeks Recent weight loss of up to 0.5kg/week for two consecutive weeks Result Result Result CARDIOVASCULAR HEALTH Heart rate <40 bpm (or inappropriately high heart rate for degree of low weight) Heart rate 40-50bpm Heart rate 50-60bpm Result Result Result Sitting Blood Pressure Systolic <0.4th centile (84-98mmHg depending on age and sex) Diastolic <0.4th centile (35-40 mmHg depending on age and sex) Sitting Blood Pressure Systolic <2nd centile (88-105mmHg depending on age and sex) Diastolic <2nd centile (40-45mmHg depending on age and sex) Result Result Result History of Recurrent Syncope Marked orthostatic changes (fall in systolic blood pressure of 20mmHg or more, or below 0.4th-2nd centiles for age, or increase in heart rate up to 30bpm) Moderate orthostatic cardiovascular changes (fall in systolic blood pressure of 15mmHg or more, or diastolic blood pressure fall of 10mmHg or more within 3 mins standing, or increase in heart rate up to 30bpm) Occasional syncope Pre-syncopal symptoms (e.g. light headedness, dizziness, blurred vision) but no orthostatic cardiovascular changes Result Result Result Irregular heart rhythm (does not include sinus arrhythmia) Result ECG QTc > 450 ms with QTc >450ms QTc < 450ms and taking  - 13 - Solent West CAMHS Eating Disorder Care Pathway November 2021 ABNORMALITIES evidence of bradyarrhythmia or tachyarrhythmia (excludes sinus bradycardia and sinus arrhythmia) ECG evidence of biochemical abnormality medication known to prolong QTc interval, family history of prolonged QTc or sensorineural deafness Result Result Result HYDRATION STATUS Severe dehydration: Low urine output Dry mouth Decreased skin turgor, sunken eyes Tachypnoea Tachycardia Moderate dehydration: Reduced urine output Dry mouth Normal skin turgor Some tachypnoea Some tachycardia Peripheral oedema Mild dehydration: May have dry mouth or Not clinically dehydrated but with concerns about risk of dehydration with negative fluid balance Result Result Result TEMPERATURE <35.5oC <36 oC Result Result BIOCHEMICAL ABNORMALITIES Hypophosphataemia Hypophosphataemia Result Result Hypokalaemia Hypokalaemia Result Result Hyponatraemia Hyponatraemia Result Result Hypocalcaemia Hypocalcaemia Result Result CALORIE INTAKE Acute food refusal or estimated calorie intake 400-600kcal per day or less Severe restriction Vomiting Purging with laxatives Moderate restriction Bingeing  - 14 - Solent West CAMHS Eating Disorder Care Pathway November 2021 Result Result Result ENGAGEMENT WITH CARE PLAN Violent when parents try to limit behaviour or encourage intake Parental violence in relation to feeding (hitting, force feeding) Poor insight into eating problems, lacks motivation to tackle eating problems, resistance to changes required to gain weight Parents unable to implement meal plan advice given Some insight into eating problems, some motivation to tackle eating problems, ambivalent towards changes required to gain weight but not actively resisting Result Result Result ACTIVITY AND EXERCISE High levels of uncontrolled exercise (>2hrs per day) Moderate levels of uncontrolled exercise (>1 hr per day) Mild levels of uncontrolled exercise (<1 hr per day) Result Result Result SELF HARM AND SUICIDE Self-poisoning Suicidal ideas with moderate-high risk of completed suicide Cutting or similar behaviours Suicidal ideas with low risk of completed suicide Result Result MUSCULAR WEAKNESS Stand from squat: Unable to get up at all from squat (score 0) Stand from squat: Unable to get up without using upper limbs (score 1) Unable to get up without noticeable difficulty (score 2) Result Result Result OTHER MENTAL HEALTH DIAGNOSIS Other major psychiatric diagnosis e.g. OCD, psychosis, depression  - 15 - Solent West CAMHS Eating Disorder Care Pathway November 2021 Result OTHER Confusion and delirium Acute Pancreatitis Gastric or oesophageal rupture Mallory Weiss Tear Gastro-oesophageal reflux or gastritis Pressure sores Poor attention and concentration Result Result Result