NSW Eating Disorders Toolkit (PDF)

NSW Eating Disorders Toolkit A practice-Based Guide to the Inpatient management of Children and Adolescents with Eating Disorders  ii NSW Health NSW Eating Disorders Toolkit NSW Ministry of Health 1 Reserve Road ST LEONARDS NSW 2065 Tel. (02) 9391 9000 Fax. (02) 9391 9101 TTY. (02) 9391 9900 www.health.nsw.gov.au Produced by: NSW Ministry of Health This work is copyright. It may be reproduced in whole or in part for clinical use, study or training purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above requires written permission from the NSW Ministry of Health. © NSW Ministry of Health 2018 SHPN (MH) 210362 978-1-76081-733-6 Further copies of this document can be downloaded from the NSW Health webpage www.health.nsw.gov.au February 2018 Medical and Physical Treatment section on pages 42-47 updated May 2021  NSW Health NSW Eating Disorders Toolkit 1 Acknowledgements The Toolkit is a revision of the original Toolkit whose development was facilitated by the former MH-Kids (now MH-Children and Young People) in conjunction with a variety of clinicians and academics throughout NSW, nationally and internationally. This revision was facilitated by MH-Children and Young People (MH-CYP), of the Mental Health Branch, NSW Health and the former Centre for Eating and Dieting Disorders (CEDD), InsideOut Institute for Eating Disorders, Sydney University. MH-CYP and InsideOut would like to thank the expert panel who assisted with the revision of this document: • Ms Danielle Maloney • Dr Sloane Madden • Ms Joanne Titterton • Ms Mel Hart • Dr Julie Adamson • Dr Michael Kohn • Dr Rod McClymont • Ms Carolyn Rae (Secretariat) • Ms Marie Hamann A small task group was involved in rewriting Medical and Physical Treatment section: • Danielle Maloney (InsideOut Institue) • Dr Joanne Morrison (ISLHD) • Dr Julie Adamson (HNELHD) • Prof Sloane Madden (SCHN) • Prof Michael Kohn (WSLHD) • Dr Claire Gaskin (SESLHD)  2 NSW Health NSW Eating Disorders Toolkit Executive Summary It is well recognised that early, timely and appropriate care will improve the likelihood of positive treatment outcomes for young people with an eating disorder. The high morbidity and mortality associated with eating disorders and the need for a multidisciplinary approach are well reported in the literature. The NSW Eating Disorders Toolkit is a practice- based manual that aims to assist health professionals in applying best-practice principles in non-specialist inpatient settings in NSW. The Toolkit aims to assist with improving access to practical information, to facilitate consultation with specialist staff and to improve consistency of care for children and adolescents with eating disorders across NSW. The Toolkit has been developed to provide practical information on key components of care for children and adolescents admitted with an eating disorder including: • Triage in the Emergency Department; • Assessment; • Identifying those in need of admission; • Admitting the patient; • Accessing specialist assistance; • Treatment planning; • Implementing treatment (primarily medical, nutritional and psychological aspects); • Involving the family and other health professionals; • Transition from inpatient care; and • Accessing further information and support. The document has been developed with the busy clinician in mind, aiming to ensure easy access to relevant information. The Toolkit has been designed to provide user friendly “pull out” sections that can be easily identified and accessed separately. The information described in the Toolkit was developed from the evidence-based literature, international eating disorder clinical practice guidelines, consultation with national and international experts and the experiences of clinicians working with patients with eating disorders in non-specialist settings. It is not the intention that this Toolkit acts as a stand-alone treatment manual as any management program must take into account the unique health care needs, and the context, of each individual patient and their family.  NSW Health NSW Eating Disorders Toolkit 3 Contents EXECUTIVE SUMMARY ..............................................2 INTRODUCTION ..........................................................7 AIMS AND SCOPE OF THE TOOLKIT .....................7 HOW TO USE THE TOOLKIT ....................................8 WHAT IS AN EATING DISORDER? ..........................8 GENERAL PRINCIPLES FOR ALL STAFF ............. 9 PREADMISSION CONSIDERATIONS ....................10 IMPORTANT POINTS ................................................10 Selecting the Most Appropriate Site for Referral .............................................................................10 Indications for Hospitalisation ..................................11 INTERVENTIONS REQUIRED .................................12 Involvement of Specialist Staff ................................ 12 THE FIRST 24 HOURS – WHAT TO DO ................13 EMERGENCY DEPARTMENT TRIAGE ..................13 EATING DISORDERS HISTORY ..............................15 DETERMINING MOST APPROPRIATE SITE FOR TRANSITION .............................................16 MANAGEMENT PLAN FOR FIRST 24 HOURS ........17 ASSESSMENT OF SUSPECTED EATING DISORDERS ................................................................19 Medical Assessment ....................................................19 Medical Investigations ................................................19 Physical Assessment ...................................................19 Other Areas to Explore ............................................20 Mental Health Assessment ........................................20 At Risk Groups ................................................................21 Mental Health Risk Management .............................21 ASSESSING GROWTH AND DETERMINING HEALTHY WEIGHT RANGE .................................... 22 Methods to Assess Growth .......................................22 Measuring Weight and Height .................................22 ‘BMI for Age’ is Used for Children and Adolescents .....................................................................22 Determining a Healthy Weight Range ..................23 Approximating the Healthy Weight Range Using BMI for Age ..........................................23 EATING DISORDER CLINICAL SUMMARY ..........24 FORMULATION OF A TREATMENT PLAN ......... 27 Treatment Plan .............................................................. 27 Working as a Team ......................................................28 The Roles of the Multidisciplinary Team Members on the Ward ...................................................................28 CARE (CASE) MANAGEMENT ...............................29 Team Cohesion and Consistency ..........................29 Maintaining Consistency ......................................29 Ward Milieu ...................................................................29 Activities ....................................................................30 Working with the Young Person and their Families and Carers ......................................................31 Therapeutic Rapport and Engagement ..........31 Externalisation ..........................................................31 Basic Counselling Skills .............................................32 Basic Counselling Techniques ............................33 Issues in Counselling ..............................................34 Motivation ..................................................................35 Stages of Change ....................................................35 Expect and Plan for Resistance ..........................36 Distress ............................................................................36 Managing Distress as Part of a Ward Program ......................................................................37 Deliberate Self-Harm .............................................37 Clinical “What Ifs?” .................................................37 Maintaining Social Connections .............................38 Leave from the Ward .................................................39 Managing Leave from the Ward .........................39 Evidence-based Therapies .......................................39 Working with the Family and Carers ...................39 Involving the Family ............................................... 40 Important Messages to Convey to Families ...................................................................... 40 Family Intervention .................................................41 Medical and Physical Treatment ............................42 Medical Instability ...................................................42 Refeeding ...................................................................42 Nasogastric Feeding ..........................................45 Risk of Refeeding Syndrome ..........................45 Management of Reefeeding Syndrome .....47 Hypothermia ..................................................................48 Acute and Chronic Hypothermia ......................48 Special Considerations for Eating Disorders ....................................................................48 Measuring Core Body Temperature ................48 Management of Hypothermia on the Ward .............................................................................49  4 NSW Health NSW Eating Disorders Toolkit Pharmacotherapy ........................................................66 Pharmacotherapy ...................................................66 Medications and Anorexia Nervosa .................66 Medications and Bulimia Nervosa ....................66 Medications used in Eating Disorders..............67 Other Management Issues ........................................68 Absconding from the Ward .................................68 Indications and Management of Abuse ..........69 How Do I Know if a Child is Being Neglected or Abused? ...........................................69 Legal Issues and Eating Disorders .........................69 Involuntary Treatment of Children and Adolescents with Eating Disorders ...................69 Parental Consent ......................................................70 Child Protection Legislation .................................70 The Guardianship Tribunal ....................................70 Use of the Mental Health Act ..............................70 The Family ....................................................................71 Survival Strategies for Clinicians .............................71 Support and Supervision .......................................71 Transition Planning ....................................................... 72 Transition from Hospital ........................................ 72 Current Level of Functioning ............................... 72 Follow-Up Arrangements ..................................... 72 Criteria For Re-Admission .................................... 72 Relapse Prevention ..................................................73 Involvement of the General Practitioner After a Hospital Admission ......................................73 During Admission ....................................................73 Post Admission ........................................................73 SPECIAL CONSIDERATIONS ................................. 74 Diabetes and Eating Disorders ................................ 74 Eating Disorders in the Aboriginal Community ..................................................................... 74 Culturally and Linguistically Diverse ............................................................................. 74 APPENDICES ............................................................. 75 Amenorrhoea ............................................................50 Osteoporosis and Osteopaenia ..............................51 Bone Health and Eating Disorders ....................51 Osteoporosis and Osteopaenia Management Plan .....................................................51 Constipation ....................................................................52 Treating Constipation ............................................52 Goals for discharge ......................................................53 Eating, Nutrition and Physical Activity .................54 Managing Meals and Snacks ...........................54 The Use of Meal Plans ............................................54 Social Eating ............................................................54 Meal and Snack Choices ........................................55 Post Meal Support ................................................55 Setting Goals and Limits .......................................55 Providing Nutrition Education .................................56 Who Provides Education? .....................................56 Bingeing ............................................................................58 Useful Strategies in the Management of Binge Eating ..........................................................58 Limiting Access to Excess Food ........................58 Purging ..............................................................................59 Steps to Cease Laxatives, Diuretics & Vomiting ...................................................................59 Physical Activity ........................................................... 60 Safety .......................................................................... 60 Excessive Physical Activity ................................. 60 Managing Physical Activity ...................................61 The Role of Physical Activity as Part of Recovery .......................................................................61 Physical Activity Guidelines During Recovery .....................................................................62 Exercise and Lifestyle Education ......................62 MANAGING COMORBIDITY ...................................64 Comorbidity in Eating Disorders ............................64 Eating Disorders and Anxiety .................................64 Eating Disorders and Depression ..........................64 Eating Disorders and Substance Misuse .............64 Treating Comorbid Psychiatric Issues .................64 Body Image Disturbance and Body Dissatisfaction ...............................................................65  NSW Health NSW Eating Disorders Toolkit 5 Abbreviations Term Definition 1:1 Nursing special one to one ARFID Avoidant Restrictive Food Intake Disorder AN Anorexia Nervosa BSL Blood Sugar/Glucose Level BMC Bone Mineral Content BMI Body Mass Index BN Bulimia Nervosa BP Blood Pressure BPM Beats Per Minute CALD Culturally and Linguistically Diverse CAMHS Child & Adolescent Mental Health Service CBT Cognitive Behaviour Therapy DADHC Department of Ageing, Disability and Home Care DoE Department of Education DEXA Dual-Energy X-ray Absorptiometry FaCS Family and Community Services DSM Diagnostic and Statistical Manual of Mental Disorders ECG Electrocardiogram ED Eating Disorder EDE Eating Disorder Examination EUC Electrolytes, Urea, Creatinine FBC Full Blood Count g Gram GP General Practitioner HCI Health Care Interpreter HCIS Health Care Interpreter Service HR Heart Rate HWR Healthy Weight Range IV Intravenous kcal Kilocalorie kg Kilogram kJ Kilojoules  6 NSW Health NSW Eating Disorders Toolkit Term Definition LFT Liver Function Test MAOI Monoamine Oxidase Inhibitor MET Motivational Enhancement Therapy MG/mg Milligrams MHA Mental Health Act ml Millilitre MPH Mid-Parental Height MRN Medical Record Number NESB Non English Speaking Background NG/NGT Naso-gastric/ Naso-gastric Tube NRVs Nutrient Reference Values NSW New South Wales NUM Nurse Unit Manager OCD Obsessive Compulsive Disorder OH&S Occupational Health and Safety OSFED Other Specified Feeding and Eating Disorder PTSD Post Traumatic Stress Disorder RS Re-feeding Syndrome SSRI Selective Serotonin Reuptake Inhibitors TG Triglyceride TIS Telephone Interpreter Service USFED Unspecified Feeding and Eating Disorders  NSW Health NSW Eating Disorders Toolkit 7 Section 1 Introduction to the Toolkit INTRODUCTION The NSW Service Plan for People with Eating Disorders 2013-2018 was launched in 2013. With the release of the plan, every Local Health District and Specialty Network across NSW has now developed a local Eating Disorders Implementation Plan which ensures that all patients with eating disorders are appropriately cared for as close to home as possible. This Toolkit acknowledges that the demand for inpatient services for eating disorders is significant and that many of the children and adolescents requiring hospitalisation may receive treatment in non-eating disorders specialist wards. With this in mind the Toolkit offers a resource for health professionals who find themselves caring for children and adolescents hospitalised with an eating disorder. The recommendations within this Toolkit should be adapted to meet your patient’s individual needs as well as your local service needs. It is not the intention that this Toolkit acts as a stand-alone treatment manual as any management program must take into account the unique health care needs, and the context, of each individual patient. Information in the Toolkit has been considered by a group of experts working in the field of eating disorders to be of significant clinical importance. The Toolkit has also been developed in line with relevant State and National health policies and documents. Reference materials are not cited in the main text but relevant references and resources are fully cited in the Appendix. AIMS AND SCOPE OF THE TOOLKIT The aim of the Toolkit is to provide practical information on key components of care for children and adolescents with an eating disorder admitted to inpatient settings across NSW. The Toolkit: • complements current clinical practice guidelines by providing practical and useful strategies based on the current evidence; • provides clarity regarding effective treatment approaches for clinicians; and • improves consistency in practice across NSW. The Toolkit is relevant for use with children and adolescents (aged 8–18 years) with all clinically significant eating disorders including Anorexia Nervosa (AN), Bulimia Nervosa (BN), Avoidant Restrictive Food Intake Disorder (ARFID), Other Specified Feeding and Eating Disorders (OSFED) and Unspecified Feeding and Eating Disorders (USFED) and secondary diagnosis eating disorders. The Toolkit is designed for use in public hospitals, including paediatric, and mental health wards, particularly those in regional and rural areas throughout NSW. The target audience does not include private and specialist eating disorder units, although the Toolkit may be helpful in these settings. It is important to note that hospital admissions are only one part of a lengthy treatment process for young people with an eating disorder. As such, admissions are not viewed as “curative”, but necessary at times to restore mental, physical and social functioning to enable continued treatment in the community.  8 NSW Health NSW Eating Disorders Toolkit HOW TO USE THE TOOLKIT The document was developed with the busy clinician in mind, aiming to ensure easy access to relevant information. The Toolkit was written as a generic document, rather than discipline-based, to allow a flow through the patient admission. The Toolkit has user-friendly “pull out” sections that can be easily identified and accessed separately. Key concepts and recommendations are highlighted throughout the document by use of text boxes and bolded text. Implementing treatment has formed the largest component of the document and includes practical information on medical, nutritional and psychological care of patients. It is envisaged staff will access and implement sections of the Toolkit that are most relevant to their needs or particular patient needs. For example, all registrars may be familiarised with the specific sections relevant to key medical management; dietitians should be familiar with sections on nutrition and refeeding; and a ll key clinicians should be familiar with the assessment, treatment planning and discharge planning sections. The Toolkit may be used quite differently by different hospitals and may be adapted according to your local services, resources and expertise. Some Local Health Districts will have limited access to some of the key clinicians (e.g., clinical psychologists); so each service will need to determine what is possible and practical in their local area. WHAT IS AN EATING DISORDER? Eating disorders are moderate to severe illnesses that are characterised by disturbances in thinking and behaviour around food, eating and body weight or shape, and are diagnosed according to specific psychological, behavioural and physiological characteristics. The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association, 2013) outlines six types of disordered eating patterns: Anorexia Nervosa (AN) is a serious illness associated with significant morbidity and mortality. The illness is characterised by a refusal to maintain a minimally normal weight for age and height, intense fear of weight gain, body image disturbance and denial of illness severity. Bulimia Nervosa (BN) is a moderate to severe illness that is predominantly characterised by recurrent episodes on bingeing and purging behaviour. Binge Eating Disorder (BED) is characterized by repeated episodes of binge eating without the use of purging or other compensatory measures following the binge. You cannot tell by looking at someone whether they have BED; people struggling with this disorder may be normal weight, overweight or obese. Avoidant Restrictive Food Intake Disorder (ARFID) is characterised by individuals who have developed some type of problem with eating (or for very young children, a problem with feeding). As a result of the eating problem, the person isn’t able to eat enough to get adequate calories or nutrition through their diet. Other Specified Feeding and Eating Disorders (OSFED) is also a moderate to severe illness and may include eating disorders of clinical significance that do not meet the criteria for AN or BN. OSFED and USFED may be as severe as AN or BN . Unspecified Feeding and Eating Disorders (USFED)  NSW Health NSW Eating Disorders Toolkit 9 GENERAL PRINCIPLES FOR ALL STAFF The following are key principles for all staff working with children and adolescents with an eating disorder (see Appendix 9 for suggested reading). Ensuring Safety A primary priority of care is to ensure that the young person is safe. This will include assessment and management of both the medical and psychological safety aspects of the young person. Creating a Therapeutic Alliance Successful treatment is dependent on the creation of therapeutic alliance. A therapeutic alliance involves developing an empathic, supportive and trusting relationship with the patient (or sometimes the parents in the first instance). It is critical in reducing resistance and facilitating change. A positive therapeutic experience for the young person may also mean that they will access appropriate care at a later stage if required. Involving Families Families should be involved in all aspects of care and considered as members of the treating team (unless there are care and protection issues). Care should be taken to avoid making families feel blamed for any aspect of the patient’s illness. Maintaining Realistic Expectations Eating disorders are chronic illnesses. Having realistic expectations about the hospital admission helps to contain family and staff anxiety. Patients will not be “cured” of their eating disorder at discharge. Managing Distress Distress is very common for young people and their families admitted to hospital for treatment of their eating disorder. Recognising and assisting the young person and family to manage distress is essential. Working with Strengths Focusing on strengths enhances assessment, treatment and building therapeutic alliance. Strengths should be assessed in terms of individual, family and psychosocial perspectives.  10 NSW Health NSW Eating Disorders Toolkit Section 2 Getting the Patient to Hospital PREADMISSION CONSIDERATIONS IMPORTANT POINTS • Early detection and intervention may improve treatment outcomes and reduce the likelihood of the eating disorder progressing to a more serious stage. • It is important to obtain enough information to assess the level of risk for each individual and to determine the most appropriate site for treatment. • The clinical condition of the patient, the available local resources and the local clinician’s experience in managing malnutrition should be the primary factors in deciding the appropriate location for care. What to Consider: Nature of the Problem • Is the presentation predominantly an eating disorder or another mental health issue? • Is this something that can be managed within your current team? • What type of health service or professional would best meet the needs of this individual? Severity of the Illness • Is the young person medically unstable? • Is the young person psychologically unsafe (risk of suicide or significant self-harm)? • Is the illness progressing despite intensive community-based care? Geographical Location • What community-based treatment services are available locally (e.g., local mental health team, dietitian with experience, therapist, paediatrician, child and adolescent psychiatrist)? (Note: local treatment services can be supported in their role by specialist services) Age of the Young Person • Some services may only accept referral for adolescents of a specific age band (e.g., younger adolescents or older adolescents). Selecting the Most Appropriate Site for Referral Community-based care is the preferred option for treatment. • Inpatient admissions should be used to manage acute medical and psychological risk or when less intensive interventions have been unsuccessful. When considering a referral to hospital: – it is important to discuss the situation with the treating team and the proposed treatment service; – consultation with a tertiary hospital with eating disorder services should be considered for more complicated patients, especially for those with medical comorbidity such as diabetes, cystic fibrosis or those who are pregnant; and – if urgent medical assistance is required, presentation to the emergency department should be the first point of contact. • If community based care is required,it should involve establishing a multidisciplinary approach to treatment. Members of the treating team should ideally have expertise in treating adolescents with an eating disorder.  NSW Health NSW Eating Disorders Toolkit 11 • Referral for inpatient care is indicated when there is significant deterioration or lack of improvement despite intensive community-based intervention, when the clinician feels beyond his or her capabilities or when hospitalisation is indicated. • If unsure about local service options, contact your Eating Disorders Coordintor (https://insideoutinstitute.org.au/support-organisations/new-south-wales) Indications for Hospitalisation A hospital admission may be indicated for any of the following criteria: • Heart Rate <50 bpm, • Cardia arrhythmia including a prolonged QTc interval (>450 msec) • Postural tachycardia >20bpm increase heart rate • Blood pressure <80/40 mm/Hg or postural drop >30 mm/Hg • Temperature < 35.5°C • Low serum potassium ≤3.0 mmol/L • BSL <3.0mmol/L • Other significant electrolyte imbalances • BMI ≤ 14 • Rapid or consistent weight loss (e.g., > 1kg each week for six or more weeks) • Acute dehydration or patient has ceased fluid intake • Intensive community-based treatment has proven ineffective • Comorbid or pre-existing psychiatric conditions that require hospitalisation • Suicidality with an active intent and plan • Other special considerations such as diabetes or pregnancy Information required when referring to Hospital Nature and extent of the problem • Health professionals’ perception of the problem and immediate concerns • Current symptoms and their duration • Severity of symptoms Assessment of safety issues • Medical safety assessment would include ,blood pressure, heart rate, temperature, rate of weight loss (if present), current weight and height and results of blood tests. • Psychological safety issues would include risk of self-harm or suicide and severity of co-morbid psychological conditions Interventions that have been attempted so far • Include inpatient, day patient and out-patient care • Indicate what has been helpful or perhaps less helpful Familial or social aspects • Factors that may impact upon the young person When referring a young person for inpatient treatment: • be open about why a referral is needed; • discuss and describe the service or program the patient is being referred to; • clarify what may happen after treatment at the service; • all efforts should be made to ensure that the referral is supported and runs as smoothly as possible; and • provide contact details for consumer organisations and support groups to the family (e.g. the Butterfly Foundation https://thebutterflyfoundation.org.au/ )  12 NSW Health NSW Eating Disorders Toolkit INTERVENTIONS REQUIRED When considering suitability for admission, the following are considered to be the minimum levels of intervention for a child or adolescent admitted with an eating disorder. If the minimum requirements cannot be met, the patient should be transferred to a hospital that has the capacity to meet the minimum levels of intervention. 1. Regular paediatrician consultation. It is preferable that young people are admitted under a paediatrician; if this is not possible, a minimum weekly paediatrician consultation is required for patients who are admitted for management of anorexia nervosa or who are medically compromised (see Indications for Hospitalisation). 2. Psychiatry consultation is required, with ongoing management as determined by the psychiatrist. This may be via telepsychiatry or consultation with a psychiatrist from a specialist service. 3. Weekly dietitian consultation is required for patients who are being re-fed. 4. Weekly care review with the treating team. 5. Staff support and confidence in their ability to treat the patient. 6. Ongoing contact between the treating community team and the inpatient team is essential and must be viable. Involvement of Specialist Staff Specialist staff with expertise in eating disorders are available for advice, consultation and support and can assist the hospital admission in many ways including providing expert guidance regarding assessment, identifying risks, appropriate treatment, management and referral of young people with an eating disorder. Specialist eating disorder services may provide an assessment of the young person and recommend treatment approaches or strategies as part of the outreach service to the treating team (see Appendix 1 for statewide services and contacts). Specialist eating disorders programs offer: • specific treatment settings, which are designed to address the more difficult problems, associated with eating disorders; • a well developed, targeted, intensive program; • best practice eating disorder treatments; • specialty trained staff; and • a therapeutic environment Specialist assistance should be sought in the following circumstances: • the primary reason for admission is the eating disorder; • the eating disorder is secondary, but forms a significant part of the admission treatment plan; • when you are treating someone with an eating disorder and believe the situation is beyond your threshold of care or capabilities; and • when you would like assistance or support in your work.  NSW Health NSW Eating Disorders Toolkit 13 Section 3 The First 24 Hours in Hospital THE FIRST 24 HOURS – WHAT TO DO It is essential in the first 24 hours that an appropriate assessment is conducted and an initial management plan is developed and implemented. Key tasks involve: 1. Conduct a thorough physical and psychological assessment (as per “Emergency Department Triage Form”, see next page). This should be carried out by appropriate medical and mental health professionals. 2. Obtain a brief history of the eating disorder (including length of illness, interventions to date and parent or carer involvement and support). 3. Determine the level of risk and most appropriate site for treatment. 4. Develop and implement an initial management plan. EMERGENCY DEPARTMENT TRIAGE The following tests should be conducted for all patients presenting to the Emergency Department with an eating disorder. Seek consultation if there are any concerns or signs indicating admission. Assessment I Test Required Signs Indicating Need For Admission Or Consultation Temperature • Temperature <35.5°C • Extremities look cold/blue Blood pressure • <80/40 mm/Hg or postural drop >30 mm/Hg Pulse • HR < 50 bpm, • Postural tachycardia>20bpm > in HR • Check for regularity as well as rate Height, weight, weight history Calculate BMI Centile • Expected body weight BMI ≤ 14 or BMI centile less than 3% • Rapid weight loss (e.g., > 1kg/week for six or more weeks) Bloods (EUC, FBC, LFTs, magnesium, phosphate) • Low serum potassium (≤3.0mmol/L); • BSL <3.0mmol/L • Other significant electrolyte disturbance ECG • Heart rate <50; • Prolonged QTc interval >450msecs • Arrhythmia Other medical criteria • Moderate-severe dehydration; ceased fluid intake • Ketosis • Other physical conditions e.g., pregnancy, diabetes Brief history of eating disorder including extent of purging behaviours and past treatment • BN with out of control vomiting • Vomiting more than 4 times a day • Weight loss of >1kg/week for six weeks Assess psychiatric comorbidity, e.g., depression, OCD, psychosis Risk assessment of suicidality, self-harm and harm to others • Moderate to high suicidal ideation • Active self-harm • Moderate to high agitation and distress • Other psychiatric condition requiring hospitalisation