18/06/18. Setting up a service from scratch: what could you include? Who should be in the community team for a population of 1 million?
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1 Setting up community services for eating disorders Dr Paul Robinson MA MD University College London Setting up a service from scratch: what could you include? Outpatient assessment Outpatient treatment Day care Home treatment Specialist ED inpatient care Liaison with medical inpatient services General psychiatric inpatient care Factors to consider when setting up a service Age structure of the population: more young people means more new eating disorders Presence of high risk institutions: ballet schools, gymnastics centres, high pressure schools Adults, children and adolescents or all age? Town or country: day care more difficult in sparsely populated areas Community AND inpatient? Oh yes, how much money is available? Who should be in the community team for a population of 1 million? Doctor (1.5 wte): One specialist in Eating Disorders Psychiatry, 0.5 trainee Psychologist (2.5 wte): able to provide and supervise different forms of therapy Senior Nurse (1 wte): Able to provide and supervise meal support Mental health nurses (6 wte) : Able to provide meal and individual support Dietitian (1 wte): specialist in Eating Disorders Occupational therapist: (1 wte) For occupational and social interventions In UK 800,000 approx or 59m Rubles Total suggested team 13 wte 1
2 18/06/18 Outpatient assessment: A female patient talks about her illness Make a note of the following What is the diagnosis? What do you think caused her eating disorder? You are asked to calculate her BMI. Her height is 5ft 5in = 1.67m Her BMI is kg/(metres x metres) So eg 50/(1.67x1.67) = 17.9 What are her current problems and how might they be addressed? Organizing outpatient assessment: the supervised team model Entire team attends for one morning 9-10: 4 patients are seen by 4 team members (any profession, trained in assessment) 10-11: All patients are discussed with the team (15 minutes each) 11-12: Each patient is briefly interviewed by a senior clinician (15 minutes each) to establish Diagnosis Agreed management plan Psychological Physical Social Training team members in assessment Any profession eligible: doctor, nurse, psychologist, dietitian, occupational therapist etc Training includes Diagnosis of eating disorders Recognition of other mental health problems Assessment of physical state and risk assessment Methods Provide interview checklist Seminars Role play Observed assessments Continued supervision Writing a report after the assessment Patient details Mini-summary Diagnosis (diagnoses) Weight, height, BMI today Management recommended Main report 2
3 Main assessment report Treatment of eating disorders in different contexts Presenting complaints Other eating disorder symptoms Weight history Dietary intake (last 24 hour recall) Psychological symptoms and problems Physical symptoms, medical problems Medication Personal and family history, social network Mental state Summary and management advice Outpatient care Day patient and domiciliary care Inpatient care Medical ward Psychiatric ward Specialist eating disorders ward Risk assessment and monitoring Outpatient care Risk assessment and monitoring Psychological therapy Cognitive behaviour therapy: CBT-E Other forms of therapy eg Interpersonal therapy Specialist supportive clinical management (less need for special training) Family involvement Carer support and education Family therapy Carer involvement in meetings History Nutrition intake Exercise Falsification Self harm Examination CVS: Pulse, BP Core temp ECG (EKG) Any abnormality Prolonged QTc Mental state Consent Severity of AN psychopathology Assess Need for medical bed Need for compulsory treatment Are medics and psychiatrists collaborating? Are all staff trained? 3
4 Use MARSIPAN and junior MARSIPAN guidelines Day patient and domiciliary care MARSIPAN CHECKLIST: Robinson and Nicholls Assessing Does the patient have anorexia nervosa? Not sure and psychiatric review requested! Are there significant risk factors? BMI <13 (adults) or <70% median BMI for age (under 18)?! Recent loss of 1kg/week for two consecutive weeks?! Little or no nutrition for >5 days! Acute food refusal or <500kcal/day for >2 days in under 18s.! Pulse <40?! BP low with postural dizziness?! Core temperature <35 0 C?! Na <130 mmol/l?! K<3.0 mmol/l?! Raised transaminase?! Glucose <3 mmol/l?! Raised urea or creatinine?! ECG: eg Bradycardia? QTc >450ms?! Is the patient consenting to treatment? No and assessment for compulsory detention requested! Refeeding Managing Is Intensive medical care needed? Are medical and psychiatric staff collaborating in care? No and regular risk monitoring in place! Increased risk of refeeding syndrome? Low initial electrolytes! Low BMI (<13 or mbmi <70%)! Significant co-morbidities (eg Infection, Cardiac failure, alcoholism, uncontrolled diabetes)! " Start at 5-10 Kcal/Kg/Day " Monitor electrolytes twice daily and build up calories swiftly: avoid underfeeding Lower risk of refeeding syndrome? " Start at Kcal/kg/day and build up swiftly " Avoid Underfeeding Syndrome Give all adults oral Thiamine and Pabrinex Monitor " electrolytes (especially P, K) " ECG " Vital signs " BMI No, psych consultation awaited! Are nurses trained in managing medical and psychiatric problems? No and appropriately skilled staff requested/training in place! Are there behaviours that increase risk? Falsifying weight! Disposing of feed! Exercising! Self harm, suicidality! Family distress/anxiety! Safeguarding concerns! " Mobilise psych team to advise on management All outpatient services PLUS Meals: supported (not enforced) Groups eg Psychotherapy (eg MBT-ED) Body image Nutrition Weekend planning and weekend review Family involvement Visits home for meal and family support Acutely ill patients Risk assessment (see MARSIPAN) eg low and/or falling BMI Muscle weakness (SUSS test) Blood or ECG abnormalities Consider admission to General hospital (eg IV required) Psychiatric hospital (eg suicidal) Specialist unit (when available) Admission to non-specialist bed Staff may not be aware of eating disorder issues Sometimes there can be a negative view of eating disorders among staff Treatment sabotaging behaviour can be missed Refeeding syndrome can be missed OR fear of refeeding syndrome can lead to underfeeding 4
5 18/06/18 Role of the Eating Disorder specialist professional A patient talks of her experience on the medical unit Establish liaison with treating team Educate staff about relevant ED issues Use MARSIPAN checklist to guide treatment Support staff in dealing with difficult behaviour Support family and patient THE SUSS TEST 5
6 18/06/18 The QT Interval Principles when managing patients with eating disorders in hospital (non-specialist) QTc=QT/ R-R Note: QT in ms, R-R in s Or: To correct the QT, divide by the square root of 60/heart rate Or: Automatic ECG report (low reliability if tracing abnormal) When eating disorders don t recover quickly: Severe and Enduring Eating Disorders SEED 1. Constant communication between psych and medical team 2. Educate staff as required 3. Provide documentation for staff to follow. 4. Support patient 5. Support family 6. Follow MARSIPAN guidelines A patient with SEED talks about her problems A proportion of patients with eating disorders (around 10% of AN) don t recover in spite of best available treatment Some present too late Some don t get good treatment They get stuck with a chronic eating disorder 6
7 How to appoach management of the patient with SEED Bio-psycho-social approach Bio: Optimise weight Treat vitamin deficiency Treat osteoporosis Treat depression Management of SEED 2 Psycho Support (not to be underrated) SSCM Specialist Supportive Clinical Management (contact me for manual) CBT Social Day centre Voluntary work Education Social netwok Occupation Summary Most patients can be treated as outpatients A minority require day care or home treatment A small number need inpatient care A multidisciplinary team can Assess and treat most outpatients Provide day care Support inpatient services using MARSIPAN Severe and Enduring eating disorders (SEED) need bio-psycho-social approaches beyond weight restoration 7
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