INTEGRATED CARE PATHWAY: EATING DISORDERS - ANOREXIA NERVOSA What is an Integrated Care Pathway? An ICP is a document which guides the multi disciplinary team of clinicians and their patients and carers within a specific area of care so that the best available care is offered, documented and audited. The results of audit and new research as it emerges can be used to improve and update the document. When to use this ICP This ICP should be used when a child or young person with, or suspected of having an eating disorders and is or appears to be physically compromised by the effects of starvation and or binging, purging and over exercising. This ICP describes a collaborative medical and mental health admission for 24 hour medical monitoring assessment and intervention, refeeding and or re-hydrating in tandem with specialist psychological support and interventions for the child, young person and their carers / families. Who should hold this ICP? As the purpose of this document is to guide appropriate care for clinicians and patients two ICP versions have been designed one for the patient containing all the information required to understand the different aspects of care available and what they are likely to experience. It is envisaged that additional information will be added as their care progresses e.g. care and meal plans, MDT reviews etc. The patient s version will also include a section for reflection on care received and variance tracking codes and comments. The clinicians version will include evidence based guidance and document and recording sheets and will be stored in the case notes in line with legal and professional guidance. (Patients and families can access health records as described in the Trusts policy). Guidelines for use of this ICP The pathway provides evidence based guidance and the necessary documentation formats for medical, nursing, dietetic, occupational therapy, play specialists and physiotherapy records. It is not a rigid document and clinicians should use their own clinical judgement as appropriate and record as a variance any alteration to the practice outlined. (Variances and deviations from the pathway should be support by MDT discussion and agreement unless provoked by an emergency situation). All sections should be fully completed. The CAMHS team should complete SECTIONS 1 7 inclusive, before or immediately following admission. Please note that IV fluid and drugs should be prescribed on the generic In-Patient Medication Administration Record. It is essential that all staff using the pathway complete the signature key box (pg..), this ensures that those using the pathway can be identified. You can then use your initials in the pathway instead of full signature and printed name. Please ensure all entries are initialled, dated and timed. Please only use abbreviations in the Pathway if they are on the list of approved abbreviations on page. of the document. Variations from the ICP should be documented on the Variance sheet (Pg..). Any problems that may be encountered should be documented on the Problem sheet (pg.) any comments about the ICP are welcomed (Pg ). ED ICP Draft 1 Page 1 of 21
EATING DISORDERS SHARED CARE PROTOCOL/ PATHWAY FOR ADMISSION TO A PAEDIATRIC INPATIENT WARD. YES CAMHS REQUESTED ADMISSION NO CAMHS Consultant Psychiatrist and or Key Worker: i. Complete Sections 1-7 ED Care Pathway, copy to Paediatric ward. ii. Attend paediatric Ward with patient and parents/carer or within 24 hours of admission. iii. Agree & implement 48 hour care plan. iv. Ensure written care plan copied to young person, parents, medical notes, paediatric named nurse. v. Key worker arrange first MDT meeting within five working days of admission. SUPPORTING GUIDANCE NOTES GN 1. GN 1a. GN 2. GN 2a GN 3. GN 3a. GN 4. GN 4a. GN 5. GN 6 GN 7 GN 8. GN 9. GN 10. GN 11. GN 12. Psychological Assessment Psychological Risk Psychosocial Assessment Psychosocial Risk Physical Assessment Physical Risk Dietetic Assessment Refeeding Risk Assessment Formulation Meal Management Negotiable/Non Negotiable Occupational Therapy Physiotherapy Legal Framework Application to HCWSS Discharge options SECTION 8 SECTION 9 SECTION 10 SECTION 11 SECTION 12 SECTION 13 SECTION 14 Admission details. In collaboration with CAMHS who should ensure sections 1-7 are completed and included in Care Pathway Pack. Initial Clinical Assessment (see GN 3, 3a) To be undertaken by paediatric nurses Medical Examination & Investigations identify any additional investigations (see GN 3,3a,4a) Biochemical monitoring during refeeding. (See GN 4a, 3, 3a.) Nurse observations. See appendix 3 & 4 for food/mood diary sheets and body checking diary sheets. Initial care plan - copy to young person, parents. (See GN 7 Negotiable. Non- Negotiable. GN 6 Meal Management) Meal plans will be reviewed daily during the first 7days (GN 4, 4a) All meal plans to be dated and signed by dietitian and young person and copied to Young Person and parents. SECTION 15 CAMHS AND PAEDIATRIC MDT MEETING WITHIN 5 WORKING DAYS OF ADMISSION SECTION 16 REVIEW AND PLANNING MEETING WITH YOUNG PERSON, PARENTS/CARERS INVOLVED MD TEAM WITHIN 24 HOURS OF CLINICIANS MEETING SECTION 17 CONTINUING CARE PLAN CONTACT Ty Bryn YPU 01633 436831 Consultation: Psychiatrist Joy Jones Wendy Clarke Assessment: Psychiatrist & CMHT SECTION 18 DISCHARGE AND TRANSFER OPTIONS GENERAL PRACTITIONER CAMHS T2 /T3 ED IN PATIENT SERVICE CAMHS T4 CAMHS - AMHs TRANSITION ED ICP Draft 1 Page 2 of 21
SIGNATURE SHEET Name DOB ADDRESS It is essential that all staff using the pathway complete the signature key box below, this ensures that those using the pathway can be identified. You can then use you initials in the pathway instead of full signature and printed name. Print Name Designation Work Area Initials Signature Date ED ICP Draft 1 Page 3 of 21
SECTION 1. FAMILY HISTORY SHEET ( To be completed by Pscychiatrist / Key worker) GENOGRAM INCLUDE AGE CORRELATION OF YOUNG PERSON WITH LIFE EVENTS AND TRANSITIONS Family History Family functioning / relationships Family as a resource to treatment INITIALS DATE INITIAL DATE SECTION VARIANCE CODE 1 ED ICP Draft 1 Page 4 of 21
SECTION 2. MENTAL STATE - To be completed by Psychiatrist and Key worker Early Development / Mile stones General Appearance Affect Mood Co morbidity Perceptions Cognitive Functioning Judgement and Insight (assess motivation for change) Self Esteem and Confidence (inc details of links to ED) Rapport (engagement with clinicians) INITIALS DATE INITIAL DATE SECTION VARIANCE CODE 2 ED ICP Draft 1 Page 5 of 21
SECTION 3 PSYCHO SOCIAL INFORMATION (To be completed by Psychiatrist / keyworker) School history/report (consider links to any features of the eating disorder, e.g. academic standards, sense of failure, increased food avoidance, energy expenditure) Peer relationships / functioning Social/cultural influences (Explore any significant vulnerability to cultural/media pressures and the reactive eating disorders behaviours. Identify impact of relationship with eating disorder on social functioning.) Individual risk and Individual protective factors (include self harm behaviours, impulsive behaviours and personal support resources (see family functioning assessment) Hobbies and Activities inc range and frequency use OT /Play Therapist INITIALS DATE INITIALS DATE SECTION VARIANCE CODE 3 ED ICP Draft 1 Page 6 of 21
SECTION 4. EATING DISORDER HISTORY (To be completed by Psychiatrist / Key worker/ Other MH Clinician) Description of Onset (identify what information is given by whom) MENSTRUAL Age and weight at onset of menses Age and weight at cessation of menses Duration of Amenorrhea STATUS Birth weight Maximum weight Patients estimate of : 5-10 yrs Lowest weight, Current weight Healthiest weight Early teens, Usual weight Desired weight Preferred weight Body Image -Attitudes and feelings about shape and size. (inc duration, previous feelings attitudes triggers for change) Body checking behaviours - (inc details of routines numbers, types and contexts of checking) Exercise - Current pattern, type and extent. Effect of missing exercise (e.g. compensatory food debits) Purging - History and details of all purging behaviours and aids to purging e.g laxatives, diuretics, misuse of insulin, self-phlebotomy, Other Eating Disorders Symptoms (inc details of any selective, restrictive, binge eating & functional dysphagia, food phobias) INITIALS DATE INITIAL DATE SECTION VARIANCE CODE ED ICP Draft 1 Page 7 of 21 4
SECTION 5. DIETETIC HISTORY (to be completed by or in collaboration with the dietitian) Past diet (inc fluids) Current Diet (inc fluids) Past eating pattern Current Eating Pattern Past Eating Behaviours Current eating behaviours (inc all food avoidant behaviours) ED ICP Draft 1 Page 8 of 21
SECTION 5. (To be completed by or in collaboration with the dietitian) Food intolerances/allergies (what food what happens, treatment and outcomes, duration) High risk foods Medium risk foods Low risk foods Religious/cultural food beliefs/behaviours - (duration of beliefs/behaviours) Dietry / nutritional information /education - (describe information given and patients parent/carer s response) Need for support/supervision during and after meal times INITIALS DATE INITIALS DATE SECTION VARIANCE CODE 5 ED ICP Draft 1 Page 9 of 21
SECTION 6. PHYSICAL EXAMINATION (TO BE UNDERTAKEN PRIOR TO ADMISSION) SYSTEM Test or Investigation Date Outcome Concern Alert <16 yrs B%WHA >BMI <80%<14 <75%<12 Weight loss per week >0.5kg >1.0kg Skin Breakdown >0.1cm >0.2cm Nutrition Circulation Musculoskeletal (squat Test Sit up test) Temperature Bone Marrow Salt /water balance Liver Nutrition Differential Diagnosis ECG Purpuric + Systolic BP <90 <80 Diastolic BP <70 <60 Postural drop (sit stand) >10 >20 Pulse Rate <50 <40 Extremities Drk blue cold Unable to get up without using arms for balance + Unable to get up without using arms as leverage + Unable to sit up without using arms as leverage + Unable to sit up at all + <35C <34.5 <98.0F <97.0F WWC <4.0 <2 Neutrophil count <1.5 <1.0 Hb <11 <9.0 Acute Hb drop (MCV and MCH raised no acute risk Platlets <130 <110 K+ <3.5 <3.0 Na+ <135 <130 Mg++ <0.5-0.7 <0.5 PO4-- <0.5-0.8 <0.5 Urea >7 >10 Bilirubin >20 >40 Alkpase >110 >200 AsT >40 >80 ALT >45 >90 GGT >45 >90 Albumin <35 <32 Creatinine Kinase >170 >250 Glucose <3.5 <2.5 TFT ESR Pulse rate <50 <40 Corrected QT intervals (QTC) >450 msec Arrythmias + + INITIALS DATE INITIALS DATE SECTION VARIANCE CODE 6 ED ICP Draft 1 Page 10 of 21
SECTION 7. ASSESSMENT & RISK FORMULATION TO BE UNDERTAKEN BY ALL INVOLVED CLINICIANS Dimension Psychological Formulation (including level of risk and protective factors) Psychiatric Psychosocial Physical Dietetic Assessment of Capacity: Is the patient able to: 1. Understand (a) nature of risk yes no (b) risks and benefits of treatment/ no treatment yes no 2 Believe (a) nature of risk yes no (b) risks and benefits of treatment/ no treatment yes no 3. Weigh up the information rationally yes no 4. Thus make a fully informed choice with full capacity yes no 5. Capacity Impaired? yes no Formulation: Recommendations regarding legal status re: 1989 children s act, 1983 Mental health act, (See guidance Note 10) Recommendations and Actions Person/s Responsible INITIALS DATE INITIAL DATE SECTION VARIANCE CODE 7 ED ICP Draft 1 Page 11 of 21
SECTION 8. ADMISSION DETAILS (To be completed by key worker /Named Paeds Nurse). Section 1-7 included Please circle Yes / No Name: Familiar Name (known as) DOB Marital Status Hospital Number Homes Address inc post code: Home Tel: Emergency Tel: Religion: GP: Practice Address: School/Occupation: Next of Kin: NOK Address: Social Worker Name: Tel: Contact Details: Relationship: Tel: Mob: Tel: Admission Date Admitting Paediatrician Paediatric Link Nurse: Admission CAMHS Paediatric OP A&E Other: route: CAMHS TEAM CAMHS Consultant: CAMHS Key worker: Contact details: Tel: Tel: CAMHS Dietitian: Tel: Nursing arrangement Include bank/agency CAMHS Patient observation level Full Description: Schedule Number: Paeds Dietitian: Tel: Full Description include arrangements for personal care Legal Status Detail: INITIALS DATE INITIALS DATE SECTION VARIANCE CODE ED ICP Draft 1 Page 12 of 21 8
SECTION 9. INITIAL CLINICAL ASSESSMENT (To be completed by Named Paediatric Nurse) Patients in the early stages of refeeding should be monitored closely for signs of biochemical, cardiovascular and fluid balance disturbance. A comprehensive base line of investigations should be undertaken to inform the pace of, and nutritional requirements for, refeeding. (See GN 3, 3a, 4, 4a) Pulse lying Standing /min /min weight height Muscle strength/wastage Squat test, Sit up test: Patient asked to rise from squatting on haunches Sit up from lying flat on a firm surface without using hands - Sensitive to myopathic weakness - TICK AS APPROPRIATE (repeat to monitor progress) BP Lying standing mmhg mmhg BW% for Height & Age BMI if >16yrs Grade 0: Completely unable to rise Grade 1: Able to rise only with use of hands Grade 2: Able to rise with noticeable difficulty Grade 3: Able to rise without difficulty Resps /min O2Sats % Temp C BM mmols rate of weight loss n.b. weighing should be undertaken in underwear or light gown with empty bladder. All subsequent weighing should be in the same clothing at agreed time and logged on weight chart. (twice weekly weighing) Current medication and allergies General Allergies: Urinalysis: Medical History: INITIALS DATE SECTION VARIANCE CODE ED ICP Draft 1 Page 13 of 21 9
SECTION 10. RECOMMENDED MEDICAL INVESTIGATIONS AT ADMISSION (To be completed by medical staff) PHYSICAL EXAMINATION SHOULD BE UNDERTAKEN WITH REFERENCE TO GN 3, 3A & 4A RECORD OUTCOME ON THE CONTINUATION SHEETS. IDENTIFY AND CORRECT ANY NUTRIENT DEFICIENCIES (see GN 3, 3a, 4a,) (map results on results sheet ESSENTIAL TICK ADDITIONAL TICK Full blood count Creatinine Kinase Urea & electrolytes Erythrocyte transketolase /serum thiamin Calcium Magnesium Plasma zinc Phosphate Glucose Serum protein Liver function Vitamin B12 folate Thyroid function test Dual-energy X-ray absorptiometry scan Electrocardiogram Pelvic ultrasound SECTION 11. RECOMMENDED BIOCHEMICAL MONITORING DURING EARLY REFEEDING (To be completed by medical staff) With reference to the child s age GN 4 and 4a, the refeeding and medical monitoring regimen should be planned revised and recorded daily by the dietitian and medical staff in full collaboration with the young person and parents. ADD ANY ADDITIONAL INVESTIGATIONS AS REQUIRED) (Map results on results sheet) Urea & electrolytes Calcium Magnesium Phosphate Glucose Liver function test Serum Protein Full blood count TICK FREQUENCY TICK FREQUENCY Folate Ferritin SECTION 12. Daily observations (To be undertaken and recorded by nursing staff on observation record sheet) * Food and mood diary sheet and Body checking diary sheet to be completed in collaboration with the young person OBSERVATIONS Frequency TICK OTHER AREAS Frequency TICK BP Pulse Resps Fluid in put and output Food/mood diary * Body checking diary * INITIALS DATE INITIAL DATE SECTION VARIANCE CODE 10 11 12 ED ICP Draft 1 Page 14 of 21
SECTION 13. INITIAL CARE PLAN (To be completed by key worker /Paeds Named Nurse in collaboration with Young person and parten/carer) Tick box to confirm copy to young person & parent /carer ADMISSION INITIAL CARE PLAN Patient observation level Staff Responsible Review Date Energy expenditure Tick as appropriate Bed /Arm chair rest Use of Wheel chair to Bathroom etc Gentle walking with nurse visit play room Other: NEGOTIABLE IDENTIFY AND AGREE NON FOOD ELEMENTS OF THE CARE PLAN SEE GN 7 NON-NEGOTIABLE Care Domain GOAL DESCRIPTION PEOPLE INVOLVED INDIVIDUAL THERAPY SESSIONS OT/PLAY THERAPY SESSIONS FAMILY SESSIONS PHYSIOTHERAPY INVOLVEMENT PATIENT & CARER COMMUNICATION STRUCTURE AND AGREED PROCESS INITIALS DATE INITIAL DATE SECTION VARIANCE CODE ED ICP Draft 1 Page 15 of 21 13
SECTION 14 MEAL PLAN (See GN 4, 4a and 5,Meal Management) Tick box to confirm copy to young person & parent /carer TIME MEAL RECOMMENDATIONS INCLUDE FOOD TYPE AND PORTION SIZE NEGOTIABLES Record three dislikes Include young person s initials and date of agreement INITIALS DATE INITIAL DATE SECTION VARIANCE CODE ED ICP Draft 1 Page 16 of 21 14
SECTION 15 - CLINICIANS MULTI DISCIPLINARY TEAM MEETING KEY WORKER / NAMED NURSE TO CONVENE THE MEETING WITHIN FIVE WORKING DAYS OF ADMISSION MEETING DATE TIME DATE: VENUE INVITATION SENT ATTENDEES: NAME DESIGNATION ATTENDED YES DNA/UTA REPORT SUBMITTED SUBSTITUTE REPRESENTATIVE Current Physical status (include dietetic /nutritional status and current weight) Current mental health status (include compliance & motivation and family s potential as a resource to recovery) Recommendations: Physical Mental health Dietetic INITIALS DATE INITIAL DATE SECTION VARIANCE CODE 15 ED ICP Draft 1 Page 17 of 21
SECTION 16 - YOUNG PERSON AND FAMILY REVIEW MEETING Tick box to confirm copy to young person & parent /carer KEY WORKER / NAMED NURSE TO CONVENE THE MEETING WITHIN 24 HOURS OF CLINICIANS MDT MEETING MEETING TIME VENUE DATE: ATTENDEES: ATTENDED REPORT SUBSTITUTE NAME DESIGNATION YES DNA/UTA SUBMITTED REPRESENTATIVE Young Person s View of Progress Parent/Carer s view of progress Recommendations from clinician s MDT Meeting: Paediatrician Mental health team Dietitian AGREED GOALS: 1. 2. 3. 4. INITIAL DATE INITIAL DATE SECTION VARIANCE CODE ED ICP Draft 1 Page 18 of 21 16
SECTION 17 - CONTINUING CARE PLAN (Key Worker to complete and sign with the young Person. Tick box to confirm copy to young person & parent /carer Patient observation level Energy expenditure Tick as appropriate Other: NEGOTIABLE Bed /Arm chair rest Staff Responsible CONTINUING CARE PLAN NUMBER ( ) Use of Wheel chair to Bathroom etc Gentle walking with nurse Review Date visit play room IDENTIFY AND AGREE NON FOOD ELEMENTS OF THE CARE PLAN SEE GN 7 NON-NEGOTIABLE Care Domain INDIVIDUAL THERAPY SESSIONS GOAL DESCRIPTION PEOPLE INVOLVED OT/PLAY THERAPY SESSION FAMILY SESSIONS PHYSIOTHERAPY INVOLVEMENT PATIENT & CARER COMMUNICATION STRUCTURE AND AGREED PROCESS INITIAL DATE INITIAL DATE SECTION VARIANCE CODE 17 ED ICP Draft 1 Page 19 of 21
SECTION 18 DISCHARGE AND TRANSFER PLAN (SEE GN 12) (Key Worker to complete and sign with the young Person. Tick box to confirm copy to young person & parent /carer DISCHARGE /TRANSFER CARE PLAN NUMBER ( ) DISCHARGE TO: IN CARE OF: CARE CO-ORDINATOR MEAL PLAN CC TO YOUNG PERSON & CARER ENERGY EXPENDITURE DESCRIBE: FIRST DIETETIC APPOINTMENT FIRST CONTACT DATE: VENUE VENUE NEGOTIABLE IDENTIFY AND AGREE NON FOOD ELEMENTS OF THE CARE PLAN SEE GN 7 NON-NEGOTIABLE Care Domain GOAL DESCRIPTION PEOPLE INVOLVED INDIVIDUAL THERAPY SESSIONS FAMILY SESSIONS GROUP THERAPY SESSION MEDICAL MONITORING PATIENT & CARER COMMUNICATION STRUCTURE AND AGREED PROCESS INITIAL DATE INITIAL DATE SECTION VARIANCE CODE 18 ED ICP Draft 1 Page 20 of 21
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