Medical emergencies in eating disorders: Guidance on recognition and management (Royal College of Psychiatrists, May 2022)

Summary

To tackle the serious harms, up to and including death, associated with eating disorders it is crucial that more is done to identify them at the earliest stage possible so that the appropriate care and treatment can be provided.

The aim of this guidance from the Royal College of Psychiatrists is to make preventable deaths due to eating disorders a thing of the past.

Content

Recommendations

1. Medical and psychiatric ward staff need to be aware that patients with eating disorders being admitted to a medical or paediatric ward may be at high risk despite appearing well and having normal blood parameters.

2. The role of the primary care team is to monitor patients with eating disorders, refer them early and provide monitoring after discharge, in collaboration with medical services and EDSs (including community EDSs). Eating disorders are covered, in England, by the term severe mental illness and physical checks in primary care should be performed, even if under specialist outpatient care. Patients with eating disorders not presenting in an emergency may nevertheless require urgent referral.

3. Physical risk assessment in primary and secondary settings should include nutritional status (including current intake), disordered eating behaviours, physical examination, blood tests and electrocardiography.

4. Assessment measures (such as body mass index [BMI] or blood pressure [BP]) for patients under 18 years must be age-adjusted.

5. Where specialist eating disorder unit (SEDU) beds are not available, general psychiatric units should be supported to provide specialist eating disorder care. This will require input from liaison psychiatry and EDSs, so that patients can be transferred safely without delay when discharge from a medical bed is appropriate.

6. Patients who require admission to medical or paediatric wards should be treated by a team with experience of treating eating disorders and involving their carers, using protocols developed in collaboration with eating disorder specialists, and having staff trained to implement them.

7. The inpatient team on the medical/paediatric unit should include (at least) a lead physician/paediatrician, a dietitian with specialist knowledge of eating disorders and a lead nurse. An eating disorders or liaison psychiatry service should provide sufficient support and training to medical/paediatric wards to allow them to manage eating disorder patients. Around this core team for each individual patient, key professionals should be added who are involved with or knowledgeable about a patient and their illnesses, needs and community care plans (e.g. nurses, therapists or psychiatrists from EDSs or community mental health teams, or diabetes team professionals), forming a multi-agency group to guide the admission and subsequent care.

8. Responsibilities of the inpatient teams are:

• Medical team:

• safely refeed the patient
• avoid refeeding syndrome caused by too rapid refeeding
• avoid underfeeding syndrome caused by too cautious refeeding
• manage fluid and electrolyte problems, often caused by purging behaviours o arrange discharge, in agreement with the mental health team and commissioners, to eating disorders community care or intensive treatment (e.g. day care or specialist inpatient care) as soon as possible once such treatment is safe and indicated
• for patients with complex problems (e.g. eating disorder and emotionally unstable personality disorder or autism spectrum disorder) consult with psychiatric experts to decide on further management.

• Mental health team:

• manage, in collaboration with the medical team, the behavioural problems common in patients with eating disorders
• occasionally assess and treat patients under compulsion using relevant mental health legislation o address family concerns and involve both patients and their families in discussions about treatment o advise on appropriate onward care following medical stabilisation.

9. Health commissioners (clinical commissioning groups and national commissioners) should:

• be aware of the local provision for severely ill patients with eating disorders
• ensure that robust plans are in place, including adequately trained and resourced medical, nursing and dietetic staff on the acute services, and specialist eating disorders staff in mental health services
• support the establishment of intensive community treatment, including outpatient and day patient services for both young people and adults.

10. Job plans for consultants in eating disorders and liaison psychiatry should allow a session for training professionals in paediatric and medical wards.

11. Units treating patients with eating disorders join peer review networks and participate in audit and quality improvement activity. (

12. Knowledge and training about the content of this guidance should be required for all frontline staff.