Eating Disorders A guide to management & referral pathways in the RPAH Emergency Department.

Eating disorders are associated with significant psychiatric and medical morbidity. Eating disorders are serious, life-threatening, psychiatric illnesses and are not a lifestyle choice. In addition to individuals presenting with the medical sequelae of an , individuals may also present to the Emergency Department with no history or diagnosis of an eating disorder, but have, for example, recently lost a significant amount of body weight and are at risk of refeeding syndrome and other medical complications.

Assessing for symptoms of eating disorders can be difficult as patients may feel uncomfortable disclosing health-related information. Consider interviewing the patient with family members (with consent of the patient) to help ascertain an accurate clinical picture.

Effective management of a patient with an eating disorder requires close collaboration between medical and psychiatric staff. The overarching principle is that each patient is entitled to access the level of treatment determined by their psychiatric and / or medical needs.

Key symptoms of eating disorder presentations may include: Low body weight for age and height or failure to achieve expected weight gain Fear of fatness or fear of weight gain Preoccupation with weight and shape Restricted dietary intake Self-induced vomiting Misuse of laxative, diuretics or appetite suppressants Excessive, compulsive exercise Binge eating episodes unusually large amounts of food Amenorrhoea or failure to reach menarche in women; loss of libido in men Acute medical symptoms may include: Dehydration Electrolyte imbalance Hypothermia Syncope Cardiac arrhythmias (especially bradycardia) Suicidal ideation or attempts Overwhelming infection, renal failure Bone marrow suppression, GIT dysfunction Acute gastric dilation from binge eating A thorough physical examination is necessary and must be completed. Also order the following investigations: BMI ECG Full blood count including electrolytes, glucose, renal function, liver function, thyroid function (T3, T4, TSH), calcium, magnesium, phosphate, amylase, ESR. Urinalysis Warning signs If patients exhibit any of the following, physician consultation and potential hospital admission is indicated:

Sections adapted from NSW Health: for Emergency Departments A Reference Guide (2009) DRAFT Version 3, 27.05.2013

Temperature <35.5C Blood pressure <90/60mmHg in adults or <80/40mmHg in adolescents Postural drop >10-20mmHg; postural increase >10-20mm/Hg Tachycardia Bradycardia (heart rate <40 in adults and <50 in adolescents) BMI <15kg/m2, or <16kg/m2 with co-existing medical conditions (e.g. diabetes, pregnancy) Rapid weight loss i.e. >1kg/week over five weeks or more Significant dehydration (>5%) Significant electrolyte disturbance e.g. low serum phosphate or low serum potassium Cardiac arrhythmia including prolonged QTc interval on ECG, corrected for rate (>450ms) Key risks Suicide and / or self harm Refeeding syndrome (a potentially lethal condition with malnourished patients. Refeeding should be managed according to the RPAH RFS Policy available on the Intranet; document RPAH_PD_2010_036) Undiagnosed physical illness Treatment resistance or ambivalence regarding receiving appropriate treatment What are the goals of inpatient treatment? 1. Medical stabilisation 2. Prevention and treatment of refeeding syndrome 3. Weight restoration 4. Reversal of the cognitive effects of starvation Managing an eating disorder admission in a medical setting Ensure referrals to the Consultation Liaison team and Eating Disorder Coordinator have been completed (see Whilst the medical team takes immediate responsibility, this is ultimately in partnership with the Eating Disorders team who should be involved on a regular basis A clear multi-disciplinary treatment and care plan to be developed as early as possible in the patients admission. Changes to the care plan are to occur only in consultation with all teams involved The patient may need specialling (see RPAH intranet for policy RPAH_PD2008_035) Discharge planning to community-based services e.g. RPAH eating disorder outpatient clinic, should commence with admission. For advice contact the RPAH eating disorder team on x58165. Who to refer to While in the Emergency Department, patients should be assessed for medical complications of starvation or purging behaviours and referred for appropriate medical review. If the patient is exhibiting eating disordered symptoms or medical complications of the illness, contact all of the teams below to facilitate admission for treatment of the acute physical symptom/s, or to facilitate appropriate community-based treatment. 1. Refer the patient to the Consultation Liaison (CL) Psychiatry team. Referral to CL Psychiatry is made by paging the on- call CL Psychiatry registrar via the switch. 2. Refer the patient to the Endocrinology team by paging the Endocrine Registrar via the switch. 3. Refer the patient to the Eating Disorder Coordinator: Brooke Adam pager 81796 / ext. 58165 4. Complete the Eating Disorder Service referral form located in (location in A&E TBA) and may also be downloaded from the Centre for Eating and Dieting Disorders (CEDD) website http://www.cedd.org.au/index.php?id=272 and fax, attention Eating Disorder Service (Brooke Adam), to 9515-5843; 5. If in need of specialist eating disorder medical advice, please page the eating disorder Psychiatry Registrar via the switch. Criteria for Medical Admission under Endocrinology: Eating Disorder plus Medical Condition: 1. BP <80/40mmHg in adults/adolescents or BP <90/60mmHg plus postural drop (> 15mmHg) 2. BMI <15kg/m2 plus acute medical issue (ie. Infection)

Sections adapted from NSW Health: Mental Health for Emergency Departments A Reference Guide (2009) DRAFT Version 3, 27.05.2013

3. Significant electrolyte disturbance (ie. serum potassium < 2.5 mmol/L, hypophosphataemia) 4. Admission for NGF 5. FBC abnormality (ie. significant anaemia Hb <70) 6. LFT dysfunction (3x upper limit of normal) 7. Hypothermia (temperature <35.5C) Joint Admission under Cardiology and Endocrinology - requires monitored bed: 1. Bradycardia (Heart rate <40 in adults and <50 in adolescents) 2. Tachycardia (Heart rate >100bpm) 3. Other cardiac arrhythmia (ie. prolonged QTc interval, corrected for rate >450ms) 4. Cardiac failure Pre-discharge checklist If the patient is assessed and discharge to the community is considered appropriate, the following should be completed: Wherever possible , liaise with their family or support network; Li; If the patient is out of area, ensure they are aware of the location of their local Emergency department; Referral to RPAH Eating Disorder Outpatient Service If the patient has private health insurance (they will need to check their level of cover), a referral can be made to one of the following: o The Northside Clinic Eating Disorders Unit, 2 Greenwich Road, Greenwich NSW 2065 P: 02 9433-3555 F: 02 9433-3599 W: www.northsideclinic.com.au o The Wesley Hospital Eating Disorder Centre, 91 Milton Street, Ashfield NSW 2131 P: 1300 924 522 F: 02 9799-6685 W: www.wesleyhospital.org.au

RPAH Eating Disorder Service P: 02 9515-8165 F: 02 9515-5843 E: [email protected] [email protected]

Centre for Eating and Dieting Disorders For more information on Australia-wide eating disorder services and resources please visit: www.cedd.org.au

Sections adapted from NSW Health: Mental Health for Emergency Departments A Reference Guide (2009) DRAFT Version 3, 27.05.2013