Eating Disorders Toolkit
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NSW Eating Disorders Toolkit A PRACTICE-BASED GUIDE TO THE INPATIENT MANAGEMENT OF CHILDREN AND ADOLESCENTS WITH EATING DISORDERS NSW Ministry of Health 73 Miller Street NORTH SYDNEY NSW 2060 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) 170582 ISBN is 978-1-76000-743-0 Further copies of this document can be downloaded from the NSW Health webpage www.health.nsw.gov.au February 2018 ii NSW Health NSW Eating Disorders Toolkit Acknowledgements The Toolkit is a revision of the original Toolkit MH-CYP and CEDD would like to thank the whose development was facilitated by the former expert panel who assisted with the revision MH-Kids (now MH-Children and Young People) of this document: in conjunction with a variety of clinicians and academics throughout NSW, nationally and • Ms Danielle Maloney internationally. • Dr Sloane Madden • Ms Joanne Titterton This revision was facilitated by MH-Children and Young People (MH-CYP), of the Mental Health • Ms Mel Hart Branch, NSW Health and the Centre for Eating • Dr Julie Adamson and Dieting Disorders (CEDD), The Boden • Dr Michael Kohn Institute of Obesity, Nutrition, Exercise and Eating • Dr Rod McClymont Disorders, Sydney University. • Ms Carolyn Rae (Secretariat) • Ms Marie Hamann NSW Health NSW Eating Disorders Toolkit 1 Executive Summary It is well recognised that early, timely and The document has been developed with the busy appropriate care will improve the likelihood of clinician in mind, aiming to ensure easy access to positive treatment outcomes for young people relevant information. The Toolkit has been with an eating disorder. The high morbidity and designed to provide user friendly “pull out” mortality associated with eating disorders and the sections that can be easily identified and need for a multidisciplinary approach are well accessed separately. reported in the literature. The information described in the Toolkit was The NSW Eating Disorders Toolkit is a practice- developed from the evidence-based literature, based manual that aims to assist health international eating disorder clinical practice professionals in applying best-practice principles guidelines, consultation with national and in non-specialist inpatient settings in NSW. The international experts and the experiences of Toolkit aims to assist with improving access to clinicians working with patients with eating practical information, to facilitate consultation disorders in non-specialist settings. It is not the with specialist staff and to improve consistency of intention that this Toolkit acts as a stand-alone care for children and adolescents with eating treatment manual as any management program disorders across NSW. must take into account the unique health care needs, and the context, of each individual patient The Toolkit has been developed to provide and their family. 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. 2 NSW Health NSW Eating Disorders Toolkit Contents EXECUTIVE SUMMARY ..............................................2 FORMULATION OF A TREATMENT PLAN ......... 27 INTRODUCTION ..........................................................7 Treatment Plan .............................................................. 27 AIMS AND SCOPE OF THE TOOLKIT .....................7 Working as a Team ......................................................28 HOW TO USE THE TOOLKIT ....................................8 The Roles of the Multidisciplinary Team Members on the Ward ...................................................................28 WHAT IS AN EATING DISORDER? ..........................8 CARE (CASE) MANAGEMENT ............................... 29 GENERAL PRINCIPLES FOR ALL STAFF ............. 9 Team Cohesion and Consistency ..........................29 PREADMISSION CONSIDERATIONS ....................10 Maintaining Consistency ......................................29 IMPORTANT POINTS ................................................10 Ward Milieu ...................................................................29 Selecting the Most Appropriate Site for Activities ....................................................................30 Referral .............................................................................10 Working with the Young Person and their Indications for Hospitalisation .................................. 11 Families and Carers ......................................................31 INTERVENTIONS REQUIRED ................................. 12 Therapeutic Rapport and Engagement ..........31 Involvement of Specialist Staff................................ 12 Externalisation ..........................................................31 THE FIRST 24 HOURS – WHAT TO DO ................ 13 Basic Counselling Skills ............................................. 32 Basic Counselling Techniques ............................33 EMERGENCY DEPARTMENT TRIAGE .................. 13 Issues in Counselling ..............................................34 EATING DISORDERS HISTORY ..............................15 Motivation ..................................................................35 DETERMINING MOST APPROPRIATE Stages of Change ....................................................35 SITE FOR TRANSITION .............................................16 Expect and Plan for Resistance ..........................36 MANAGEMENT PLAN FOR FIRST 24 HOURS ........ 17 Distress ............................................................................36 ASSESSMENT OF SUSPECTED EATING Managing Distress as Part of a Ward DISORDERS ................................................................19 Program ...................................................................... 37 Medical Assessment ....................................................19 Deliberate Self-Harm ............................................. 37 Medical Investigations ................................................19 Clinical “What Ifs?” ................................................. 37 Physical Assessment ...................................................19 Maintaining Social Connections .............................38 Other Areas to Explore ............................................20 Leave from the Ward .................................................39 Managing Leave from the Ward .........................39 Mental Health Assessment ........................................20 Evidence-based Therapies .......................................39 At Risk Groups ................................................................ 21 Working with the Family and Carers ...................39 Mental Health Risk Management ............................. 21 Involving the Family ............................................... 40 ASSESSING GROWTH AND DETERMINING Important Messages to Convey to HEALTHY WEIGHT RANGE .................................... 22 Families ...................................................................... 40 Methods to Assess Growth ....................................... 22 Family Intervention .................................................41 Measuring Weight and Height ................................. 22 Medical and Physical Treatment ............................42 ‘BMI for Age’ is Used for Children and Refeeding Syndrome: Risk Assessment Adolescents ..................................................................... 22 and Management .....................................................42 Management of Refeeding Syndrome .............43 Determining a Healthy Weight Range .................. 23 Hypothermia ................................................................. 44 Approximating the Healthy Weight Range Using BMI for Age .......................................... 23 Special Considerations for Eating Disorders ................................................................... 44 EATING DISORDER CLINICAL SUMMARY .......... 24 Measuring Core Body Temperature ............... 44 Management of Hypothermia on the Ward .............................................................................45 Amenorrhoea ................................................................46 NSW Health NSW Eating Disorders Toolkit 3 Osteoporosis and Osteopaenia .............................47 Pharmacotherapy ........................................................63 Bone Health and Eating Disorders ...................47 Pharmacotherapy ...................................................63 Osteoporosis and Osteopaenia Medications and Anorexia Nervosa .................63 Management Plan ....................................................47 Medications and Bulimia Nervosa ....................63 Constipation ....................................................................48