Eating Disorders - Refeeding Pathway v3.0: Table of Contents Inclusion Criteria · 5-17 years (if ≥18, call ADO Med and Psych re: consent issues that may preclude admission) · Concern for eating disorder (Anorexia nervosa, avoidant restrictive food intake Stop and disorder, eating disorder unspecified, Bulimia nervosa) Review Exclusion Criteria · Other diagnosis resulting in severe malnutrition that is NOT an eating disorder (e.g. cystic fibrosis, IBD) · ≥18 years with refusal to consent to refeeding & NG tube or ≥ 21 years old Eating Disorders - Refeeding Care ED Inpatient PBMU: Medical Service (MBB) PBMU: Psychiatry Service Appendix Version Changes Approval & Citation Evidence Ratings Bibliography For questions concerning this pathway, contact: Last Updated: January 2021 [email protected] Next Expected Review: April 2022 If you are a patient with questions contact your medical provider, Medical Disclaimer © 2021 Seattle Children’s Hospital, all rights reserved Eating Disorder- Refeeding Pathway v3.0: Emergency Department Inclusion Criteria · 5-17 years (if ≥18, call ADO Med and Psych re: consent issues that may preclude admission) Stop and · Concern for eating disorder (Anorexia nervosa, avoidant restrictive Review food intake disorder, eating disorder unspecified, Bulimia nervosa) Exclusion Criteria · Other diagnosis resulting in severe malnutrition that is NOT an eating disorder (e.g. cystic fibrosis, IBD) · ≥18 years with refusal to consent to refeeding & NG tube or ≥ 21 years old Psychiatry admission · Consider PBMU admit if patient does not meet criteria for med admit AND patient is Evaluation/initial therapies not safe to receive treatment · Vital signs, orthostatics, weight (after void), height, cardiorespiratory monitor at an eating disorder · Enter weight & height in EHR to obtain BMI and z-score residential center (suicidality, · Labs: Electrolytes, BUN, Creatinine, Phos, Mg, Ca, ALT, CBC, TSH, UA, urine preg elopement, eating disorder nd · IVF bolus if needed (start with 10mL/kg and then re-evaluate if 2 bolus is needed) behaviors that may require · Correct electrolytes at same time/prior to refeeding restraint). · EKG (if not done already) · Contact MHE as indicated. Meets admit criteria? Discharge Instructions · Follow-up with PCP within one week of discharge and Admission criteria weekly thereafter for blind weight and vital signs. Admit if one or more of the following: · Provide family with Return to · Electrolyte disturbance (e.g. hypokalemia, hyponatremia, hypophosphatemia) Activity Guidelines · EKG abnormalities (e.g. prolonged QTc males>450ms/females>470ms or severe If new patient: bradycardia) · Recommend referral to ADO · Physiologic instability unresolved after management in ED Med Clinic; PCP to place · Severe bradycardia (HR<45 BPM) referral. · Hypotension MAP <57 No · Follow-up with established · Hypothermia (Temp <96F or 35.6C) outpatient team (Mental · Symptomatic orthostasis (systolic BP decrease >20mmHg systolic, or diastolic BP Health Therapists, Medical decrease >10mmHg), despite adequate fluid resuscitation Providers, Dietitian) as soon · Acute medical complications of malnutrition (e.g. syncope, seizures, cardiac failure, as possible. pancreatitis) If followed by SCH ADO Med: After work-up complete: · Recommend appointments · Call Adolescent Med (ADO) on-call if plan to admit or other questions with medical provider and RD · Provide meal or oral supplement (Boost Plus if ≥ 11yr, or BKE 1.5 if <11yr) . in 2-3 weeks. See PCP weekly until available. · Follow-up with mental health Yes, meets admission criteria. provider as soon as possible Prior to leaving ED · Admit to Inpatient- Abnormal EKG or HR <30 BPM ! requires telemetry Provider · Add Blind Weight Flag in EPIC Job Aid · Provider, RN, or PMH reviews Restoring Nutrition- for Difficult Refeeding (PE643) with family. Conversations For questions concerning this pathway, contact: Last Updated: January 2021 [email protected] Next Expected Review: April 2022 If you are a patient with questions contact your medical provider, Medical Disclaimer © 2021 Seattle Children’s Hospital, all rights reserved Eating Disorder- Refeeding Pathway v3.0: Inpatient Inclusion Criteria · 5-17 years (if ≥18, call ADO Med and Psych re: consent issues that may preclude admission) · Concern for eating disorder (Anorexia nervosa, avoidant restrictive food intake Stop and disorder, eating disorder unspecified, Bulimia nervosa) Review Exclusion Criteria · Other diagnosis resulting in severe malnutrition that is NOT an eating disorder (e.g. cystic fibrosis, IBD) · ≥18 years with refusal to consent to refeeding & NG tube or ≥ 21 years old ! Consistent Messaging is critical. Confer before you set treatment plans with family. Therapy or Assessment Refer to Restoring Nutrition- Refeeding. Admit Nursing · Medical Team · Follow GOC: Eating Disorders and Refeeding · Initiate Medical Stabilization Eating Disorder orders Labs · Add Blind Weight Flag in EPIC · On admit check electrolytes/BUN/creatine/Phos/Mg/Ca/ · Provide family with Restoring Nutrition-Refeeding (PE 643) and describe · Provide family with Restoring Nutrition-Refeeding (PE 643) and describe ALT/CBC/TSH/UA/urine preg / EKG (if not already done) feeding protocol feeding protocol · Check electrolytes, Ca, Mg, Phos daily for *refeeding day Vitals #1-5 then Mon/Thurs · Continuous cardiorespiratory monitoring; vitals q 4 hours *Refeeding day #1 = 24 hours after completion of 100% · Abnormal EKG or HR<30 BPM requires telemetry prescribed nutrition Activity Consults (to facilitate consistent messaging) · Bedrest with bathroom privileges; avoid excess movement · Consult Adolescent Medicine, Dietitian, Psychiatry C&L · Wear long sleeves/long pants/socks/under covers within 24 hours · Recommend bathroom restriction 60 minutes after all meals/snacks Education · Showers 5 minutes; use shower stool due to fall risk Education · Provide family with info about Meal Support Classes Refeeding · Provide family with info about Meal Support Classes · Family Care Conference Monday or Thursday · Monitor for refeeding syndrome · Family Care Conference Monday or Thursday · Total length of hospital stay averages 2-3 weeks for safe · Initiate refeeding protocol at 1200 kcal per day until assessed by Dietitian · Total length of hospital stay averages 2-3 weeks for safe refeeding, to be determined by interdisciplinary team · Correct electrolytes at same time/prior to refeeding refeeding, to be determined by interdisciplinary team · Proceed with NG tube placement with FIRST incomplete meal, snack, or water AND incomplete oral supplement · Call Support Nurse if needed DDiisscchhaarrggee CCrriitteerriiaa · Resolution of physiologic instability (daytime HR >50 (required) and nighttime HR>45 (recommended), EKG changes, symptomatic orthostasis PBMU transfer · All electrolyte abnormalities corrected (no longer on supplements) ! · Can consider transfer to MBB, · Low risk for refeeding syndrome (highest risk in first 2 weeks of refeeding) if eating disorder behaviors or · Eating all prescribed nutrition in the form of solid food (recommended) Provider Job co-occurring psychiatric Aid for Difficult · Complete education and care coordination symptoms where the patient is Conversations Discharge Instructions worsening psychiatrically or · Follow-up with PCP within one week of discharge and weekly thereafter failing to stabilize nutritionally for blind weight and vital signs. on the Medical Unit · Provide family with Return to Activity Guidelines · Contact Psych Consult and If new patient: Liaison · Recommend referral to ADO Med Clinic · Follow-up with established outpatient team (Mental Health Therapists, Medical Providers, Dietitian) as soon as possible. · If followed by SCH ADO Med: · Recommend appointments with medical provider and RD in 2-3 weeks. See PCP weekly until available. · Follow-up with mental health provider as soon as possible For questions concerning this pathway, contact: Last Updated: January 2021 [email protected] Next Expected Review: April 2022 If you are a patient with questions contact your medical provider, Medical Disclaimer © 2021 Seattle Children’s Hospital, all rights reserved Eating Disorder- Refeeding v3.0: PBMU - Medical Service/MBB Inclusion Criteria · Concern for eating disorder (Anorexia nervosa, avoidant restrictive food intake disorder, eating disorder unspecified, Stop and Bulimia nervosa) Review Exclusion Criteria ! · Other diagnosis resulting in severe malnutrition that is NOT an eating disorder (e.g. cystic fibrosis, IBD) Provider Job · ≥ 18 years old Aid for Difficult Conversations MBB Psychiatry admit and/or transfer Admit Activity and Nursing · Page Psychiatry C&L Team to coordinate timing with PBMU & · Per patient recovery level, see GOC: Eating Disorders and arrange review of roadmap with patient and family (no tours) Refeeding · Use orderset: Eating Disorder-Refeeding admission including PBMU Labs orders · On admit check electrolytes/BUN/creatine/Phos/Mg/Ca/ALT/CBC/ · Add Blind Weight Flag in Epic TSH/UA/urine preg / EKG (if not already done) · Medical team continues to be primary team, same consultant teams · Check electrolytes, Ca, Mg, Phos daily for **refeeding day 1-5 then (ADO, Psych, Nutrition), same interdisciplinary meeting Mon/Thurs · Provide family with Restoring Nutrition-Refeeding (PE 643) *Refeeding day #1 = 24 hours after completion of 100% prescribed Vitals nutrition · Vitals q 4 hours Consults