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Structured, supported feeding admissions for restrictive eating disorders on paediatric wards
  1. Karen Street1,
  2. Susie Costelloe1,
  3. Michelle Wootton1,
  4. Sonja Upton2,
  5. Julie Brough2
  1. 1Department of Paediatrics, Royal Devon and Exeter Foundation Trust, Wonford Hospital, Exeter, UK
  2. 2Devon CAMHS, Virgin Care, Unit 1 Capitol Court, Exeter, UK
  1. Correspondence to Dr Karen Street, Department of Paediatrics, Royal Devon and Exeter Foundation Trust, Child Health, Wonford Hospital, Barrack Road, Exeter EX2 5DW, UK; Karenstreet{at}nhs.net

Abstract

Background Restrictive eating disorders in young people are increasingly requiring admission to the hospital and can be a challenge to manage on acute general paediatric wards.

Methods We have developed a joint working model with Child and Adolescent Mental Health services (CAMHS) using short, structured, supported feeding admissions to supplement outpatient treatment in high risk or ‘stuck’ cases.

Results We have successfully managed the majority of young people in the community avoiding lengthy, expensive, specialist CAMHS eating disorder inpatient unit admissions (tier 4). Local ward admissions are easier to manage and the attitudes of nursing and medical staff towards these young people have changed.

Discussion Joint working between paediatric and CAMHS teams enables shorter, more manageable local ward admissions, reducing the need for tier-4 units.

  • General Paediatrics
  • Adolescent Health
  • Child Psychiatry
  • Multidisciplinary team-care

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What is already known on this topic?

  • Hospital admissions for young people with restricted eating disorders are increasing and are longer compared to other admission episodes.

  • Managing restricted eating disorders on acute paediatric wards can be a challenge for medical and nursing staff.

What this study adds?

  • Short, structured paediatric ward admissions for supported feeding can be an effective part of the multi professional management of young people with restricted eating disorders.

  • The need for specialist inpatient eating disorder unit admissions can be reduced by effective joint working between paediatric medical and mental health services.

  • Paediatric ward medical and nursing staff have a more positive attitude towards the role of short, structured supported feeding admissions for restricted eating disorders.

Introduction

The number of young people in England with restrictive eating disorders requiring hospital admission is increasing.1 Eating disorders are mental health conditions with significant physical health effects. Associated mortality is higher than in any other mental health disorder and greater than most physical disorders treated on general paediatric wards.2

The management of restrictive eating disorders is challenging and may be considered beyond the scope of an acute general paediatric ward. However, removing young people from their family, school and local community into specialist eating disorder units for extended periods of time is expensive and has many negative effects.3

The model of brief medical stabilisation and outpatient care for young people with eating disorders is reported by specialist eating disorder units around the world but we are not aware of any reports describing the use of general paediatric inpatient units.

Junior Management of the Really Sick Inpatient with Anorexia Nervosa guidelines, published by the Royal College of Psychiatrists in 2012, recommend close working between paediatric medical, dietetic and mental health services to manage young people with eating disorders.4 We have developed a joint working model to safely manage young people in the community, using local hospital admissions more effectively. This report describes the current pathway, impact on local paediatric wards and outcomes for young people. Our pathway has been acknowledged as one of five good-practice models in the recent National Health Service England Guide to Commissioners.3

Background

Seven young people were admitted to the general paediatric ward with restrictive eating disorders and high-risk physical factors, between 2008 and 2010, with mean length of stay 80 days, 3/7 requiring nasogastric tube (NGT) feeding and tier-4 inpatient admission required in 6/7. Nursing and medical staff found behavioural management of eating on the ward extremely challenging, and were negative towards the role of an acute hospital setting. Eating disorders were poorly understood; young people were perceived as difficult or attention seeking.

Methods

In 2012, Child and Adolescent Mental Health services (CAMHS) and the paediatric service in Exeter, East and mid Devon jointly developed a pathway to deliver care to children with restrictive eating disorders. Within CAMHS, there is a dedicated eating disorder team led by family therapists, involving individual therapists and rapid access to psychiatry as needed, delivering the Maudsley approach of family-based treatment.5 Alongside, and enhancing this approach, the hospital-based team of lead local paediatrician, specialist dietitian, and nurse, offer outpatient assessments, follow-up and inpatient admissions when needed (figure 1).

Figure 1

Joint Child and Adolescent Mental Health services/paediatric restrictive eating pathway.

A unified referral point takes all restricted eating cases and offers CAMHS family therapy appointment within 1–2 weeks. If <16 years, <85% median body mass index, rapid weight loss, physical symptoms or if specifically requested by the general practitioner they are also seen in the dedicated weekly medical/dietetic clinic. Joint assessment with CAMHS is offered within days of any identified as high physical risk.

The medical team exclude other physical diagnoses, assess physical risk and raise anxiety accordingly with the intention of motivating the parents and young person to work with CAMHS and increase food intake according to dietetic advice.

Ongoing physical risk is monitored by a consultant paediatrician while CAMHS work to effect change and establish weight gain through intensive input. Both teams communicate regularly to ensure consistency of advice.

In moderate/high-risk cases, inpatient admission to the general paediatric ward is used urgently, or semi-electively when all else has failed, to stabilise physical risk and re-establish intake of sufficient calories to achieve weight gain. This consists of a 3-week structured, supported feeding admission, which is presented as a way to try and avoid otherwise inevitable tier-4 admission for young people who are not engaging, or supportively for those who have engaged but struggle to achieve adequate food intake at home.

Young people are nursed in open bays. The hospital school provides art/craft activities for relaxation/distraction but no formal education. Week 1 is bed rest, prescribed refeeding meal plan and close monitoring for refeeding or underfeeding syndrome. Week 2 is consolidation on the full meal plan sufficient for weight gain. Week 3 is preparing for home after a discharge planning meeting.

Every meal/snack has standardised nursing supervision. Initially, parents are not present at mealtimes and discouraged from discussing food with their young person. If meal/snack is not completed in entirety within a time limit then they are expected to take a supplement drink. The energy content of the drink exceeds that of the meal to encourage compliance with eating solids. If this is not consumed in a given time, a NGT is briefly passed to deliver the supplement and then removed so that each meal/snack is a fresh start.

As weight increases and physical observations stabilise, mobilisation is allowed for purposeful activities only, for example, toilet, shower, these remain supervised. The CAMHS team provide support on the ward for the young person and parents. Towards the end of admission, parents take over meal supervision. A home meal plan is prepared with parents and dietitian prior to discharge.

Following discharge, the teams continue to work together to ensure ongoing weight gain, school reintegration and gradual return to normal activity. This continues until good physical health is restored. CAMHS input often continues after medical discharge.

If at any time the joint team feels that a young person’s physical or mental health recovery is not progressing, referral to a tier-4 unit is considered. Psychiatric review is available at any stage of the patient journey.

Results

Around 60–70 young people with restrictive eating disorders are managed jointly with 40–50 new referrals per year, majority as outpatients.

Over August 2012–August 2015, 31 patients were admitted, 30 females, ages 10–17 years (mean 14.5). Fourteen were urgent new presentations, 17 semielective supportive admissions. The average length of stay was 20 days. Two needed NGT for one meal only, two were transferred to tier-4 units from the ward and two accessed local adult tier-4 services (1–2 years post admission) when physically safe but struggling with mental health recovery. None required use of the Mental Health Act. The remaining 27 were discharged before age 18 years with good physical health.

Ward staff views, sought through focus groups, were that, time-limited admissions, with consistent and boundaried care plans, are easier to manage, they feel more supported by CAMHS and positive about their role in helping the young person. Staff also described improved understanding of eating disorders and positive attitudes towards young people.

Discussion

Our small numbers limit rigorous statistical analysis. During the service development, we did not collect sufficient individual patient data to allow analysis and comparison of recovery; however, we now have a service database and recovery data will be collected and reported.

Joint working with CAMHS required a change in working practice, understanding of professional roles, breaking down of barriers/stereotypes, and moving on from previous negative experiences. Joint education meetings, case-based discussion, regular email contact and social events all helped to foster the excellent working relationships that are key to the success of our model.

The level of communication required for effective joint working is time consuming. The service was initially established through unpaid additional time and displacement of other activity. The benefits of reduced tier-4 admissions and improved quality of local service were recognised by commissioners, leading to formal commissioning of the pathway.

We have been able to identify patient factors (eg, comorbid mental health problems, mental illness in parents, family disruption) that were more common in those who struggled with our model. We now identify these cases early and alter our approach by involving psychiatry and social care colleagues where needed. Since February 2015, we also have a CAMHS Assertive Outreach Team who can provide meal support at home.

Summary

We have developed a model of joint working between CAMHS and hospital-based medical/dietetic teams that has successfully maintained many young people with restrictive eating disorders in the community during their treatment. The change in ward admissions has created a more positive attitude among staff towards young people.

The key to success has been communication and joint working between professionals, and removal of the artificial divide between physical and mental health, medical and CAMHS teams.

References

Footnotes

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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