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Eating Disorder Care Pathway (DRAFT)

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Overview

Eating disorders (EDs) have the highest mortality of any mental health condition. Early recognition and intervention are key. This page is will help you complete a referral to CAMHS eating disorders services with the appropriate information and identify those patients at very high risk that might require more immediate medical intervention.

PLEASE NOTE Until the deadline 27^th January 2025, the LMC advises GPs continue to offer medical investigation and monitoring required for Eating Disorders Patients until alternative pathways have been implemented to ensure the continued safe treatment of this high risk group. Please see your GP Bulletin that outlines this.

How to refer

We advise GPs complete the attached CAMHS Eating Disorders Service referral form

The form outlines the minimum history and the mandatory baseline observations, bloods and ECG needed for us to accept the referral and initiate triage and assessment safely. GP’s risk having the referral declined if they do not complete the form due to the baseline information needed.

A referral not on our form, risks being bounced back, as a referral done as a letter needs to include all the information below:

Patient’s name, NHS Number and DOB
Contact number for parent/carer (for initial triage) and young person if no adult involved
Referrers name, surgery and contact details
Weight summary – we must have weight AND height and a description of rate of weight loss (previous weights are very helpful). If no weight available ask about clothing size
ED concerns Please screen and describe the frequency and severity of the following behaviours associated with Eating Disorders : Food restriction, Vomiting, Binging, Laxative, Exercise and Eating Disorders Cognitions (which the young person may deny).

Below is the minimum physical health data we require to safely triage and we will ask you to complete this using our form if not included with your referral

Height	Weight	BMI
Pulse (sitting)	Pulse (standing	Menarche:
BP (sitting)	BP (standing)	LMP:
Temperature	Squat test	Other medical HX

Below is the minimum medical investigations we require to safely triage. Please note clicking the ‘Eating Disorders referral under 18’ profile on ICE system, will select the bloods needed for the referral to be accepted. You do not have to wait for results to send referral – UNTIL 27^th January 2025, the LMC advises GPs continue to offer medical investigation and monitoring required for Eating Disorders Patients until alternative pathways have been implemented

Bloods – FBC, U&E, Phosphate, Magnesium, LFT, TFT, Calcium, Glucose, Ferritin, Coeliac screen, Vitamin D Clicking the ‘Eating Disorders referral under 18’ profile on ICE system will select these bloods for you	Requested?	Y / N	if no why?
	Attached to form?	Y / N	If not, when is this booked for?
ECG	Requested?	Y / N	If not, why?
ECG	Attached to form?	Y / N	If not, when is this booked for?

As with all referral to CAMHS we would expect any relevant previous medical history, mental health history, medications and safeguarding and family concerns relevant to be included.

Identifying those at high risk

GPs may use MEED (Managing Medical Emergencies in Eating Disorders guidance) when assessing the patient with suspected eating disorder when assessing which is the all-age guidance from Royal College of Psychiatrists. The MEED Checklist (page 184 of the linked document) is a shorter questionnaire that can be a quick clinician aide for identifying those at highest risk MEEDChecklist_2.pdf

Below is some of the key information from MEED summarised from CAMHS ED all age risk assessment table helpful. Those scoring red in multiple domains are high risk and need to be referred urgently and you may want to consider if emergency medical treatment is indicated. Please note this is an abridged version of some of the key domains so please do cross check with MEED if you have concerns.

	Red (high risk) –consider urgent medical treatment	Amber (alert to high concern)	Green (low risk) –
BMI and weight	Under 18 years: median BMI (weight for height) <70% (Over 18: BMI <13)	Under 18: median BMI 70–80% (Over 18: BMI 13–14.9 )	Under 18: median BMI >80% (Over 18: BMI >15 )
Weight loss	Recent loss of weight of 1 kg or more/week for 2 consecutive AND/OR Acute food refusal or estimated calorie intake <500 kcal per day AND/OR Severe purging behaviours (vomiting and exercise	Recent loss of weight of 500– 999 g/week for 2 consecutive weeks AND/OR moderate food refusal AND/OR moderate purging behaviours (vomiting and exercise	Recent weight loss of < 500 g/week or fluctuating weight
HR (awake)	< 40 bpm (THIS NEEDS TO BE DISCUSSED WITH HOSPITAL)	40-50 bpm	>50 bpm
Cardiovascular health	Standing BP > 0.4th centile for age or less than 90 Postural drop in BP of >20 mm Hg or increase in HR of over 30 bpm (35 bpm in <16 years) Recurrent syncope	Standing BP <0.4th centile or <90 if 18+ Postural drop in BP of >15 mm Hg or increase in HR of up to 30 bpm (35 bpm in <16 years	Normal standing BP for age and gender with reference to centile charts Normal orthostatic cardiovascular changes Normal heart rhythm
Assessment of hydration status	Fluid refusal and signs of severe dehydration	Severe fluid restriction With signs of Moderate dehydration	Minimal fluid restriction
Temperature	<35.5°C tympanic or 35.0°C axillary	<36^oC	>36^oC
ECG abnormalities	Under 18: Females: QTc >460 ms Males: QTc 400 ms	Under 18: Females: QTc >460 ms Males: QTc 400 ms	Under 18: Females: QTc <460 ms Males: QTc 400 ms
Biochemical abnormalities	Hypophosphatamia Hypokalaemia (<2.5 mmol/L) Hypoalbuminaemia Hypoglycaemia (<3 mmol/L) Hyponatraemia Hypocalcaemia Transaminases >3x normal range In patients with diabetes mellitus: HbA1C >10% (86 mmol/mol) Low white cell count Haemoglobin <10 g/L	-	-

If high risk (scoring red in multiple domains on MEED) which can be easily checked using our CEDS all age risk assessment table, please consider if medical stabilisation is indicated and discuss with on call acute paediatrics at Bristol Children’s Hospital for under 16s. You may want to call Eating Disorder (ED) paediatric consultant phone which will be held Monday – Thursday 0830 - 1700 on 07340558582. Outside of these hours please liaise with acute Paediatrics. BCH also offers an email advice line for non urgent clinical queries: paedseatingdisorderadvice@uhbw.nhs.uk.

For 16-17 year olds please liaise with adult gastroenterology at either Bristol Royal Infirmary or Southmead Hospital

If further urgent advice is needed then please phone the on call Eating Disorder / General Paediatric consultant via the UHBW switchboard.

The locality teams can also be contacted to discuss.

North Bristol 0117 354 6800 awp.northcamhsadmin@nhs.net

South Bristol 0117 919 0330 awp.southcamhsadmin@nhs.net

EC Bristol 0117 3408600 awp.admineastandcentralcamhs@nhs.net

South Glos. 01454 862431 awp.southglosadmin@nhs.net

North Somerset 0300 125 6700 awp.nsomcamhsadmin@nhs.net

Please also be aware of refeeding syndrome. This is a potentially life-threatening complication caused by overly rapid re-feeding. This can cause phosphate, potassium and magnesium levels to fall rapidly resulting multi-organ failure. Monitoring of phosphate, electrolytes and Magnesium levels is needed during the first week or two of treatment for some patients to ensure we mitigate against risk of refeeding syndrome.

Resources

MEDICAL EMERGENCIES IN EATING DISORDERS (MEED)

The Royal College of Psychiatrists have published MEED in May 2022, this new guidance has been endorsed by the Academy of Medical Royal Colleges. You can view this updated all age-guidance (replacing Junior MARSIPAN and MARSIPAN guidance) here: Medical emergencies in eating disorders (MEED): Guidance on recognition and management (CR233) (rcpsych.ac.uk)

It also includes information and advice on how to manage physical, nutritional and psychiatric care in this patient group and includes an eating disorders risk assessment tool using a ‘traffic light’ system, to aid decisions on emergency management. Please see Appendix 3: Medical emergencies in eating disorders risk checklist for clinicians

The guidance also provides a set of summary sheets with tailored advice for the different target groups of this document, this is the link to the one most helpful to GP (college-report-cr233---annexe-1.pdf (rcpsych.ac.uk) – page 7

The EDHIT Team have recently created a 'Eating Disorders Support & Resources' guide.

The guide is designed for anyone affected by eating disorders or problems around eating and bodyweight, including those struggling personally, parents, families, friends and professionals. It contains a range of signposting information, advice and guidance from local and National charities and organisations. Many of the organisations listed contain advice on self-help as well as access to support. There is also a section on 'coping with an eating disorder during Coronavirus'.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.