Care Pathway

Overview

Eating disorders (EDs) have the highest mortality of any mental health condition. Early recognition and intervention are key. See NICE CKS guidelines for Eating Disorders which gives advice on assessment and diagnosis of patients with eating disorders. Please also see new all- age guidance from Royal College of Psychiatrists Managing Medical Emergencies in Eating Disorders guidance which replaces the Junior and adult MARSIPAN guidance.

The range of conditions and behaviours classed as eating disorders include anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED).

Eating disorders can occur in anyone at any age and may present in people of normal or above normal weight. Behaviours associated with eating disorders are often covert so patients may deny or minimise. Eating disorders may present atypically or with faltering growth or delayed puberty in children and adolescents.

Eating disorders are high risk, so it’s important to carry out a physical and mental health risk assessment, this can be safely done by completing the CEDS (CAMHS Eating Disorders Service) referral form.

We would also recommend looking at our CEDS all age risk assessment table that will help you assess risk and decide on referral urgency. The MEED Checklist (page 182 of the linked document) is a shorter questionnaire that can be a quick clinician aide for identifying those at highest risk.

Other causes must be excluded but clinicians should have a high index of suspicion in people presenting with weight loss, faltering growth, delayed puberty or menstrual irregularities.

Refeeding syndrome is a potentially life-threatening complication caused by too-rapid re-feeding. Sudden reversal of prolonged starvation can call phosphate, potassium and Magnesium levels to fall rapidly resulting multi-organ failure. Monitoring for hypophosphataemia is essential as its one of the earliest clinical indicators for a potentially fatal complication that is easily treatable if identified early.

Please be prepared to repeat Phosphate (and U&E and Magnesium) levels during the first weeks of treatment to ensure we mitigate against risk of Refeeding Syndrome. The treating CAMHS team will liaise directly with the surgery to initiate this in cases where clinically indicated.

Who to refer

Please refer to our CEDS all age risk assessment table which indicates the course of action to take based on the risk.

Calculate BMI using this Combo Weight4Height spreadsheet. (You will need to Download the spreadsheet and then Enable Editing at the top of the spreadsheet to be able to enter data)

This has been updated in keeping with the see new guidance from Royal College of Psychiatrists Managing Medical Emergencies in Eating Disorders guidance which replaces the Junior and adult MARSIPAN guidance. The MEED Checklist (page 182 of the linked document) is a shorter questionnaire that can be a quick clinician aide for identifying those at highest risk.

Red Flags

If high risk (scoring red in multiple domains) based on the CEDS all age risk assessment table, please consider if medical stabilisation is indicated and discuss with on call paediatric gastro consultant (Adult Gastro if >16yo) and also make an urgent CAMHS referral by completing CEDS (CAMHS Eating Disorders Service) referral form and attach to a completed SPE form.

Please note the mandatory baseline observations required on referral form and essential investigations (bloods and ECG) listed on form necessary for safe and effective triage and assessment and initiation of safe treatment and refeeding. Clicking the ‘Eating Disorders referral under 18’ profile on ICE system will select these bloods for you.

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

Before referral

Please note the mandatory baseline observations required on referral form and essential investigations (bloods and ECG) listed on form necessary for safe and effective triage and assessment and initiation of safe treatment and refeeding. Clicking the ‘Eating Disorders referral under 18’ profile on ICE system will select these bloods for you.

Consider prescribing a multivitamin containing vitamin D such as forceval junior/sanatogen.

Referral

If referring to CAMHS Complete CEDS (CAMHS Eating Disorders Service) referral form and attach to a completed SPE form. This should also be available as an EMIS template.

Submit to:

Single Point of Entry 
Unit 9, Eastgate Office Centre,
Eastgate Road
Eastville
Bristol
BS5 6XX

Tel: 0300 125 6905  Email: sirch.singlepointofentry@nhs.net

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

SELF-CARE RESOURCES

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.