Working together... 5 year experience of South London and the Maudsley & King’s College Hospitals...
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Transcript of Working together... 5 year experience of South London and the Maudsley & King’s College Hospitals...
Working together...5 year experience of South London and the Maudsley & King’s College Hospitals
Dr Mima Simic MSc MD MRCPsychConsultant Child and Adolescent Psychiatrist
Dr Simon Chapman BA BM FRCPCHConsultant Paediatrician
The Role of the Paediatrician in Eating Disorders
Care pathway: BEFORE 2010Child and Adolescent Eating Disorder
ServiceMaudsley Hospital, London
Referral from GP, Tier 2 or
Tier 3 CAMHS
Screening Assessment
Inpatient Treatment
Multifamily Therapy
Programme
Specialist Outpatient Treatment
Care pathwayChild and Adolescent Eating Disorder
ServiceMaudsley Hospital, London since 2010
Referral from GP, Tier 2 or
Tier 3 CAMHS
ScreeningAssessment
Brief paediatric admission
Intensive Treatment
Programme(ITP)
Inpatient Treatment
Multifamily Therapy
Programme
Specialist Outpatient Treatment
RCT of inpatient treatment for anorexia nervosa in medically unstable adolescents (Madden et al. 2014)
First study to compare different inpatient interventions
Iceland –average length of stay in AN adolescents 129.7days (Sigurdardottur et al. 2010)
France -135 days (Stirk Lievers e al. 2009) UK - 106.4 days (Gowers et al. 2010) USA – 16 days for medically unstable (Chu et
al. 2012)
Madden et al. cont…
82 eligible from 266 consecutive admission of eating disorders to two specialist paediatric units
Young people aged 12-18 years with the duration of illness < 3 years
Eligible if medically unstable: 1. temperature <35.5 C2. heart rate < 50 beats/min3. <80 mmHg systolic and < 40 mmHg diastolic4. orthostatic instability >20 beats/min, systolic
blood pressure decrease >20mm Hg or QT >0.45s
Madden et al. cont…
Randomised to1. Medical stabilization(MS) +family based treatment
(FBT)2. Hospitalization for weight restoration + FBT
All were re-fed according to standard protocol commencing with 24-72h of continuous nasogastric feeds (ceased during day if medically stable) followed by a combination of nocturnal nasogastric feeds and supported meals with the total caloric intake between 2400 and 3000 kcal/day
Cont…
Patients in MS group were discharge to outpatient FBT if they had no markers of medically instability for 72 ours of cessation of NG feeding
Patients in WR group were discharged to outpatient FBT when they reached 90% of Expected Body Weight (EBW)
ResultsFirst admissiondays
Days in hospitalat 12 months
Fully recoveredat 12 months
Partially recovered at 12 months
No Family Therapy sessions
Additional treatment in %
MS 21.73 45.20 30.00% 90.00% 24.25 30.6%
WR 36.89 65.50 32.50% 85.00% 31.30 45.5%
Results
Effect size 0.43 – moderate effect size in favour of MS group
Outpatient treatment cost 10% of inpatient treatment (Katzman et al. 2000) + prolonged admission reduces contact with the family, friends, peers and educational attainment, socialization and identity development (Meads et al 2001)
Patients with higher EDE score and higher compulsive behaviour did better in MS group - longer admission magnifies the rigidity and inflexibility (LeGrange et al. 2012)
Summary (Madden et all, 2014)
Hospitalization is shorter if family therapy for anorexia nervosa is available
For adolescents with AN of duration less than 3 years, treatment programmes that integrate outpatient family therapy with inpatient treatment for medical stabilization is likely to lead to more cost-effective care
What is a paediatrician for?■Exclude other causes■Physical Risk
assessment■Management of
refeeding■The ‘voice of concern’■Psychoeducation■ ‘The late effects’
What do the medics need to manage Eating Disorders?
• A&E, Paediatric Ward access, Adolescent policy• Access to specialties:
– Gastroenterology & Dietetics– HDU/ITU– Endocrinology– Neurology– Cardiology– Radiology– CAMHS/Liaison Psychiatry 24/7
• Pathways, Guidelines, Protocols• Time: Clinics/Admin/Discussion and Advice• Trained nursing staff• Support from the kitchens• Supportive Colleagues/OOH policy
The barriers• Cultural: ‘Not on my ward’• Lack of familiarity and training
– Nursing– Medical– Dietetic
• Access to specialist eating disorders expertise/national shortage of in-patient CAMHS
• Access to HDU/ITU• Access to
gastroenterology/endocrinology/cardiology/radiology• Pressure to discharge
Outpatients Inpatient CAMHS (Snowsfield) - teenagers
Inpatient CAMHS (Acorn Lodge) - children
Follow Up Clinic
Intensive therapy Programme (Day
Hospital
New Patient Clinic
Paediatric Ward
Assessment
Kings
SLaM
Medical PathwayPrinciples• Paediatrician in the
initial assessment• Clear risk assessment
pathway (in and outpatient)
• Specialist Eating Disorders input for medical patients
• Regular follow up medical clinics
TriageHeightWeight%mBMI* BPTempPulseBlood sugar
ECGGas Machine Electrolytes
Medical Assessment
Red Criteria Amber Criteria Green/Blue Criteria
Stabilize, NGT if refusing meal plan INVOLVE PSYCHIATRY
Will tolerate meal plan?AND
LOW/MODERATE RISK OF REFEEDING SYNDROME (see REFEEDING RISK ASSESSMENT chart)
Allow Home with meal plan with Eating Disorders Team follow up
Discuss with Eating Disorders Team/ Liaison PsychiatryADMIT
NO
YES
* BMI = height in metres x (weight in kg)2
%mBMI = (actual BMI/50th Centile BMI) x 100 [see chart for 50th Centile BMI Values]
exclude medical causes of cachexia
Using RISK ASSESSMENT FRAMEWORK FOR YOUNG PEOPLE WITH EATING DISORDERS
Medical Risk Assessment of Young People with Eating
Disorders in the Emergency Department
Physical risk assessment for King’s Emergency
Department
BEDREST (consider RMN)
Rewarm
Correct Electrolyte Abnormalities
Cardiac Monitor (if prolonged QTc)
EARLY REINTRODUCTION OF NUTRITION
(meal plan or NGT)
DAY 1: 1200KCAL/24H
DAY 2: 1500KCAL/24H
DAY 3: 1750 KCAL/24H
DAY 4: 2000 KCAL/24H
DAY 5: 2250 KCAL/24H
DAY 6: 2500 KCAL/D
Involve Child and Adolescent Eating Disorders Team early to plan transfer
IN HOURS: 020 32282545
OUT OF HOURS: Child & Adolescent Psychiatry On-Call
Initial InvestigationsFBC/Ferritin/filmU&E/LFT/Bone/MgGlucose (if hypoglycaemia <2.6mmol/L, also plasma Betahydroxybutyrate/Nonesterified fatty acids/Cortisol/Insulin/CPeptide/Acyl carnitines/urine organic acids, ketones (dipstick)B12/Folate/Vitamin DChloride/Bicarbonate/Potassium if history of vomitingAmylase/lipids if history of vomiting/abdominal painTFTIf amenorrhoea present: Prolactin, FSH, LH, Estradiol, AFP, BHCGCoeliac Screen12 Lead ECG: clear documentation of the corrected QT is essential (QT/√RR): note that a prolonged QTc can be associated with cardiac arrhythmia. It is sex-dependent. (See Appendix 1 for criteria)
MO
NIT
OR
GLU
CO
SE
, U
&E
, M
AG
NE
SIU
M,
PH
OS
PH
AT
E d
aily
NOTE: 80% of hypophosphataemia
occurs by Day 4
Medicines
phosphate sandoz 500mg bd (32mmol/d)
vitamin B complex strong (contains B1 [thiamine] and B2 [riboflavin], nicotinamide, B6 [pyridoxine)])
2 tablets TDS
or if liquid used (Vigranon B)
age: 1-12y 10ml TDS
12-18y 15ml TDS
multivitamin. (sanatogen or forceval one tab od)
NB: if strong suspicion of thiamine deficiency
Use Pabrinex instead of Vitamin B complex
Vial 1 (contains B1 [thiamine] 250mg and B2 [riboflavin] 4mg, B6 [pyridoxine) 50mg])
Vial 2 (contains C [ascorbic acid] 500mg, nicotinamide 160mg, Glucose 2000mg)
ADULT DOSE: 10ml of each ampoule diluted with 50-100ml of (0.9% saline or 5% dextrose) given over 30 mins
CHILD DOSE:
6 - 10 years 1/3 of the adult dose
10 - 14 years 1/2 to 2/3 of the adult dose
14 years and over as for the adult dose
Avoid treating hypoglycaemia with hypostop unless symptomatic or nonketoticPhysical risk assessment for King’s In
Patients
Case HistoryInvolved professionals Gastroenterology
(Consultant, Dietician, Psychologist)
Gastroenterology ward at KCH
Gastroenterology ward at Private Hospital
Local hospital general paediatric team
Child & Adolescent Eating Disorders Team
Local CAMHS Specialist Inpatient CAMHS
What can the Paediatrician do?
Good at talking to children, young people and families
The voice of ‘objectivity’
The voice of concern Negotiate change
Medicalise and stabilise
‘Psychoeducation’