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Assessment and Management of Eating Disorders – Adult/Pediatric – Inpatient

Assessment and Management of Eating Disorders – Adult/Pediatric – Inpatient - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nutrition




1

Assessment and Management of Eating
Disorders – Adult/Pediatric – Inpatient
Clinical Practice Guideline
Table of Contents
EXECUTIVE SUMMARY ........................................................................................................... 3
SCOPE ...................................................................................................................................... 4
METHODOLOGY ...................................................................................................................... 5
DEFINITIONS ............................................................................................................................ 5
INTRODUCTION ....................................................................................................................... 7
RECOMMENDATIONS .............................................................................................................. 7
Admission.......................................................................................................................... 7
Initial Discussion of Treatment Plan with the Patient ......................................................... 9
Health Care Team Communication...................................................................................10
Vital Signs and Patient Monitoring ....................................................................................10
Activity and Supervision ...................................................................................................11
Fluids and Medications .....................................................................................................11
Laboratory Tests and Tests ..............................................................................................12
Nutrition: Meal Planning ...................................................................................................13
Nutrition: Meal and Snack Time Procedures .....................................................................13
Discharge Planning and Criteria .......................................................................................15
UW HEALTH IMPLEMENTATION ............................................................................................16
APPENDIX A. RATING SCHEMES FOR THE STRENGTH OF THE
EVIDENCE/RECOMMENDATIONS ..........................................................................................17
REFERENCES .........................................................................................................................18
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2
Contact for Content:
Name: Kristin Shadman, MD, FAAP- Pediatrics- Hospitalists
Phone Number: (608) 265-8561
Email Address: kshadman@pediatrics.wisc.edu

Name: Heather Peto, MD- Medicine- Hospitalists
Phone Number: (608) 262-2434
Email Address: hpeto@medicine.wisc.edu

Contact for Changes:
Name: Lindsey Spencer, MS- Center for Clinical Knowledge Management (CCKM)
Email Address: lspencer2@uwhealth.org

Coordinating Team Members:
Paula Cody, MD, MPH- Adolescent Medicine
Mary Ehlenbach, MD- Pediatrics- Hospitalists
William Taft, MD- Psychiatry-General
Michael Peterson, MD. PhD- Psychiatry- General
Burr Eichelman, MD, PhD- Psychiatry
M. Denise Connelly- Rehabilitation- Health Psychology
Rebecca Mogensen, RN, MS, ACNP-BC, APNP- Medicine- Hospitalists
Deborah Dalsing, RN- Nursing- Acute Medicine (D6/5)
Shelly VanDenBergh, CNS- Nursing- General Medicine (D4/4)
Clara (Katie) Winsor, RN- Nursing- General Medical Unit (D4/4)
Windy Smith, RN- Pediatric General Medicine Unit (P5)
Rachel Parks, MS, RD, CNSC, CSSD- Clinical Nutrition
Laura Bodine, MS, RD, CNSC, CD- Clinical Nutrition
Kathleen Golos, MS, RD, CNSC- Clinical Nutrition
Joanna Otis, MS, RD, CD- Clinical Nutrition
Robin Welcher, MS, RD, CNSC- Clinical Nutrition
6HDQ�2¶+DUD- Culinary Services
Norman Fost- SMPH Medical History and Bioethics
Jennifer Grice, PharmD, BCPS- Center for Clinical Knowledge Management (CCKM)

Review Individuals/Bodies:
Teresa Darcy, MD- Pathology- General
Sarah Hackenmueller, PhD- Pathology- Lab Medicine
Lynnda Zibell-Milsap, CNS- Nursing- Practice Innovation
Julie Henige- Nursing- Coordinated Care
Sommer Gromowski- Nursing- Coordinated Care
Lindsey DuBenske- Nursing- Coordinated Care
Julie Lechelt- Nursing- Coordinated Care
Cindy Gaston, PharmD, BCPS- Drug Policy Program
Susan Luskin, PharmD- Pharmacy- Inpatient Services
Caitlin Curtis, PharmD- Pharmacy- Inpatient Services

Committee Approvals/Dates:
Nutrition Committee (October 2015)
Clinical Knowledge Management (CKM) Council (Last Periodic Review: 11/19/2015)
ξ Interim revisions: 09/22/2016

Release Date: September 2016 | Next Review Date: November 2017

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3
Executive Summary
Guideline Overview
This guideline provides recommendations for the inpatient management of pediatric/adolescent
and adult patients with an eating disorder.

Key Revisions (2016 Interim Update)
1. Modified name of nutrition supplement due to formulary change.
2. Added additional meal plans to the calorie progression appendix.

Key Practice Recommendations
1. It is recommended that patients who meet at least one of the following admission criteria
(Table 1) are admitted for inpatient care.1-4 (UW Health Low quality evidence, weak
recommendation)
2. It is recommended to present the treatment plan matter-of-factly without offering options--
WKLV�VKRXOG�EH�D�³WDNH-it-or-leave-LW´�DSSURDFK��,Q�JHQHUDO��DYRLG�WULJJHU�ZRUGV�VXFK�DV�³IRRG´��
³FDORULHV´�DQG�³ZHLJKW�´��,QVWHDG��UHIHU�WR�WKH�WUHDWPHQW�LQ�PHGLFDO�WHUPV�VXFK�DV�³PHGLFLQH´��
³QRXULVKPHQW´��RU�³HQHUJ\�
3. Multidisciplinary meeting should be held within 24-48 hours after admission with
representation from resident team, attending hospitalist plus supporting Eating Disorders
(EDO) team. Involve patients and their families in care planning.
4. All patients should have their vital signs measured every 4 hours.5,6 This interval may be
increased to every 8 hours if the patient is stable for 3 days. (UW Health Very low quality
evidence, strong recommendation) Orthostatic vitals should be measured daily (preferably in
the morning) while lying down, sitting, as well as standing. Patients should be lying or
standing for 3 minutes prior to taking vital signs.7 (UW Health Very low quality evidence, strong
recommendation)
5. Continuous monitoring of cardiac rhythm/telemetry should be completed (including when the
patient is outside of their room), until all ECG and electrolyte abnormalities are resolved for
24 hours. Assessments of neurological status should also be completed every 4 hours (or
every 8 hours if appropriate as determined by the medical team). (UW Health Very low quality
evidence, strong recommendation)
6. Weight measurements should be obtained daily in the morning, post-void and prior to eating
or drinking anything.6 Weight should not be discussed with the patient.
7. Patients should be placed on bed rest restriction; however it is acceptable for the patient to
walk to and from the bathroom.6 (UW Health Very low quality evidence, weak recommendation)
8. Patients with eating disorders need continuous supervision for safety and compliance.8,9
(UW Health Low quality evidence, strong recommendation)
9. The primary goal of medical hospitalization for an eating disorder is to safely restore
physiological stability through nutritional rehabilitation.4,10 For the refeeding process, patients
should be started on a meal plan based on the current severity of malnutrition and recent
caloric intake.11,12 (UW Health Low quality evidence, weak recommendation) Meals should be
planned by Clinical Nutrition and patients should not be allowed to order their own
meals.13 (UW Health Low quality evidence, strong recommendation)
10. Weight should never be used as the sole criterion for discharge from inpatient care. (APA
Class I) Patients should not be discharged until they meet at least one of the following
discharge criteria7,8 (Table 2) and have a discharge plan in place (i.e., discharge to referral
inpatient facility vs. outpatient follow-up).

Companion Documents
1. Quick Guide for Inpatient Management of Patients with an Eating Disorder
2. Personal Food Preferences Worksheet
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4
3. After-Hours Meals (for RN reference if patient admitted in evening)
4. &DORULH�3URJUHVVLRQ�³%HOO�Meal Replacement *XLGHOLQHV´
5. Discharge Meal Planning Guide
6. FAQs During Admissions for Medical Stabilization of an Eating Disorder
7. UW Health Concentrated Intravenous Electrolytes ± Adult ± Inpatient Clinical Practice
Guideline
8. UW Health Use of Oral and Enteral Electrolytes ± Adult ± Inpatient Clinical Practice
Guideline




Scope
Disease/Condition(s): Eating Disorders, which include but are not limited to:
ξ Anorexia Nervosa,
ξ Avoidance/Restrictive Food Intake Disorder,
ξ Bulimia Nervosa,
ξ Binge Eating Disorder, and
ξ Other Specified Feeding and Eating Disorder (OSFED)

Clinical Specialty: Family Medicine, Internal Medicine, Pediatrics, Psychiatry, Psychology,
Clinical Nutrition, Nursing

Intended Users: Physicians, Advance Practice Providers, Dietitians, Psychiatrists and
Psychologists, Nursing

CPG objective(s):
To provide evidence-based recommendations to health care professionals responsible for the
management of patients with eating disorders acutely admitted to the hospital for medical
stabilization.

Target Population:
Pediatric patients (approximately 8 years or older) and adult patients (18 years or older) who are
in a medically unstable condition secondary to an eating disorder.

Interventions and Practices Considered:
1. Nutritional rehabilitation
2. Vitamin and electrolyte supplementation

Major Outcomes Considered:
1. Patient compliance with plan of care
2. Physical/pubertal development
3. Body mass index (BMI)
4. Restoration of healthy diet
5. Psychosocial and interpersonal functioning




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5
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches were conducted by CCKM and other workgroup members to
collect evidence for review. Expert opinion and clinical experience were also considered during
discussions of evidence.

Methods Used to Formulate the Recommendations:
The interdisciplinary workgroup agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussions of the literature evidence and
expert experiences. Recommendations developed by the workgroup were reviewed and
approved by appropriate UW Health committees prior to full endorsement and implementation of
the recommendations.

Methods Used to Assess the Quality and Strength of the Evidence/Recommendations:
Recommendations developed by an external organization maintained the evidence grade(s)
assigned within the source document and were adopted for use at UW Health.
Recommendations which were developed internally using primary literature evidence during the
workgroup meetings were evaluated using the Grading of Recommendations Assessment,
Development and Evaluation (GRADE) algorithm (see Figure 1 within Appendix A).

Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the various rating schemes used within this document.
Definitions
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and Statistical Manual of Mental Disorders, fifth edition (DSM-5)14:

Anorexia Nervosa is defined as:
ξ Restriction of energy intake relative to requirements leading to a significantly low body
weight in the context of age, sex, developmental trajectory, and physical health.
ξ Either an intense fear of gaining weight or of becoming fat, or persistent behavior that
interferes with weight gain (even though significantly low weight).
ξ Disturbance in the way in which one's body weight or shape is experienced, undue
influence of body weight or shape on self-evaluation, or denial of the seriousness of the
current low body weight.

Bulimia Nervosa is defined as:
ξ Recurrent episodes of binge eating characterized by BOTH of the following:
1. Eating in a discrete amount of time (within a 2 hour period) large amounts of food.
2. Sense of lack of control over eating during an episode.
ξ Recurrent inappropriate compensatory behavior in order to prevent weight gain (purging).
ξ The binge eating and compensatory behaviors both occur, on average, at least once a
week for three months.
ξ Self-evaluation is unduly influenced by body shape and weight.
ξ The disturbance does not occur exclusively during episodes of anorexia nervosa.

Binge eating disorder is defined as:
ξ Recurrent episodes of binge eating. An episode of binge eating is characterized by both of
the following:
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6
A. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of
food that is definitely larger than what most people would eat in a similar period
of time under similar circumstances.
B. A sense of lack of control over eating during the episode (e.g., a feeling that one
cannot stop eating or control what or how much one is eating).
ξ The binge-eating episodes are associated with three (or more) of the following:
A. Eating much more rapidly than normal.
B. Eating until feeling uncomfortably full.
C. Eating large amounts of food when not feeling physically hungry.
D. Eating alone because of feeling embarrassed by how much one is eating.
E. Feeling disgusted with oneself, depressed, or very guilty afterward.
ξ Marked distress regarding binge eating is present.
ξ The binge eating occurs, on average, at least once a week for 3 months.
ξ The binge eating is not associated with the recurrent use of inappropriate compensatory
behavior as in bulimia nervosa and does not occur exclusively during the course of
bulimia nervosa or anorexia nervosa.

Avoidant/Restrictive Food Intake Disorder is defined as:
ξ An eating or feeding disturbance (e.g., apparent lack of interest in eating or food;
avoidance based on the sensory characteristics of food; concern about aversive
consequences of eating) as manifested by persistent failure to meet appropriate
nutritional and/or energy needs associated with one (or more) of the following:
A. Significant weight loss (or failure to achieve expected weight gain or faltering
growth in children).
B. Significant nutritional deficiency.
C. Dependence on enteral feeding or oral nutritional supplements.
D. Marked interference with psychosocial functioning.
ξ The disturbance is not better explained by lack of available food or by an associated
culturally sanctioned practice.
ξ The eating disturbance does not occur exclusively during the course of anorexia nervosa
RU�EXOLPLD�QHUYRVD��DQG�WKHUH�LV�QR�HYLGHQFH�RI�D�GLVWXUEDQFH�LQ�WKH�ZD\�LQ�ZKLFK�RQH¶V�
body weight or shape is experienced.
ξ The eating disturbance is not attributable to a concurrent medical condition or not better
explained by another mental disorder. When the eating disturbance occurs in the
context of another condition or disorder, the severity of the eating disturbance exceeds
that routinely associated with the condition or disorder and warrants additional clinical
attention.

Other Specified Feeding and Eating Disorder is defined as:
ξ Presentations in which symptoms characteristic of a feeding and eating disorder that
cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning predominate but do not meet the full criteria for any of the
disorders in the feeding and eating disorders diagnostic class.
ξ The other specified feeding or eating disorder category is used in situations in which the
clinician chooses to communicate the specific reason that the presentation does not
meet the criteria for any specific feeding and eating disorder. This is done by recording
³RWKHU�VSHFLILHG�IHHGLQJ�RU�HDWLQJ�GLVRUGHU´�IROORZHG�E\�WKH�VSHFLILF�UHDVRQ��H�J���³EXOLPLD�
QHUYRVD�RI�ORZ�IUHTXHQF\´��
ξ ([DPSOHV�RI�SUHVHQWDWLRQV�WKDW�FDQ�EH�VSHFLILHG�XVLQJ�WKH�³RWKHU�VSHFLILHG´�GHVLJQDWLRQ�
include the following:
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7
A. Atypical anorexia nervosa: All of the criteria for anorexia nervosa are met, except
WKDW�GHVSLWH�VLJQLILFDQW�ZHLJKW�ORVV��WKH�LQGLYLGXDO¶V�ZHLJKW�LV�ZLWKLQ�RU�DERYH�WKH�
normal range.
B. Bulimia nervosa (of low frequency and/or limited duration): All of the criteria for
bulimia nervosa are met, except that the binge eating and inappropriate
compensatory behaviors occur, on average, less than once a week and/or for less
than 3 months.
C. Binge-eating disorder (of low frequency and/or limited duration): All of the
criteria for binge-eating disorder are met, except that the binge eating occurs, on
average, less than once a week and/or for less than 3 months.
D. Purging disorder: Recurrent purging behavior to influence weight or shape (e.g.,
self-induced vomiting; misuse of laxatives, diuretics, or other medications) in the
absence of binge eating.
E. Night eating syndrome: Recurrent episodes of night eating, as manifested by
eating after awakening from sleep or by excessive food consumption after the
evening meal. There is awareness and recall of the eating. The night eating is not
EHWWHU�H[SODLQHG�E\�H[WHUQDO�LQIOXHQFHV�VXFK�DV�FKDQJHV�LQ�WKH�LQGLYLGXDO¶V�VOHHS-
wake cycle or by local social norms. The night eating causes significant distress
and/or impairment in functioning. The disordered pattern of eating is not better
explained by binge-eating disorder or another mental disorder, including substance
use, and is not attributable to another medical disorder or to an effect of medication.
Introduction
Eating disorders are complex illnesses that are affecting adolescent and adult patients with
increasing frequency. Unique features of adolescents and the developmental process of
adolescence are critical considerations in determining the diagnosis, treatment, and outcome of
eating disorders in this age group. Patients experiencing serious medical compromise often
require hospitalization; however, significant variability in admission criteria and inpatient
management exist across North America.15 This clinical practice guideline works to outline an
evidence-based approach for the inpatient management of UW Health patients with an eating
disorder.
Recommendations
Admission
It is recommended that patients who meet at least one of the following admission criteria (Table
1) are admitted for inpatient care.1-4 (UW Health Low quality evidence, weak recommendation)

Patients may be admitted for medical stabilization of an eating disorder; however, the patient is
EHLQJ�DGPLWWHG�IRU�DQ�³DFXWH�H[DFHUEDWLRQ´�RI�D�³FKURQLF�GLVHDVH´��7KHUHIRUH��WKH�DGPLWting
diagnosis should be accompanied by a description of the acute symptoms/exacerbation (i.e.,
bradycardia, severe weight loss). Another example is admitting a patient with cystic fibrosis for
³CF bronchopulmonary exacerbation” not just “cystic fibrosis”.

Data suggest hospitalization on units which specialize in the care and treatment of patients with
an eating disorder produce better outcomes than hospitalization across general medical
units.4,16 (APA Class II) Whenever possible, adult patients (18 years and older) who are admitted
with eating disorders should be admitted to the Hospitalist 3 service and assigned to the D4/4
unit. Pediatric patients (17 years or younger) should be admitted to the Pediatric Hospitalist
service and assigned to the P5 unit.
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8
Table 1. Admission Criteria for Inpatient Treatment
Medical Indications for Inpatient Treatment
Weight14
< 75% IBW/EBW (Approximate BMI < 15.99 in adults)
Rapid Weight Loss (i.e., > 10 lbs. in 2 wks.)
Arrested growth and development
Temperature Hypothermia (< 96.0°F or 35.6°C)
Cardiovascular7
Heart rate < 50 bpm (daytime) or < 45 bpm (nighttime)
Orthostatic blood pressure measurements that feature a decrease in systolic blood
pressure of > 20 mmHg OR decrease in diastolic blood pressure of > 10 mmHg OR
increase in heart rate of > 20 bpm.
Arrhythmia
Chest Pain
Lab Values17

Clinically significant abnormal lab values for the following:
Electrolytes:
ξ Sodium
ξ Potassium
ξ Chloride
ξ Magnesium
ξ Calcium
ξ Phosphorus

Malnutrition indicators:
ξ Blood Urea Nitrogen
ξ Creatinine
ξ Glucose
ξ Albumin

Anemia evaluation (Complete Blood Count):
ξ Red Blood Cell count
ξ Hemoglobin
ξ Hematocrit




For Females only (order serum labs only if in
amenorrhea):
ξ Follicle-stimulating Hormone
ξ Luteinizing Hormone
ξ Prolactin
ξ Urine Beta- HCG
Additional
Symptoms
Acute medical complications (e.g., syncope, seizures, cardiac failure, esophageal tears,
etc.)

Acute food refusal

Uncontrollable bingeing and purging
Failure of ambulatory/outpatient therapy

Calculation of the Body Mass Index (BMI) for pediatric and adult patients:
���,GHQWLI\�WKH�SDWLHQW¶V�KHLJKW��PHWHUV��P��DQG�ZHLJKW��NLORJUDPV��NJ���
���&DOFXODWH�WKH�SDWLHQW¶V�ERG\�PDVV�LQGH[��%0,��YLD�WKH�IROORZLQJ�HTXDWLRQ��
BMI = Weight / (Height)2

Calculation of Ideal Body Weight (IBW) for adult patients:
For Males:
1. IdenWLI\�WKH�SDWLHQW¶V�KHLJKW��LQFKHV��LQ���
2. For the first 60 inches, or 5 feet, establish 106lbs for the IBW.
3. Add 6 lbs. to 106 lbs. for every inch greater than 5 feet.

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9
For Females:
���,GHQWLI\�WKH�SDWLHQW¶V�KHLJKW��LQFKHV��LQ���
2. For the first 60 inches, or 5 feet, establish 100 lbs. for the IBW.
3. Add 5 lbs. to 100 lbs. for every inch greater than 5 feet.

Calculation of Expected Body Weight (EBW) via the BMI method for pediatric patients:
���,GHQWLI\�WKH�SDWLHQW¶V�KHLJKW��PHWHUV��P��DQG�ZHLJKt (kilograms, kg).
2. Identify the median (50th percentile) BMI for the patient using the appropriate CDC BMI-for-
Age Growth Chart (by gender and age).
3. Calculate the EBW or body weight needed for the patient to achieve a BMI-for-age at the 50th
percentile using the following equation:
EBW (kg) = median BMI-for-age (kg/m2) x (Height, m)2
���7R�REWDLQ�WKH��(%:��FRPSDUH�WKH�SDWLHQW¶V�DFWXDO�ERG\�ZHLJKW��$%:��WR�WKH�FDOFXODWHG�(%:�
using the following equation:
%EBW = ABW/EBW × 100

Initial Discussion of Treatment Plan with the Patient
Most children and adults with eating disorders are rule-followers and will respond to quiet, firm
and kind limit-setting. Therefore, it is recommended to present the treatment plan matter-of-
factly without offering options--this should be a ³take-it-or-leave-it´ approach. Allow the patient
to understand how the treatment of their condition will proceed from the outset. Clear
presentation of the plan will avoid bargaining and dissent when he/she arrives to the floor.

,Q�JHQHUDO��DYRLG�WULJJHU�ZRUGV�VXFK�DV�³IRRG´��³FDORULHV´�DQG�³ZHLJKW�´��,QVWHDG��UHIHU�WR�WKH�
treatment in medical terms such as ³PHGLFLQH´��QRXULVKPHQW´, RU�³HQHUJ\�´�The patient will
receive energy in order to keep their body safe and provide what the heart and vital organs
QHHG�LQ�RUGHU�WR�SHUIRUP�EDVLF�IXQFWLRQV���7KH�ZRUG�³QXWULWLRQ´�PD\�EH�XVHG�DIWHU�WKH�SURYLGHU�
KDV�LQWURGXFHG�WR�WKH�SDWLHQW�WKH�LGHD�WKDW�³QXWULWLRQ´�LV�WKH�³treatment needed to make the body
VDIH�´

Emergent Behavioral Situations
It is important to follow good general de-escalation strategies:
ξ Have any people who are targets for the crisis behavior step out of the room.
ξ Keep as few staff as possible in the room, but keep enough to provide for safety.
ξ Do not engage in bargaining or argument.
ξ Use simple, declarative statements to tell the patient what to do with their body to stay
safe.
ξ If there is agitation, consider calling Security right away. They are unlikely to put hands
RQ�WKH�SDWLHQW�EXW�FDQ�EH�D�FDOPLQJ�³VKRZ�RI�IRUFH´�ZKRVH�SUHVHQFH�FDQ�UHPLQG�WKH�
patient to be civil.

For pediatric patients:
Feel free to page Child Psychiatry at any time for advice. There is someone in the hospital
about half of the time. If after hours, page the psychiatry resident on call.
The Nurse/Resident can contact the UW Main Hospital Adult Psychiatry Unit for other support or
guidance as necessary.
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For adult patients:
Unlike other medical disorders, patients with an eating disorder require providers to kindly,
quietly, but firmly assume control. It is important not to negotiate. Providers should express
FRQFHUQ�IRU�WKH�SDWLHQW¶V�ZHOO-being and use simple, declarative statements to tell the patient
what they need to do in order to stay safe. If done in a kind, caring manner, and in the context of
a trusting relationship, patients have later reflected that the action was perceived as care and
help rather than compulsion or coercion.6,18,19 (UW Health Moderate quality evidence, weak
recommendation)

Adult providers often express concerns regarding patient right of refusal in eating disorders.
Patients with an eating disorder demonstrate impaired judgment in this area of their lives, even
though they may demonstrate capacity in areas not influenced by obsession with food and/or
body weight.20,21 Decision-making regarding capacity is a complex process in patients with
eating disorders. If questions arise regarding decisional capacity, providers may request
assistance from the Psychiatry consultation service or page the Ethics provider on-call. (UW
Health Moderate quality of evidence, weak recommendation)

It is suggested to have a plan to consult Psychiatry BEFORE it comes to an emergent or against
medical advice (AMA) discharge situation. Do NOT rely solely on Psychiatry as an emergency
backup. If patients are threatening to leave AMA, providers may call or page Psychiatry (Adult
Psychiatry: pager 0079). Questions regarding whether to implement emergency detention may
be directed to Psychiatry. For questions regarding whether to implement the emergency
detention plan before Psychiatry arrives, refer to the hospital Emergency Detention Policy.
Clinicians are able to request physical detention of a patient when they lack decisional capacity
DQG�WKHLU�PHGLFDO�FRQGLWLRQ�SRVHV�DQ�LPPLQHQW�ULVN��H�J���³PHGLFDO�KROG´���6HFXULW\�DQG�WKH�
Behavioral Response Team may be able to assist with physically holding a patient sufficiently
long to have the patient evaluated for their decisional capacity and medical condition.
Health Care Team Communication
For procedural information, see Quick Guide for Inpatient Management.

The assessment and treatment of patients with an eating disorder should be interdisciplinary
and is best accomplished by a team consisting of medical, nursing, nutritional, and mental
health providers.2,4,22 Multidisciplinary meeting should be held within 24-48 hours after
admission with representation from resident team, attending hospitalist plus supporting EDO
team (staff nurse, clinical nurse specialist, nurse manager, psychiatry, health psychology, case
management, social work, nurse practitioner or physician assistant, adolescent medicine and
clinical nutrition).
Vital Signs and Patient Monitoring
All patients should have their vital signs measured every 4 hours.5,6 This interval may be
increased to every 8 hours if the patient is stable for 3 days. (UW Health Very low quality evidence,
strong recommendation) Orthostatic vitals should be measured daily (preferably in the morning)
while lying down, sitting, as well as standing. Patients should be lying or standing for 3 minutes
prior to taking vital signs.7 (UW Health Very low quality evidence, strong recommendation)

Refeeding syndrome is of particular concern in patients with an eating disorder and can occur in
severely malnourished patients who receive nutritional replenishment too rapidly. When fed too
quickly, patients can exhibit cardiovascular, neurological, and hematological complications.
These complications arise as a result of electrolyte abnormalities (e.g., shifts from extracellular
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11
to intracellular spaces in patients who have total body depletion) caused by malnutrition.11,23,24
Therefore, continuous monitoring of cardiac rhythm/telemetry should be completed (including
when the patient is outside of their room), until all ECG and electrolyte abnormalities are
resolved for 24 hours. Assessments of neurological status should also be completed every 4
hours (or every 8 hours if appropriate as determined by the medical team). (UW Health Very low
quality evidence, strong recommendation)

Height should be measured on admission (or monthly if prolonged inpatient stay).
Weight measurements should be obtained daily in the morning, post-void and prior to eating or
drinking anything.6 Patients should be dressed in a hospital gown and underwear (no bra) with
dry hair (i.e., before showering). All measurements should be obtained with the patient facing
away from the scale. Weight should not be discussed with the patient.
Activity and Supervision
For procedural information, see Quick Guide for Inpatient Management.

Patients should be placed on bed rest restriction; however it is acceptable for the patient to walk
to and from the bathroom.6 (UW Health Very low quality evidence, weak recommendation) Patients
may be allowed sit in up in bed, but not in a chair. Due to the risk of falling, patients who request
to attend hospital activities outside of their room should be escorted in a wheelchair pending the
approval of the attending physician. (UW Health Very low quality evidence, weak recommendation)

Patients with eating disorders need continuous supervision for safety and compliance.8,9 (UW
Health Low quality evidence, strong recommendation) If there is a concern for self harm or suicidal
behavior, an order for additional suicide precautions (Suicide Precautions- Non-Psychiatry) can
be ordered, and safety should be fully assessed. Minimum supervision may be considered after
2-3 days of weight gain or after 1 week. Under minimum supervision, the patient should have a
staff member present at all meal times, one hour after meals and snacks, as well as during
bathroom/shower use. Family members or friends should NOT be permitted to substitute for
staff providing constant observation under any circumstances.

It is recommended to implement precautions for purging behavior including removing all loose
trash cans from the room, and providing supervision during use of the bathroom and shower.
(UW Health Very low quality evidence, strong recommendation) The bathroom door should be open
at all times when the patient is using the bathroom or shower. This should be done to ensure
that the patient does not drink extra water while in the bathroom or purge their food. One 5-
minute shower per day may be allowed when electrolytes and cardiovascular system are stable.
Patients should not be allowed bathroom privileges for 1 hour after a meal or snack OR the
patient may have supervised use of the bathroom to ensure no purging behavior is completed.
Fluids and Medications
Patients who are dehydrated upon admission may receive intravenous fluid. Pediatric patients
may receive a bolus of normal saline 10-20 mL/kg. Adult patients may receive 500 mL aliquots
of normal saline, with reassessment as needed due to possibility of precipitating heart failure.
(UW Health Moderate quality evidence, strong recommendation)

In/Outs should be strictly measured every 4 hours.
Total Fluid Order: IV + PO = maintenance (minimum) to 1.5x maintenance (maximum),
as calculated by the Holliday-Segar Method for pediatric and adult patients.25
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12
Maintenance fluids should be administered as part of meals. Clinical Nutrition should
specify in the diet order the amount of additional water that the patient may have from
Nursing. Ideally, all fluids should be provided orally.

Table 2. Holliday-Segar Method for Calculating Fluid Requirements
Holliday-Segar Method Holliday-Segar Estimate
First 10 kg 100 mL/kg/day 4 mL/kg/hr
10-20 kg 1000 mL + 50 mL/kg for each kg above 10 kg 2 mL/kg/hr
> 20 kg 1500 mL + 20 mL/kg for each kg above 20 kg 1 mL/kg/hr

It is recommended to continue all home medications during hospitalization. However,
stimulant medications (i.e., Ritalin or Adderall) should be discontinued. Electrolyte or
vitamin supplementation may be appropriate based upon laboratory values obtained at
or during admission.4,12,26 (APA Class I) Dosing information for electrolyte supplementation
can be found within the UW Health Electrolyte ± Inpatient Guidelines.

Bowel motility agents (such as senna-docusate) or fiber supplements should be
avoided. (UW Health Very low quality evidence, strong recommendation) Patients who require
bowel management medications for constipation may be given polyethylene glycol. (UW
Health Very low quality evidence, weak recommendation)

Table 3. Recommended Electrolyte/Vitamin Supplementation and Bowel Motility Agents
Laboratory Tests and Tests4-6,10,17,26,27
Upon admission it is recommended to obtain the following labs and tests (UW Health Low
quality evidence, weak recommendation):
ξ Electrocardiogram (EKG)
ξ Serum labs: CBC without differential, CMP (sodium, potassium, chloride, total
carbon dioxide, anion gap, glucose, BUN, creatinine, calcium, albumin, total
protein, total bilirubin, AST, ALT, alkaline phosphatase), magnesium, phosphate.
ξ Urine labs: UA with urine specific gravity; urine drug screen.
ξ For Females only: Urine Beta-HCG; serum labs for FSH, LH, and protein only in
presence of amenorrhea.

Subsequently, electrolytes (sodium, potassium, chloride, total carbon dioxide),
magnesium, and phosphate labs should be measured every 12 hours for 3 days. (UW
Health Low quality evidence, weak recommendation) Daily labs are recommended starting at
Day 4 of treatment. Once the patient achieves goal calorie intake, or maintains stable
electrolyte levels, the frequency of labs to monitor for refeeding syndrome may be
decreased or discontinued. Urine specific gravity labs may be ordered as needed to
Suggested Medications Recommended Dose-
Pediatric
Recommended Dose-
Adults
Multivitamin 1 tablet/day 1 tablet/day
Thiamine ---- 100 mg/day
Polyethylene glycol 17 g 17 g
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13
help ascertain the extent to which the measured weight reflects excessive water intake.4
(APA Class I)
Nutrition: Meal Planning
The primary goal of medical hospitalization for an eating disorder is to safely restore
physiological stability through nutritional rehabilitation.4,10 For the refeeding process,
patients should be started on a meal plan based on the current severity of malnutrition
and recent caloric intake.11,12 (UW Health Low quality evidence, weak recommendation) Meals
should be planned by Clinical Nutrition and patients should not be allowed to order
their own meals.13 (UW Health Low quality evidence, strong recommendation)

It is recommended that Clinical Nutrition meet with the patient within 24 hours of
admission to assess nutritional status and discuss mealtime expectations.6 To capture
patient preferences, see Personal Food Preferences Worksheet.

Patients should start at a minimum of 800-1000 kcal/day, with calorie provision
increases by 200-400 kcal/day. Weight maintenance during the initial refeeding phase is
acceptable and may occur. The eventual goal is for the patient to gain a minimum of 0.8
kg per week.28 (UW Health Low quality evidence, weak recommendation) Patients should be
required to consume 100% of their provided meals and snacks before requesting extra
food. This request for additional food should be discussed with Clinical Nutrition and
should not exceed 200 calories in a 24-hour period during the refeeding stage.

Nutrition: Meal and Snack Time Procedures
For procedural information, see Quick Guide for Inpatient Management.

There is limited evidence to support a single most effective method of achieving weight
restoration during inpatient treatment.29 However, uniform, structured meal practices
have been shown to produce weight gain in patients admitted with eating disorders.30
(UW Health Low quality evidence, weak recommendation)

If a patient is admitted in the evening when Clinical Nutrition is unavailable, Nursing
should order one of the pre-planned meal options (Table 4). Patients may choose to
either eat the meal or drink one can of 1.5 kcal/mL oral nutritional supplement (e.g.,
Boost Plus, Ensure Plus). No snacks should be given until the patient is assessed by
Clinical Nutrition.








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14
Table 4. Admission Meals for Evenings/Weekends (all options provide 325-375 calories)
Breakfast
Standard Dairy Free Vegetarian

Breakfast Sandwich:
English muffin- 1 whole muffin
Scrambled egg- 1 whole egg
Cheddar cheese- 1 slice

Strawberries- 1 serving (4 oz.)

Breakfast Sandwich:
English muffin- 1 whole muffin
Scrambled egg- 1 whole egg
Turkey sausage- 1 patty

Strawberries- 1 serving (4 oz.)

Cheerios- 1 box
Skim milk (or soy milk)- 8 oz.

Dannon Fruit on the Bottom yogurt- 6 oz.

Strawberries- 1 serving (4 oz.)
Lunch/Dinner
Standard Dairy Free Vegetarian

Whole Sandwich:
Whole wheat bread- 2 slices
Roast turkey- 2 oz.
Cheddar cheese- 1 slice
Lettuce- 1 leaf
Tomato- 2 slices

Fresh fruit cup- 1 serving (4 oz.)

Whole Sandwich:
Whole wheat bread- 2 slices
Roast turkey- 2 oz.
Lettuce- 1 leaf
Tomato- 2 slices

Chicken noodle or tomato soup- 6 oz.
Saltines- 1 package

Fresh fruit cup- 1 serving (4 oz.)

Half Sandwich:
Whole wheat bread- 1 slice
Peanut butter- 1 tablespoon
Strawberry jam- 1 packet

Vegetable soup- 6 oz.
Saltines- 1 package

Fresh fruit cup- 1 serving (4 oz.)


Patient should receive 3 meals and 0-3 snacks per day, depending on calorie level.
Meals should be scheduled to arrive between 0800-0830, 1200-1230, 1700-1730.
Snacks should arrive between 1000-1030, 1500-1530, and 2000-2030. If a tray is late,
the RN should page Clinical Nutrition.

Patient should be required to eat 100% of the food on their tray within 30 minutes (for
meals) or 20 minutes (for snacks). Meals include calorie-containing beverages and
condiments. Water bottles should be required to be consumed prior to the arrival of the
next tray.

If the patient eats <100% of a meal or snack, then the patient should be offered a
specified volume of 1.5 kcal/mL oral nutritional supplement (e.g., Boost Plus, Ensure
Plus) (see Calorie Progression ³Bell Meal Replacement Guidelines´). The appropriate
portion should be poured into a separate cup for administration. The actual can of 1.5
kcal/mL oral nutritional supplement should not be given to the patient. If the patient is
unable or unwilling to drink the 1.5 kcal/mL oral nutritional supplement within 15
minutes, then (at first refusal) a nasogastric feeding tube (NG) will be placed and the 1.5
kcal/mL oral nutritional supplement will be given via NG tube bolus.4,10,23

If the patient refuses the NG tube, it is important to remind him/her that the NG tube is a
valuable part of a safe treatment plan for the condition since it may be challenging to eat
the full amoXQW�RI�QRXULVKPHQW�WKH�SDWLHQW¶V�KHDUW�DQG�ERG\�QHHGV��Providers should
emphasize that the NG tube will allow the patient to relax and receive the nourishment
safely, without worry or pressure. Providers should not negotiate and should NOT
convey the NG tube as punitive.
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15
Discharge Planning and Criteria
The overall goal of treatment in the inpatient and outpatient setting is to help the patient
achieve and maintain physical and psychological health. It is recommended that the
multidisciplinary team meet weekly (at a minimum) to set discharge goals. Per team
discretion, WKH�SDWLHQW¶V�family should be included as possible.

Weight should never be used as the sole criterion for discharge from inpatient care.
(APA Class I) Patients should not be discharged until they meet at least one of the
following discharge criteria7,8 (Table 5) and have a discharge plan in place (i.e.,
discharge to referral inpatient facility vs. outpatient follow-up).

If the patient is being discharged home, a discharge meal plan should be coordinated
between the patient and the dietitian (see Discharge Meal Planning Guide), and
exercise parameters should be provided by the provider to the patient at discharge.

Table 5. Discharge Criteria from Inpatient Treatment
Medical Indications for Discharge
Weight > 75% IBW OR weight stabilization
Temperature Normothermia for 24 hours
Cardiovascular*
Heart rate > 40 bpm OR stable heart rate per attending physician discretion
Resolution of EKG abnormalities
Resolution of orthostatic symptoms (e.g., dizziness, light-headedness, etc.)
Lab Values* Stable Labs
*Note: The following are REQUIRED 72 hours prior to discharge if the patient is transferring to a
referral inpatient facility (e.g., Rogers Memorial): EKG; CBC with differential, CMP (sodium, potassium,
chloride, total carbon dioxide, anion gap, glucose, BUN, creatinine, calcium, albumin, total protein, total
bilirubin, AST, ALT, alkaline phosphatase), magnesium, phosphate, Urine Pregnancy, Urinalysis with
Microscopy, TSH, Free T4, Urine Drug Screen Labs

Given the high rates of relapse, recurrence, crossover (i.e., change from anorexia
nervosa to bulimia nervosa) and comorbidity in patients with an eating disorder, smooth
transitions of care are important.4 Prior to discharge, necessary appointments should be
made with the following (APA Class I):
ξ Primary Care Provider
ξ Outpatient Registered Dietitian
ξ Eating Disorder MD- Adolescent Medicine OR Primary Care Doctor, per team
discretion
ξ Psychiatrist and/or Psychologist

(Note: Appointments are not necessary if the patient is transferring to another inpatient unit)

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16
UW Health Implementation
Potential Benefits:
ξ Stabilization of heart rate, blood pressure, electrolytes, etc.
ξ Weight gain

Potential Harms:
ξ Refeeding syndrome

Pertinent UW Health Policies & Procedures
1. UW Health Clinical Policy 1.2.1- Emergency Detention ± State Mental Health Act

Patient Resources
1. Health Information- Eating Disorders, Cultural and Social Factors
2. Health Information- Eating Disorders: Feeling Better About Yourself
3. Health Information- Eating Disorders: Malnutrition Tests
4. Health Information- Eating Disorders: Things That Put a Person at Risk

Guideline Metrics:
1. Staff satisfaction with virtual NA video monitoring, percentage of time virtual monitoring
switched to physical patient safety attendant
2. Average length of stay for patients with an eating disorder
3. Readmission rate
4. Number of pages to Clinical Nutrition
5. Number of PSN events filed related to meal time procedures

Implementation Plan/Clinical Tools
1. Guideline will be housed on U-Connect in a dedicated folder for CPGs.
2. Release of the guideline will be advertised in the Clinical Knowledge Management Corner
within the Best Practice newsletter.
3. Appropriate Health Link or equivalent tools will be reviewed, revised, or created to match the
guideline recommendations, including:
ξ IP ± Eating Disorders ± Pediatric ± Admission [5036] Order Set
ξ IP ± Eating Disorders ± Adult ± Admission [6075] Order Set

Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
LQWHQGHG�WR�UHSODFH�D�FOLQLFLDQ¶V�MXGJPHQW�RU�WR�HVWDEOLVK�D�SURWRFRO�IRU�DOO�SDWLHQWV��,W�LV�
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.
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17
Appendix A. Rating Schemes for the Strength of the
Evidence/Recommendations

Grading of Recommendations Assessment, Development, and Evaluation (GRADE)

Figure 1: GRADE Algorithm

GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it is also
possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations
Strong for using/
Strong against using
The net benefit of the treatment is clear, patient values and circumstances are
unlikely to affect the decision.
Weak for using/
Weak against using The evidence is weak or the balance of positive and negative effects is vague.

Figure 2. APA Grading Scheme
I Recommend with substantial clinical confidence.
II Recommend with moderate clinical confidence.
III May be recommended on the basis of individual circumstances.




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References
1. Golden NH, Katzman DK, Sawyer SM, et al. Position Paper of the Society for
Adolescent Health and Medicine: medical management of restrictive eating disorders in
adolescents and young adults. J Adolesc Health. Jan 2015;56(1):121-125.
2. Golden NH, Katzman DK, Kreipe RE, et al. Eating disorders in adolescents: position
paper of the Society for Adolescent Medicine. J Adolesc Health. Dec 2003;33(6):496-
503.
3. Rosen DS, Adolescence AAoPCo. Identification and management of eating disorders in
children and adolescents. Pediatrics. Dec 2010;126(6):1240-1253.
4. Association AP. Treatment of patients with eating disorders,third edition. American
Psychiatric Association. Am J Psychiatry. Jul 2006;163(7 Suppl):4-54.
5. Kohn MR, Madden S, Clarke SD. Refeeding in anorexia nervosa: increased safety and
efficiency through understanding the pathophysiology of protein calorie malnutrition. Curr
Opin Pediatr. Aug 2011;23(4):390-394.
6. Sylvester CJ, Forman SF. Clinical practice guidelines for treating restrictive eating
disorder patients during medical hospitalization. Curr Opin Pediatr. Aug 2008;20(4):390-
397.
7. Shamim T, Golden NH, Arden M, Filiberto L, Shenker IR. Resolution of vital sign
instability: an objective measure of medical stability in anorexia nervosa. J Adolesc
Health. Jan 2003;32(1):73-77.
8. Garber AK, Michihata N, Hetnal K, Shafer MA, Moscicki AB. A prospective examination
of weight gain in hospitalized adolescents with anorexia nervosa on a recommended
refeeding protocol. J Adolesc Health. Jan 2012;50(1):24-29.
9. Kells M, Davidson K, Hitchko L, O'Neil K, Schubert-Bob P, McCabe M. Examining
supervised meals in patients with restrictive eating disorders. Appl Nurs Res. May
2013;26(2):76-79.
10. Yager J, Devlin M, Halmi K, et al. Guideline Watch (August 2012): Practice Guideline for
the Treatment of Patients with Eating Disorders. 3rd ed: American Psychiatric
Association; 2012.
11. Stanga Z, Brunner A, Leuenberger M, et al. Nutrition in clinical practice-the refeeding
syndrome: illustrative cases and guidelines for prevention and treatment. Eur J Clin Nutr.
Jun 2008;62(6):687-694.
12. Association AD. Position of the American Dietetic Association: Nutrition intervention in
the treatment of anorexia nervosa, bulimia nervosa, and other eating disorders. J Am
Diet Assoc. Dec 2006;106(12):2073-2082.
13. Leacy KA, Cane JN. Effect of non-select menus on weight and eating concern in
adolescents hospitalized with anorexia nervosa. Eat Disord. 2012;20(2):159-167.
14. Association AP. Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Fifth
ed. Arlington, VA: American Psychiatric Association; 2013:
http://dsm.psychiatryonline.org.ezproxy.library.wisc.edu/book.aspx?bookid=556.
15. Schwartz BI, Mansbach JM, Marion JG, Katzman DK, Forman SF. Variations in
admission practices for adolescents with anorexia nervosa: a North American sample. J
Adolesc Health. Nov 2008;43(5):425-431.
16. Yager J, Andersen AE. Clinical practice. Anorexia nervosa. N Engl J Med. Oct
2005;353(14):1481-1488.
17. Becker AE, Grinspoon SK, Klibanski A, Herzog DB. Eating disorders. N Engl J Med. Apr
1999;340(14):1092-1098.
18. Tan JO, Stewart A, Fitzpatrick R, Hope T. Attitudes of patients with anorexia nervosa to
compulsory treatment and coercion. Int J Law Psychiatry. 2010 Jan-Feb 2010;33(1):13-
19.
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
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19
19. Elzakkers IF, Danner UN, Hoek HW, Schmidt U, van Elburg AA. Compulsory treatment
in anorexia nervosa: a review. Int J Eat Disord. Dec 2014;47(8):845-852.
20. Gans M, Gunn WB. End stage anorexia: criteria for competence to refuse treatment. Int
J Law Psychiatry. 2003 Nov-Dec 2003;26(6):677-695.
21. Tan DJ, Hope PT, Stewart DA, Fitzpatrick PR. Competence to make treatment decisions
in anorexia nervosa: thinking processes and values. Philos Psychiatr Psychol. Dec
2006;13(4):267-282.
22. Ozier AD, Henry BW, Association AD. Position of the American Dietetic Association:
nutrition intervention in the treatment of eating disorders. J Am Diet Assoc. Aug
2011;111(8):1236-1241.
23. Adolescence AAoPCo. Identifying and treating eating disorders. Pediatrics. Jan
2003;111(1):204-211.
24. Abed J, Judeh H, Abed E, Kim M, Arabelo H, Gurunathan R. "Fixing a heart": the game
of electrolytes in anorexia nervosa. Nutr J. 2014;13:90.
25. Meyers RS. Pediatric fluid and electrolyte therapy. J Pediatr Pharmacol Ther. Oct
2009;14(4):204-211.
26. Mehanna HM, Moledina J, Travis J. Refeeding syndrome: what it is, and how to prevent
and treat it. BMJ. Jun 2008;336(7659):1495-1498.
27. Yahalom M, Spitz M, Sandler L, Heno N, Roguin N, Turgeman Y. The significance of
bradycardia in anorexia nervosa. Int J Angiol. Jun 2013;22(2):83-94.
28. Lund BC, Hernandez ER, Yates WR, Mitchell JR, McKee PA, Johnson CL. Rate of
inpatient weight restoration predicts outcome in anorexia nervosa. Int J Eat Disord. May
2009;42(4):301-305.
29. Hart S, Franklin RC, Russell J, Abraham S. A review of feeding methods used in the
treatment of anorexia nervosa. J Eat Disord. 2013;1:36.
30. Redgrave GW, Coughlin JW, Schreyer CC, et al. Refeeding and weight restoration
outcomes in anorexia nervosa: Challenging current guidelines. Int J Eat Disord. Jan
2015.








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R eferenc e: Eatin g Diso r der – Pe di atric /Adu lt – In patie nt Gu ide lin e
Page 1 of 4
Quick Guide for Inpatient Management of Patients with an
Eating Disorder
ADMISSION
Key
Points
Admitting Diagnosis:
Patients may be admitted for medical stabilization of an eating disorder; however the patient is being admitted
for an “acute exacerbation” of a “chronic disease”. Therefore, the admitting diagnosis should be accompanied
by a description of the acute symptoms/exacerbation (e.g., bradycardia, severe weight loss). Another example
is admitting a CF patient for “CF bronchopulmonary exacerbation” not just “Cystic Fibrosis”.
Admitting Service/Unit:
1. If patient is 17 years or younger- Pediatric Hospitalist Service (P5 unit)
2. If patient is 18 years or older- Hospitalist 3 Service (D4/4 unit)
Medical Indications for Inpatient Treatment
Failure of ambulatory/outpatient treatment
Weight
ξ < 75% IBW/EBW (Approximate BMI < 15.99 in adults)
ξ Rapid Weight Loss (i.e., > 10 lbs. in 2 wks.)
ξ Arrested growth and development
Temperature Hypothermia (< 96.0°F or 35.6°C)
Cardiovascular
ξ Heart rate < 50 bpm (daytime) or < 45 bpm (nighttime)
ξ Orthostatic blood pressure measurements that feature a decrease in systolic blood pressure of > 20 mmHg
OR decrease in diastolic blood pressure of > 10 mmHg OR increase in heart rate of > 20 bpm.
ξ Arrhythmia
ξ Chest Pain
Lab Values
Clinically significant abnormal lab values for the following:
Electrolytes:
ξ Sodium
ξ Potassium
ξ Chloride
ξ Magnesium
ξ Calcium
ξ Phosphorus
Malnutrition indicators:
ξ BUN
ξ Creatinine
ξ Glucose
ξ Albumin

Anemia evaluation:
ξ CBC without differential
For Females only (serum labs only if
amenorrhea):
ξ FSH
ξ LH
ξ Prolactin
ξ Urine Beta-HCG
Additional
Symptoms
ξ Acute medical complications (e.g., syncope, seizures, cardiac failure, esophageal tears, etc.)
ξ Acute food refusal
ξ Uncontrollable bingeing and purging

PATIENT COMMUNICATION & EMERGENT BEHAVIORAL SITUATIONS
Key Points
Avoid trigger words such as “food”,
“calories” and “weight.” Instead, refer to
the treatment in medical terms such as
“medicine”, nourishment”, or “energy.”
Patients with an eating disorder demonstrate impaired
judgment in this area of their lives, even though they
may demonstrate capacity in areas not influenced by
obsession with food and/or body weight.
De-escalation
Strategies
ξ Have any people who are targets for the crisis behavior step out of the room.
ξ Keep as few staff as possible in the room, but keep enough to provide for safety.
ξ Do not engage in bargaining or argument.
ξ Use simple, declarative statements to tell the patient what to do with their body to stay safe.
ξ If there is agitation, consider calling Security right away. They are unlikely to put hands on the
patient but can be a calming “show of force” whose presence can remind the patient to be civil.
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R eferenc e: Eatin g Diso r der – Pe di atric /Adu lt – In patie nt Gu ide lin e
Page 2 of 4




PATIENT ACTIVITY AND SUPERVISION
Key
Points
Patients with eating disorders need continuous
supervision (i.e., physical attendant or virtual
monitoring) for safety and compliance.
Family members or friends should NOT be
permitted to substitute for staff providing
constant observation under any circumstances.
Activity
1. Patients should be restricted to bed rest. PSAs should retrieve and put away patient belongings, as the
patient is not allowed to walk back and forth in the room.
2. Patients may be allowed to sit up in bed, but not in a chair.
3. MD permission is needed to attend hospital activities in a wheelchair.
Bathroom
1. The bathroom door should be open at all times when the patient is using the bathroom or shower. It is
important to ensure that the patient does not drink extra water or purge their food.
2. Patient should NOT be allowed bathroom privileges for 1 hour after a meal or snack OR the patient may
have SUPERVISED use of the bathroom to ensure no purging behavior is completed.
3. One 5 minute shower per day may be allowed when electrolytes and cardiovascular system are stable.
Purging
Behavior
1. Remove all loose trash cans from the room.
2. Patient should NOT be allowed bathroom privileges for 1 hour after a meal or snack OR the patient may
have SUPERVISED use of the bathroom to ensure no purging behavior is completed.






HEALTH CARE TEAM & COMMUNICATION
Key Points
Multidisciplinary team will include representation from: resident team, attending hospitalist, and
supporting Eating Disorders team (NP or PA, Adolescent Medicine, staff RN, CNS, RN manager,
Psychiatry, Health Psychology, Case Management, Social Work, and Clinical Nutrition).
Meet within 24-48 hours after admission Meet weekly (at a minimum) to set discharge goals
30 min.
Meetings
~ 20 minutes- Debriefing, planning for inpatient care and setting discharge goals
~ 10 minutes- Discuss the plan with patient and/or family (if pediatric patient)
Meeting
Coordination
Pediatric Patients:
1. Daily rounding time to be determined by 7:45 am
2. Senior resident to send group text page to team
3. Any available member of the Eating Disorders support team will round with resident team

Adult Patients:
1. Daily rounding should occur during Care Team Rounds
2. Group page sent to team members to coordinate rounds
3. Care Team Rounds should be held outside the patient room in order to discuss sensitive
information (such as weight changes)
4. Selected team members should still enter the patient room daily in order to talk with the patient.
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Page 3 of 4

MEALS AND SNACK TIME
Key
Points
Clinical Nutrition meet with patient within 24
hours of admission to discuss food
preference, restrictions and limitations

All meal planning completed by Clinical
Nutrition; patients cannot order their own
meals.
Meals arrive between:
0800-0830, 1200-1230,
1700-1730

Snacks arrive between:
1000-1030, 1500-1530,
and 2000-2030
Absolutely no
outside food is
permitted.

Family members
may eat in the
patient’s room, but
cannot share with
the patient or
dispose of their
food in the room.
Patients are required to eat 100% of
meals/snacks within 30 min (meals) or 20 min
(snacks)
Cans of 1.5 kcal/mL oral
nutritional supplement
sent to the unit (Nurse’s
Station) daily at the
1000 snack time
Patient
Preferences
Patients will be allowed to specify their 3 favorite foods and top 3 foods to avoid. The personal
food preferences document cannot be updated or changed.
ξ Lactose free and vegetarian diets will be honored, however vegan diets will not.
ξ Patients are not allowed to have caffeinated beverages or diet beverages or diet foods.
ξ Patients may have one packet of salt per meal.
Mealtime
Procedures
1. All trays should arrive during designated time. If tray is late, RN to page Clinical Nutrition.
2. All trays should be delivered to the Nurse’s Station.
3. RN should compare the tray ticket to the content of the tray before delivering the tray to the
patient. If there is a discrepancy, RN should page Clinical Nutrition.
4. Cans of 1.5 kcal/mL oral nutritional supplement (e.g., Boost Plus, Ensure Plus) should not be
given to the patient unless indicated.
5. Patients must eat on bedside table (not in lap). Ensure tray is clear and no food is hidden.
6. Patients are required to eat 100% of the food on their tray within 30 minutes (for meals) and
within 20 minutes (for snacks). Meals include calorie-containing beverages and condiments.
7. Water bottles that come with meals may be kept on the patient’s bedside table for > 30
minutes, but must be consumed prior to the arrival of the next tray.
8. If patient eats < 100% of a meal or snack, offer specified volume of 1.5 kcal/mL oral
nutritional supplement. The appropriate portion should be poured into a separate cup for
administration.
9. If patient is unwilling or unable to take the 1.5 kcal/mL oral nutritional supplement orally within
15 minutes, an NG tube should be placed for administration.
10. Patients will be required to eat 100% of their provided meals and snacks before requesting
extra food. This request for additional food should be discussed with Clinical Nutrition.
RN
Documentation
1. RN will keep all tray tickets and record the amount of each food eaten (percentage) directly
on the tray ticket.
2. RN will send all meal and snack tickets to Tube Station 214 (adults) or the P8 Pharmacy
(pediatric) by 11pm each day.
3. This information will be calculated by Clinical Nutrition and entered into Health Link
flowsheets the next morning.
Evening and
Weekend
Admissions
If a patient is admitted in the evening when Clinical Nutrition is unavailable, then:
1. The RN will make the patient an RS-2 room service class and call Culinary Services to place
orders for the dinner and breakfast meals, per the attached document.
2. The patient can choose whether to eat the pre-planned meal OR drink 1 can of 1.5 kcal/mL
oral nutritional supplement.
3. No snacks will be given until the patient is assessed by Clinical Nutrition.
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

R eferenc e: Eatin g Diso r der – Pe di atric /Adu lt – In patie nt Gu ide lin e
Page 4 of 4

DISCHARGE
Key Points
Patients should not be discharged until they meet at least one discharge criteria.
Necessary follow-up appointments should be scheduled.
If Going Home 1. Discharge meal plan should be coordinated between the patient and the dietitian
2. Exercise parameters should be provided by provider
If Going to
Referral Facility
(e.g., Rogers
Memorial)
1. Social Worker/Nurse Case Management will contact a referral facility on hospital day 1-2 to
arrange possible transfer
2. Social Worker/Nurse Case Management and Psychiatry will assist parents in setting up a phone
interview with the designated referral facility
3. Social Worker/Nurse Case Management or Nursing will fax admission H&P, discharge summary,
and most recent Clinical Nutrition progress note to referral facility upon patient discharge

NOTE- The following tests are REQUIRED 72 hours prior to discharge: EKG; CBC with differential,
CMP (Sodium, Potassium, Chloride, Total Carbon Dioxide, Anion Gap, Glucose, BUN, Creatinine,
Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase), Magnesium,
Phosphate, Urine Pregnancy, Urinalysis with Microscopy, TSH, Free T4, Urine Drug Screen Labs
Medical Indications for Discharge
Weight > 75% IBW OR weight stabilization
Temperature Normothermia for 24 hours
Cardiovascular
ξ Heart rate > 40 bpm OR stable per attending physician
ξ Resolution of EKG abnormalities
ξ Resolution of orthostatic symptoms (e.g., dizziness, light-headedness, etc.)
Lab Values Stable lab values

Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

Last revised/reviewed: 11/2015
Contact Clinical Nutrition for questions.
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Top 3 Foods: Favorites
List three favorite foods and we will do our best to include them as often as possible into
your meal plan. Please remember we do not honor vegan diets and we do not serve
diet foods, or caffeinated or diet beverages.
1. _________________________________________________________
2. _________________________________________ ________________
3. _________________________________________________________
Top 3 Foods: To Avoid
List three foods that you do not care to eat. We will do our best to limit these foods in
your meal plan, although there may need to be exceptions. Please know that we cannot
exclude an entire food group such as dairy or carbohydrates.
1. _________________________________________________________
2. _________________________________________________________
3. _________________________________________________________
*Please note that this food preference sheet will be used for your whole admission. It
cannot be updated or changed while you are here.
Patient Name:
Date:
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

$GPLVVLRQ�0HDOV�IRU�(YHQLQJV�:HHNHQGV�$YDLODEOH�IRU�
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(All meal options provide 325-375 calories)
Breakfast
Standard Dairy Free Vegetarian
Breakfast Sandwich:
English muffin- 1 whole muffin
Scrambled egg- 1 whole egg
Cheddar cheese- 1 slice
Strawberries- 1 serving (4 oz.)
Breakfast Sandwich:
English muffin- 1 whole muffin
Scrambled egg- 1 whole egg
Turkey sausage- 1 patty
Strawberries- 1 serving (4 oz.)
Cheerios- 1 box
Skim milk (or soy milk)- 8 oz.
Dannon Fruit on the Bottom yogurt- 6 oz.
Strawberries- 1 serving (4 oz.)
Lunch/Dinner
Standard Dairy Free Vegetarian
Whole Sandwich:
Whole wheat bread- 2 slices
Roast turkey- 2 oz.
Cheddar cheese- 1 slice
Lettuce- 1 leaf
Tomato- 2 slices
Fresh fruit cup- 1 serving (4 oz.)
Whole Sandwich:
Whole wheat bread- 2 slices
Roast turkey- 2 oz.
Lettuce- 1 leaf
Tomato- 2 slices
Chicken noodle or tomato soup- 6 oz.
Saltines- 1 package
Fresh fruit cup- 1 serving (4 oz.)
Half Sandwich:
Whole wheat bread- 1 slice
Peanut butter- 1 tablespoon
Strawberry jam- 1 packet
Vegetable soup- 6 oz.
Saltines- 1 package
Fresh fruit cup- 1 serving (4 oz.)
Note: Nursing must call 5-0202 to order these pre-planned meals until Clinical Nutrition
is available to take over meal planning responsibilities.
Last reviewed: 11/2015
Contact Clinical Nutrition with questions.
Reference: Eating Disorders ± Adult/Pediatric ± Inpatient Clinical Practice Guideline
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

Page 1 of 2
Contact Clinical Nutrition with questions.
Reference: Eating Disorders ± Adult/Pediatric ± Inpatient Clinical Practice Guideline
&DORULH�3URJUHVVLRQ�³%HOO�0HDO�5HSODFHPHQW�*XLGHOLQHV ´

NOTES: For patients with an eating disorder, Clinical Nutrition will determine the starting calorie level.
See nutrition assessment note for details.

1.5 kcal/mL oral nutritional supplement (ONS) (e.g., Boost Plus, Ensure Plus) should be presented to patient
pre-measured, in a cup without nutrition information visible.

800 Calorie Meal Plan
3 meal s of ~ 270 kca l
0 snack s
1000 Calorie Meal Plan
3 meal s of ~ 340 kca l
0 snack s
1.5 kcal/mL oral nutrition supplement replacement: 1.5 kcal/mL oral nutrition supplement replacement:
If pt eat s <5 0% of ME AL 6 oz If pt eat s <5 0% of ME AL 7.5 oz
If pt eat s 50 - 99 % of ME AL 3 oz If pt eat s 50 - 99 % of ME AL 4 oz
If pt eat s <5 0% of SN A CK NA If pt eat s <5 0% of SN A CK NA
If pt eat s 50 - 99 % of SN AC K NA If pt eat s 50 - 99 % of SN AC K NA


1200 Calorie Meal Plan
3 meal s of ~ 400 kca l
0 snack s
1400 Calorie Meal Plan
3 meal s of ~ 400 kca l
1 snack ( 8p m) o f ~ 2 00 kca l
1.5 kcal/mL oral nutrition supplement replacement: 1.5 kcal/mL oral nutrition supplement replacement:
If pt eat s <5 0% of ME AL 9 oz If pt eat s <5 0% of ME AL 9 oz
If pt eat s 50 - 99 % of ME AL 4.5 oz If pt eat s 50 - 99 % of ME AL 4.5 oz
If pt eat s <5 0% of SN A CK NA If pt eat s <5 0% of SN A CK 4.5 oz
If pt eat s 50 - 99 % of SN AC K NA If pt eat s 50 - 99 % of SN AC K 2.5 oz


1600 Calorie Meal Plan
3 meal s of ~ 400 kca l
2 snack s ( 3p m & 8p m) of ~ 20 0 kca l
1800 Calorie Meal Plan
3 meal s of ~ 400 kca l
3 snack s of ~ 20 0 kcal
1.5 kcal/mL oral nutrition supplement replacement: 1.5 kcal/mL oral nutrition supplement replacement:
If pt eat s <5 0% of ME AL 9 oz If pt eat s <5 0% of ME AL 9 oz
If pt eat s 50 - 99 % of ME AL 4.5 oz If pt eat s 50 - 99 % of ME AL 4.5 oz
If pt eat s <5 0% of SN A CK 4.5 oz If pt eat s <5 0% of SN A CK 4.5 oz
If pt eat s 50 - 99 % of SN AC K 2.5 oz If pt eat s 50 - 99 % of SN AC K 2.5 oz


2000 Calorie Meal Plan
3 meal s of ~ 45 0 kcal
3 snack s of ~ 2 20 kca l
2200 Calorie Meal Plan
3 meal s of ~ 500 kca l
3 snack s of ~ 2 4 0 kca l
1.5 kcal/mL oral nutrition supplement replacement: 1.5 kcal/mL oral nutrition supplement replacement:
If pt eat s <5 0% of ME AL 10 oz If pt eat s <5 0% of ME AL 11 oz
If pt eat s 50 - 99 % of ME AL 5 oz If pt eat s 50 - 99 % of ME AL 5.5 oz
If pt eat s <5 0% of SN A CK 5 oz If pt eat s <5 0% of SN A CK 5.5 oz
If pt eat s 50 - 99 % of SN AC K 2.5 oz If pt eat s 50 - 99 % of SN AC K 3 oz

*If a patient is consistently taking 100% supplements at calorie levels > 2200 kcal/day, consider using a carbohydrate
modular additive or switching to a different enteral formula to achieve daily calorie goals without micronutrient excess.
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

Page 2 of 2
Contact Clinical Nutrition with questions.
Reference: Eating Disorders ± Adult/Pediatric ± Inpatient Clinical Practice Guideline
2400 Calorie Meal Plan
3 meal s of ~ 53 0 kca l
3 snack s of ~ 270 kca l
2600 Calorie Meal Plan
3 meal s of ~ 5 7 0 kca l
3 snack s of ~ 3 00 kca l
1.5 kcal/mL oral nutrition supplement replacement: 1.5 kcal/mL oral nutrition supplement replacement:
If pt eat s <5 0% of ME AL 12 oz If pt eat s <5 0% of ME AL 13 oz
If pt eat s 50 - 99 % of ME AL 6 oz If pt eat s 50 - 99 % of ME AL 6.5 oz
If pt eat s <5 0% of SN A CK 6 oz If pt eat s <5 0% of SN A CK 6.5 oz
If pt eat s 50 - 99 % of SN AC K 3 oz If pt eat s 50 - 99 % of SN AC K 4 oz
2800 Calorie Meal Plan
3 meal s of ~ 63 0 kca l
3 snack s of ~ 3 1 0 kca l
3000 Calorie Meal Plan
3 meal s of ~ 6 60 kca l
3 snack s of ~ 340 kca l
1.5 kcal/mL oral nutrition supplement replacement: 1.5 kcal/mL oral nutrition supplement replacement:
If pt eat s <5 0% of ME AL 14 oz If pt eat s <5 0% of ME AL 15 oz
If pt eat s 50 - 99 % of ME AL 7 oz If pt eat s 50 - 99 % of ME AL 7.5 oz
If pt eat s <5 0% of SN A CK 7 oz If pt eat s <5 0% of SN A CK 7.5 oz
If pt eat s 50 - 99 % of SN AC K 3.5 oz If pt eat s 50 - 99 % of SN AC K 4 oz
3200 Calorie Meal Plan
3 meal s of ~ 72 0 kca l
3 snack s of ~ 35 0 kca l
3400 Calorie Meal Plan
3 meal s of ~ 76 0 kca l
3 snack s of ~ 380 kca l
1.5 kcal/mL oral nutrition supplement replacement: 1.5 kcal/mL oral nutrition supplement replacement:
If pt eat s <5 0% of ME AL 16 oz If pt eat s <5 0% of ME AL 17 oz
If pt eat s 50 - 99 % of ME AL 8 oz If pt eat s 50 - 99 % of ME AL 8.5 oz
If pt eat s <5 0% of SN A CK 8 oz If pt eat s <5 0% of SN A CK 8.5 oz
If pt eat s 50 - 99 % of SN AC K 4 oz If pt eat s 50 - 99 % of SN AC K 5 oz
3600 Calorie Meal Plan
3 meal s of ~ 80 0 kca l
3 snack s of ~ 4 00 kca l
3800 Calorie Meal Plan
3 meal s of ~ 85 0 kca l
3 snack s of ~ 4 2 0 kca l
1.5 kcal/mL oral nutrition supplement replacement: 1.5 kcal/mL oral nutrition supplement replacement:
If pt eat s <5 0% of ME AL 18 oz If pt eat s <5 0% of ME AL 19 oz
If pt eat s 50 - 99 % of ME AL 9 oz If pt eat s 50 - 99 % of ME AL 9.5 oz
If pt eat s <5 0% of SN A CK 9 oz If pt eat s <5 0% of SNA CK 9.5 oz
If pt eat s 50 - 99 % of SN AC K 4.5 oz If pt eat s 50 - 99 % of SN AC K 5 oz
4000 Calorie Meal Plan
3 meal s of ~ 90 0 kca l
3 snack s of ~ 4 4 0 kca l
1.5 kcal/mL oral nutrition supplement replacement:
If pt eat s <5 0% of ME AL 2 0 oz
If pt eat s 50 - 99 % of ME AL 10 oz
If pt eat s <5 0% of SN A CK 10 oz
If pt eat s 50 - 99 % of SN AC K 5 oz
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

'LVFKDUJH�0HDO�3ODQQLQJ�*XLGH�IRU�3DWLHQWV�ZLWK�DQ�(DWLQJ�'LVRUGHU
Calories Per
Exchange
Approximate Exchanges Per Day
800 1000 1200 1400 1600 1800 2000 2200 2400
Grains 80 3 4 5 6 7 8 9 10 11
Protein 55 3 3 4 4 5 6 7 8 9
Milk 90 2 2 2 3 3 3 3 3 3
Fruit 60 2 3 3 4 4 5 5 6 6
Fat 45 2 3 4 4 4 5 5 6 6
Vegetable 25 2 2 2 2 3 3 4 4 5
Calories Per
Exchange
Approximate Exchanges Per Day
2600 2800 3000 3200 3400* 3600 3800 4000
Grains 80 12 13 14 15 16 18 19 21
Protein 55 10 11 12 13 14 14 14 14
Milk 90 4 4 4 4 4 4 4 4
Fruit 60 6 7 7 7 7 7 7 7
Fat 45 6 6 7 8 9 11 13 14
Vegetable 25 5 5 5 6 6 6 6 6
* For meal plans >3400 calories, consider adding oral nutrition supplements to help patients achieve their exchange goals.
Contact Clinical Nutrition with questions.
Last revised/reviewed: 11/2016
Reference: Eating Disorders ± Pediatric/Adult ± Inpatient Clinical Practice Guideline
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

Fo r rev isio ns, co ntact CCKM . | Last rev ised/ rev iewe d: 11 /2 015
Refe rence: Assessment and Managem ent of Eating Diso rders – Pediatric/ Adult – Inpatient Guideline
FAQ’s During Admissions for Medical Stabilization
of an Eating Disorder: Information for Clinicians
This document provides answers to frequently asked questions regarding hospital admissions of pediatric,
adolescent, and adult patients with an eating disorder. It is a component of the Assessment and Management of
Eating Disorders – Pediatric/Adult – Inpatient Clinical Practice Guideline.
Why am I here?
You were admitted to the hospital because of medical problems that come from poor nutrition.
This hospital stay will work on improving your nutrition. As your nutrition improves, your heart
rate, blood pressure and body chemistry will return to normal levels. It is our goal to help you
restore your nutrition in a place that will be supportive, and as rapidly as is safe. While you are
with us, there are several things we will be doing to ensure your safety, and return you to a
healthier state as quickly as possible.
These are the things we will focus on during your hospital stay:
ξ Correct your poor nutrition in a slow and steady way, and monitor the health of organs like
your heart. It is very dangerous if your nutrition is not managed in a proper way.
ξ Correct any problems with the salts in your blood (sodium, magnesium, phosphorous,
potassium). These chemicals in the blood need to be at certain levels for your body to be
able to function in a healthy way.
ξ Develop a post-hospitalization plan for you to continue to progress in your recovery once
discharged from the hospital.
ξ Ensure that you have resources to help you and your family understand your nutritional
needs after discharge.
What exactly will happen while I am here?
You will receive medicine in the form of energy to keep your body safe. We need to provide
your heart and vital organs with this medicine so that they can perform basic
functions. Sometimes this medicine will be delivered via a nasogastric, or NG tube, which
will be placed on the floor. We will also need to help you conserve energy in order to
protect your vital organs and restore your energy balance. All of this is part of restoring
your energy balance in order to make your body safe.
Can my parents or support person stay with me?
Your parents are welcome, and encouraged, to stay with you throughout your stay, however
they may not bring any food in from home for you. They also may not dispose of any food or
other items in your room.
Why is there someone watching me in my room all the time? Don’t you trust me?
You may have more than one nurse and care partner during your stay. A care partner (also
called patient safety attendant) will be with you in the room or watching you on a video monitor.
A lot of the things we ask you to do here at the beginning of the hospitalization are difficult, and
the PSA will help you keep up with them all. The goal is to ensure your safety and most rapid
recovery.
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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Why do I need to be hooked up to a heart monitor and have my vital signs checked?
Because your blood pressure may drop when you stand up, we will be checking your blood
pressure while you are lying in bed and upon standing each morning. Due to low heart rates and
the possibility of heart rhythm problems, you will be placed on a heart monitor. This monitor will
alert the nurse if there is a concern. We will also be checking your blood pressure, temperature,
and oxygen saturation periodically throughout the day.
Why do you need to check my blood and do all of these tests?
As your body moves from its state of malnutrition to health we will monitor blood tests to make
sure that change does not happen too fast. If that change happens suddenly there can be
dangerous effects on your heart and brain. To look for and prevent that danger, we need to
check some blood tests on admission and frequently (every 12 hours, or possibly more often)
after that. We also need to do an EKG (electrocardiogram) to check your heart. We will try to
draw blood from an IV. If you do not have an IV or we are unable to, we have a numbing cream
that we can put on your skin so that the blood tests are less uncomfortable.
Who are all these people coming into my room?
Because poor nutrition has compromised your health, we have a large medical team to help you
get healthy again. This includes pediatric hospitalist physicians, resident physicians, nurse
practitioners or physician’s assistants, psychiatrists, adolescent medicine specialists, nurses,
and patient safety attendants. You will also have a team of clinical nutritionists and dieticians to
help plan and monitor your nutritional treatment, since food is the medicine that you need to get
healthy. You may see other health care team members such as physical or occupational
therapists, social workers, case managers, or health psychologists. We work together to help
you become healthy again soon.
I don’t like hospital food, can I choose my own?
During your stay, we will provide a nutritious diet. This will include providing the vitamins and
minerals your body needs to be healthy. All of your food must come from the hospital kitchen.
No outside food is allowed. Your meals will be planned by your dietician. Your dietitian will go
over your food preferences on admission. We will do our best to incorporate the foods you like
and avoid the foods you prefer not to eat. Once your Food Preference worksheet is turned in,
you cannot make any changes. These rules are in place to make sure you have adequate
nutrition in proper amounts and makeup, and that the pace of your recovery is safe and steady.
I am a slow eater; can I have more time for my meals and snacks? When do meals
and snacks arrive?
Your meals and snacks will be delivered to your room within specific time frames. Your nurse
can tell you these times so that you feel prepared. You will be required to eat the number of
meals and snacks on your meal plan. You will always have 3 meals. Snacks will be incorporated
slowly. You will have 30 minutes to eat meals, and 20 minutes to eat snacks. If you are not able
to finish a meal or snack, you will be given a liquid supplement to make up for it. No one will be
angry with you if you take the supplement instead of finishing the meal. If you are not able
to drink the supplement, the nurse will give the supplement through a nasogastric tube.
I don’t understand why I may need a nasogastric tube. Why might it be necessary?
The medicine that your body needs in order to treat this condition and help your heart regain
strength is nutritional energy. Sometimes it is very challenging to take that energy orally. The
nasogastric tube is a simple way of making the process of taking the energy easier so that your
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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heart and body reach a safer state. The nurses will place the tube for you. After that you will be
able to relax and receive the energy safely and without worry or pressure.
I don’t like to be in bed all the time, I don’t feel well when I do, so can I get up?
You will need to rest a lot and you may not exercise. We will place you on bed rest and fall
precautions when you arrive. Resting in bed is necessary to help your heart regain strength as
soon as possible. Therefore, you may sit up in bed, but may not walk around the room. The
team may allow you to participate in hospital activities and spend some time out of bed or out of
room in a wheelchair when your vital signs and heart rhythm are stable.
A note about bathroom privileges:
If you are stable, you can shower and use the bathroom however you may only be up 5 minutes
at a time. You can shower only once per day. Please do not flush the toilet as nursing will be
recording all output. You may not use the bathroom for 1 hour after meals or snacks unless
directly supervised. For bathroom and shower breaks, you will need to be supervised by your
nurser or care partner in case you feel faint.
A note about weight measurements:
Staff will obtain your weight every morning. You should not eat or drink anything before the
weight. Please empty your bladder before weighing. You will wear your underwear and a patient
gown for the weight (no bra). Your hair must be dry (we will weigh you before your shower). We
will have you face away from the scale. We will not discuss the weight with you.
I don’t like all these rules!?
These rules are not made to punish you. These rules have been shown to help keep this
hospitalization safe and as short as possible. While the rules are strict, they are necessary while
we are helping to improve your nutrition and help your body work normally again. We want you
to become healthy again in a safe way.
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org