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Quick Guide for Inpatient Management of Patients with an Eating Disorder

Quick Guide for Inpatient Management of Patients with an Eating Disorder - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nutrition, Related


Reference: Eating Disorder – Adult/Pediatric – Inpatient Guideline
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.
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

Reference: Eating Disorder – Pediatric/Adult – Inpatient Guideline
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.
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2016CCKM@uwhealth.org

Reference: Eating Disorder – Pediatric/Adult – Inpatient Guideline
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 Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2016CCKM@uwhealth.org

Reference: Eating Disorder – Pediatric/Adult – Inpatient Guideline
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 Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2016CCKM@uwhealth.org