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Canberra Hospital and Health ServicesClinical Guideline Adults with Eating Disorders – Management of (Inpatients)Contents

Contents....................................................................................................................................1

Guideline Statement.................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Assessing for an Eating Disorder.............................................................................3

Section 2 – Emergency Department Triage...............................................................................4

Section 3 – Refusal of Care........................................................................................................5

Section 4 – Management of an inpatient admission.................................................................8

Section 5 – Principles of inpatient ward management..............................................................9

Section 6 – Structure of an inpatient admission.....................................................................10

Section 7 – Medical Management...........................................................................................12

Section 8 – Recognising and managing refeeding syndrome..................................................13

Section 9 – Nutritional management......................................................................................14

Section 10 – Managing Enteral Nutrition via Nasogastric Feeding..........................................18

Section 11 – Nursing Management.........................................................................................18

Section 12 – Psychological management................................................................................21

Section 13 – Discharge Planning and Transition......................................................................21

Implementation...................................................................................................................... 23

Related Policies, Procedures, Guidelines and Legislation.......................................................23

References.............................................................................................................................. 24

Definition of Terms................................................................................................................. 24

Search Terms.......................................................................................................................... 25

Attachments............................................................................................................................25

Attachment 1 – Adult Eating Disorder: Weekly management Plan.....................................26

Doc Number Version Issued Review Date Area Responsible PageCHHS18/120 1 09/04/2018 01/02/2022 Medicine 1 of 26Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Guideline Statement

This document is designed to be used by nursing, medical and allied health staff in the management of adult patients with eating disorders on medical wards at Canberra Hospital and Health Services (CHHS).

BackgroundPatients with potentially life-threatening manifestations of eating disorders (e.g. anorexia nervosa) should be admitted to medical wards for stabilisation. International consensus guidelines advocate a multi-disciplinary, consistent approach to management to promote optimal medical, nutritional and psychological outcomes, and to prevent avoidable deaths. This document reflects the recommendations of the United Kingdom’s Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN) Guideline 1 and the Guidelines for the Inpatient Management of Adult Eating Disorders in General Medical and Psychiatric Settings in NSW 2.

Key ObjectiveTo provide guidance to CHHS medical, nursing and allied health staff on the admission criteria, assessment and management of adults with eating disorders presenting for in-patient medical and nutritional stabilisation.

AlertsMedical complications of severe anorexia nervosa can be life-threatening. Inadequate treatment of under-nutrition or under-recognition of the refeeding syndrome can also lead to poor outcomes including death. Refusal of treatment is not an uncommon scenario in this context, and knowledge of the legal framework under which medical management can be continued is required.

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Scope

This guideline applies to adults (aged 16 years and above) admitted to CHHS with or suspected of having an eating disorder. For Paediatric patients (aged under 16 years) please see Clinical Guideline – Inpatient Management of Anorexia Nervosa (Adolescents) on the CHHS Policy Register.

This Guideline applies to the following CHHS Staff working within their scope of practice: Medical Officers Nursing Staff Allied Health Staff Students with direct supervision.



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Section 1 – Assessing for an Eating Disorder

People with an eating disorder may feel uncomfortable disclosing information about their behaviours, making the detection of disordered eating symptoms difficult.Although the incidence of Eating Disorders tends to peak between the ages of 13-25 years, they can affect people of all ages. The ratio of anorexia nervosa (AN) in females to males is 3:1 before puberty, and 10:1 after.

Parents, partners or carers should be included in the assessment process wherever possible. Endeavour to interview family members and carers of adults as part of the assessment procedure, with prior consent from the patient.

A thorough medical history and examination is mandatory on presentation to hospital. Persons with an eating disorder will often not disclose eating disorder symptoms at presentation but will present for treatment for a variety of other, often related, physical signs and symptoms (as listed below). Co-morbid psychiatric illnesses are seen in up to 80% of patients with an eating disorder and therefore should be actively screened for.

Table 1: Characteristics of Patients with an Eating disorderHallmark Symptoms of an Eating Disorder

Physical signs and associated abnormalities

Co-morbid Mental Health Presentations

Low body weight or failure to achieve expected weight gains

Fear of weight gain Body image disturbance Severe body dissatisfaction

and drive for thinness Preoccupation with food,

weight and shape Restricted dietary intake Self-induced vomiting Misuse of laxatives,

diuretics or appetite suppressants

Excessive exercise Amenorrhoea/oligo-

menorrhoea or failure to reach menarche

Loss of sexual interest Binge eating with loss of

control & eating unusually large amounts of food

Self-imposed restrictions –

Dehydration Hypothermia Syncope (e.g. low Blood

Pressure, postural drop) Cardiac arrhythmias Suicide attempts Infection Renal failure Bone marrow

suppression Gastrointestinal

dysfunction Acute massive gastric

dilation from bingeing Enlarged parotid gland

from purging Electrolyte imbalance Self-harm (cutting) Effortless vomiting

Major depressive disorder

Anxiety disorder Obsessive

Compulsive Disorder Substance abuse /

dependence Self-harm and

suicidal ideation


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Hallmark Symptoms of an Eating Disorder

Physical signs and associated abnormalities

Co-morbid Mental Health Presentations

vegan/dairy free/gluten free


Section 2 – Emergency Department Triage

Patients attending the Emergency Department who are suspected of having an eating disorder (based on the characteristics outlined in Table 1) should be referred for either inpatient or community management.

Indicators for In-patient Medical AdmissionAn in-patient admission is indicated for patients who are at significant risk of mental or physical harm. Table 2 (below) outlines criteria for which medical admission should be considered under the General Medicine Unit at CHHS – essentially those patients that are high or extreme risk of re-feeding syndrome.

Patients presenting at extreme risk of refeeding syndrome with evidence of cardiac or neurological dysfunction (e.g. haemodynamic compromise, cardia failure, Electrocardiography (ECG) abnormalities, decreased conscious state) or profound metabolic disturbance (e.g. severe hypoglycaemia), should be referred to High Dependency Unit(HDU)/Coronary Care Unit (CCU) for monitoring.

Consultation with a senior clinician is strongly advised as it can be difficult to decide whether a patient meets criterion for medical admission, especially if the patient is uncooperative or lacks insight into their illness. Clinical judgment regarding the best clinical setting should always be exercised, although when in doubt admission to hospital is the recommended action.

Indicators for Referral from the Emergency Department to Community CareIf the patient is medically and psychologically stable, does not meet criteria for hospital admission, and has the support of their General Practitioner (GP), a patient should considered for referral to a community eating disorder service (e.g. ACT Eating Disorder Service, Philip Health Centre, T: 62051519), local dietitian and/or the local Mental Health Team.

A phone call to the patient’s GP is strongly advised.

The recommended approach for community care for people with an eating disorder is multidisciplinary coordinated care, involving the GP and including other medical specialists, psychological and dietetic health professionals with others professionals included as indicated.


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Table 2: Indicators for Admission based on Re-feeding RiskRE-FEEDING RISK HIGH EXTREME

Weight Body Mass Index (BMI) < 16kg/m2

BMI < 14kg/m2

Weight loss > 10% body weight loss within the last 3-6 months or ≥1 kg/week over several weeks

Oral Intake Little or no nutritional intake for > 5 days (<500 kcal, or 50 g carbohydrate/d)& underweight (BMI <18.5kg/m2)

Systolic BP < 90mmHg < 80mmHgPostural BP >10mmHg drop when standing >20mmHg drop when standingHeart Rate < 40bpm or >110bpm or significant

postural tachycardia (> 10bpm when standing)

Temperature <35.5°C <35°C or extremities are cold and blueECG findings Any arrhythmia including QTc

prolongation or non-specific ST or T wave changes including inversion or

biphasic wavesBlood sugar <3.5mmol/L <2.5mol/L

Sodium <130mmol/L <125mmol/LPotassium <3.5mmol/L <3.0mmol/L

Magnesium 0.7 – 1.0mmol/L <0.7mmol/LPhosphate 0.8mmol/L <0.8mmol/L

Albumin <35g/L <30g/LLiver enzymes Mildly elevated Markedly elevated (aspartate

transaminase (AST) or alanine transaminase (ALT)>500)

Neutrophils <2.0 x109/L <1.0x109/LSeverity of Eating

disorder Symptoms- Bulimia nervosa (BN) without control of vomiting- Vomiting more than 4 times per day- BN with hypokalaemia- Excessive daily laxative use

Risk Assessment - Suicidal ideation- Active self-harm- Moderate to high agitation and distress- Other psychiatric condition requiring hospitalisation

Other - Not responding to outpatient treatment- Averse family relationships or severe family stress

Note: any biochemical abnormality that has not responded to adequate replacement within the first 24 hours of admission should be reviewed by a medical registrar urgently


Section 3 – Refusal of Care

Refusal of care will occur frequently. In the situation where a patient has an acute and potentially life threatening illness, a decision must be made regarding the degree to which


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the patient can be involved in the medical decision making process (i.e. by evaluating their decision-making capacity). Involvement of a psychiatrist is advisable at this point.

The following hospital policies are relevant: Consent and Treatment Policy Emergency Detention in the Inpatient Setting and a Person’s Rights Under the Mental

Health Act Procedure Care of Persons Subject to Psychiatric Treatment Orders Procedure

Aspects about decision making capacity from the Mental Health Act 2015 (The Act)

Note: A person with a mental disorder or mental illness is assumed to have decision-making capacity, unless it is established otherwise.

Under The Act, a person has capacity to make a decision in relation to their treatment, care or support for a mental disorder or mental illness (decision-making capacity) if they can (with assistance if needed): a) understand when a decision about treatment, care or support for the person needs to be

made; and b) understand the facts that relate to the decision; andc) understand the main choices available to the person in relation to the decision; andd) weigh up the consequences of the main choices; ande) understand how the consequences affect the person; andf) on the basis of paragraphs (a) to (e), make the decision; and g) communicate the decision in whatever way the person can.

In considering a person’s decision-making capacity under The Act, the following principles must be taken into account: a) a person’s decision-making capacity is particular to the decision that the person is to

make;b) a person must be assumed to have decision-making capacity, unless it is established that

the person does not have decision-making capacity;c) a person who does not have decision-making capacity must always be supported to

make decisions about the person’s treatment, care or support to the best of the person’s ability;

d) a person must not be treated as not having decision-making capacity unless all practicable steps to assist the person to make decisions have been taken;

e) a person must not be treated as not having decision-making capacity only because—i. the person makes an unwise decision; orii. the person has impaired decision-making capacity under another Act, or in relation to

another decision;


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f) a person must not be treated as having decision-making capacity to consent to the provision of treatment, care or support only because the person complies with the provision of the treatment, care or support;

g) a person who moves between having and not having decision-making capacity must, if reasonably practicable, be given the opportunity to consider matters requiring a decision at a time when the person has decision-making capacity.

A person’s decision-making capacity must always be taken into account in deciding treatment, care or support, unless The Act expressly provides otherwise.An act done, or decision made, under The Act for a person who does not have decision-making capacity must be done in the person’s best interests.

Detention or treatment under the Mental Health Act 2015:In life threatening situations where a patient with an eating disorder refuses treatment, enforced treatment for physical illness can be initiated under duty of care provisions (e.g. Intravenous (IV) fluids, blood tests). For patients with non-life threatening illness who are refusing care, it may become necessary to utilise the Mental Health Act 2015 to enable ongoing medical care and/or apply for Emergency Guardianship.

Patients may be detained under the Mental Health Act 2015 (first on an Emergency Action [EA]/Emergency Detention), then under an ED3/11) under specific circumstances:

Emergency Action/Emergency Detention (green form): If a doctor believes on reasonable grounds that a person attending an approved mental health facility (voluntarily or otherwise) is a person to whom the following criteria apply, the doctor may detain the person at the facility: The person has a mental disorder or mental illness; and either the person requires immediate treatment, care or support; or the person’s condition will deteriorate within 3 days to such an extent that the person

would require immediate treatment, care or support; and the person has refused to receive that treatment, care or support; and detention is necessary for the person’s health or safety, social or financial wellbeing, or

for the protection of someone else or the public; and Adequate treatment, care or support cannot be provided in a less restrictive

environment.

ED3 (blue form): Involuntary detention of a person at an approved mental health facility may be authorised for an initial period not exceeding 3 days, on the basis of that:1. the person requires immediate treatment, care or support; and2. the person has refused to receive that treatment, care or support; and3. detention is necessary for the person’s health or safety, social or financial wellbeing, or

for the protection of someone else or the public; and4. adequate treatment, care or support cannot be provided in a less restrictive

environment.


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This can be extended by a further 11 days (ED11) before proceeding to a Psychiatric treatment orders (PTO)/Community care orders (CCO).

Note: No treatment for physical illnesses can be provided under these Emergency orders. Such treatment must be provided under duty of care if this is applicable, otherwise a PTO/CCO needs to be applied for with the specific request for such treatment to be authorised.

Psychiatric treatment orders /Community Care Orders:If a person has a mental illness or mental disorder and is refusing consent to treatment or refusing to receive the treatment, PTO (for mental illness) or CCO (for mental disorders) can be applied for under specific circumstances. Please refer to Mental Health Act 2015 for more information. Eating disorders may fulfil these criteria, and refeeding may constitute appropriate treatment that may be covered by psychiatric or community treatment orders.The ACT Civil & Administrative Tribunal (ACAT) may authorise a person/s (i.e. the “Guardian”) to make decisions on behalf of an adult person (≥18 years) whose decision making ability is impaired. A Guardian can give consent for a medical procedure (e.g. Nasogastric (NG) tube insertion) or other treatment (e.g. enteral feeds). Certain prescribed medical procedures cannot be consented to by a Guardian (generally related to reproductive health). The Guardian also cannot consent to use of restraints (e.g. chemical or physical) but if sedation is required to manage agitation (for example), medical practitioners can invoke Duty of Care provisions.

Emergency Guardianship orders to appoint the Public Advocate as Guardian for a period of 10 days can be made between 8.45am and 4.45pm Monday to Friday.


Section 4 – Management of an inpatient admission

Multi-disciplinary team management of the patient should commence immediately. The team should consist of: Medical and nursing staff Dietitian with specialist knowledge in eating disorders, preferably within a nutrition

support team Consultation Liaison Psychiatry team Clinical psychologist Social worker Physiotherapist Gastroenterologist (as required) General Practitioner Family members.

Goals of Admission


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The Goals of Admission should be discussed with the patient and documented at the beginning of every admission. Ideally this discussion has commenced in the outpatient setting prior to admission.

If a patient presents with a low BMI, restoration of a normal weight is unlikely within one admission.

The goals of a medical inpatient admission should include: Treating medical complications and restoring medical stability (including bone,

endocrine, and cardiovascular health). Beginning the process of nutritional rehabilitation to increase the patients BMI to a safer

level whilst avoiding refeeding syndrome. Reducing acute purging or other eating disorder behaviours sufficient to restore medical

and behavioural stability. Aiming for sufficient normalisation of eating disorder behaviours that allows transition

to a less restrictive treatment environment (day program, intensive outpatient, hospital in the home).

Providing appropriate psychological support during the inpatient stay and ensuring continuity of care whilst transitioning into the community on discharge.

Managing family concerns.


Section 5 – Principles of inpatient ward management

General Approach A consistent multi-disciplinary team approach is essential to minimise the potential for

splitting between patient and individual members of the team. A clear plan for the purpose of admission and what medical risk factors are present will

assist to identify restrictions that may be put in place e.g. physical activity. Collaborative application of the care plan involving the patient and, wherever possible

and appropriate, the family and carers. Patients with eating disorders require a firm, but understanding, non-judgmental, and

non-punitive approach to management. Opportunities for debriefing, discussing adherence to the care plan, and discussing

strategies for distress tolerance techniques for staff and patient need to be frequently available. The Clinical Psychology Department (extension 43373) can support staff in this regard.

Physical activity: Limiting physical activity on the ward is important from time of admission as it is harder

to enforce as admission progresses. The amount of physical activity allowed/permitted will be dependent on the medical

stability of the patient. The amount and frequency of activity should be clearly identified and timed e.g. 10

minute walk around ward 3 times per day.


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The amount of exercise can be increased with weight gain, and should be reduced if there is weight loss or lack of progress.

Ward Leave: If medically stable, the patient may be granted leave from the ward. Leave should be for a set period of time:

o The patient should be in a wheel chair (if medically necessary or activity is to be reduced) and

o Accompanied by family, a carer or friends. Those accompanying the patient should be informed and clear about the patient’s care plan.

Supervision Supervision is a priority as any unobserved time can be used for purging food or exercise

(including excessive fidgeting or moving about whilst on bed rest, for example sit-ups) including time in bathroom and shower. When supervision is limited, locating the patient as close to the nurse station as possible is ideal (supervision and bed rest are strongly advised post-meal as outlined in nursing management).

Managing Family ConcernsIt is important for staff to be aware and sensitive to families and carers, as this is a highly stressful and distressing experience for all involved. Families will require large amounts of consistent and reliable information, with frequent updates. A nominated multidisciplinary team member should be the contact person for the family/carers.

Treatment agreement: It is recommended that a “treatment agreement” be developed for each patient that

clearly specifies aspects of care to be provided on the ward:o Goals of admissiono Activity restrictionso Levels of supervisiono Access to bathroom / toileto Management of challenging behaviours (e.g. purging, tampering with naso-gastric

feeds, conflict with staff, etc.)o Meal support and supervisiono Helpful/unhelpful phraseso Leave arrangements (i.e. gate leave).

An example of a Treatment Agreement is provided in Attachment 2.


Section 6 – Structure of an inpatient admission

Patients admitted to the General Medical Unit for management of an eating disorder will follow a structure timeline of processes as outlined in Figure 1 and Table 3.


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Figure 1: Structure of a Medical Admission for Patients with an Eating disorder

Table 3: Medical Admission Processes Stage of Admission Key Processes

Referral to Hospital Liaison between community treatment team and

General Medicine service at CHHS to organise elective vs. emergency admission

Medical Admission and Multi-disciplinary

Assessments

Medical and allied health assessments within 24 hours of admission

Multidisciplinary team (MDT) Goal setting meeting within 48 hrs of admission

Treatment Agreement signed by patient and team

Ward management

Daily ward rounds Weekly MDT meetings with patient Supervised meal times Twice weekly weights Blood tests and other investigations as required

Discharge Planning Must commence soon after admission Involve key stakeholders in community Discussed at weekly MDT meeting Follow up plan must be clearly defined

Discharge to Community or Appropriate facility

Liaison between community treatment team and General Medicine service

+/- Ongoing review at General Medicine Outpatients


Section 7 – Medical Management

Table 4 summarises the medical management of a patient with eating disorders in terms of required observations, investigations, supplements and electrolyte replacement.


Elective referral from Community

orEmergency

Department presentation

Medical Admission

& Multi-

disciplinary assessments

Ward management

Discharge Planning

Community management

or Transfer to

Appropriate Facility

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Monitoring Admission bloods : Full blood count (FBE), renal and liver function tests, calcium,

phosphate and magnesium (CMP), Vitamin B12, Folate, Thyroid Function Test (TFT), Vitamin D. If BMI<14: add Zinc, Selenium, Copper

BMI > 12: The patient should have daily clinical monitoring and blood tests for at least the first 7 days of re-feeding, including: renal function (electrolytes, urea and creatinine (EUC)), FBE, CMP, Liver Function Tests (LFT) and ECG - and be monitored for at least 2 weeks following, even if normal.

BMI < 12: Twice daily clinical and biochemical monitoring and ECGs for the first 5 days. Blood Glucose Levels (BGL) four times a day (QID) for extreme risk of re-feeding patients

— early morning, and 1–2 hrs after meals, as low glycogen stores and an abnormal insulin response may lead to post-meal low BGLs, and low BGLs in the morning/overnight. Hypoglycaemia (<3.0mmol/L) may also indicate occult infection.

From day 8, second daily bloods should be undertaken until goal energy intake is reached.

ECG should be performed on admission – if abnormal, refer the patient to HDU/CCU for continuous ECG monitoring. Daily ECGs should be performed for the first week.

The management plan needs to be discussed with the patient and support person at the initial and subsequent MDT meetings. This plan should be documented clearly (See Weekly Management Plan (Attachment 1)

Supplementation Commence prophylactic supplementation immediately: thiamine 100mg twice daily

orally, or if unable to take orally, then IV or via naso-gastric tube for first 3 days, then oral administration thereafter.

1 tablet of multivitamins twice a day (bd); 1 tablet zinc sulphate 50mg daily; and 1 tablet Phosphate-Sandoz 500mg bd (or equivalent) (some patients may require IV supplementation).

Hypoglycaemic episodes often occur in the early re-feeding stage of severely malnourished clients and/or with occult infection. Low BGLs (<4.0mmol/l) should be managed with appropriate simple oral carbohydrate (e.g. sugar in orange juice) and MUST be accompanied by a slow acting carbohydrate with protein (e.g. one of the following: Fortisip 200ml bottle/Sandwich with protein filling, to be given at the same time.

If IV dextrose (≥5%) is required to correct profound or persistent hypoglycaemia, it must be accompanied by IV thiamine (100mg) replacement administered prior or simultaneously.

Other Bowels – ask about bowel habits and manage constipation (use a stool softener e.g.

lactulose rather than a laxative/stimulant) Venous Thromboembolism (VTE) Prophylaxis - Commence VTE prophylaxis if patient

restricted to bed and/or extreme refeeding risk (BMI < 14), as per the Venous Thromboembolism prevention procedure found on the policy register.


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Table 4: Medical Management Chart

Admission day Day 1 - 7 Day 8 - 14 Day 15 +

Ward RoundsCompliance with Meal Plan

Palpitations, SyncopeBloating, pedal oedema

Purging behaviourExercise / Activities

Bowel habitsMental state

Compliance with Meal PlanPurging behaviourExercise / Activities

Bowel habitsMental state

ObservationsRoutine Observations QID

+/- Cardiac monitoring if ECG changesWeight & Height on admission

Stool chart

Routine Observations QIDSupervised Meals

Weight (Mon / Thurs morning)Stool chart

InvestigationsOn admission:

FBE, UEC, CMP, LFT, BGL Vitamin B12, Folate, TFTs, Vitamin D,

Zinc, Selenium, Copper (BMI < 14)

Investigations*:FBE, EUC, CMP, LFT

QID BGL (extreme risk of re-feeding)Daily ECG

Alternate day bloods:

FBE, EUC, CMP, LFT

Less frequent bloods and BGLs may be appropriate later in the admission (e.g. twice weekly depending on progress)

SupplementsCommence the following prophylactic supplementation on admission

(Oral if tolerated otherwise via NG or IV):Thiamine 100mg BD Multivitamin 1 tab BDZinc Sulphate 50mg daily Sandoz Phosphate 500mg BDStool softener (e.g. lactulose) if reporting constipation or sluggish bowelsVTE Prophylaxis

Further Replacement

IV dextrose must be accompanied by IV thiamine and phosphate administered simultaneously

Potassium, Magnesium and Phosphate should be immediately replaced (IV/NG/PO) if found to be low

* Twice daily UEC, CMP if admission BMI < 12


Section 8 – Recognising and managing refeeding syndrome

Prompt referral to the clinical dietitian should be made before beginning a refeeding regime. The dietitian can assist in determining whether oral or NG feeding is recommended.

Refeeding Syndrome is the term used to describe the adverse metabolic effects and clinical complications when a starved or seriously malnourished individual commences refeeding. If nutrition is not managed carefully, a variety of detrimental effects can occur including: o sensory disturbances, confusion, depression, irritability o glucose intolerance, hyperglycaemia, polyuria


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o impaired muscle contraction (including heart, respiratory and gastrointestinal muscles)

o neuromuscular weakness o reduced oxygenation of tissues, ventilation difficulties o cardiac arrhythmias o cardiac arrest.

Confusion (delirium) is often the first sign, accompanied by chest pains, muscle weakness, and then heart failure.

Avoidance of the syndrome can be achieved by prophylactic supplementation of phosphate, thiamine and multivitamins along with gradually increasing nutritional intake beginning with a nutritionally balanced diet, adequate in protein and fat content.

Managing risk of refeeding syndrome must be balanced against risk of under-feeding the patient; adequate nutritional supplements along with fat and protein in the diet, should mitigate the risk of refeeding syndrome so as not to have to slow the feeding rate too much.

Monitor markers of possible refeeding syndrome via clinical observations twice daily and biochemical review daily (EUC, CMP, ECG).

Avoidance of refeeding syndrome can also be assisted by reducing carbohydrate calories and increasing supplementation of phosphate as directed by the dietitian.

Enteral feeding via NG tube is recommended for all inpatients identified at extreme risk of refeeding syndrome with BMI <14kg/m2 (Table 2) as nutrition can be provided at a gradual rate via continuous pump feeding. NG feeding is also recommended for inpatients identified at high risk of refeeding syndrome who have known issues around compliance with meal plan. The dietitian will provide guidance on feeding rates and progression throughout admission. NG feeding may not be required for duration of admission but can be an important intervention for managing refeeding period.

Minor or even moderate abnormalities in liver function (e.g. ALT up to four times the upper limit of the normal range) should not delay gradual increases in feeding.

Patients may need to be referred to a High Dependency Care service for monitoring if evidence of cardiac or neurological decompensation.


Section 9 – Nutritional management

Initial Assessment On admission Dietitian should conduct a complete nutrition assessment including

Patient Generated Subjective Global Assessment (PG-SGA) and then liaise with MDT to identify severity of risk of refeeding syndrome and nutrition intervention recommendations.

Patients should be initially commenced on the Anorexia Admission Diet (3500kJ/day) until nutrition assessment and management plan can be discussed with medical team.

Dietitian should ensure medical management of risk of refeeding syndrome (as detailed above) is in place before starting oral or enteral feeding plan.


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Basal Metabolic Rate (BMR) can be determined via Schofield equations or estimation equations according to clinical conditions (e.g. 84-125kJ/kg/day).

Commencing NutritionFor patients with BMI ≤12kg/m2 on admission. Patients admitted with BMI ≤12kg/m2 and any other indicator for extreme risk of

refeeding syndrome as indicated in Table 2 should be commenced with lower energy value as 21-42kJ/kg/day.

Recommend initial nutrition provided solely via 24 hour continuous NG tube feeding (using 4.2kJ/ml, fibre free formula) for the first 2-4 days to assist in managing refeeding syndrome.

Clinical and biochemical review should occur twice daily and enteral feed should be increased in steps to reach BMR within 2-7 days unless there is a contraindication.

Fluid intake recommendations are maximum 30-35ml/kg/24 hours of fluid from all sources as refeeding oedema is well recognised.

Once clinically and biochemically stable with energy intake at BMR recommend progress to overnight feeds as 50ml/hr x 12 hours overnight between 18.00-06.00 (providing approximately 2500kJ/day) as part of set meal plan for nutrition repletion (detailed in Section 9.3).

For patients with BMI 12-14kg/m2 on admission. Patients should commence with NG feeding if admitted with BMI 12-14kg/m2 and any

one other indicator for extreme risk of refeeding syndrome as indicated in Table 2 OR have BMI 14-16kg/m2 with more than one indicator for extreme risk of refeeding syndrome. The patient should be educated as to the need of NG feeding and consent granted prior to NG tube insertion. Patient refusal should be discussed with medical team and Consultation Liaison Psychiatry team as psychiatric treatment orders may be required.

Recommend commence with 42-63kJ/kg/day via 24 hour NG feeding (using 4.2kJ/ml, fibre free formula) and (if possible) continued anorexia admission set diet (estimate patient likely to consume 50-75% or approximately 1750-2500kJ/day).

Note: Patients should commence on kJ value equivalent to preadmission nutritional intake if higher than 63kJ/kg/d.

Increase energy intake daily if electrolytes are within reference ranges and no clinical symptoms of refeeding syndrome present. Aim to reach BMR in 2-7 days.

Fluid intake may need to be restricted to estimated fluid requirements (30-40ml/kg/day) from all sources if oedema develops.

Once clinically and biochemically stable with energy intake at BMR recommend progress to overnight feeds as 50ml/hr x 12 hours overnight between 18.00-06.00 (providing approximately 2500kJ/day) as part of set meal plan for nutrition repletion (detailed in Section 9.3).


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For patients with BMI >14kg/m2 on admission. Patients admitted with BMI >14kg/m2 and no indicators for extreme risk of refeeding

syndrome as indicated in Table 2 should initially commence with oral meal plan. However some patients will require NG feeding for optimal treatment if compliance with oral meal plan fails.

Commence with set meal plan closest to approximately 84-105kJ/kg/day OR kJ value equivalent to preadmission intake if higher than 105kJ/kg/day (as detailed in section 9.3).

Nutrition Repletion Set meal plans of varying energy values are used to ensure oral intake is nutritionally

balanced to support oral intake in line with the Australian Guide to Healthy Eating for Adults. Set meal plans can also assist in managing eating disorder behaviours and anxiety.

Meal plans consist of 3 main meals +/- 3 snacks and it is the dietitian’s role to order meals and snacks through ‘MyMeal’ integrated food service management system.

Patients may request 2 dislikes of single food/drink items which will not be included in the meal plans.

Restrictive diets (e.g. vegetarian) can only be accommodated if there is evidence they were followed prior diagnosis of the eating disorder.

Set meal plans available include:o Anorexia admission meal plan (3500kJ)o Meal plan 1 (5000kJ) +/- enteral feeds (2500kJ) o Meal plan 2 (7000kJ) +/- enteral feeds (2500kJ) o Meal plan 3 (9,000kJ) +/- enteral feeds (2500kJ)o Meal plan 4 (11,000kJ) +/- enteral feeds (2500kJ)o Meal plan 5 (13,000kJ) +/- enteral feeds (2500kJ)o Copies of meal plans are saved in nutrition department shared electronic drive.

Bolus feeds (1.5kJ/ml oral nutrition supplement) are to be given if the meal plan is not able to be consumed as specified. Patients are to be offered the chance to drink the bolus first, with use of NG tube only if they refuse or are unable to consume the volume required. Volumes vary according to amount of meal consumed: o If patient consumes <50% of the main meal, to be given a full bolus.o If patient consumes >50% but <100% of the main meal, to be given a half bolus.o If patient consumes <100% of a prescribed snack, to be given a full bolus.

Boluses may be slightly larger than the energy content of some meals/snacks as they are intended to act as an incentive to meet their nutrition needs orally.

Dietitian should coordinate the patient to progress to higher kJ value set meal plans once or twice weekly until reach kJ value required to achieve consistent weight gain of 0.5-1kg per week (additional 4200kJ/d required to achieve weight gain). Further progress to higher kJ meal plans may be required throughout admission as weight/mobility increases to maintain weight gain.

Dietitian may consider ceasing overnight NG feeding if patient is achieving weight gain, compliant with oral meal plan, and is not experiencing symptoms of refeeding syndrome.


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Dietitian may consider removing NG tube if patient is medically stable, consistently achieving weight gain, demonstrating consistent compliance with meal plan orally, and patient is progressing towards discharge/transfer to appropriate specialised eating disorder service.

Table 5: Summary of Nutritional Management

Nutrition commencement pathway according to refeeding syndrome management requirementsSeverity of risk of refeeding syndrome

BMI ≤12kg/m2 + any other extreme risk indicator

BMI 12-14kg/m2 & any other extreme risk indicator OR BMI 14-16kg/m2 with >1 indicator for extreme risk of

BMI >14kg/m2 & no indicators for extreme risk of refeeding syndrome

Starting energy Intake 21-42kJ/kg/day 42-63kJ/kg/day 84-105kJ/kg/day OR kJ value equivalent to preadmission intake if higher

Nutrition provision method

24 hour NG feeding only for first 2-4 days then consider oral anorexia admission diet (if possible)

24 hour NG feeding & (if possible) oral anorexia admission diet

Oral set meal plan

Frequency to progress energy intake

Increase feeding rate twice daily (12 hourly) if biochemistry and clinical symptoms allow

Increase feeding rate daily if biochemistry and clinical symptoms allow

Time frame to reach BMR

Within 2-7 days unless contraindicated Usually immediately or within 2 days

Fluid Recommendations

Restrict to 30-35ml/kg/24 hours

If oedema develops restrict to 30-40mL/mg/day

Transition to nutrition repletion phase (when clinically & biochemically stable)

Change to overnight feeds as 50ml/hr x 12 hours between 18.00-06.00 Progress to higher kJ value meal plans 1-2 times/week until reach desired weight gain 0.5-1.0kg/week.

Explain meal plans to patients, offer the patient a copy, discuss dislikes, and ensure nursing staff are aware of meal plan and supplemental bolus requirements.


Section 10 – Managing Enteral Nutrition via Nasogastric Feeding

Refer to Nasogastric Tube Management Guideline on the policy register for insertion. NG feeding and resultant weight gain will likely be a source of great anxiety for the

patient and may result in sabotaging behaviour as weight increases. 1:1 nursing ensures that the patient does not sabotage NG feeding. A lockable pump is preferred to prevent patients from switching off the device or altering

the settings.


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The NG tubing should be visible to nursing staff at all times, not covered by clothing or bed linen; this will prevent kinking or holes being put into the tube.

Encourage distraction activities or offer medication to assist with anxiety. Inspect tube at the start and end of the feed. Make sure no syringes are left in the patient’s room unattended, even in another

patient’s cubicle. Access to bathroom/ sinks should be discouraged to prevent syphoning off feeds down

drains (bathrooms should be locked and the patient needs to request to use facilities as needed, with the door kept open whilst toileting).

Feed times are often highly anxiety-provoking and distressing for the patient and therefore encouragement, understanding, firm management of boundaries and assistance with distress tolerance will be needed.


Section 11 – Nursing Management

Engage with the patient, and build a trusting relationship. Provide information as often as required (memory and cognition are both affected by starvation). Provide support and encouragement to the patient during the difficult process of early nutritional rehabilitation. Enforce care plan with compassion and be firm without being punitive.

Distress in eating disorder patients at this stage of treatment is normal. The patients are being exposed to food multiple times a day in quantities they have avoided for a long time. Nursing staff will need to teach the patient skills in tolerating and managing this distress.

For the patient’s family and carers an inpatient admission is often a stressful and distressing time. It will be natural for the family to be sympathetic to the appeals from their loved one for an alteration in treatment plan. It can be helpful to involve the family as much as possible in understanding the care plan, the rationale for it, and the clinical milestones needed. Provide the family with a copy of the care plan, wherever possible. It can be helpful to arrange for a family member to attend a portion of ward round each week to reduce splitting.

In general leave from the ward is not granted due to medical risk, and when appropriate monitor leave as per care plan carefully.

On admission the patient’s belongings should be searched for laxatives, diuretics, diet pills, chewing gum, water bottles, and small weights. The patient’s personal belongings should be searched again after any leave from the ward.

Observations should be taken 4 hourly until stable for a minimum of 72 hours. Then they should they be changed to QID.

The patient should have QID lying & standing blood pressure. Nursing staff should call for a clinical review or activate a local rapid response if: o Pulse is below 60 o Temperature below 35.5oco Systolic BP below 90mmHg o Significant postural drop of more than 10mmHg


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The patients BGL should be taken QID, for the first 5 days of admission. Suggested BGL times are 0400, and 1–2 hrs post each main meal. Treat blood glucose levels of <4.0mmol/l as per Medical Management Supplementation (page 13).

The patient should have a daily ECG initially and continue with daily ECG until medical stability maintained for a minimum of 72 hours.

Record the following in the patients clinical notes:o Weight: Measure and record, weight, & urine specific gravity the morning after

admission at 6.30am after voiding, and repeat each Monday and Thursday as per Guidelines for Weighing (below)

o Height (on admission only): Check patient is standing at full height o Bowel chart: record bowel activity (or lack of) daily as patient may have reduced gut

motility (they may find this distressing and want to reduce eating and will need encouragement, and support, explaining continued eating is the only way to resolve discomfort)

o Intake: Record all offered intake as well as all consumed food & fluids. Check all meals against the meal plan; patient should not be allowed to choose meal from the meal plan at this stage (see nutritional management plan)

Request family members to assist with the management plan, by NOT bringing in food and medications (e.g. laxatives) from home or allowing patient to exercise.

The patient needs to be monitored for eating disorder behaviours: o Visually observe the patient at least every 60 minutes. o Watch for the patient completing exercise, vomiting, chewing or spitting o It is often more effective particularly on medical wards to provide 1:1 constant

supervision. o Rooming the patient in a shared room (rather than single room) – if possible position

the patient closer to the door to increase staff observation. Ensure the patient sticks to the limited physical activity as per treatment plan (the

patient may require bed rest to reduce energy expenditure). The patient will require support at meals and post meals e.g. crosswords, puzzles for

distraction. The patient needs to access the toilet prior to meals (encourage patients to use

bathroom before meals as access after will be denied for one hour after meals). When risk is high, supervision is required during toileting and shower use to reduce opportunities for purging behaviour(s) and or laxatives/diuretics use. Lock any bathroom ensuites and restrict the patient to using the ward toilet.

Manage any constipation with education regarding the biological factors that influence this including inadequate food intake, lack of dietary fibre and fluid restriction. Use stool softeners with caution and only when clinically indicated. Do not allow laxatives to be brought from home.

Inappropriate fluid intake: o Monitor fluid intake for under or over drinking o If possible provide supervision during and after meals to observe and record intake.

Meal Management Only food prescribed by the dietitian is to be consumed.


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Supervised mealtimes are recommended. Meal tray items should be observed by nursing staff prior to the patient starting the meal and tray should be removed from the room promptly at the end of the meal to avoid patient tampering with items.

All food eaten (type and portion) is to be recorded on food chart by supervising nursing staff familiar to the patient.

Time allowed to complete meals/ snacks is to be decided by the care team and enforced by supervising staff, and documented clearly on the treatment plan.

Uneaten food is to be replaced with a supplement NG bolus (as directed by dietitian/clinician).

Bed rest or supervised quiet time for 1 hour after meals and snacks is required. No bathroom access for 1 hour post meals. Direct patients to use bathroom before meal. As eating is often highly distressing for the patient, distraction methods (e.g.

conversation), gentle encouragement, and enforcement of boundaries during the meal, and distress tolerance assistance post-meals is almost always needed.

Managing weighing Weighing is non-negotiable. Patients should be weighed wearing a hospital gown with underwear only and hair

accessories removed, on consistent predetermined days (Monday and Thursday) using the same scales each time

Patients are weighed in the morning prior to breakfast and after having emptied their bladder.

If you suspect the weight has been falsified (water loading, salt loading, secreting weights in underwear, and/or bra) share concerns with team and document. In this instance a ‘spot weight’ should be conducted. This involves weighing the patient at a random time, when they are not expecting to be weighed.

As weighing is often extremely anxiety provoking for the patient, distraction and distress tolerance methods should be utilized (e.g. engaging the patient in light conversation during the weight, encouraging them to do crosswords or knitting etc. afterwards).

In some cases ‘blind weighing’ or the MDT deciding collaboratively with the patient that it may be best for them to not know their weight can be helpful in these early stages of recovery where immediate weight restoration is essential (later exposure to weight and shape as an outpatient will be important). Discussing its advantages with the patients may be important. The team should agree on the weight approach and it be clearly outlined in the progress notes and treatment plan to avoid confusion and splitting. Potentially use the sitting down scales where the patient will not be able to see their weight recording.


Section 12 – Psychological management

Poor motivation and/or inability to engage in therapy because of compromised brain function and neuro-cognitive inefficiencies (e.g. cognitive inflexibility, weak coherence) are often encountered with eating disordered patients and pose particular difficulties for participation in psychotherapy.


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There are a number of treatment options used with adult eating disorder patients. Commonly used approaches are for example Cognitive Behaviour Therapy for Eating Disorders (CBT-E) and Radically Open-Dialectical Behaviour Therapy (RO-DBT). In the case of severe and chronic anorexia nervosa patients, resistance to treatment is often encountered. Clinicians are required to choose the most appropriate approach depending on the individual patient’s needs and level of engagement.

Based on research in the field of eating disorders, Cognitive Remediation Therapy (CRT) and Emotion Skills Training (EST) should be considered as an appropriate approach especially for severely underweight patients in the in-patient setting. CRT was developed as a standalone pre-treatment to target neuro-cognitive inefficiencies whilst engaging severely underweight patients in the process of therapy. It is a non-threatening, non-‘eating focussed’ approach that can be utilised to enable engagement, build rapport and set the foundation for therapy readiness whilst transitioning into the community on discharge.


Section 13 – Discharge Planning and Transition

Discharge needs to be carefully planned with the patient, family and carers, preferably from the outset of admission.

These critically ill patients will require a long treatment trajectory involving numerous treatment settings, of which the inpatient medical admission is only one.

Preparing families or carers and the patient will be important to contain anxiety and set realistic expectations about likely readmissions, the need for ongoing treatment, and outcomes.

Ascertain the local treatment options outside of the inpatient setting and begin referral processes early in the admission. Follow-up with the patient’s GP and local dietitian and psychologist is required at a minimum. It is recommended that the patient’s GP and/or Outpatient service (e.g. Phillip Eating Disorder Program) is invited to the weekly MDT.

Wherever possible, transfer of the patient from the inpatient environment to an intensive day program environment should be arranged to prevent weight loss and rapid readmission, and to consolidate change once outside of hospital. The Phillip Adult Eating Disorder Program offers Day Program to adults 18 years and above. Referral needs to be made prior to discharge as clients may need to be placed on a waiting list. There is limited capacity to take clients with severe and enduring eating disorders or those requiring individual therapy.

Discharge is best avoided on Friday or Saturday when continuity of care in the community is limited. It is ideal if discharge can occur earlier in the week to allow for follow-up appointments with a GP and/or outpatient team for later the same week.

A multidisciplinary meeting should be facilitated to ensure appropriate referrals for community-based care have been made with follow-up appointments scheduled; if transferring to a different medical or psychiatric setting, ensure the team is aware of who is responsible for organising the transfer and writing the discharge summary.


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With the permission of the patient, family, carers or support can be invited to the discharge planning meeting.

An outpatient appointment with the General Medicine Clinic at CHHS should be arranged 1-2 weeks post discharge for follow up of blood tests and other outstanding investigations, nutritional and hydration status. The General Medicine clinic will make follow up appointments and liaise with community supports (e.g. GP and community eating disorders services).

Consider discharge to Hospital in the Home (HITH) if other arrangements for post-admission follow up are not available or suitable. This should be a time-limited arrangement (e.g. 2-4 weeks) with the purpose of transitioning care to community services and weight stabilisation. CHHS dietetics and psychology services may be able to support patients discharged via HITH on a case-by-case basis with the aim of preventing rapid relapse and to support transition out of hospital. The General Medicine Advanced trainee will continue to manage these patients in HITH with the assistance of the HITH Advanced Trainee. Clear weekly goal setting is required.

Consider transfer to HITH program if the patient meets the following circumstances:o ACT Resident.o Not suitable and/or able for prompt follow up by Phillip Eating Disorder Service or

private providers (e.g. GP, dietitian, psychologist).o Patient agreeable to at least weekly review in HITH for weight measurement, blood

tests and medical review.o Patients requiring NG feeding on an ongoing basis are not contra-indicated from

admission with HITH although this should be discussed on a case-by-case basis depending on feasibility and home supports.

o Haemodynamically stable.



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Implementation

This guideline will be available to all staff on the CHHS policy register. A copy of this guideline will be placed in the patient clinical folder during admissions. It

will also be used for training of staff on Ward 7B General Medicine including nursing, medical and allied health staff.

This protocol is to be used more generally if patients with eating disorders requiring medical stabilisation are admitted to other CHHS medical wards.


Related Policies, Procedures, Guidelines and Legislation

Policies Health Directorate Nursing and Midwifery Continuing Competence Policy CHHS Patient Identification and Procedure Matching Policy Consent and Treatment Policy Emergency Detention in the Inpatient Setting and a Person’s Rights Under the Mental


Procedures CHHS Healthcare Associated Infections Clinical Procedure CHHS Patient Identification and Procedure Matching Procedure Nasogastric Tube Management Procedure Emergency Detention in the Inpatient Setting and a Person’s Rights Under the Mental


Guidelines CHHS Fasting Guidelines – Elective and Emergency Surgery

Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004 Mental Health Act 2015 Guardianship and Management of Property Act 1991



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References

1. Royal Colleges of Psychiatrists. MARSIPAN: Management of Really Sick Patients with Anorexia Nervosa. 2nd Edition. October 2014. Accessed: 27 September 2017 http://www.rcpsych.ac.uk/files/pdfversion/CR189.pdf

2. CEDD. Guidelines for the Inpatient Management of Adult Eating Disorders in General Medical and Psychiatric Settings in NSW. Centre for Eating and Dieting Disorders. NSW Ministry of Health. 2014. Accessed: 27 September 2017 http://cedd.org.au/wordpress/wp-content/uploads/2014/09/Guidelines-for-the-Inpatient-Management-of-Adult-Eating-Disorders-in-General-Medical-and-Psyciatric-Settings-in-NSW-Developed-by-Centre-for-Eating-Dieting-Disorders-2014.pdf


Definition of Terms

Mental disorder—a) means a disturbance or defect, to a substantially disabling degree, of perceptual

interpretation, comprehension, reasoning, learning, judgment, memory, motivation or emotion; but

b) does not include a condition that is a mental illness.

Mental illness means a condition that seriously impairs (either temporarily or permanently) the mental functioning of a person in 1 or more areas of thought, mood, volition, perception, orientation or memory, and is characterised by—a) the presence of at least 1 of the following symptoms:

i. delusions;ii. hallucinations;iii. serious disorders of streams of thought;iv. serious disorders of thought form;v. serious disturbance of mood; or

b) sustained or repeated irrational behaviour that may be taken to indicate the presence of at least 1 of the symptoms mentioned in paragraph (a).

Re-feeding Syndrome is the term used to describe the adverse metabolic effects and clinical complications when a starved or seriously malnourished individual commences refeeding.

AbbreviationsFBC = Full blood countEUC = Electrolytes, Urea and CreatinineLFT = liver function testsMg = MagnesiumECG = electrocardiogramTFTs = Thyroid Function Tests


http://cedd.org.au/wordpress/wp-content/uploads/2014/09/Guidelines-for-the-Inpatient-Management-of-Adult-Eating-Disorders-in-General-Medical-and-Psyciatric-Settings-in-NSW-Developed-by-Centre-for-Eating-Dieting-Disorders-2014.pdf



http://www.rcpsych.ac.uk/files/pdfversion/CR189.pdf

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Kj – Kilojoule


Search Terms

Eating disorder, Refeeding syndrome, Anorexia, anorexia nervosa, Bulimia, Bulimia nervosa, Nasogastric tube, Enteral feeding


Attachments

Attachment 1 – Adult Eating Disorder: Weekly management Plan

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval

This document supersedes the following: Document Number Document Name


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Attachment 1 – Adult Eating Disorder: Weekly management Plan


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