Risk Management in Eating DisordersDr Phil Crockett

Risk Management

• Risk in Eating Disorders-Why Worry?• Risk Assessment vs Risk Management• The Physical, Psychological, Social• Context• Transitions • Communication• Networks and Frameworks• Taking advice• Summary

Risk in Eating Disorders-Why Worry?

• For A.N.: 5-30% long term mortality(Theander, Halmi(1992))

• Difficulties in psychological adjustment up to 50% (Pike, 1998)

• Wide variation outcome-depends on study centre e.g. Korndorfer (2003), Johnson et al (2003) more benign

• Keski-Rahkonen, (2008): Finnish nationwide• N=2880: 5yr recovery 67%

Risk in Eating Disorders-Why Worry?

• B.N. sig psychological impairment and physical morbidity

• AN can:– Sudden death– Cardiac failure– GI bleeds– Sepsis– Suicide

» (Millar,2005)

Risk Assessment vs Risk Management

• Risk Assessment: an estimation of the likelihood of particular adverse events occurring under particular circumstances. Within a specified period of time

• Risk Management: organised attempts to minimise the likelihood of adverse events

Risk Assessment vs Risk Management

• Approaches to risk assessment broadly grouped into ‘clinical’ versus ‘actuarial’ .

• The actuarial approach: clues to broad populations at risk, but informs us inadequately on the individual

• The clinical perspective: “individualised and contextualised assessment” , vulnerable to poor inter-rater reliability and influence of other considerations

• Remember the protective…• Only tells you about the current situation

From Feenay, A

Five-step structured professional judgement approach to Five-step structured professional judgement approach to

risk management risk management (Doyle and Duffy (2006))(Doyle and Duffy (2006)) Step 1:

Step 2 :

Step 3 :

Step 4 :

Step 5:

Case information

History, mental state, substance use, physical parameters

Presence of risk factors

Historical, current, contextual, physical

Presence of protective factors

Historical, current, contextual, physical

Risk formulation

Nature, severity, imminence, likelihood, risk reducing/enhancing

Management plan

Treatment, management, monitoring, supervision,

The Physical• Starvation and Malnutrition

• Other Behaviours

• Co-morbidities and complications

• Self Harm and Suicide

• Re-feeding Syndrome

• Past history and factors

Re-Feeding Syndrome

• The major physical risk of treatment• Cascade of metabolic and electrolyte changes• Hypophosphataemia, hypomagnesaemia,

hypokalaemia major risks• Raised risk with n.g. re-feeding• Very slow initiation feeding• Take advice• “Have you considered re-feeding syndrome”

The Psychological• Depression

• Anxiety

• Personality Disorder

• Obsessionality (OCD)

• Hopelessness and Frustration

• Past history and individual

factors

The Social

• Families and Friends

• Work and studies

• Home environment

• Professionals

• The In-Patient Environment

• The Unexpected

• Past history and factors

Context

• Context always important

• Major influence on risk for individual

• Major influence on judgement of risk

• Part of risk assessment

• Will alter most appropriate course of action

Transitions

• Geographical and Developmental

• Life cycle challenges

• In-patient units

• Travel and relocation

• The Scottish Ombudsmen's Report, 2006

Communication

• Ensuring care plans are a team effort

• Note limitations of them

• Liaison between areas important

• Patients and carers involved

• Recording

Networks

• For patients protective and maladaptive

•A way for professionals to gain guidance

•EDSECT

•MCNs

•Benchmarking and audit

Guidelines and Frameworks• NICE and QIS

• APA

• Specific for context

• Crisis planning

• Consistently reviewed/revised

• CPA/MHA

Taking Advice•Role of the Gastroenterologist/Physician

•Especially when very high risk

•Co-morbidities

•Second opinions and consultations

Conclusions• No simple methods to quantify risk in EDs

• Physical/Psychological complications common including resulting from intervention

• Broad assessment important

• Principles risk assessment/management useful

Conclusions

• Developing appropriate frameworks to the context you are based in

• Applying the guidelines

• Making use of containing networks and maintain communication

• Take advice