Care and treatment of eating disorders - national specification: consultation

Outcome 5: Assessment and Medical Monitoring

Outcome Statement

All individuals have a holistic assessment and where clinically appropriate receive ongoing medical monitoring and management.

Rationale

This outcome is aimed at the generic assessment process within specialist eating disorder services and associated risk assessment and medical monitoring in both primary care and specialist services.

Assessment in specialist eating disorder services should be holistic, covering physical health, mental health (including comorbidities), social factors, and co-occurring considerations. This should be completed by an experienced and appropriately trained clinician. An assessment should not be based on single measures (for example BMI) and instead should identify the full range of eating disorder symptomatology and comprehensively review an individual’s circumstances. Screening tools and physical observations should never be used in isolation to determine whether someone has an eating disorder.

A holistic assessment should result in a shared understanding of the presenting problem and the person’s needs. This will enable a review of available evidence-based treatment options to support the individual in making an informed and collaborative decision about their treatment and care. Assessment is a continuous process and any changes to an individual’s presentation should be monitored and reviewed with care plans regularly updated to reflect current needs.

Assessment in eating disorder services should be proactive using an outreach approach to support engagement. Clinicians should be prepared that they may at times support individuals with some uncertainty about engaging in treatment. Although patients may have a good understanding, reasoning, and appreciation of their illness, the change in values and sense of identity that can result from their illness can impact on decision making. The issue of treatment acceptance and patient autonomy is therefore complex and not static. MEED highlight that the common factors in successful services seem to be cooperation, trust, shared protocols, regular networking, and intensive, proactive (rather than reactive) care (MEED, 2022).

Responsibility for outreach and follow up to support engagement with assessment lies with the service, and clear time frames and service expectations should be set to support this. This approach should be person-centred supporting appropriate service flexibility in times and locations of assessment appointments. As part of this engagement and assessment process, family and carer support can be provided without breaching patient confidentiality and should be offered to families or carers, when appropriate, even if an individual is not accessing services (SIGN, 2022). Peer support workers could also be used as a tool for supporting engagement with treatment for adults with eating disorders.

Medical monitoring refers to both psychiatric and physical health monitoring. It is essential that eating disorder services have the capacity to monitor and manage the physical health of people with eating disorders including having the skills, equipment, and systems required to provide safe and efficient medical monitoring. Along with physical monitoring, it is essential that the clinician assesses risks in psychological and social domains while paying attention to matters of insight, motivation, consent, and the legal framework for intervention. Thus, risk assessment in eating disorders needs to be multidimensional. When a patient is very unwell or highly distressed, they may lack capacity/competence in relation to particular decisions. Also, the nature of the illness and associated eating disorder cognitions may affect the capacity to provide an accurate account of presentation; this can also falsely assure clinicians of risk. Teams should document the nature and level of risk, and the nature of the best interest decision and act to reduce risk and preserve life (MEED, 2022). The need for emergency medical or psychiatric admission for anyone at risk of serious physical complications, suicide or serious self-harm should also be considered.

Initial physical and psychiatric risk assessment in primary care allows specialist eating disorder service to prioritise referrals and for a referrer to indicate the urgency of care that is required. Clear guidance should be in place for primary care based on MEED (2022) and access to consultation with specialist services when required. In some instances, a shared care approach may be used between specialist eating disorder services and primary care. If this has been formally agreed, clear protocols should be in place for medical monitoring based on the detailed guidance supplied by MEED (2022). This protocol should be collaboratively developed at an organisational level including clear documentation of the responsibilities for each service in the undertaking of medical monitoring, checking results, and actioning any escalation that may be required in a timely manner. Clear service protocols should also be in place detailing the process and clinical responsibility for monitoring changes in presentation or risk while an individual is waiting to be assessed or being supported to engage in this process. This should include documenting who holds clinical responsibility at this time, and the associated processes for monitoring changes in presentation and risk. All individuals involved in medical monitoring should have the necessary skills and training to identify monitor and manage eating disorder behaviours, symptomatology, and associated risk.

Primary care practitioners should not be required to hold medical responsibility for significant or severe eating disorders, except where this is appropriate for specific cases in partnership or agreement with specialist medical practitioners.

Outcome in Action

5.1 Holistic assessments are completed by an experienced and appropriately trained clinician.

5.2 Clear service protocols and pathways are in place while an individual is waiting to be assessed or is being supported to engage in this process detailing:

• who holds clinical responsibility, and
• associated processes for monitoring changes in presentation or risk, who is responsible for this and how this is escalated if appropriate.

5.3 Clear clinical practice guidelines for medical monitoring are in place and easily accessible for referrers and clinicians within the service that:

• align with MEED (2022)
• are followed by risk assessment and documented escalation processes, as appropriate, and
• detail potential challenges to accurate risk assessment.

5.4 Where a shared care approach is used between specialist eating disorder services and primary care for ongoing medical monitoring, a clear protocol exists including:

• agreement and documentation of which service holds clinical responsibility, and
• associated expectations for medical monitoring including who undertakes the medical monitoring, checks results, and associated risk assessment. There should be protocols for escalating if required.

5.5 Organisations ensure health care professionals have the necessary training and skills appropriate to their role, responsibilities, and workplace setting, to identify, monitor and manage eating disorder behaviours.

5.6 Organisations ensure that staff have the appropriate skills and competencies to predict and monitor early biochemical signs of refeeding syndrome and how to manage medical risk in line with MEED (2022).

5.7 Organisations ensure services use protocols for refeeding within acute and community settings that emphasise the need to avoid under-nutrition and refeeding syndrome.

5.8 Organisations ensure that there are protocols in place to establish baselines as part of physical health monitoring. Baseline data should be considered in the context of, and following discussion with, the person.

5.9 Patients with purging behaviour, are supported to access regular dental visits for dental monitoring and treatment.

5.10 Clinicians should consider whether the Mental Health (Care and Treatment) (Scotland) Act 2003 needs to be invoked when a patient (of any age) declines treatment. There may be a responsibility to provide compulsory treatment if there is a risk to the person’s life or to prevent significant deterioration health and wellbeing (SIGN, 2022).

5.11 Organisations ensure services have access to psychiatric and/or acute inpatient treatment for stabilisation when indicated for those at immediate risk. Specialist eating disorders teams should establish close links and shared care during inpatient admission for continuity of patient care.

5.12 Organisations ensure that services provide robust physical health monitoring and appropriate referral during antenatal, perinatal and postnatal periods.

5.13 Organisations ensure the provision of accurate, reliable, and responsive information and support on excessive training and exercise and misuse of steroids.

5.14 Organisations ensure that patients with a long standing eating disorder, experience a person-centred approach to medical monitoring.

5.15 Organisations demonstrate they are implementing MEED (2022) and SIGN (2022).

What does this mean for the person receiving care?

You:

• will receive a comprehensive assessment by a specialist eating disorder clinician to support a shared understanding of the presenting problem and your individual needs
• will be supported to engage in the service to meet your needs
• are safely medically monitored throughout the course of your wait, assessment, and treatment with the service.

What does this mean for staff?

Staff are:

• provided with the necessary training to support the provision of a holistic assessment and safe and effective medical monitoring
• can access physical health monitoring equipment to safely and effectively provide medical monitoring within the service, and this is regularly audited and maintained
• supported to take a proactive outreach approach to support individuals to engage with/in the service, and
• aware of service protocols on medical management and shared care clinical responsibilities of each service if appropriate.

What does this mean for the organisation?

The organisation ensures:

• there is clear and easily accessible guidance on medical management for primary care colleagues to support risk management
• medical monitoring protocols are based on MEED (2022) guidance, and
• that if shared care with primary care is used, that this is agreed at an organisational level, with clear documented protocols detailing clinical responsibilities

Practical examples of evidence of achievement (Note: this list is not exhaustive)

• Shared care agreements between the specialist eating disorder service and primary care to support medical monitoring in a remote and rural location.
• Protocol detailing who holds clinical responsibility and associated processes for each step of the monitoring process.
• Protocol outlining outreach approaches to support engagement.
• Details of training and support available to staff.
• Evidence of implementation of SIGN and MEED guidance.
• Evidence of information (in a range of languages and formats) to support patients in their decision making including the use of steroids.