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Medical Emergencies in Eating Disorders

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Why are we so concerned about eating disorders?

Eating disorders are common and can affect anyone. The prevalence is increasing, and it is likely that all of us will see young people with eating disorders in our practice. They can be difficult to diagnose and may present to the emergency department in crisis, or with non-eating related symptoms. Sadly, eating disorders also have the highest mortality of any psychiatric illness (from suicide or from medical complications) and signs of severe illness are often missed. Most deaths are preventable with early treatment and support.  As healthcare professionals, if we CARE about eating disorders, we can help young people to have a better chance of recovery.

What is MEED?

Medical Emergencies in Eating Disorders (MEED) is a new guideline on the recognition and management of eating disorders. The guidance is a collaboration between the Royal College of Psychiatrists (RCPsych) and University College London. The main guideline includes a new checklist to help guide assessment and a summary sheet for Emergency Department professionals. It is endorsed by the Academy of Royal Colleges.

How were the MEED guidelines developed?

In 2017 the Parliamentary Health Services Ombudsman (PHSO) produced a detailed report called ‘Ignoring the alarms: How NHS eating disorder services are failing patients’. It reviewed several tragic cases and found that after a series of missed opportunities deterioration and death was avoidable. A number of key themes were repeatedly identified including an overall lack of awareness with the severity and signs of deterioration often not recognised in time. Moreover, there was a lack of awareness of the sabotaging behavioural components of eating disorders which resulted in self-harm. The report describes, for example, the case of a patient being inappropriately discharged with ongoing suicidal thoughts. A lack of experience and knowledge amongst front door practitioners (e.g. GP, Emergency, and Acute Care Services) was seen, and communication between services, and high-risk transitions both in services and in the personal lives of patients (for example moving area or starting at school/college/university) were also seen as inadequate. Subsequently, a review of training was recommended, and this prompted the formation of a working group to address recommendations.

Guideline development was led by the RCPsyh Eating Disorders Faculty and included authors of previous editions of the MARSIPAN and Junior MARSIPAN guidelines. The development process was similar to that used for NICE guidelines.

Evidence-based recommendations were made from systematic reviews of existing research and a comparison of international guidelines. Where there was a lack of high-quality evidence, consensus statements were reached through discussion with an expert reference group.

How is MEED different to the Junior MARSIPAN guidance?

There were several significant changes between the Junior MARSIPAN and MEED guidance which have improved both the clinical and academic value of the guidance.

MEED guidance now includes guidance for all ages. This helps to reduce the confusion around transition ages and differences in approaches between age groups. It is also useful for professionals who are treating patients across the spectrum of ages and presentations. Similarly, whereas anorexia was the focus of the Junior MARSIPAN guidance, MEED includes guidance on all eating disorders and recognises the risk associated with all of them. The widely used risk assessment tool in Junior MARSIPAN has been updated to include greater emphasis on behavioural and psychiatric risk assessment, additionally, specific management advice is given for all domains of risk.

MEED includes updated guidance on the physical, nutritional and psychiatric management of all eating disorders with extensive information about refeeding syndrome and the management of Type 1 diabetes and eating disorders (T1DE).

The holistic approach to patient care in the MEED guidance is admirable. There are advice and summary sheets for a diverse range of healthcare professionals as well as for relatives and carers. There is also a comprehensive section aimed at helping parents, relatives and carers which includes a table of dos and don’ts on helping care for a young person with an eating disorder and for getting their own support.

What red flags should we be looking for?

All children and young people presenting to the emergency department with symptoms and signs that could be due to an eating disorder should have a thorough risk assessment. This should include a detailed history, examination, and basic investigations, with more in-depth investigations as necessary. Collateral history from parents/carers should be sought as they may disclose worrying symptoms and behaviours that the young person lacks insight into.

The competency of the young person should also be explored and confidentiality, including its limits, should be explained.

Red flags are shown below. The full traffic light risk assessment can be found in the guidance.

How should we treat high-risk patients?

The risk assessment aids decision-making on emergency management and treatment decisions such as the need for admission for psychiatric assessment, specialist nursing care, monitoring, and refeeding. Any young person with red flags (or several amber flags) should be considered high risk and there should be a low threshold for admission.

Due to complexity, young people with eating disorders and other co-morbidities or pathology should have early specialist input.

Common Pitfalls

– Not asking about eating issues in HEEADSSS assessment
– Not considering eating disorders as a reason for physical, psychiatric, or behavioural disturbances
– Not realising that children and young people with eating disorders that do not present in an emergency may still require urgent referral
– Not taking a collateral history from parents/carers
– Not realising that children and young people with anorexia may have increased energy and exercise levels right up until the point of physical collapse
– Not taking undertaking a risk assessment for suicidal ideation and self-harm
– Not recognising that poor insight can lead to an inaccurate history from the child or young person
– Being falsely reassured by well-looking children and young people or normal blood results
– Reassuring or dismissing a child or young person with low-risk features. This can reinforce the disorder itself and cause them to think that change isn’t necessary.

Take Home Points

-Ask about eating issues
-Assess for red flag features in the history, examination, and investigations
– Use the ED checklist to structure assessment and decision making
– Regardless of risk refer all young people with eating disorders for NICE-approved psychological therapy
– Consider the effect of eating disorders and parents/carers. Involves parents/carers in the assessment and decision-making and consider the support that they may also require

References

Hibberd O, Hall D, Walsh Ó. Take Time to CARE about Young People with Eating Disorders. Don’t Forget the Bubbles. 2022. Available at: https://doi.org/10.31440/DFTB.47515

RCPsych. Medical Emergencies in Eating Disorders: Guidance on Recognition and Management. RCPsych College Report [CR233]. 2022. Accessed online at https://www.rcpsych.ac.uk/improving-care/campaigning-for-better-mental-health-policy/college-reports/2022-college-reports/cr233

About the authors

  • Owen Hibberd is an Emergency Medicine Trainee in Cambridge, currently studying on the QMUL PEM MSc. Interested in Paediatric Emergency Medicine, Pre-Hospital Emergency Medicine and Medical Education. He/him.

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