Safe Management by a Pop-Up Eating Disorder Team.

Background Anorexia nervosa has a high mortality complicated by risks of under-nourishment, over-nourishment and care can be compromised by behavioural issues. Methods This is a retrospective study of ten patients with eating disorders admitted to Sligo University Hospital, treated by a "pop-up"/on demand multidisciplinary eating disorder team. Results All were female, mean BMI on admission was 14.35kg/m2, on discharge was 16.59kg/m2, (p=0.001) and was significantly lower than the initial measurement and may represent water-loading or bowel retention. Admission biochemistry was normal in nine subjects. Six subjects experienced refeeding syndrome, one was hypoglycaemic (3.1mmol/L) in the setting of an aspiration pneumonia, and five exhibited treatment avoiding behaviour including food caching, micro exercising. The mean length of stay was 38 days and was positively correlated with weight gain during admission (p=0.02). 6-month follow up BMI was higher than admission in eight subjects and the other two voluntarily withdrew from follow-up. Conclusion There was a high incidence of treatment avoiding behaviour, initial weights were misleadingly high, admission biochemistry misleadingly normal, hypoglycaemia associated with infection, and incidence of refeeding syndrome is high. Notwithstanding this these patients can be managed safely and effectively in a general hospital with a coordinated, well-structured approach by a multidisciplinary team.

The Experience of the Management of Eating Disorders in a Pop-up Eating Disorder Unit

Anorexia nervosa affects 0.5% of the population (90% female) with the highest mortality of any psychiatric illness, usually suicide, or cardiovascular or neurological sequelae of either malnutrition or refeeding syndrome. The latter two conditions occur in the inpatient setting, carry a high mortality and are thoroughly avoidable with careful informed clinical management. This paper provides an overview of the service and care of these patients in a general hospital setting in Ireland. In response to a number of acute presentations a cross discipline Pop-up Eating Disorder Unit (psychiatrist, physician, dietician, nurse) was established in Sligo University Hospital in 2014 and has experience of 20 people treated according to the MARSIPAN guideline (Management of Really Sick Inpatients with Anorexia Nervosa). They are nursed in a designated ward with continuous cardiac monitoring (in addition 2 required ICU admission), with one-to-one continuous supervision, complete bed rest, careful calorie titration (usually nasogastric) with twice daily phosphate, magnesium, calcium and potassium concentrations measured and replaced. Sabotaging behaviour witnessed includes micro-exercising, requests for windows to be opened (in order to shiver/micro exercise), food concealment, faecal/urinary loading on weighing days, heavy hair accessories, vigorous page turning/toothbrushing/use of computer keypads and animated conversations. A cross disciplinary coordinated approach to this cohort, who often inventive in their resistance to treatment, allows safe management in a general hospital setting.

Misuse of the London ambulance service: How much and why?

OBJECTIVES: To assess the degree of inappropriate use of the London Ambulance Service and analyse the reasons for misuse. DESIGN: An immediate assessment of the appropriateness of the "999" call by the ambulanceperson and casualty senior house officer followed by a retrospective review of each case by the accident and emergency (A&E) consultant. SETTING: A busy inner London A&E department. METHODS: Three hundred consecutive emergency ambulance arrivals to the A&E department underwent assessment as to the appropriateness of the call. RESULTS: Overall 53.7% of patients were considered justified in their call, 15.7% of calls were inappropriate, and in 19.0% of cases a unanimous decision was not reached. Eleven per cent of all forms were incompletely filled. CONCLUSIONS: Almost 16% of emergency ambulance calls were considered unanimously to be inappropriate. This suggests that 75,000 emergency calls per year to the London Ambulance Service are not necessary. The commonest reason for inappropriately calling an ambulance was that the caller felt that they had a serious or life threatening condition. The need for public education and deterrents of ambulance abuse are discussed. The further introduction of a nursing led triage "hot line" to appropriately dispatch ambulances according to clinical needs of the patient, and other alternatives to this are discussed.