Patients' experiences of clinical team meetings (ward rounds) at an adult in-patient eating disorders ward: mixed-method service improvement project.

AIMS: Ward rounds are key to treatment-related decision-making, but are often stressful. This project aimed to explore and improve patients' experiences of the clinical team meeting (CTM; historically known as ward round) in an adult in-patient eating disorders unit. A mixed-method approach was adopted with in vivo observations, two focus groups and an interview. Six patients participated. Two former patients contributed to data analysis, co-production of service improvement initiatives and write-up. RESULTS: The mean CTM duration was 14.3 min. Patients spoke half of the time, followed by psychiatry colleagues. 'Request' was the most discussed category. Three themes were identified: CTMs are important but impersonal, a sense of palpable anxiety was generated and staff and patients had divergent views regarding CTM goals. CLINICAL IMPLICATIONS: The co-produced changes to CTMs were implemented and improved patient's experiences despite COVID-19 challenges. Factors beyond CTMs, including the ward's power hierarchy, culture and language, need addressing to facilitate shared decision-making.

The alarms should no longer be ignored: survey of the demand, capacity and provision of adult community eating disorder services in England and Scotland before COVID-19.

AIMS/METHOD: This national pre-pandemic survey compared demand and capacity of adult community eating disorder services (ACEDS) with NHS England (NHSE) commissioning guidance. RESULTS: Thirteen services in England and Scotland responded (covering 10.7 million population). Between 2016-2017 and 2019-2020 mean referral rates increased by 18.8%, from 378 to 449/million population. Only 3.7% of referrals were from child and adolescent eating disorder services (CEDS-CYP), but 46% of patients were aged 18-25 and 54% were aged >25. Most ACEDS had waiting lists and rationed access. Many could not provide full medical monitoring, adapt treatment for comorbidities, offer assertive outreach or provide seamless transitions. For patient volume, the ACEDS workforce budget was 15%, compared with the NHSE workforce calculator recommendations for CEDS-CYP. Parity required £7 million investment/million population for the ACEDS. CLINICAL IMPLICATIONS: This study highlights the severe pressure in ACEDS, which has increased since the COVID-19 pandemic. Substantial investment is required to ensure NHS ACEDS meet national guidance, offer evidence-based treatment, reduce risk and preventable deaths, and achieve parity with CEDS-CYP.

Risk, demand, capacity and outcomes in adult specialist eating disorder services in South-East of England before and since COVID-19.

AIMS AND METHOD: This is a longitudinal cohort study describing the demand, capacity and outcomes of adult specialist eating disorder in-patient services covering a population of 3.5 million in a South-East England provider collaborative before and since the COVID-19 pandemic, between July 2018 and March 2021. RESULTS: There were 351 referrals for admission; 97% were female, 95% had a diagnosis of anorexia nervosa and 19% had a body mass index (BMI) <13. Referrals have increased by 21% since the start of pandemic, coinciding with reduced capacity. Waiting times have increased from 33 to 46 days. There were significant differences in outcomes between providers. A novel, integrated enhanced cognitive behaviour theapy treatment model showed a 25% reduction in length of stay and improved BMI on discharge (50% v. 16% BMI >19), compared with traditional eclectic in-patient treatment. CLINICAL IMPLICATIONS: Integrated enhanced cognitive behaviour theapy reduced length of stay and improved outcomes, and can offer more effective use of healthcare resources.

Integrated enhanced cognitive behavioural (I-CBTE) therapy significantly improves effectiveness of inpatient treatment of anorexia nervosa in real life settings.

BACKGROUND: Inpatient treatment of anorexia nervosa can be lifesaving but is associated with high rates of relapse and poor outcomes. To address this, the Oxford service has adapted the enhanced cognitive behavioural treatment (CBTE) model, first developed for inpatients in Italy to a UK national health service (NHS) setting. In this study, we compared the outcomes from treatment as usual (TAU), integrated CBTE (I-CBTE), and alternative treatment models in routine UK clinical practice. METHODS: This is a longitudinal cohort study, using routinely collected data between 2017 and 2020 involving all adults with anorexia nervosa admitted to specialist units from a large geographical area in England covering a total population of 3.5 million. We compared TAU with (1) I-CBTE (13 weeks inpatient CBTE, restoration to a healthy weight, combined with 7 weeks day treatment followed by 20 weeks of outpatient CBTE; (2) standalone inpatient CBTE (due to insufficient resources since the pandemic; and (3) 6-8 weeks admission with partial weight restoration as crisis management. Primary outcome measures (min. 1 year after discharge from hospital) were defined as: (1) good outcome: Body Mass Index (BMI) > 19.5 and no abnormal eating or compensatory behaviours; (2) poor outcome: BMI < 19.5 and/or ongoing eating disorder behaviours; (3) readmission; or (4) deceased. Secondary outcomes were BMI on discharge, and length of stay. RESULTS: 212 patients were admitted to 15 specialist units in the UK depending on bed availability. The mean age was 28.9 (18-60) years, mean admission BMI was 14.1 (10-18.3), 80% were voluntary. At minimum 1-year follow up after discharge, 70% of patients receiving I-CBTE and 29% standalone inpatient CBTE maintained good outcomes, in contrast with < 5% TAU and crisis management admission. Readmission rates of I-CBTE were 14.3% vs ~ 50% (χ2 < 0.0001) in the other groups. The main predictors of good outcome were reaching healthy BMI by discharge, I-CBTE and voluntary status. Age, psychiatric comorbidity and length of stay did not predict outcomes. BMI on discharge and length of stay were significantly better in the CBTE groups than in TAU. CONCLUSIONS: Our main finding is that in a real-life setting, I-CBTE has superior short- and minimum 1 year outcomes as compared with alternative inpatient treatment models. Dissemination of I-CBTE across the care pathway has the potential to transform outcomes of inpatient treatment for this high-risk patient population and reduce personal and societal costs.

Outcomes for adults requiring inpatient treatment for anorexia nervosa are poor. The aim of this work was to evaluate a recently introduced Integrated Cognitive Behavioural Therapy (I-CBTE) in Oxford, adapted from a model first developed for inpatients in Italy, compared with alternative inpatient treatment programmes in the UK. I-CBTE is an innovative approach which combines a time limited, planned admission of 13-weeks with the goal of full weight restoration, 7-weeks day treatment and ongoing outpatient CBTE. Treatment as usual includes an eclectic multidisciplinary approach, which is often unplanned and poorly coordinated across the care pathway in routine practice.Between 2017 and 2020, we systematically analysed routinely collected data for patients admitted to 15 specialist units from a population of 3.5million in England. We looked at outcomes between admission and discharge, and at one year follow up. 70% of patients receiving I-CBTE, maintained healthy weight at one year after discharge from hospital (without binging or purging), in contrast with less than 5% of those in alternative programmes that result in partial weight restoration. Readmission rates were 14.3% and ~ 50% respectively. Partial weight restoration resulted in high readmission rates and therefore should be discouraged.Our findings show that continuity and consistency of the I-CBTE approach are fundamental for maintaining good outcomes.

The Tensile Behaviour of Highly Filled High-Density Polyethylene Quaternary Composites: Weld-Line Effects, DIC Curiosities and Shifted Deformation Mechanisms.

The interactive effects between additives and weld lines, which are frequent injection-moulding defects, were studied in high-density polyethylene (HDPE) and compared to weld-line-free reference samples. These materials were formulated around a D- and I-optimal experimental design, based on a quadratic Scheffé polynomial model, with up to 60 wt% calcium carbonate, masterbatched carbon black and a stabiliser package. Where reasonable and appropriate, the behaviours of the systems were modelled using statistical techniques, for a better understanding of the underlying trends. The characterisations were performed through the use of conventional tensile testing, digital image correlation (DIC) and scanning electron microscopy (SEM). A range of complex interactive effects were found during conventional tensile testing, with DIC used to better understand and explain these effects. SEM is used to better understand the failure mechanics of some of these systems through fractography, particularly regarding particle effects. A measure is introduced to quantify the deviation of the pre-yield deformation curve from the ideal elastic case. Novel analysis of DIC results is proposed, through the use of combined time-series plots and measures quantifying the extent and localisation of peak deformation. Through this, it could be found that strong shifts in the deformation mechanisms occur as a function of formulation and the presence/absence of weld lines. Primarily, changes are noted in the onset of continuous inter- and intralamellar slip and cavitation/fibrillation, seen through the onset of localised deformation and stress-whitening.