(PO-124) (PO-124) Protocolized Interdisciplinary Behavioral Management of Medically Decompensated Eating Disorder Patients on a Consultation-Liaison Service Can Reduce Length of Stay

Background: Medically decompensated eating disorder patients are often challenging to manage on a consultation-liaison psychiatry service due to the lack of a specialized milieu and limited training of medical staff. Meeting medical clearance criteria for psychiatric admission can be difficult and delay initiation of formal treatment. While specialized eating disorder units have implemented structured behavioral care plans geared toward rapid weight restoration¹, this has not been extensively studied in primary medical settings. We describe the case of an eating disordered patient who was highly resistant to refeeding during her medical admission, but did ultimately respond to a rigorous interdisciplinary behavioral protocol. The patient achieved medical clearance for transfer to an inpatient psychiatric unit within a shorter time frame than is typical for similar patients on our service.





Case: R.Q. is a 27-year-old woman with anorexia nervosa whose family brought her to the hospital for severe weight loss. Her BMI on admission was 12.4 and her labs were notable for transaminitis. Upon consultation, we instituted a behavioral care plan with initial restrictions including 1:1 observation, limitation of exercise, and strict meal times. The protocol involved a “reward” system with successive privilege levels in which restrictions were incrementally loosened based on the patient’s meal consumption. Conversely, failure to meet caloric parameters would result in initiation of nasogastric tube feeding. We explained and distributed this plan to the patient and family, primary team, nursing, and nutrition services. The patient was ultimately able to meet medical clearance criteria for psychiatric admission; her medical length of stay was 14 days (compared to an average of 20.7 days on our service).





Discussion: This case illustrates an effective approach to refeeding eating disorder patients in the general hospital setting, facilitating medical clearance while simultaneously initiating important behavioral treatment that would otherwise be deferred to the inpatient psychiatric setting. Successful implementation necessitates engagement of all involved disciplines in order to avoid splitting and mixed messages. Staff education is also critical, since non-psychiatric providers may have strong countertransference and become entangled in futile bargaining that ultimately hinders medical stabilization. Clear and consistent communication helps reduce confusion while reinforcing the goals of treatment.





Conclusion:

There are no standardized guidelines that exist in the literature for managing the refeeding of eating disorder patients on primary medical services. We propose that C-L services consider more broadly implementing interdisciplinary, regimented behavioral care plans akin to those used on psychiatric eating disorder units. This may help ensure that such patients receive the psychiatric standard of care while simultaneously reducing length of stay and time to medical clearance.





References:

1. Redgrave GW, Coughlin JW, Schreyer CC, et al. Refeeding and Weight Restoration Outcomes in Anorexia Nervosa: Challenging Current Guidelines. Int J Eat Disord 2015; 48(7):866-873.