Joint CAMHS/Paediatric Protocol for Managing Children and Young People with Suspected or Diagnosed Eating Disorders.
Young people with suspected eating disorders may present to paediatrics or CAMHS. The teams may need to liaise:
1 To confirm diagnosis
2 To manage medical complications and ensure optimal nutritional management during the course of the illness
The aim of this joint protocol is to set out the appropriate pathways for liaison between paediatric and CAMHS teams. For the medical management of sick young people with eating disorders on the paediatric wards, please refer to the Junior Marsipan guidelines:
Presentation:
A young person witha suspected eating disorders may come to attention in a number of ways.
- He/she may present to the GP and be referred directly to CAMHS for outpatient assessment
- He/she may present to the GP and be referred to paediatric outpatients for assessment
- He/she may present to the paediatricians in ED with an acute problem eg faint – either via GP referral or self referral
Liaison to confirm diagnosis/exclude medical conditions
Initially seen in CAMHS as an outpatient
CAMHS will most often confirm the diagnosis themselves, with no need to consult paediatrics. However, if a paediatric opinion is required to exclude other medical conditions or assess current medical risk, the CAMHS Consultant should contact the paediatric Consultant of the week by telephone (01865 741166 Bleep 4734) to discuss what investigations are required, or if the Consultant is not available the Paediatric registrar on call. For children resident in the North of the county, initial contact should be with the paediatric Consultant of the week at the Horton Hospital (through the hospital switch board 01295 275500 and/or Bleep 403). If it is felt the young person needs to be seen in paediatric outpatients, the paediatric Consultant will facilitate an urgent appointment. If it is felt that a more urgent assessment in Paediatric ED is indicated, the Consultant or paediatric registrar will facilitate this.
Initially seen in paediatrics as an outpatient
Once the paediatric Consultant is satisfied that medical conditions have been excluded and an eating disorder is the most likely diagnosis, he/she should contact the relevant CAMHS team(see appendix 1) either by telephone to the Consultant or duty workerif the situation is urgent or there is a need to discuss the issues; or by sending/faxing a referral letter to request assessment.
Initially seen in paediatrics in the Emergency Department
The young person will be admitted for investigations and observation, to Melanie’s ward (unless lack of bed capacity necessitates another ward being used in the first instance) at the John Radcliffe. Children from the North of the county should in the first instance be assessed on Children’s ward at the Horton. At present there is insufficient dietetic support at the Horton to support an inpatient admission for weight stabilisation, so if, after an initial assessment, it is agreed between the paediatric Consultant at the Horton and the relevant CAMHS Consultant that admission is required with the prime focus being to stabilise the weight, the young person should be transferred to Melanie’s ward. The acute paediatric team, led by the Consultant of the week, will be responsible for medical stabilisation and relevant investigations.
The acute paediatric team will contact the relevant CAMHS Consultant or duty worker (see appendix 1) to arrange an assessment, once the Consultant of the Week is satisfied that an eating disorder is the most likely diagnosis, or at least needs to be considered. If there are problems contacting the relevant team, Dr Mina Fazel, Consultant CAMHS liaison may be approached for advice on the next step (see appendix 1 for contact details). The patient and family would need to be assessed (or at least initial consultation provided over the phone) by the CAMHS team (Consultant or clinician from eating disorder team) within the next 24 hours.
The identified CAMHS Consultant (or relevant clinician) and the Paediatric Consultant should then agree ongoing management which would include involvement of JR dietician, establishment of meal plan, further assessment if diagnosis is not clear, further stabilisation of eating/drinking where indicated, continued input from CAMHS and discharge planning once the diagnosis is confirmed and the young person is fit to be discharged.
The CAMHS Consultant might involve the CAMHS Crisis team to provide meal time support, engage the family and plan support following discharge.
Management of acute medical problems, including ongoing weight loss/lack of compliance with dietary plan in young people with a confirmed diagnosis of eating disorder.
The need for paediatric support in a young person being treated by CAMHS may become apparent in a variety of ways:
- On routine monitoring, the CAMHS team may find worrying blood results eg hypokalaemia, concerning physiological parameters eg profound bradycardia or evidence of lack of compliance with dietary plan leading to worryingly low weight. This may apply to CAMHS outpatients or CAMHS inpatients; and includes worryingly low weight at first CAMHS outpatient assessment .
- A young person with an established diagnosis may present acutely to paediatrics via ED with an acute problem eg fainting.
Involvement of paediatric care when CAMHS identify concerns eg worrying bradycardia
If a young person who is already under CAMHS presents in any of the above ways: the paediatric Consultant of the week should be contacted by telephone (01865 741166 Bleep 4734), preferably during normal working hours, Mon- Sun. In the evenings or overnight the duty paediatric registrar should be contacted first, who will then discuss the case with the Consultant on call. For children resident in the North of the county, initial contact to arrange assessment should be with the paediatric Consultant of the week at the Horton Hospital at any time of the week (Resident paediatric consultant on call- out of hours bleep 403).Where possible, the phone call should be made by the CAMHS Consultant who knows the patient: if not, by the most senior member of CAMHS staff involved.
If it is felt that the conditions warrants admission to paediatric care: the acute paediatric team will arrange an admission to Melanie’s ward (or other ward, depending on bed availability) at the John Radcliffe. As stated above, whilst young people from the North of the county could be assessed and monitored on the Children’s ward at the Horton, if admission to stabilise weight is required, they should be transferred to Melanie’s ward.
The initial management for the acute medical problem, as decided by the paediatric and CAMHS teams in consultation, will be the responsibility of the acute paediatric team.
A member of the CAMHS team will review the young person on the ward as soon as possible, ideally on the next working day, and liaise directly with paediatric Consultant of the Week re: ongoing management. If this is not possible, the responsible CAMHS Consultant or care co-ordinator should have a telephone discussion with the paediatric Consultant of the week on the next working day after admission to agree the principles of management and the timing of CAMHS review.
Involvement of CAMHS when paediatrics identify concerns eg ED presentation
If the young person is deemed to require hospital admission, he/she will be admitted to Melanie’s ward (or children’s ward at the Horton) under acute paediatrics, and care should proceed as above.
If it is felt that medical admission is not required: the paediatric Consultant of the week or duty registrar should contact the referring CAMHS Consultant, or duty team member if Consultant not available, as soon as possible, to advise of assessment and agree the plan for discharge home. Out of hours, the Paediatric Consultant can discuss with the CAMHS SpR/Consultant on call if necessary.
Specific Aspects of Inpatient Management for those admitted to Melanie’s Ward
Meal plans
For any young person with an eating disorder under CAMHS who is admitted to the Childrens Hospital, an appropriate meal plan should be agreed.
The Paediatric Dietitian will review and asses intake on admission. She will then liaise with CAMHS dietitians for support and guidance on appropriate meal plans. Appropriate plans (meal plans/enteral feeding plan) will be provided during admission and reviewed as deemed necessary by the Dietitian. On discharge the Paediatric Dietitian will handover care to CAMHS Dietitian for follow up in the community.
The nursing staff, with parents, are responsible for monitoring compliance with the meal plan on the ward, and documentation of intake. The CAMHS crisis team will assist with selected meal times on an individually agreed basis.
The acute paediatric team are responsible for monitoring for refeeding syndrome, if appropriate.
Nasogastric feeding should be viewed as a last resort and only instituted if agreed by the dietitian, paediatric and CAMHS Consultants as the only remaining option.
The young person should be weighed regularly (normally at least twice a week).
Discharge planning
If a young person is admitted to Melanie’s ward/Children’s wardwith an eating disorder, whatever the reason for and circumstances of the admission, the potential length of stay must be discussed during the first conversation between CAMHS consultant and paediatric Consultant of the Week. This information will be relayed to the ward sister by the paediatrician. It may be possible to be clear on an approximate number of days, but it may be more appropriate to agree discharge goals. An assessment should be made at this stage as to whether discharge is likely to be back home or to the Highfield unit. If the former and if this is first diagnosis, the CAMHS team will start to institute plans for ongoing care early in the admission.
During any admission lasting longer than 48 hours, the CAMHS team will review the young person with their family on the ward at a minimum every 3 days (or make phone contact where this is not possible). The paediatric team will review daily: and let the CAMHS team know of any important changes.
If it is felt there needs to be a multidisciplinary meeting prior to discharge: the key person from CAMHS and the paediatric Consultant will agree who should be invited and who should issue each invitation, and the paediatric team will facilitate finding a room for the meeting.
JC v 7 June2013
Appendix 1 : CAMHS contact details
Dr Mina Fazel : 07779 638941;
Team / Telephone / FaxSouth Oxfordshire CAMHS (Abingdon, Wallingford, Henley, Farringdon, Wantage, Didcot) / 01235 205425 / 01235 208700
North Oxfordshire CAMHS: (Banbury, Bicester, Kidlington) / 01295 819090 / 01295 819096
Central Oxfordshire CAMHS (Oxford City and Witney) / 0845 2191002
01993 202130 / 0845 2191444
01993 202131
North Bucks CAMHS (Aylesbury) / 01296 564032 / 01296 398 802
South Bucks CAMHS (Amersham and Wycombe) / 01296 564130 / 01296 564 170/1
Highfield Adolescent Unit / 01865 738770
Nurses office: 01865 728776 / 01865 738779
CAMHS MAIN Switchboard01865 741717
Oxon Assertive Outreach and Crisis Team / 0845 219 1497 / 0845 219 1488Assertive Outreach (OSCA) & Crisis Team (Bucks) / 01296 564130 / 01296 564 1701