The guidelines are aimed at all medical, nursing and dietetic staff working in hospitals to which a patient with severe anorexia nervosa could be admitted. They provide advice on the physical assessment of patients, required members of the in-patient medical team, the use of mental health legislation, and advice for commissioners on required services for this group of very ill patients.
The guidelines have been produced by the MARSIPAN working group, which stands for the MAnagement of Really SIck Patients with Anorexia Nervosa. The group was established in 2008 because of serious concerns over the number of deaths of young people with severe anorexia on general medical wards. Some died from medical complications such as pneumonia. Others died from, re-feeding syndrome (RFS) when food intake is increased too rapidly after weeks of starvation, or from “underfeeding syndrome” when nutrition intake is increased too slowly.
Most people with severe anorexia nervosa should be treated on specialist eating disorder units (SEDU). However, they may be admitted to a medical ward if a SEDU bed is not available, or if they need treatments that are not available on a psychiatric ward such as intravenous infusions or artificial ventilation. Anorexia nervosa has one of the highest mortalities of any psychiatric condition, and some deaths are inevitable. But patients admitted to medical wards are often at high risk and may not be seen by staff with specialist knowledge.
The guidelines make 9 key recommendations including:
- Physical risk assessment in these patients should include body mass index (BMI), physical examination, including muscle power, blood tests and electrocardiography (ECG).
- The in-patient medical team should be supported by a senior psychiatrist, preferably an eating disorders psychiatrist.
- The in-patient medical team should contain a physician and a dietician with specialist knowledge in eating disorders, preferably within a nutrition support team, and have ready access to advice from an eating disorders psychiatrist.
- Key tasks of the in-patient medical team are to: safely refeed the patient, avoid re-feeding syndrome, avoid underfeeding syndrome caused by too cautious rates of re-feeding; manage, with the help of psychiatric staff, the behavioural problems common in patients with anorexia nervosa, such as sabotaging nutrition and arrange transfer to a SEDU without delay as soon as the patient can be managed safely there.
- Health commissioners should be aware of the often inadequate local provision for patients, and ensure medical, nursing and dietetic staff on acute services are adequately trained and resourced.
The guidelines are accompanied by a one-page quick reference guide summarising the key points for hospital staff to remember when treating people with severe anorexia.
Dr Paul Robinson, executive member of the RCPsych Eating Disorders Section and chair of the MARSIPAN group, said: “Tragic deaths of people who are often young, occur too often in medical wards. Avoiding these events is only possible when medical and psychiatric teams work together so that the physical and psychological problems faced by such patients are addressed simultaneously. The MARSIPAN report represents a very important initial stage in this process. Disseminating its advice and providing education to clinical staff in primary care, medical units and psychiatric, including eating disorder services, are now necessary to make sure that life threatening complications of eating disorders are, in future, adequately managed.”
RCP Registrar Dr Patrick Cadigan said: “Doctors working in the acute medical setting need to be aware of the major challenges posed by this extremely ill group of patients. These guidelines provide vital information for physicians on how to manage the physical aspects of care, and remind them of the need to seek specialist medical, dietetic and psychiatric advice.”
The guidelines have been endorsed by four other organisations including beat, the eating disorders charity. Beat chief executive Susan Ringwood said: “We welcome these guidelines as we know how important it is to assess and manage the physical aspects of this serious mental illness. From our daily contact with families, we are aware of the risks that arise when someone needs urgent medical care and no specialist eating disorders support is available – risks that too often end with tragic results. The MARSIPAN guidelines will make an important contribution to avoiding preventable deaths of people seriously ill with eating disorders.”
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Royal College of Psychiatrists and Royal College of Physicians of London (2010) MARSIPAN: Management of Really Sick Patients with Anorexia Nervosa – Report from the MARSIPAN group (College Report CR162). Royal College of Psychiatrists.
Note to editors:
The MARSIPAN report is published jointly by the Royal College of Psychiatrists and the Royal College of Physicians of London. It is endorsed by: beat; the British Association for Parenteral and Enteral Nutrition; the Intercollegiate Group on Nutrition; the Specialty Advisory Committee on Clinical Biochemistry of the Royal College of Pathologists.