Risk Management in Eating Disorders Training Day

1. EEATS TRAINING DAY Risk Management in Eating Disorders Dr Phil Crockett

2. Risk Management • Risk in Eating Disorders-Why Worry? • Risk Assessment vs Risk Management • The Physical, Psychological, Social • Context • Transitions • Communication • Networks and Frameworks • Taking advice • Summary

3. Risk in Eating Disorders-Why Worry? • For A.N.: 5-30% long term mortality(Theander, Halmi(1992)) • Difficulties in psychological adjustment up to 50% (Pike, 1998) • Wide variation outcome-depends on study centre e.g. Korndorfer (2003), Johnson et al (2003) more benign • Keski-Rahkonen, (2008): Finnish nationwide • N=2880: 5yr recovery 67%

4. Risk in Eating Disorders-Why Worry? • B.N. sig psychological impairment and physical morbidity • AN can: • Sudden death • Cardiac failure • GI bleeds • Sepsis • Suicide • (Millar,2005)

5. Risk Assessment vs Risk Management • Risk Assessment: an estimation of the likelihood of particular adverse events occurring under particular circumstances. Within a specified period of time • Risk Management: organised attempts to minimise the likelihood of adverse events

6. Risk Assessment vs Risk Management • Approaches to risk assessment broadly grouped into ‘clinical’ versus ‘actuarial’ . • The actuarial approach: clues to broad populations at risk, but informs us inadequately on the individual • The clinical perspective: “individualised and contextualised assessment” , vulnerable to poor inter-rater reliability and influence of other considerations • Remember the protective… • Only tells you about the current situation From Feenay, A

7. Five-step structured professional judgement approach to risk management (Doyle and Duffy (2006))

8. The Physical • Starvation and Malnutrition • Other Behaviours • Co-morbidities and complications • Self Harm and Suicide • Re-feeding Syndrome • Past history and factors

9. Re-Feeding Syndrome • The major physical risk of treatment • Cascade of metabolic and electrolyte changes • Hypophosphataemia, hypomagnesaemia, hypokalaemia major risks • Raised risk with n.g. re-feeding • Very slow initiation feeding • Take advice • “Have you considered re-feeding syndrome”

10. The Psychological • Depression • Anxiety • Personality Disorder • Obsessionality (OCD) • Hopelessness and Frustration • Past history and individual factors

11. The Social • Families and Friends • Work and studies • Home environment • Professionals • The In-Patient Environment • The Unexpected • Past history and factors

12. Context • Context always important • Major influence on risk for individual • Major influence on judgement of risk • Part of risk assessment • Will alter most appropriate course of action

13. Transitions • Geographical and Developmental • Life cycle challenges • In-patient units • Travel and relocation • The Scottish Ombudsmen's Report, 2006

15. Communication • Ensuring care plans are a team effort • Note limitations of them • Liaison between areas important • Patients and carers involved • Recording

16. Networks • For patients protective and maladaptive • A way for professionals to gain guidance • EDSECT • MCNs • Benchmarking and audit

17. Guidelines and Frameworks • NICE and QIS • APA • Specific for context • Crisis planning • Consistently reviewed/revised • CPA/MHA

18. Taking Advice • Role of the Gastroenterologist/Physician • Especially when very high risk • Co-morbidities • Second opinions and • consultations

19. Conclusions • No simple methods to quantify risk in EDs • Physical/Psychological complications common including resulting from intervention • Broad assessment important • Principles risk assessment/management useful

20. Conclusions • Developing appropriate frameworks to the context you are based in • Applying the guidelines • Making use of containing networks and maintain communication • Take advice