Admission Criteria for AN Patients Vary Widely

Anorexia nervosa (AN) is the third most common chronic disease among female adolescents, and the death rate from all complications among these patients is estimated to be 5.6% per decade of life, the highest of all psychiatric disorders. Treatment for AN often requires long-term care, including hospitalization. According to the results of a recent survey of physicians in 25 states and a Canadian province, criteria for admission and refeeding for patients with AN vary widely throughout North America (J Adolesc Health. 2008; 43:425).

A team of researchers from Children’s Hospital, Boston, Harvard Medical School, and The Hospital for Sick Children, Toronto, surveyed 51 members of the 2001-2003 Eating Disorder Special Interest Group from the Society for Adolescent Medicine about their admission practices and patterns of inpatient care for teens with AN. The participants were surveyed with a structured telephone interview with case vignettes to investigate admission thresholds for heart rate, percent ideal body weight (% IBW), and refeeding protocols.

Admission practices

When the physicians were asked to specify the threshold levels of certain indicators of medical instability below which they would always admit a 15-year-old girl with AN, most said they would admit patients when the heart rate fell below 40 beats/minute. As for %IBW, responses ranged from 60% to 85%, and 75% IBW, was the most common response (52% of physicians). Admission thresholds based on potassium levels were evenly split between 2.5 and 3.0 milliosmoles per liter (mmol/L). Physicians in the western U.S. were more likely to admit teens with lower heart rates than were physicians in other parts of the country and Canada.

Inpatient care

The length of hospitalization for AN treatment ranged from 2 days to 90 days (mean stay: 11 days). Most of the physicians said they estimated the number of days, and only 24% based their answers on collected data. In 77% of cases, the length of hospital stay was affected by insurance considerations.

While patients were hospitalized, 90% of physicians reported that they weighed patients daily, and 92% had patients void before being weighed. However, only 36% required patients to meet certain weight gain goals while in the hospital. Those who reported having weight gain goals required patients to gain from 0.2 to 0.4 kg/day. As for letting patients know their weights, 28% never let patients know their weights; 32% always told patients their weights; and 40% sometimes allowed patients to know their weights, depending upon the individual patient.

Refeeding protocols

Refeeding practices and protocols also varied. For example, although 57% of physicians said they used personal refeeding protocols, only 37% followed protocols that were standardized by their institutions. To start refeeding a patient who was at 70% IBW and had been eating 500 kcal/day before being hospitalized, physicians started refeeding at levels ranging from 100 kcal/day (2%) to 1500 kcal/day (2%); 23% of the physician started refeeding patients beginning at 1000 kcal/day. Ninety percent of physicians preferred starting refeeding with regular food.

The physicians described 28 different methods of increasing a patient’s diet during the course of hospitalization for treatment of AN. When asked how they would advance intake, 77% cited doing so on the first day of hospitalization; some cited weight gain, others cited vital signs or laboratory values. Most plans included snacks in the diet and had time limits for meals. Nutritionists were involved in admission and meal planning in 98% of cases.

As for phosphorus supplementation, the practitioners reported a variety of practices during hospitalization and refeeding: 15% prescribe phosphorus supplements at admission for all teens with AN, while others determine the need for supplementation on an individual patient basis.

The wide variation results from multiple protocols

The authors attribute the tremendous variation in care for inpatients with AN to several factors. Because physicians have only position papers on adolescents with eating disorders and insufficient data to direct their clinical decisions about admitting and caring for patients with AN, they have to turn to institutional protocols, insurance criteria, or their own clinical judgment to decide whether admission for treatment of AN is warranted. This is also true for determining the course of hospitalization and how the patient will be refed.

The researchers reported that the decision whether or not to admit a teen with AN is affected by the fact that protocols allow clinicians to use their own judgment. Physicians admit patients for a variety of reasons, from detecting changes in vital signs that represent severe malnutrition that may be life-threatening, to belief that the illness is out of control and that hospitalization would be helpful to the patient and the family. The physicians also often found it difficult to articulate a specific reason for admitting these patients.

According to the authors, there is a real need to determine ways to manage both immediate medical complications and long-term psychological recovery for AN patients. More specific evidence-based guidelines need to be developed to reduce confusion and improve patient outcome in this challenging population.