North of Scotland Managed Clinical Network for Eating ... Annual Report - printed final version… · supporting a constant process of evolution in eating disorder treatments. I hope

North of Scotland Managed Clinical Network for Eating DisordersAnnual Report April 2010 – March 2011

Tay Rail Bridge, Tayside

St Magnus Cathedral, Orkney

Crathes Castle, Grampian

Urquhart Castle, Loch NessLerwick, Shetland

Isle of Lewis

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contents

Contents

Foreword 4

Introduction 5

Network Activities

• The Eden Unit - (Report by J Morris) 6

• North of Scotland Inpatient and Outpatient Activity 2010 -2011 10

• NHS Grampian Eating Disorder Conference - 2010 15

• Annual MCN Workshop - Complex Case Presentations – May 2010 16

• Electronic Clinical Record - Update from Dr P Crockett 17

• Eating Disorders Education & Training 18

Grampian Eating Disorders Service 20

Tayside Eating Disorders Service 22

Highland Eating Disorders Service 25

Financial Report 27

Annual Workplan 2010/2011 29

Appendices

Appendix 1 - An Audit of Length of Stay in Eating Disorders 33

Appendix 2 - The Eden Unit - One Year On 49

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North of Scotland Managed Clinical Network for Eating Disorders Annual Report April 2010 – March 2011

Foreword This has been a year of transitions for the Eating Disorders Managed Clinical Network. Dr Harry Millar has retired as Clinical Lead and Dr Phil Crockett took on this position in December 2010.

I would just like to take this opportunity to thank Dr Millar, along with his many friends and colleagues for the hard work he put into the MCN over the past 5 years. As the inaugural Lead Clinician he achieved an enormous amount for the MCN and laid a good foundation for the work of the MCN to carry on and progress.

We welcomed back Alison Sherriffs from Maternity leave in January 2011. Alison is now working 2 days a week for us. Mrs Brenda Leel is our information Officer and she works 1 day per week in the MCN Office.

Dr Philip Crockett is also the Consultant Psychiatrist in the Grampian Outpatient Eating Disorders Service as well as being a Consultant Psychotherapist in the Psychotherapy Department, Royal Cornhill Hospital. We will hear more from Dr Crockett later in the report.

Once again we would like to thank all staff across the Managed Clinical Network for their continued hard work and enthusiasm over the past year.

Linda Keenan Network Manager

Contact: Linda Keenan, Network Manager, Managed Clinical Network for Eating Disorders, Bennachie Building,Royal Cornhill Hospital, Cornhill Road, ABERDEENAB25 2ZH

Tel: 01224 557858 Email: [email protected]: www.eatingdisorder.nhsgrampian.org

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Introduction

April 2010 – March 2011

The North of Scotland Managed Clinical Network for Eating Disorders remains very active around its core tasks of supporting the development of services, improving on quality, improving on education and training in the field of Eating Disorders. This report will detail these activities as well as some of the outcomes of this work. It spans a region that is diverse geographically with a well-spread population of 1,306,000 from the southern boundaries of Tayside up to the furthest reach of the Northern Isles. The challenge is therefore helping ensure consistency and improvement of services across a variety of contexts, hence the MCN has been closely involved in the ever deepening breadth of use of new technologies to improve on communications. Some of this work will be detailed in the report as well.

The MCN staff team listed elsewhere in this report and ably led by Ms Linda Keenan, MCN manager continue to provide the hard work behind many of the challenges and tasks the MCN is required to address in its role for the region.

I am aware from my visits to local services of the hard work that goes on and the enthusiasm for supporting a constant process of evolution in eating disorder treatments. I hope some of this enthusiasm comes over in this report, a report that marks the second full year of the new North of Scotland Regional Inpatient Unit, The Eden Unit, which of course remains a flagship for NHS provision in Scotland for Eating Disorders.

Dr P Crockett Consultant Psychiatrist in Eating Disorders and Psychotherapy Clinical Lead, Managed Clinical Network for Eating Disorders

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Eden Unit Report on The Eden Unit March 2011 Dr Jane Morris

OverviewI have been in post now for almost a full year. I have been challenged by the particularly severe nature of the complex eating disorders presented by these patients, and supported wholeheartedly and generously in meeting the challenges by Pauline Milne and her incredible team of nurses and AHPs. I could not be happier to be part of this endeavour.

CaseloadThe Unit has managed over 40 patients to date. Linda Keenan and her colleagues have kept records of activity which will be presented separately. In the past year we have been almost constantly at full capacity, in contrast to the early days of the Unit. As a result there has been no question of providing places for patients from elsewhere in the country or admitting patients under the age of 18. Indeed a small number of patients from Tayside and Highland have had to be admitted to private Eating Disorders Units. Just before I was appointed one Grampian patient was electively admitted to a private Unit but was transferred to our care early this summer.

ReferralsWe have set up a weekly referrals meeting so that the team can discuss management of referrals to both IPU and DP. I have kept handwritten records of referral activity which will shortly be transferred to an electronic record. We are increasingly aware of the different reasons for and goals of admission and the need to negotiate at least informal referral contracts with patients and their carers to minimise abortive admissions which can result in premature self-discharge, waste valuable clinical resource and build patient resistance to further work. There has also been a considerable increase in consultation about patients who may not necessarily be admitted, and we have also consulted with clinicians caring for patients in other units to discuss the pros and cons of transfer.

Length of StayWe have been fortunate to have the services of a series of enthusiastic medical students engaged on audit projects. Ashley Simpson has audited length of stay on our Unit and compared this with other Units in Scotland and England (a copy of her study is included in this report - Appendix 1]). Our mean LOS is 116.6 days (SD 117.9). That of the Glasgow Priory Hospital has been reported as 136 days (Collin et al). Mean LOS for Lothian adolescents was 89.3 days (SD 79.6).

It would be expected that adult patients with longer, resistant illness courses would require longer treatment than adolescents. Many of our patients have been ill for their entire teenage and adult lives, and their ages range from late teens to late fifties. The average age is surprisingly high.

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Interestingly, though, our own mean LOS is also 89 days if the 3 ‘outliers’ with abnormally long admissions are removed from the analysis.

Analyses from England (Treasure et al, in preparation) indicate considerably longer admissions than in Scotland, with an equally broad variation and range. We plan to further investigate LOS across Scottish Units and to add in further detail about treatment received.

Progress of PatientsOur audit has shown that patients have improved significantly with our specialist inpatient programme, as measured by CGI, EDE-Q, HADS, and medical measures including BMI. Our patients gained a significant amount of weight during inpatient stay, though not to the levels recommended by NICE and QIS. Increased LOS was associated with a better Clinical Global Improvement (CGI) outcome.

Clinical ProtocolsWe are revisiting the Clinical Protocol with Dr A McKinlay and colleagues at ARI who have dedicated sessions for Eden. The protocol was designed before the Unit opened and was based on the best theoretical evidence available. Two years’ experience has brought the Unit’s practice to the forefront of understanding of medical management of anorexic patients, so that we are able to refine advice and also add to practical aspects of theoretical matters.

Most recently we have presented relevant issues arising from the protocol at a meeting with the Junior Doctors’ On Call rota and as a result have feedback that we enjoy improved communications with them. In addition we are now encouraged to re-structure the Clinical Protocol to acknowledge not only what needs to be done to care for patients but also whose responsibility it should be to instigate management and where interventions are most safely undertaken .

Communication, Information And PublicitySince last MCN meeting we have set up monthly business meetings with each of our main Outpatient Partner teams – Grampian, Tayside and Highland. The two latter groups use Videoconferencing for the meetings. After a year of building a distinct identity for the Eden Unit, we have sought to work ever more closely with our Outpatient Colleagues. We enjoy joint training sessions organised by Dr Lakshmi Venkatraman and Journal Clubs organised by Neil Laurensen.

Concerns about low weight prospective patients travelling long distances in winter to visit the Unit have led to a search for alternative ways to introduce ourselves to referred patients and their families. We have used videoconferencing to organise pre-admission discussions and contracts. This has led to a reduction in early self-discharge as well.

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Therapy On The Unit

We have a flourishing group programme but feel strongly that our particularly complex patients benefit from individually tailored treatment with a great deal of individual therapy and management to support the group experience. In line with the evidence base we prescribe medication for both anorexia and underlying obsessive and depressive conditions as well as nutritionally sound diets and supplements.

Most weekdays begin with a short Community Meeting, which we have recently surveyed. More than half of all staff and patients responded to a questionnaire and provided unstructured comments too, which will be fed back to the group and contribute to re-shaping of the meeting.

We have continued to follow Eden’s practice of conducting individual patient formulation meetings after a few weeks of admission, and six weekly review meetings for each patient, over and above the weekly ward rounds. Such reviews include local clinicians, family and other lay carers, using videoconference if appropriate. Minutes are circulated to those unable to attend and to patients’ GPs. The last of the review meetings serves as a discharge planning meeting. Lately we have also set up ‘post discharge’ meetings in some cases, to ensure that difficult transitions are contained and supported. Short readmissions are then encouraged as preferable to decline and further prolonged stay.

Family therapies are strongly evidence based in adolescent cases of anorexia. We have pioneered use of Couples therapy for patients with partners available to support adult patients and offer more traditional family work to our younger patients and their parents – many of those in their early 20s are developmentally immature compared with peers who have not had to deal with severe illness. We are on the point of setting up monthly family psychoeducation classes to introduce our philosophy and teach inpatient skills to carers, encouraging use of the NEEDS support groups in parallel and after discharge.

Day ProgrammeWe were originally resourced for 4 Day Places but have mostly had higher numbers than this with extra support from all staff. There is little doubt that with improved resource we could prevent more admissions altogether, as we have done in several cases from the local EDS. Even more strikingly, the DP has prevented relapse in patients who have never before spent more than a few weeks outside hospital without losing weight.

Day Programme suffers from lack of room space, generally inadequate staffing and in particular lack of physiotherapy input. We are delighted to have extra OT provision which supports Day Programme, and look forward to advertising the Psychotherapist post. We are still without a dedicated Eden Social Worker, and this is particularly distressing for Day Patients because of their need for support with accommodation, transport, work and education.

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Staffing

TrainingSome members of the team are undertaking the EEATS accreditation, one is training on the Dundee CBT course, and another has completed the one week IPT training. We undertake Weekly Team training in addition to basic resuscitation, MUST training, fire and aggression and violence training and child protection awareness. The team was supported by nursing colleagues to arrange one Away Day and we are currently planning a second Day, which will focus on – amongst other issues – group training and experience.

It would be particularly useful to consider a whole team training in the DBT model which is particularly suited to the needs of inpatient teams delivering care to patients with complex and multi-impulsive eating disorders and co-morbid personality disorders: the very patient population we see.

Eden is also a source of Training for many different disciplines – Art therapy trainees, student nurses, medical students and junior doctors amongst others.

ResearchThe SMHRN-sponsored Anorexia Nervosa Protocol Development Group continues to plan and participate in several strands of research, many of them centred on the Eden population but involving multi-centre designs to maximise study power, to examine the broader context of eating disorders and to make comparisons with practice elsewhere. We enjoy close links with both Aberdeen and Robert Gordon Universities as well as with the University of Edinburgh, and through their interests have plans to explore a range of interests from the molecular (such as the role of selenium and zinc) through to complex body image interventions and studies of service provision.

Medical

Nursing

Dietetic

Physiotherapy

Occupational Therapy

Art Therapy

Psychotherapy

Social Work

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Eden Unit Activity and Outpatient Activity Across the North of Scotland April 2010 - March 2011Over the past year the Eden Unit has been running with an occupancy rate of between 78.2% and 98.7% which gives an overall average of 89.8% occupancy. (These figures include information regarding patient “pass days).

Admissions to the Eden Unit - April 2010 to March 2011

There have been a total of 17 admissions to the Eden Unit from April 2010 to March 2011. The total broken down by area is as follows:-

• NHS Grampian – 8

• NHS Tayside – 7

• NHS Highland – 2

• NHS Orkney – 0

• NHS Shetland - 0

• NHS Western Isles – 0

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Grampian 1 0 0 1 0 2 1 1 2 0 0 0

Highland 0 0 0 0 1 0 0 0 0 0 0 1

Tayside 2 0 0 2 1 0 0 0 0 1 1 0

Orkney 0 0 0 0 0 0 0 0 0 0 0 0

Shetland 0 0 0 0 0 0 0 0 0 0 0 0

1

2

3

4

5

No. o

f Adm

issio

ns

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Eden Unit Discharges by Area April 2010 - Feb 2011

Under 18 18-20 21-25 26-30 31-35 36-40 41-45 46-50

Breakdown by Age of Admission to Eden Unit Feb 2009 - Feb 2010

The Chart below shows a breakdown of age on admission to the ~Eden unit

1

7

3

2

1

2

1

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Grampian 1 0 1 1 3 1 0 0 1 1 0 0

Highland 0 1 0 0 0 0 0 0 1 0 0 0

Tayside 1 0 0 0 0 0 1 1 1 1 1 0

No. o

f Disc

harg

es

0.5

1

1.5

2

2.5

3

3.5

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Occupied Bed Days by area

The graph below shows the Occupied Bed days per month broken down by geographical area.

April 10 May June July Aug Sep Oct Nov Dec Jan 11 Feb Mar Grampian 160 186 156 140 101 73 94 136 151 174 140 155 Tayside 81 93 90 141 161 180 181 129 100 101 79 93 Highland 30 11 0 0 9 30 31 30 9 0 0 17

March 2011

February 2011

January 2011

December 2010

November 2010

October 2010

September 2010

August 2010

July 2010

June 2010

May 2010

April 2010

0 20 40 60 80 100 120 140 160 180

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Day Patient Activity The table below indicates the activity levels for the Day Patient part of the service. There are 4 day places available and patients may attend on a variety of days e.g. one day per week or every day. They may also attend for a just a few hours per day or all day dependent on the individual needs of the patient. The day patient programme has been utilised both by NHS Grampian and NHS Tayside patients.

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5

4

3

2

1

0Jun09 July Aug Sept Oct Nov Dec Jan10 Feb Mar April May June July Aug Sept Oct Nov Dec Jan11 Feb Mar

Grampian 1 1 2 2 2 2 1 4 3 4 5 4 3 3 3 3 5 4 3 5 5 0 Tayside 1 1 2 2 2 2 2 3 3 4 4 2 2 2 1 1 1 2 2 2 2 0 Highland 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

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Outpatients - North of Scotland The Outpatient services across the North of Scotland continue to be busy with both NHS Tayside and NHS Highland seeing quite a large increase in the number of new referrals over the past year, although this does not appear to be the case in NHS Grampian. The number of patients who have been previously seen in an outpatient service and have been re-referred appears to be quite stable with no great increase or decrease in numbers.

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NHS Grampian Eating Disorders Conference – November 2010Another very successful Eating Disorders Conference was hosted by NHS Grampian in November 2010. The Conference was entitled Discovering New Skills: The Journey to Recovery. Once again the conference had managed to attract some great presenters including Professor Janet Treasure, Department of Academic Psychiatry, Guys Hospital London and Professor Walter Vandereycken, Professor of Psychiatry, Catholic University of Leuven, Belgium. A Poster Presentation session was also well received with several extremely interesting posters submitted. The Eden Unit submitted a poster at this session and a copy is attached in this report. This is the third year that a poster presentation session has been held and although the number of posters entered is relatively low the session proves very interesting and is growing in popularity.

With the current financial climate in the NHS the certainty of the conference going ahead in 2011 was in a little bit of doubt but after negotiation and a slight change in format I am happy to say that it was agreed to go ahead and it will be held on 10th/11th November at the AECC in Aberdeen.

The title for this years conference is entitled The Therapeutic Relationship in Eating Disorders and we have already confirmed some well known and reknowned speakers.

The conference is now a well established annual event and is attracts audiences from far and wide. If you wish to book a place on the conference for this year please contact Carol Deans ([email protected]) who will be happy to assist you.

Below is some of the feedback received from the November 2010 conference:-

“I think this has been the best Aberdeen Conference to date. There has been a good variety of presentations and workshops that can relate to all health professionals”.

“Very well organised conference with excellent speakers and workshops”.

“Overall excellent learning opportunity”.

“I feel inspired to examine my own practise and embark on some new ways of working”.

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Annual MCN Clinical Workshop – May 2010The annual MCN clinical workshop was held on 6th May 2010. For this years workshop we had decided upon presenting Complex Clinical Cases.

The workshop concentrated on the Management of Seriously Ill Patients and there were presentations from Highland and Grampian and Tayside.

Dr Peter Carr from NHS Highland gave an extremely interesting presentation entitled “The Mince Man” – A case of Selective Eating Disorder treated with EMDR.

Mrs Marie McKimmie/ Dr Emma Lewington SpR, NHSG gave a presentation entitled “Confrontation, Collusion or …”. Their presentation differed from Dr Carr’s, in that, they were asking for suggestions, comments or advice on how to deal with a particular case, whereas, Dr Carr’s gave an insight into using EMDR as a treatment.

Ms. Louise Hobbs, Clinical Psychologist, NHST gave a presentation entitled “A medley of interesting Themes for Sharing, Exploring and Discussing….” which covered a variety of complex cases.

These presentations are available on the MCN website. www.eatingdisorder.nhsgrampian.org

These presentations provoked further discussion around the problems with appropriate general physician liaison being available in NHS Highland and NHS Tayside. It was agreed that this was something that the MCN could take forward and should be added into the MCN Workplan for the future.

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Electronic Clinical RecordThe Eating Disorder Services in Aberdeen: The Eden Unit and the Grampian Eating Disorders Service have continued their work with the national pilot of an Electronic Patient Record, otherwise called Excelicare.

This has involved continuing meetings with Excelicare developers where electronic forms have been refined and glitches ironed out. There is no doubt the Excelicare system is now an up and running electronic patient record and we have learnt a lot through its implementation about both the power but also the limits of electronically based records. A new challenge has emerged however- with the advent of the Patient Management System, otherwise called Trakcare, as developed by Intersystems. This is now in the process of being rolled out to Mental Health following the roll-out to the Acute Sector of Grampian NHS. All IT systems they have their day and Excelicare is now approaching the end of its shelf life with us. This transition is not unexpected given the rise of the Trakcare system and the need for Eating Disorders to also interface with a whole range of departments including medical records and other Psychiatric Departments in a way that it hasn’t been able to do previously. I am in the lucky position of also being the Clinical Lead for Mental Health PMS in Grampian which has given me the ideal situation with which to try and help manage the transition of Excelicare into the new Trakcare system. The timescales for the latter are still being negotiated for a variety of unsurprising reasons given the complexity of the task, but it is clear that the future of Electronic Patient Records in Eating Disorders lies with a newer system beyond Excelicare. The MCN staff have all been working on issues in and around this development in the last few months, as well as closing off gradually the Exilicare project.

What about the other parts of the North of Scotland Region? These have not been forgotten and there have been attempts to make Excelicare at least accessible for read only view but as things stand this has not been possible to facilitate. Data protection rules remain a major issue at this level access.

Our approach therefore will now change and we have made clear the resource we have in our Information Officer Brenda Leel in providing help with managing databases and refining them. Obviously through MCN Steering Groups we can hope maybe to standardise the information held. Of course this will need to then align alongside Psychological Therapies Heat targets and ICP recording. It feels like a big task but one that is closely related to the tasks that Mental Health as a whole are confronting at the moment. The work here will continue into the coming year.

Dr P Crockett Consultant Psychiatrist in Eating Disorders and Psychotherapy Clinical Lead, Managed Clinical Network for Eating Disorders

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Eating Disorders Education and Training ScotlandEEATS is a unique organisation designed to complement recent quality initiatives at service level with quality assessment of individual eating disorders clinicians. Over the past year EEATS has moved on from its early NES- supported development to become an established independent venture, attracting international interest via the website, and boasting a solid core group of trained supervisors overseeing the training of more than a score of registered accreditees from a wide range of disciplines, settings and geographical locations, as hoped. Some of the pilot group of trainees are now approaching graduation as the first EEATS accredited specialists in Eating Disorders, whilst supervisors are submitting the new Re-accreditation applications.

We have not said adieu to the wonderful Linda Keenan, who managed the early work and website, as she has remained interested and supportive whilst handing over formally to our new administrator, Linda’s close colleague, Rona Walker. Finances, which were kindly hosted by NHS Grampian, have now passed to SEDIG, under the care of its Treasurer, Ian MacDonald. SEDIG was fundamental to the initial design of EEATS and continues to provide regular accredited training days - including a workshop on EEATS this June, as part of its Research and Development Day Conference. Meanwhile, EEATS identifies, publicises and encourages Scottish Courses and Conferences as well as linking up with those further afield. Above all, our fees provide for regular, compulsory training days for our Supervisors to ensure that those registering to be accredited can be coached, mentored and evaluated to maintain high standards.

Three recent Supervisors’ days have been held in Tayside, Glasgow and Aberdeen, led by Jane Morris, Phil Crockett and Maggie Gray, involving a mixture of development work (compiling the Reaccreditation pack, for instance), training in supervision skills, and reporting on the progress of individual accreditees. Future Supervisors’ days will be held in other geographical venues around Scotland and will include marking exercises, website maintenance, Higher Accreditation for Supervisors and Trainers, and linking with different Professional Bodies.

Dr Jane MorrisChair of EEATS

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The Scottish Anorexia Nervosa Research GroupAfter the publication of the QIS Recommendations for the management of Eating Disorders (2006), Scotland invested in improved resources for patients with anorexia nervosa, including the Eden Unit, the first NHS Specialist inpatient Eating Disorders Unit in the country. Alongside service developments, we were keen to develop Scotland’s reputation in this field, and some of us had already participated in multi-centre studies with colleagues in the Maudsley group, whilst others had conducted studies in collaboration with the Priory Hospital. Meanwhile colleagues at Huntercombe Hospital Edinburgh were adding to their own company’s research portfolio. The evidence base for the prevention and treatment of anorexia nervosa remains disappointing, but a larger number of potential research subjects is now available across Scotland and, in our experience, eager to participate in studies.

In 2009 proposal submitted for funding to set up an anorexia nervosa Protocol development group supported by the new Scottish Mental Health Research network. The group was one of 4 groups chosen for adoption at the SMHRN’s launch in the autumn of 2009. Members included the most active clinicians in the field who now wished to integrate their experience and resource with the small group of Scottish academics with expertise in this and related relevant areas. The group and its various subgroups met regularly throughout the year, which culminated in a research development meeting and dinner in Aberdeen in September 2010, at which group members presented and discussed draft research proposals.

The group has remained active and has welcomed a broader membership. Progress was evident at the Research Day held in Perth Royal Infirmary in June 2011 under the auspices of SEDIG.

The Scottish Anorexia Nervosa PDG is currently investigating:

• Infertility and Eating Disorders examining fertility, pregnancy and perinatal experiences of patients who have had a diagnosis of anorexia in the past. A paper is in preparation examining the pros and cons of screening for eating disorders in infertility clinics. Future work may be informed by studies at Aberdeen’s Rowett Institute where animal models of starvation have already yielded information on malnutrition in pregnancy.

• Length of Inpatient Stay – This group has now completed an audit of length of stay in all seven Scottish units where adults and adolescents receive specialist inpatient treatment for severe eating disorders, the first time all seven units have collaborated jointly on a piece of work. A paper has been submitted for publication.

• Couples therapy In the context of family therapy providing the most robustly evidenced treatment for adolescents with anorexia, the group is piloting a modified version of Prof Bulik’s UCAN, a CBT based intervention to unite couples against anorexia. We are calling this UKCAN. The initial aim is to describe a series of cases.

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• Medication for low weight anorexia In addition to the single well-evidenced ‘gold standard’ family therapy, some promising new treatments include medication with olanzapine, or with high dose SSRIs. A multi-centre randomised placebo-controlled trial of these treatments separately and in combination has long been needed. In preparation for this our group has conducted an audit ‘snapshot’ of prescribing for inpatients, and is circulating a questionnaire to prescribing clinicians about their attitudes and practices.

• Body image therapies In association with colleagues at Aberdeen’s Robert Gordon University, Dr Phil Crockett and other group members are piloting the use of various body imaging techniques including both 2D and 3D imaging, to explore acceptability and possible creative additions to therapy for body image disorder. The work was recently presented at the International Eating Disorders London Conference.

• Management of Diab-eat-es Clinical experience continues to demonstrate the greater difficulty of reaching recovery and the hugely multiplied risk of death in people with both IDDM and obsessive drive to lose weight. Michelle Quilter’s study involves a series of workshops with both eating disorders clinicians and diabetic experts as well as patients themselves in the hope of designing a more integrated approach to caring for these vulnerable individuals.

• Antecedents of Anorexia in young high risk subjects The Scottish population offers particular opportunities for prospective longitudinal family-based studies using the principles and outline designs pioneered by research at the University of Edinburgh in the fields of Schizophrenia (Johnstone et al) and bipolar affective disorder (Mackintosh, current affiliate of SMHRN). Our group will research the field of anorexia nervosa. We will test hypothesised antecedents and predictors of the disorder in genetically ‘high risk’ individuals, explore the nature and consequences of the disease, and examine and develop better treatments.

• Young psychologists from different parts of Scotland have been researching and trialing Cognitive Remediation approaches to the imbalance seen in central coherence seen in patients with eating disorders.

• Most recently Dr Giovanna Bermani has been examining the role of selenium in anorexia and refeeding, whilst Dr Lesley Pilans and colleagues have been exploring 24 hour blood glucose profiles in inpatients We welcome interest from students, junior doctors and established research scientists as well as senior clinicians, and we particularly appreciate the interest and support shown by patients and their families, in particular RL who attended the research day in September to offer a service users’ perspective.

Jane Morris, Chair of the Research group

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Grampian Eating Disorder ServiceGrampian Eating Disorder Service in the past year had to meet fresh challenges around staffing levels and further attempts to fill temporary vacancies are still ongoing.

Despite this the Service has continued to offer a good range of therapeutic interventions ranging from medical and psychiatric management through to cognitive behavioural treatment groups for Bulimia Nervosa and Binge-eating Disorder. The Service increasingly uses a motivational stance in its work with sufferers of eating disorders, a stance that has advantages in encouraging sufferers to challenge their eating disorders in the most helpful way and at a pace that they find possible. To ensure the quality of the work in this and the other therapeutic work there is regular supervision for staff in terms of their therapeutic modalities, as well as departmental supervision on a regular basis as well.

The services ongoing and consistent work over many years, including the original work by Dr Harry Millar in establishing the Service, was recognised by a nomination for a Best Service Award from the BEAT National Charity Annual Award Ceremony. The department was pipped to the post for the top award but were invited down to attend the Award ceremony at the Houses of Parliament back in December of 2010.

Future developments we hope to tie in with the North of Scotland Region through the work of the MCN. Developments in treatment particularly have in mind are training staff in Cognitive Remediation Therapy, which has a growing evidence base for use in Anorexia Nervosa, and likewise re-instituting at least a small availability of systemic based family therapy work. Plans are in hand for these.

In terms of what has been running in between 2010 and 2011 the groups have been the Contemplation Group (the motivational work based group), the Nutrition Education Group, a Mentalization-Based Treatment group(for Anorexia Nervosa), a Bulimia Nervosa Therapy Group and a Binge Eating Disorder Group. There is provision obviously for ongoing individual therapy, although as indicated there have been challenges through 2010 and 2011 due to low staff numbers in respect of providing availability of individual therapists up to a sufficient level. Discussions are underway about addressing aspects of this with the management team, as well as job’s currently advertised.

Grampian EDS continue to be a major hub for teleconferencing work within Grampian NHS and we have regular contacts for various reasons with the Scottish Centre for Tele-Health. Likewise an interest in other new technologies continues in the running of the Excelicare computerised Electronic Patient Record and I myself am the Clinical Lead for the Mental Health Development of the new system that is coming into Grampian Mental Health-Trakcare. Finally research and audit continues to take place within the Department and the most recent projects completed and coming to submission are focused around innovative technology for use in body-image related therapy and nature of some therapeutic interventions.

Dr P CrockettConsultant Psychiatrist in Eating Disorders and Psychotherapy Service Team Leader, Grampian Eating Disorder Service

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NHS Tayside Eating Disorder ServiceNHS Tayside Eating Disorders Service is based in Dundee, and provides outpatient clinics in Dundee, Angus, and Perth and Kinross. The service offers specialist assessment and treatment to adults suffering from severe and/or enduring eating disorders, having access to psychological, nursing, psychiatric and dietetic interventions.

The service also seeks to support the work of colleagues managing eating disorders at the Primary Care and Community Mental Health Team levels within NHS Tayside, through training events, consultation and advice. NHS Tayside Eating Disorders Service forms part of the North of Scotland Managed Clinical Network for Eating Disorders and has access to inpatient beds at the Eden Unit, Royal Cornhill Hospital, Aberdeen.

Current Clinical Staff• 0.6 wte Consultant Clinical Psychologist/Lead Clinician – Dr Paula Collin.

• 1.3 wte Clinical Psychologists – Dr Suzanne Deas (Perth and Kinross), Dr Diane Forrest (Dundee) and Ms Louise Hobbs (Angus).

• 1.0 wte Specialist Nurse – Mr Brian Grieve.

• 0.8 wte Specialist Dietitian – Ms Kareen Taylor.

• 0.5 wte Consultant Psychiatrist – Dr Lesley Dolan.

• 0.4 wte Trainee Clinical Psychologist – Ms Vivien Smith.

• 0.1 wte Lead Mental Health Dietitian – Ms Elizabeth Stewart.

Service Developments 2010/11• Management responsibility for the service has transferred from Angus to Dundee

Community Health Partnership in the past year, and the service base has shifted from Constitution House to 4 Dudhope Terrace, Dundee.

• Since August 2010, the service has been fully staffed for the first time, although the staffing pro files for Clinical Psychology and Dietetics have been altered slightly.

• Referrals to the service have increased significantly over the past year, prompting the introduction of group interventions such as that for Bulimia Nervosa. Referrals from the service to inpatient care providers have also increased (there have been nine admissions – seven to the Eden Unit – between April 2010 and March 2011).

• The service has seen the full implementation of the MiDIS (clinical), SSTS (rostering) and TOPAS (administrative) electronic systems in the past year.

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Service Challenges and Innovations 2010/11• Administrative support to the service has been compromised by an extended period of

staff absence spanning December 2010 to date.

• Work continues around ensuring adequate access to videoconferencing materials and clinical records systems, in order to facilitate liaison across the North of Scotland in respect of the Managed Clinical Network and Eden Unit eating disorders inpatient service.

• Staff have developed a service resource pack covering all aspects of the management of eating disorders and for use by all Tayside healthcare staff. A range of patient and carer information leaflets have also been produced in collaboration with members of the North of Scotland Managed Clinical Network for Eating.

Disorders• Service staff have worked with University of Dundee Student Health Service staff to

establish a support group for eating disorders sufferers in Tayside.

• Mr Brian Grieve was awarded a grant to undertake the Edinburgh training course in Interpersonal Psychotherapy in April 2010, while Ms Vivien Smith won a bursary to attend the London Eating Disorders Conference in March 2011.

TeachingTeaching on the management of eating disorders is provided by the service on an ongoing basis, to both professional and non-professional groups, locally and nationally, e.g.

• North of Scotland Managed Clinical Network for Eating Disorders, presentation on complex cases – Ms Louise Hobbs.

• Angus Adult Psychological Therapies Service, presentation on motivational interviewing – Ms Louise Hobbs.

• University of Dundee medical undergraduate teaching – Dr Lesley Dolan.

• University of Stirling Clinical Associate in Applied Psychology teaching – Dr Paula Collin.

Training ProvidedThere is currently 1.0 wte (five-year, flexible) Trainee Clinical Psychologist, Ms Vivien Smith, attached to the service. In addition, short-term placements have been provided for student doctors and nurses over the past year.

Training Undertaken• Cognitive Remediation Therapy Training Course (London, December 2010) – Dr Paula Collin.

• Interpersonal Psychotherapy Training Course (Edinburgh, April 2010) – Mr Brian Grieve.

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• Eating Disorders Education and Training Scotland Supervisors’ Training Course – Dr Paula Collin, Dr Suzanne Deas, Mr Brian Grieve and Dr Lesley Dolan.

• NHS Education Scotland Generic Supervisors’ Training Course – Ms Louise Hobbs.

• Grampian Eating Disorders Conference (November 2010) – Ms Louise Hobbs, Mr Brian Grieve, Ms Kareen Taylor, Dr Lesley Dolan and Ms Vivien Smith (poster presentation).

• London Eating Disorders Conference (March 2011) – Dr Paula Collin, Dr Lesley Dolan and Ms Vivien Smith (poster presentation).

Research Activities• Psychology staff attached to the service continue to undertake eating disorder research in

partnership with the Priory Hospital in Glasgow and, more recently, with the inpatient and outpatient eating disorders services based in Aberdeen.

Research papers accepted for publication/published 2010/11:

• The Effectiveness of, and Predictors of Response to, Inpatient Treatment of Anorexia Nervosa (Collin, Power, Karatzias, Grierson and Yellowlees) – Published, European Eating Disorders Review.

• A Mediational Model of Self-esteem and Social Problem Solving in Anorexia Nervosa (Paterson, Power, Collin, Grierson, Yellowlees and Park) – Published, European Eating Disorders Review.

• General Psychopathology in Anorexia Nervosa: The Role of Psychosocial Factors (Karatzias, Chouliara, Power, Collin, Yellowlees and Grierson) – Published, Clinical Psychology and Psychotherapy.

• The Relationship Between Disordered Eating, Perceived Parenting and Perfectionistic Schemas (Deas, Power, Collin, Yellowlees and Grierson) – Published, Cognitive Therapy and Research.

Committees/Professional Groups• Scottish Eating Disorders Interest Group – Dr Paula Collin, Dr Suzanne Deas (committee

member), Ms Louise Hobbs, Mr Brian Grieve, Ms Kareen Taylor and Dr Lesley Dolan.

• Eating Disorders Education and Training Scotland Committee – Dr Paula Collin, Dr Suzanne Deas and Dr Lesley Dolan.

• Scottish Eating Disorders Section of the Royal College of Psychiatrists – Dr Lesley Dolan.

• Scottish Dietitians’ Eating Disorders Clinical Forum – Ms Kareen Taylor and Ms Elizabeth Stewart.

• North of Scotland Managed Clinical Network for Eating Disorders Steering Group – Dr Paula Collin, Mr Brian Grieve and Dr Lesley Dolan.

Dr Paula Collin Consultant Clinical Psychologist

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Highland Eating Disorder Service2010 – 2011 has seen the return of a full staffing compliment for our service. Our Consultant Psychiatrist returned to work at the beginning of the year and we appointed a new secretary. One of our Nurse Therapists has returned from maternity leave and we have successfully recruited another Nurse Therapist for our 1 day a week training secondment. Our Staff Grade Psychiatrist has altered his sessional commitment to allow him to pursue his interest in EMDR and do more trauma focussed work. We have also had a part-time Clinical Psychology post developed which is now filled by the Psychology Trainee who worked with us last year. Staffing levels now stand at: -

• Consultant Psychiatrist 0.3wte

• Two Nurse Therapists 1.4wte

• Dietetic input 0.3wte

• Staff Grade Psychiatrist 0.5wte

• Clinical Psychologist 0.5wte

• Secretary 1.0wte

Our referral rate has remained consistent at around 100 referrals a year. We continue to meet our waiting list targets of seeing urgent cases within a working week and routine referrals within 2 to 3 months.

One of our Nurse Therapists and the training secondment Nurse has registered with EEATS for Specialist Training. The other Nurse Therapist has registered as a Supervisor with EEATS and will be providing their supervision. Our Clinical Psychologist has registered with EEATS and will be supervised by our Consultant Psychiatrist who is also registered as a Supervisor for EEATS. Given the levels of experience and commitment to continuing professional development in our team we are hopeful that the majority of our clinical staff will be accredited by EEATS in the not too distant future.

Our Clinical Psychologist has now completed a piece of research for her Thesis looking at a comparison of neuropsychological test performance on the Ravello profile between patients with Bulimia Nervosa and Anorexia Nervosa. This has provided an excellent introduction to the Ravello profile for us (with some team members undergoing the battery of tests to provide controls for the study) and we are now able to access this neuropsychological testing as part of assessment for some of our patients. At the end of last year both our Clinical Psychologist and Consultant Psychiatrist participated in training in Cognitive Remediation Therapy. This appears to link up nicely with the information coming from neuropsychological testing and we plan to offer our first Cognitive Remediation Therapy Group for outpatients in spring.

Our Nurse Therapists and Consultant Psychiatrist continue to maintain accreditation with the BABCP. One of the Nurse Therapists has successfully undergone their re-accreditation process this year.

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As a multi-disciplinary team we are able to offer Cognitive Behavioural Therapy, Interpersonal Therapy, Dialectical Behavioural Therapy, Mindfulness, Eye Movement Desensitisation & Reprocessing and Cognitive Remediation Therapy. Our Dietician also continues to offer individual dietetic assessments and nutritional support.

Our links to Grampian have been strengthened by both the Eden Unit Consultant and the MCN Manager visiting our service and spending a day each with the team. We are now meeting through teleconferencing with the Eden Unit staff on a regular monthly basis. We also continue to have alternative monthly in-house teaching sessions and service development meetings. Now that we are back to our full staffing compliment we are able to offer teaching and training to other health professionals again. This kicks off with a trip to Skye planned for next month when our Psychologist and Dietician will provide some training to staff at the Mental Health Drop-in Centre there. We also continue to offer regular tutorials in both Eating Disorders and Cognitive Behavioural Therapy to medical students on placement in Highland.

Since the publication of the MARSIPAN recommendations for the management of severely ill anorectic patients, our Consultant Psychiatrist has been liaising with an interested GI Physician at Raigmore Hospital to see if a local version of the guidelines can be adopted.

As a team we continue to participate fully in MCN activity and to contribute to EEATs and SEDIG developments. Further details of our service are available on both the MCN website and Highland Intranet site.

Dr Yvonne EdmonstoneConsultant Psychiatrist

27

MCN for Eating Disorders Finance Report – April 2010 March 2011MISCELLANEOUS INCOME

Account Code Account Level 9 Name Annual Budget YTD Budget YTD Actuals YTD Variance

Other Miscellaneous Income -£59,177.00 -£59,177.00 -£50,096.00 -£9,082.00Sum -£59,177.00 -£59,177.00 -£50,096.00 -£9,082.00

NON-PAY


Pur:comp & Software £1,004.00 £1,004.00 £0.00 £1,004.00

S/C: Comp & Software £700.00 £700.00 £146.00 £554.00

S/C: Other Equipment £0.00 £0.00 £449.00 -£449.00

Travel & Subsistence Budget £0.00 £0.00 £16.00 -£16.00

Travel £1,000.00 £1,000.00 £82.00 £918.00

Subsistence £0.00 £0.00 £5.00 -£5.00

Travel Booking Fee £0.00 £0.00 £16.00 -£16.00

Hire Charge £0.00 £0.00 £365.00 -£365.00

Hospitality Chgs £200.00 £200.00 £469.00 -£269.00

Course Travel - Subs £3,500.00 £3,500.00 £561.00 £2,939.00

Printing £0.00 £0.00 £1,028.00 -£1,028.00

Stationery £502.00 £502.00 £0.00 £502.00

Other Miscellaneous £0.00 £0.00 £128.00 -£128.00

Sum £6,906.00 £6,906.00 £3,265.00 £3,642.00

PAY


Cons - Psych - Mi £34,479.00 £34,479.00 £22,930.00 £11,549.00

Office Services Band 4 £12,188.00 £12,188.00 £0.00 £12,188.00

Office Services Band 5 £0.00 £0.00 £1,927.00 -£1,927.00

Office Services Band 6 £36,800.00 £36,800.00 £12,267.00 £24,533.00

Patient Services Band 4 £0.00 £0.00 £2,548.00 -£2,548.00

Patient Services Band 5 £0.00 £0.00 £3,970.00 -£3,970.00

Patient Services Band 6 £0.00 £0.00 £25,333.00 -£25,333.00Admin Officer H L -Gen/Man Svs £552.00 £552.00 £0.00 £552.00

Admin Manager - Gen/Manage Svs £4,396.00 £4,396.00 £0.00 £4,396.00

Sum £88,415.00 £88,415.00 £68,975.00 £19,441.00

FHS EXPENDITURE


GMS2 EXPENDITURE £0.00 £0.00 -£2.00 £2.00

Sum £0.00 £0.00 -£2.00 £2.00


MCN FOR EATING DISORDERS £36,144.00 £36,144.00 £22,142.00 £14,003.00

28


Membership of the Managed Clinical Network for Eating Disorders Steering Group

Name Title NHS Board Area/Organisation

Ms Jackie Agnew Service Manager NHS Highland

Mr Peter Cartwright Lead Nurse (MH) NHS Argyll & Bute

Dr Paula Collin Consultant Clinical Psychologist NHS Tayside

Dr Yvonne Edmonstone Consultant Psychiatrist NHS Highland

Dr Jane Morris Consultant Psychiatrist NHS Grampian

Mrs Pauline Milne The Eden Unit NHS Scotland

Mr Neil Fraser Strategy & Performance Manager NHS Tayside

Mr Bill Harrison General Manager NHS Grampian

Ms Roseanne Urquhart Head of Healthcare Strategy NHS Highland

Mrs Linda Keenan MCN Manager NHS North Scotland

Mr Alan Murdoch Community MHT Manager NHS Shetland

Dr Elaine Anderson Consultant Psychiatrist NHS Western Isles

Vacancy General Practitioner

Mrs Lorna Carrol Dietitian NHS Highland

Dr Jeanette Eagles (CAMHS) Consultant Psychiatrist NHS Grampian

Mr Brian Grieve Nurse Therapist NHS Tayside

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Managed Clinical Network For Eating Disorders

North Scotland Annual Workplan April 2011 – March 2012

30


Subject/Aim Rationale Objective for 2011/2012 Proposed Action

The Steering Group should provide the overall direction and focus of the Managed Clinical Network

HDL (2002) 69 and (2007) 21 state that each MCN should have clarity about its management arrangements.

To continue to provide direction, assist in decision making and contribute to any service redesign.

Regular steering group meetings.

Communication Development of modern standards and guidelines continues e.g. Royal College of Psychiatrists, MARSIPAN Guidelines.

To ensure communication across the region of relevant standards, guidelines and urgent information with relevant stakeholders.

Develop intra-regional system to ensure dissemination.

Patient & Carer Involvement

HDL (2002) 69 and (2007) 21 state that patient involvement is integral to the development of the MCN.

To continue to involve users of the EDS services in developments of the MCN.

Continue to develop patient involvement in MCN Activities.

Explore methods of collecting patient satisfaction data.

Continued involvement by clinical lead to support supervision of NEEDS patient-carer organisation.

MCN continue to support National Carers conference and local developments of support groups and networks.

Development of Care Pathways

HDL (2002) 69 and (2007) 21 – Each network should have a defined structure, which sets out the points at which service is to be delivered and the connections.

between them, clearly indicating the ways in which the network relates to the planning function of the body or bodies to which it is accountable.

Care pathways are currently in place but will be kept under review in the light of experience of the new regional in patient unit

Transitions from CAMHS to Adult Services to be reviewed.

Continue to be involved with the implementation of NHS Tayside Eating Disorders Service Care Pathway.

Work with whole network to clarify the monitoring of outcomes along all steps of care pathway. Develop a care pathway for CAMHS to Adult services.

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Quality Assurance HDL (2002) 69 and (2007) 21 – Each network must have a Quality Assurance programme.

To Develop a Quality Assurance Framework .

Prioritise Quality Assurance and Risk Factors as a workstream.

Link region with QED standards as devised by the RCPsych for In-Patient and Out-Patient Care.

Quality Assurance Sub-Group to look at audit and take forward QAP – ongoing due to staff shortages over the past year, now to move forward with this agenda.

Establish ties with QED.

To continue to develop the website to meet the requirements of stakeholders

Information should be available to patients/carers and health professionals.

Keep website updated with current information for both health professionals and patients/carers.

Continue to keep website up to date and investigate further possible developments to enhance the site.

Education & Training

HDL (2002) 69 and (2007) 21 states that educational and training potential should be used to the full.

Continue to raise awareness with GP’s/Counselling services across the region.

Make links with medical colleagues to aid implementation of the MARSIPAN and other quality assurance related guidelines.

Continue to host Educational Events for the Region.

Investigate using VC for educational purposes between areas within region.

Make closer links with medical colleagues across the region.

Educational annual event planned for May 2011.

32


Tier 4 Services HDL (2002)69 and (2007) 21 states that there must be evidence that the potential for networks to generate better value for money has been explored.

Review Eden Unit’s 2nd operational year. Ensure risk share agreement is implemented and data collection/monitoring continues.

Review outcome data for the Eden Unit.

Assist with process of mandatory review of funding formula for the Eden Unit.

IT Systems Ensure Excelicare data is ready to be transferred to new PMS system within NHS Grampian.

Assist all areas with ED services’ needs will be included in any new IT system implemented in their area.

Improve data quality of information being input.

Information Officer to assist all areas of region with data management and extraction of useful outcome data.

Liaise with NHSG IT PMS team to ensure transfer of data runs smoothly.

Keep up to date with other HB’s plans for new IT Systems.

IT officer will continue to improve data entry quality.

Information officer to establish work flows and priorities for other parts region-Tayside and Highland.

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Appendix 1

An Audit of Length of Stay in Eating DisordersIntroduction: Inpatient treatment for eating disorders is a scarce and expensive resource, used only in a minority of patients. We aimed to examine mean length of stay (LOS) in eating disorders in Scotland. Additionally, we sought to identify a relationship between LOS and outcome at discharge, and to explore factors which correlate with LOS.

Method: Audit of 72 admissions between 2008 and 2011; 38 adults and 34 adolescents Demographic and clinical data was collected from electronic database and patient case files.

Results: Mean LOS of adults was 116.6 days (SD 117.9); mean LOS for adolescents was 89.3 days (SD 79.6). Patients gained a significant amount of weight during inpatient stay. Increased LOS in adults was associated with a better Clinical Global Improvement (CGI) outcome. In adolescents, an increased LOS was associated with a greater degree of change in BMI; in addition, patients who were treated under the Mental Health Act or fed via nasogastric tube had a significantly longer LOS.

Conclusion: Patients with eating disorders improved significantly with a specialist inpatient programme. Future efforts should be invested in establishing a follow-up study, assessing patient outcome at 1year, 2 years and 5 years post-discharge and assessing for correlation with LOS.

Anorexia NervosaWith an estimated population of 5.1 million, it has been suggested that 413 new cases of anorexia nervosa (AN) will be diagnosed per annum in Scotland i. Of these patients, 50% will recover, 30% will achieve partial recovery, and 20% will experience a chronic illness with relapsing course ii. Thus, even though AN is a relatively uncommon condition, its high morbidity and mortality rates, and costs both economically and in terms of quality of life, warrant further research into effective management and treatment options for those affected.

Inpatient TreatmentBritish expert opinion holds that most people with AN should be managed on an outpatient basis with psychological therapy provided by a service that is competent in providing such treatmentiii. Indeed, studies in a Child & Adolescent setting have shown that, where it is safe to offer this, outpatient treatment in a non-specialist service can be as effective as inpatient treatment, and is more cost-effective over a 5-year follow-up period iv. Inpatient treatment is usually considered as the last resort, used only in a minority of cases of acute medical or psychiatric need v. According to NICE Guidelines, when a patient with AN does require admission, it should ideally be to a specialised unit within a reasonable travelling distance from their home. Additionally, admission should be to an age-appropriate setting, with those under 18 years of age managed under Child and Adolescent Mental Health Services (CAMHS), and those over 18 managed under adult services vi. However, whilst inpatient treatment for eating disorders is necessary for some patients, the precise indications for hospitalisation are not established, specific goals of inpatient treatment are not widely agreed upon, and the optimum length of stay is unknown vii. Finally, the impact of hospitalisation on the long-term outcome of eating disorders is not clear, with a study in 2000 concluding that though admission

34


to hospital can clearly provide short-term benefits, and may be life saving, there is a possibility that lengthy admissions may undermine the potential for longer-term recovery viii.

Length of StayFew studies have examined length of stay (LOS) in AN. A literature search was carried out through Medline using key words “anorexia nervosa” and “inpatient”/“hospitalisation”. This search returned 725 articles published between 1964 and 2010. These studies were checked for relevance on the basis of their abstracts, and 35 full articles were obtained. Of these, 16 were found to contain data regarding LOS (Table 1):

Table 1: Studies detailing LOS in Anorexia Nervosa

Study (year of publication) Mean LOS (SD) Number of admissions

Steinhausen (1985) ix 77.0 24

Nozoe et al.(1995) x 114.8 55

Howard et al. (1999) xi 48.7 0 (30.7) 59

Kahn & Pike (2001) xii 83.1 (52.4)

Tanaka et al (2001) xiii 88.3 (62.2)

Maguire et al (2003) 24

(results from 5 different regions)

106.8 (98.8)58.0 (46.6)55.1 (42.7)72.8 (65.5)52.1 (38.3)

218

Woodside et al. (2004) xiv 74.2 (44.1) 166

Castro et al. (2004) xv 31.2 (17.3) 100

Willer et al. (2005) xvi 73.1 (37.6)39.5 (28.3)

59127

Gowers et al (2007) xvii 106.4 54

Steinhausen (2008) xviii 76.0 (85.3) 212

Strik-Lievers et al (2009) xix 135 (97) 268

Lund et al (2001) xii 103.4 (38.7) 83Salbach-Andrae et al (2009) xxi 89.6 (24.5) 57

Huas et al. (2010) xviii 82.6 (48.3) *65.8 (40.6) **

320 *281**

Collin et al. (2010) 1 135.1 ± 70.9 90

Values followed by superscript * are for anorexia nervosa restrictive subtype; those followed by ** are for anorexia nervosa

binge/purge subtype; mean LOS followed by † is for data collected in 1975, and †† indicates data

35

As demonstrated, there is a considerable degree of variation in reported LOS, with means ranging from 31.2 days to 135 days. However, whilst these studies do provide us with an insight in to the range of LOS, only five studies related the LOS to patient outcome. Willer et al. (2005) found that the mean LOS significantly decreased over a period of twenty years, reporting a fall from 73.1 days in 1975, to 39.5 days in 1995. The group associated this decreased LOS with a higher risk of readmission16. In 2004, Castro et al. found that insufficient weight gain during hospitalisation increased the risk of readmission18. As such, it may have been expected that an increased LOS, theoretically providing more time for weight restoration, would be associated with a decrease in readmission risk; however, the group failed to find a correlation between LOS on first admission and the number of subsequent admissions. This was reinforced by Steinhausen (2008), who also found that LOS failed to distinguish between patients requiring single or repeated admissions18. Finally, Maguire et al. (2004) found that an increased LOS was associated with a greater degree of change in BMI24; this was later supported by Collin et al. (2010)1.

Factors Influencing Length of Stay There are a large number of variables which may influence LOS. These variables can be broadly grouped into three categories: factors related to the patient and their illness; factors related to the treatment received; and factors related to the health care systemxxiii (Table 2). Our literature search identified three studies concerning factors correlated to LOS, in which the following six variables were identified: minimum body weight after onset of eating disorder, age at admission to inpatient unit, number of previous admissions for treatment of an eating disorder, body mass index (BMI) on admission, presence of a co-morbid disorder, and use of tube feeding during inpatient stay10,19, xxiv. However, the relative contribution of each of these factors in determining LOS is not clear, and no single study has been able to verify all of these factors as being predictive of LOS.

By identifying clinical variables which may influence the LOS in patients with eating disorders it is hoped that new treatment strategies could be developed which may optimise LOS, reduce the duration of illness, and improve short-term and long-term outcome. Optimising treatment for individual patients, based on targeting such clinical variables, may also improve patient compliance by allowing more informed treatment choices, thus limiting negative clinical and economic consequences.

36


Table 2: Factors which may influence the length of inpatient stay in eating disordersFactors related to the patient and their illness:

• Gender

• Age on admission

• Age at onset of eating disorder

• Duration of eating disorder on admission

• ICD-10- diagnosis

• Weight and BMI on admission

• Minimum body weight (kg) post-development of eating disorder

• Number of previous admissions to inpatient unit

• Co-morbid psychiatric diagnoses

• Was the patient treated under the Mental Health Act?

• Did the patient require admission to a medical ward before or during admission?

• Social circumstances/living arrangements

• Education (number of years of education)

• EDE, CORE, or HAD scores on admission

Factors related to the treatment:

• Reason for admission

• Use of tube feeding during inpatient stay

• Individual consultant opinion

• Criteria for discharge

Factors related to the health care system:

• Availability of intensive outpatient treatment or day services

• Service from which the patient was referred

• Locality of treatment services

• Service to which the patient was discharged

Table 2: Factors which may influence the length of inpatient stay in eating disorders

37

Project ProposalIn view of this current literature, the primary aim of this project is to examine length of stay in patients with eating disorders in Scotland, together with measures of range. We will then assess for a relationship between length of stay and outcome at discharge, and examine factors which may correlate with length of stay.

MethodologyLead clinicians from all seven Scottish inpatient units, both adult and adolescent, NHS and Private, which specialise in the management of patients with eating disorders, were invited to participate in our study. Four affirmative responses were received, however two of these were received too late to be included in this report, which describes data obtained from one NHS adult and one NHS adolescent inpatient unit; the Eden Unit and the Lothian CAMHS Inpatient Unit. After obtaining clinical managers’ consent, data was collected from electronic database or patient case notes. Data was anonymised and stored within a database on a password-protected network. The University of Edinburgh’s advice on Ethical Permission demonstrates that this survey does not constitute an intervention requiring Ethics Committee Approval.

Measures of OutcomeOn admission to the Eden Unit patients are requested to complete 3 self-reporting questionnaires: the Eating Disorder Examination (EDE-Q), Clinical Outcomes in Routine Evaluation (CORE v.2) and Hospital Anxiety and Depression (HAD) score; these are repeated at discharge. The EDE-Q is designed to assess psychopathology associated with eating disordersxxv; the CORE system is used to measure outcome following psychotherapyxxvi; and the HAD scale is used to assess the extent of mood disorderxxvii. The difference in score for each of these can be used as measure of outcome at the point of discharge; with a reduction in score indicating an improvement in psychopathology. Furthermore, patients are assessed using the Clinical Global Improvement score (CGIC), an observer-rated scale which is used at the point of discharge to measure improvement in the patients’ mental healthxxviii.

Statistical AnalysisStatistical analysis was performed using Statistical Package for the Social Sciences v.19 (SPSS). Qualitative variables are described using proportions and percentages. Quantitative variables are described using mean, standard deviation (SD), median and range. Means were compared using two-tailed paired or independent Student T-tests. LOS data, which did not conform to a normal distribution, and data for which the sample sizes were unequal, were analysed using the non-parametric Mann-Whitney U and Kruskal-Wallis tests. The correlation between variables and LOS was assessed by visualising data through scatter-plots, followed by Pearson correlation where indicated.

Study PopulationThis retrospective study includes 72 admissions, involving 55 patients, with a primary diagnosis of eating disorder according to ICD-10 criteriaxxix: 38 adult- and 34 adolescent- admissions. Adult patients were admitted and discharged between 2009 and 2011; adolescents between 2008 and 2011.

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Variable

The Eden Unit(Aberdeen)

Lothian CAMHS Inpatient Unit (Edinburgh)

Mean (SD, median, range) Mean (SD, median, range)

Age on admission (years) 28.9 (SD 9.5, median 27, range 17-57)

14.9 (SD 1.3, median 15, range 12-17)

Length of Stay (days) 116.6 (SD 117.9, median 86.5, range 1-489)

89.3 (SD 79.6, median 60, range 1-317)

BMI (kg/m2):•Minimum

14.4 (SD 1.5 median 14.1, range 10.6-17.0)

14.4 (SD 1.3, median 14.3, range 11.7-16.2)

•Onadmission 15.5 (SD 2.0, median 15.3, range 10.6-19.4)*

14.9 (SD 1.7 median 14.6, range 12.3-19.1)^

•Atdischarge 17.5 (SD 1.9, median 17.5, range 13.8-22.1)*

16.7 (SD 1.8, median 16.6, range 13.3-20.0)^

Body weight (kg):•Minimum

38.8 (SD 5.3, median 39.1, range 28.1-46.5)

38.4 (SD 4.0, median 37.4, range 30.3-47.4)

•Onadmission 41.9 (SD 6.7, median 42.1, range 28.1-51.7)**

40.0 (SD 5.2, median 39.3, range 30.7-53.6)^^

•Atdischarge 47.4 (SD 6.1, median 48.1, range 35.4-61.0)**

44.9 (SD 5.6, median 43.3, range 34.7-56.0)^^

Total weight gain (kg) during inpatient stay

5.5 (SD 6.1, median 4.3, range -3.3-18.5)

4.6 (SD 4.1, median 3.4, range -3.6-10.7)

Weight gain (kg) per week 0.2 (SD 0.6, median 0.25, range -2.03-1.19)

0.36 (SD 0.47, median 0.32, range -0.9-1.88)

Not considered an accurate measure of outcome in an adolescent sample; however we included this data as it allows a useful comparison to the adult sample.

In 27 (71.7%) adult cases discharge was planned; in 11(28.9%) cases patients were discharged against medical advice (DAMA). In the adolescent sample, 32 (94.1%) discharges were planned, and only 2 (5.9%) patients were DAMA. We conducted an intention to treat analysis including all of these cases. Analyses regarding weight/BMI included only those cases with a BMI less than 20 kg/m2 on admission, as patients above this cut-off would not have been admitted for the purposes of weight gain.

ResultsThe demographic and clinical characteristics of the sample are described in Table 3:

Table 3: Population Description for Adults (The Eden Unit) and Adolescents (Lothian CAMHS)

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The Eden UnitThe 10-bed Eden Unit opened in February 2009 as Scotland’s first NHS inpatient eating disorders unit. The unit is based at Aberdeen’s Royal Cornhill Hospital, and takes referrals from Grampian, Tayside, Highland, Orkney, Shetland and the Western Isles. This sample includes 38 admissions for 29 patients. Nine cases (23.7%) were repeat admissions (2 patients admitted three times, 5 patients admitted twice). Twenty-seven (71.1%) admissions were for Anorexia Nervosa (F50.0); 7 (18.4%) were for Atypical Anorexia Nervosa (F50.1), 2 (5.3%) were for Bulimia Nervosa (F50.2), and 2 (5.3%) were for Eating Disorder Unspecified (F50.9). The great majority of admissions were female (94.7%). Eighteen (47.4%) were from Grampian, 12 (31.6%) were from Tayside, and 8 (21.1%) from the Highlands and Islands.

These figures are what we would expect given the relative populations of these areas . Four (10.5%) admissions were made under the Mental Health (Care and Treatment) (Scotland) Act 2003 (Section 44 – Short Term Detention Certificate (STDC)). Nine patients (23.7%) were treated in a medical ward immediately prior to admission; and in two (5.3%) admissions patients required feeding via a nasogastric tube whilst in the Eden Unit. Twelve admissions (31.6%) met criteria for a co-morbid diagnosis; 6 (15.8%) with a personality disorder, 3 (7.9%) with an affective disorder, 1 (2.6%) with an obsessive compulsive disorder, 1 (2.6%) with Autism Spectrum Disorder, and 1 (2.6%) with a phobic disorder. Information regarding the total number of previous admissions was not available at the time of data collection. In the eleven cases where patients were DAMA, 5 (45.5%) were from Grampian, 3 (27.3%) were from Tayside, and 3 (27.3%) were from the Highlands and Islands. Data concerning services which patients were referred from- and discharged to- is displayed in Figure 1 below:

Figure 1: Services which patients were referred from- or disharged to:

78.9%

7.9%

5.3%5.3% 2.6%

44.8%50.0%

2.6% 2.6%

Specialist Eating Disorder Day

Programme

General Psychiatric Inpatient Ward

Specialist Eating Disorder Outpatient

Service

General Psychiatric Outpatient Service

Referred Discharged

40


As is shown, the majority of patients were referred from a specialist eating disorder outpatient service (78.9%), with only a minority being referred from other services. At the point of discharge, the majority of patients were discharged either to the Grampian Day Programme (50%) or to a specialist eating disorder service (44.8%). Patient EDE-Q, CORE and HAD scores significantly decreased between admission and discharge; indicating an improvement in psychopathology (p<0.005) [results not shown]. However, there was no correlation between EDE-Q, CORE or HAD scores and LOS, or any other variables.

Length of StayThe mean LOS for the 38 admissions to the Eden Unit was 116.6 days (SD 117.9), with a median of 87 days and a range of 488. Table 5 shows a comparison between mean LOS for different categorical variables:

As would be expected, patients who were DAMA had a significantly shorter LOS compared to those who completed treatment, and gained significantly less weight (p=0.043). However, there was no significant difference in admission or discharge weights between these two groups (p>0.05) [results not shown]. There was a significant association between LOS and CGIC score at discharge, with a longer LOS associated with a better outcome. We found no significant difference in LOS between any other categorical variables, and scatter plot diagrams indicated no correlation between LOS and any continuous variables.

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Categorical Variable Mean LOS (days)

SD Median Significance(p value)

Diagnosis on Discharge:

•AnorexiaNervosa(n=25)

•AtypicalAnorexiaNervosa(n=7)

Co-morbid Psychiatric Diagnosis:

•Yes(n=11)

•No(n=25)

NHS Health Board:

•Grampian(n=18)

•Tayside(n=12)

•Highland&Islands(n=8)

Status on admission:

•Voluntary(n=34)

•DetainedunderMHA(n=4)

Nature of Discharge:

•Planned(n=27)

•DAMA(n=11)

Was patient discharged to the Day Programme?

•Yes(n=18)

•No(n=18)

Clinical Global Improvement (CGIC) at Discharge:

•Verymuchimproved(n=4)

•Muchimproved(n=14)

•Minimallyimproved(n=7)

•Nochange(n=7)

•Minimallyworse(n=3)

125.1

109.4

100.4

126.0

128.9

122.2

89.9

126.7

50.0

142.3

63.3

136.5

99.8

155.0

137.8

148.6

23.9

46.7

112.3

172.4

142.6

110.5

147.2

110.4

59.0

123.8

43.2

118.3

108.5

127.3

112.2

49.8

116.0

160.8

24.9

28.3

104

64

58

108

64

104

93

101

34

109

19

103

73

150

107

138

14

62

0.287 mwu

0.113 mwu

0.853 kw

0.234 mwu

0.005 mwu

0.393 mwu

0.009 kw

Table 5: Length of stay for categorical variables for adult patients (Eden Unit)

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X2.9%2.9%2.9%2.9%2.9%2.9%

Lothian

Lanarkshire

Fife

Borders

Forth Valley

Greater Glasgow and Clyde

Highland

Tayside

78.9%

8.8%

17.4%

Lothian CAMHS Inpatient UnitThe Lothian CAMHS inpatient unit is a 12-bed unit, which provides psychiatric services to young people living in the Lothian area. The unit also accepts referrals from ‘Out of Area’ on a case-by-case basis. This sample includes 34 admissions for 26 patients. Eight admissions (23.5%) were repeat hospitalisations (3 patients admitted three times, 2 patients admitted twice). Out of these 34 admissions, 27 (79.4%) were for Anorexia Nervosa (F50.0); 1 (2.9%) was for Atypical Anorexia Nervosa (F50.1); 3 (8.3%) were for Bulimia Nervosa (F50.3); 1 (2.9%) was for Atypical Bulimia Nervosa (F50.3); and 3 (8.3%) were for Eating Disorder Unspecified (F50.9). Figure 2 displays the NHS Health Board from which patients were referred. The majority of admissions were female (88.2%). Eight admissions (23.5%) were made under the MHA; seven under STDC, one under a Compulsory Treatment Order (CTO, Section 64(4)), one under STDC which was later converted to a CTO. In 4 (11.8%) admissions, patients required feeding via a nasogastric tube whilst on the ward. Sixteen (47.1%) cases met criteria for co-morbid diagnoses; 7 (20.3%) with an affective disorder, 7 (20.3%) with a history of deliberate self harm, 4 (11.8%) with an obsessive compulsive disorder, 1 (2.9%) with a social phobia (F40.1) and 1 (2.9%) with post-traumatic stress disorder (PTSD) (NB: some patients had more than one co-morbidity).

Figure 2: NHS Health Board from which patient was referred:

In eighteen (52.9%) admissions patients were referred from a general CAMHS outpatient service, 7 (20.6%) were referred from a day patient programme, 2 (5.9%) were referred from an intensive outpatient treatment service, 2 (5.9%) were referred by their general practitioner, 1 (2.9%) was referred from a general paediatric outpatient clinic, 1 (2.9%) was referred from a general psychiatric inpatient unit, and 1 (2.9%) was referred from a medical ward. At the point of discharge, all patients have the opportunity to attend the Lothian day patient programme; however only 15 (44.1% patients chose to utilise this service. A further 15 (44.1%) patients were referred to a general CAMHS outpatient service, and 3 (8.8%) patients were referred to an intensive outpatient treatment service.

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Categorical Variable Mean LOS (days)

SD Median Significance(p value)

Diagnosis on Discharge:

•AnorexiaNervosa(n=27)

•Other(n=7)

Co-morbid Psychiatric Diagnosis:

•Yes(n=16)

•No(n=16)

NHS Health Board:

•Lothian(n=25)

•Other(n=9)

Status on admission:

•Voluntary(n=26)

•DetainedunderMHA(n=8)

Did the patient require nasogastric tube feeding?

•Planned(n=29)

•DAMA(n=4)

Was patient discharged to the Day Programme?

•Yes(n=16)

•No(n=18)

84.3

108.9

85.6

80.7

77.3

122.7

67.6

159.9

70.4

169.5

73.6

89.8

74.1

102.3

79.3

63.5

78.2

78.0

62.2

92.9

61.3

73.1

57.9

79.2

58.0

60.0

54.0

60.0

49.0

125.0

49.5

153.5

50.0

179.5

58.0

60.0

0.394 mw

0.806 mw

0.064 mw

0.010 mw

0.018 mw

0.539 mw

Length of StayThe LOS for the 34 admissions to the Lothian CAMHS Inpatient Unit was 89.3 (SD 79.6) days, with a median of 60 days and a range of 316. Table 6 shows a comparison between mean LOS and different categorical variables:

Table 6: Length of stay for categorical variables for adolescent patients (Lothian CAMHS Inpatient Unit)

Patients who were detained under the MHA had a significantly longer LOS compared to those patients who were treated voluntarily. These patients also gained significantly more weight during their stay (p=0.001), and had a greater BMI at discharge (p=0.007), despite no significant differences between these groups on admission [results not shown]. Average weight gain per week was not significantly different between those who were detained and those who were treated voluntarily. Patients who required NG tube feeding had a significantly longer LOS compared to those who did not, however there was no difference in weight gain between these two groups (p=0.232) [results not shown]. No differences were found between LOS any other categorical variables. Scatter plot diagrams indicated a correlation between LOS and change in weight during inpatient stay, with an increasing LOS associated with a greater increase in weight change. Pearson correlation showed this to be significant (p=0.01). No correlation was found between LOS and any other continuous variables.

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DiscussionThe primary aim of this study was to describe length of stay in patients with eating disorders in Scotland. Our results involve data collected from one NHS adult and one NHS adolescent inpatient unit, with a mean length of stay of 116.6 days (SD 117.9) and 89.3 days (SD 79.6) respectively. Our mean length of stay for adults is similar to that published in a recent study from a private Scottish adult inpatient unit, which quoted a figure of 135.1 days (SD 70.9)1. Collin et al. (2010) concluded that a longer length of stay stay was associated with a greater degree of change in BMI, a result which echoes that of Nozoe et al. (1995)10 and Maguire et al. (2003)24.

Unfortunately we were unable to corroborate these findings in this sample, despite similarities in both mean length of stay and mean BMI on admission and discharge in the study populations. Interestingly, when we excluded outliers from our adult sample (n=3), our mean length of stay dropped to 89.2 days (SD 71.6); almost identical to that of our adolescent sample (p=0.995), and considerably lower than that of Collin et al (2010). The significance of this difference is unknown; however it invites consideration of the therapeutic and economic policies of these inpatient units.

Our mean length of stay for our adolescent sample is similar to that of a number of other studies in this age group, which quote mean length of stay of between 76 and 90 days 9,18,21. We found a significant correlation between length of stay and change in weight/BMI in our adolescent sample, with a longer length of stay associated with a greater increase in weight and BMI; a result which has been found in a number of other studies1,10,24.

Current literature indicates that there are a number of factors which may influence length of stay. In our adolescent sample, we found that nasogastric tube feeding during admission was associated with a greater length of stay, a result which corresponds with the findings of Strik-Lievers (2009)19. Unfortunately, we were unable to correlate length of stay with any of the other factors identified in previous studies10,19,24.

However, we found that adolescents who were treated under the Mental Health Act had a significantly longer length of stay compared to those treated voluntarily. This greater length of stay cannot be solely attributed to the compulsory nature of the treatment, as the majority of these patients were admitted under STD certificates, which are valid for only 28 days. However, this finding is perhaps not surprising; as one could envisage that patients who require to be detained are inherently resistant to treatment, thus require a longer length of stay to achieve weight restoration. We were unable to reproduce this result in the adult sample.

As there are limited resources in the North of Scotland for providing day programme services for eating disorders, with the geographical spread of patients making this difficult to provide, we had hypothesised that adults from peripheral health boards would have a longer length of stay than those from Grampian, where a day programme is available. However, we did not find this to be the case (p=0.853), and there was also no significant difference in length of stay between those who were discharged to the day programme and those discharged to other services (p=0.393).

45

Conversely, adolescent patients who were local to the unit tended to have a shorter length of stay compared to those admitted from peripheral health boards (p=0.064). Again, we hypothesised that this trend may be explained by the availability and accessibility of day programme services within Lothian; however, we found no significant difference in length of stay between those who were discharged to the day programme and those who discharged to other services. Another potential explanation for this discrepancy in length of stay is the ease of involvement of relatives in therapeutic work. Perhaps it is easier to engage the families of local patients as the travelling time and expense is relatively small, particularly when compared to patients from peripheral health boards.

Family therapy has a strong evidence base in anorexia nervosa in this age group , and perhaps this engagement, in addition to the option for the patient to have regular passes home, may allow local patients to be discharged earlier.

Alternatively, it is possible that Lothian patients feel psychologically more able to cope on an outpatient basis at an earlier stage in the knowledge that the inpatient unit is easily accessible if they are having difficulties. Patients from areas where this resource is not available may feel less able to make the transition to outpatient treatment, thus have a longer length of stay. This is an area which requires further research.

In addition to completing self-reported questionnaires, outcome in adult patients was assessed by the Clinical Global Improvement score (CGIC); an observer-rated scale which measures improvement in mental health following an intervention. Encouragingly, patients with a longer length of stay were more likely to score as showing “much-” or “very much-” improvement. However, this scoring system is likely to be biased as it is completed by clinicians who have been responsible for delivering patient care, who may be reluctant to admit unfavourable outcomes. We found no significant correlation between length of stay and any of the other variables we considered.

Both adults and adolescents gained a significant amount of weight during admission, with a mean gain of 5.5kg and 4.6kg respectively. However, this weight in the adult sample equates to only 0.2kg per week; falling short of the 0.5-1.0kg/week recommended during inpatient treatment . This discrepancy may be due to the fact that the Eden Unit is a newly opened ward, and the first of its kind within NHS Scotland.

As such, the Unit is still in the early stages of defining clinical and operational protocols, and may not yet have optimised weight restoration procedures. However, whilst weight gain is an important treatment goal, medical stabilisation of patients must first be achieved ; and this may account for a large proportion of the initial inpatient stay. Nonetheless, the Eden Unit has shown to be beneficial for patients in terms of reducing eating disorder-associated psychopathology; with EDE-Q, CORE and HAD scores significantly decreasing over the course of inpatient stay. And, without this improvement in psychopathgology it is unlikely that any weight gain would be sustained.

46


Study LimitationsLow numbers in both samples hinder interpretation of our data, and we can only very tentatively say that our study has shown significant results. Tardy communication from colleagues from other inpatient units meant that we failed to achieve the sample size we had anticipated. We hope that, in time, we will be able to expand our study to include all Scottish inpatient units.

Unfortunately, we were unable to obtain as much patient-related data as we had hoped. Due to the retrospective nature of this project, there was a considerable amount of information that was not available, largely because it is not routinely collected on admission. For example, we were unable to collect data regarding relationship- and educational- status, and living arrangements of patients.

Had this been a prospective study, admission clerk-in forms could have been modified to include these factors. Another factor which we were unable to consider was the age of onset of eating disorder, thus we were also unable to determine the duration of eating disorder on admission; a factor which has been shown to influence length of stay 10,19. We hypothesise that an increased duration of illness may account for the increased length of stay found in our adult patients; who are likely to have longer clinical histories than their adolescent counterparts.

Whilst our length of stay results are comparable to those of other studies, the interpretation of length of inpatient stay as a reflection of duration of treatment for eating disorders is limited. With the increasing availability of day programmes, where patients can continue to receive high levels of therapeutic support, a trend may develop whereby patients are discharged sooner than previously anticipated. Perhaps future studies should also take in to account the duration of day programme support received by patients, as this may account for a substantial proportion of their treatment. It would also be of interest to see whether or not day programmes are successful in preventing inpatient admission, and to compare the efficacy of these treatment approaches.

ConclusionInpatient treatment for eating disorders is a scarce and expensive resource, which is usually considered as the last resort and used only in a minority of cases. In this study we have shown that, even at the extremes of illness, inpatient treatment can result in significant weight restoration and a reduction in eating disorder-associated psychopathology. Future efforts should be invested in the establishment of prospective and follow up studies, collecting a wider range of clinical and demographic data, and assessing patient outcome at 1year, 2 years and 5 years post-discharge.

It would also be of great interest to interview patients who have good outcomes, to see which part of their treatment they feel contributed most to their recovery. Further research should be directed towards examining for an optimum length of stay, with the ultimate aim of reducing the duration of illness, and improving long-term outcome.

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Appendix 1

An Audit of Length of Stay in Eating DisordersCollin, P., Power K., Karatzias, T., Grierson, D., Yellowlees, A.. (2010). The effectiveness of, and predictors of response to, inpatient treatment of anorexia nervosa. Eur Eat Disord Rev; 18(6):464-74.

Steinhausen, H. (2002). The outcome of anorexia nervosa in the 20th century. American Journal of Psychiatry; 159, 1284–1293.

Arcelus, J., Palmer, B. (2008). Specialist Referral. In: Morris, J ABC of Eating Disorders. Oxford: Wiley-Blackwell. p43-46.

Gowers, S.G., Clark, A.F., Roberts, C., Byford, S., Barrett, B., Griffiths, A., Edwards, V., Bryan, C., Smethurst, N., Rowlands, L., Roots, P. (2010). A randomised controlled multicentre trial of treatments for adolescent anorexia nervosa including assessment of cost-effectiveness and patient acceptability - the TOuCAN trial. Health Technology Assessment; 14(15).

Fairburn, C.G., Harrison, P.J. (2003) Eating disorders. Lancet; 361:407–416

NICE 2004. Eating Disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. CG9 Eating disorders: full guideline. Available: http://www.nice.org.uk/CG009.

Vandereycken, W. (2003). The place of inpatient care in the treatment of anorexia nervosa: questions to be answered. Int J Eat Disord; 34:409-422.

Gowers, S.G., Weetman, J., Shore, A., Hossain, F., Elvins, R. (2000). Impact of hospitalisation on the outcome of adolescent anorexia nervosa. The British Journal of Psychiatry; 176: 138-141

Steinhausen, H.C. (1985). Evaluation of inpatient treatment of adolescent anorexic patients. Journal of Psychiatric Research; 19(2-3):371-5.

Nozoe, S., Soejima, Y., Yoshioka, M., Naruo, T., Masuda, A., Nagai, N., Tanaka, H. (1995). Clinical features of patients with anorexia nervosa: assessment of factors influencing the duration of inpatient treatment. J Psychosom Res; 39:271–281.

Howard, W.T., Evans, K.K., Quintero-Howard, C.V., Bowers, W.A., Andersen, A.E. (1999). Predictors of success or failure of transition to day hospital treatment for inpatients with anorexia nervosa. Am J Psychiatry; 156(11):1697-702.

Kahn, C., Pike, K.M. (2001). In search of predictors of dropout from inpatient treatment for anorexia nervosa. International Journal of Eating Disorders; 30:237–244.

Tanaka, H., Kiriike, N., Nagata, T., Riku, K. (2001). Outcome of severe anorexia nervosa patients receiving inpatient treatment in Japan:An 8-year follow-up study. Psychiatry and Clinical Neurosciences; 55, 389–396

Woodside, D.B., Carter, J.C., Blackmore, E. (2004). Predictors of premature termination of inpatient treatment for anorexia nervosa. American Journal of Psychiatry; 161:2277–2281.

Castro, J., Gila, A., Puig, J., Rodriguez, S., Toro, J. (2004). Predictors of rehospitalisation after total weight recovery in adolescents with anorexia nervosa. Int J Eat Disord; 36:22–30.

Willer, M.G., Thuras, P., Crow, S.J. (2005). Implications of the changing use of hospitalization to treat anorexia nervosa. Am J Psychiatry; 162(12):2374-6.

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Gowers, S.G., Clark, A., Roberts, C., Griffiths, A., Edwards, V., Bryan, C., Smethurst, N., Byford, S., Barrett, B. (2007). Clinical effectiveness of treatments for anorexia nervosa in adolescents. Br J Psychiatr; 191:427–35.

Steinhausen, H.C., Grigoroiu-Serbanescu, M., Boyadjieva, S., Neumärker, K.J., Winkler Metzke, C. (2008). Course and predictors of rehospitalization in adolescent anorexia nervosa in a multisite study. Int J Eat Disord; 41(1):29-36.

Strik Lievers, L., Curt, F., Waller, J., Perdereau, F., Rein, Z., Jeammet, P., Godart, N. (2009). Predictive factors of length of inpatient treatment in anorexia nervosa. Eur Child & Ad Psychiatry; 18(2):75 – 84.

Lund, B.C., Hernandez, E.R., Yates, W.R., Mitchell, J.R., McKee, P.A., Johnson, C.L. (2009). Rate of inpatient weight restoration predicts outcome in anorexia nervosa. Int J Eat Disord; 42(4):301-5.

Salbach-Andrae, H., Schneider, N., Seifert, K., Pfeiffer, E., Lenz, K., Lehmkuhl, U., Korte, A. (2009). Short-term outcome of anorexia nervosa in adolescents after inpatient treatment: a prospective study. Eur Child Adolesc Psychiatry; 18(11):701-4.

Huas, C., Godart, N., Foulon, C., Pham-Scottez, A., Divae, S., Fedorowicz, V., Peyracque, E., Dardennes, R., Falissard, B., Rouillon, F. (2010). Predictors of dropout from inpatient treatment for anorexia nervosa: Data from a large French sample. Psychiatry Res; (doi: 10.1016/j.psychres.2009.12.004).

Huntley, D.A., Cho, D.W., Christman, J., Csernansky, J.G. (1998). Predicting length of stay in an acute psychiatric hospital. Psychiatr Serv 49:1049–1053.

Maguire, S., Surgenor, L.J., Abraham, S., Beumont, P. (2003) An international collaborative database: its use in predicting length of stay for inpatient treatment of anorexia nervosa. Aust N Z J Psychiatry; 37(6):741–747.

Fairburn, C.G., Cooper, Z. (1993). The eating disorder examination. In C.G. Fairburn & G. T. Wilson (Eds.), Binge eating: Nature, assessment, and treatment (12th ed., pp. 317-360). New York: Guilford.

Evans, C., Mellor-Clark, J., Margison, F., Barkham, M., Audin, K.,Connell, J., McGrath, G. (2000). CORE: Clinical Outcomes in Routine Evaluation. Journal of Mental Health; 9(3): 247-255.

Zigmond, A.S., Snaith, R.P. (1983). The Hospital Anxiety And Depression Scale. Acta Psychiatr Scand; 67:361-70.

Clinical Global Impression (CGI). In: ECDEU Assessment Manual for Psychopharmacology. (1976). Guy W, editor. Rockville,MD, U.S. Department of Health, Education, and Welfare.

World Health Organisation. (2007). International Statistical Classification of Diseases and Related Health Problems - 10th Revision. Available: http://apps.who.int/classifications/apps/icd/icd10online. Last accessed 27th November 2010.

SCROL. (2001). Scotland’s Census Results Online. Available: www.scrol.gov.uk. Last accessed 28th January 2011.

Mental Health (Care and Treatment)(Scotland) Act 2003. Available: www.legislation.gov.uk/asp/2003/13/contents.

Lock, J., LE Grange, D., Stewart, A., Move, A., Bryson., Jo, B. (2010). Randomized Clinical Trial Comparing Family-Based Treatment With Adolescent-Focused Individual Therapy for Adolescents With Anorexia Nervosa. Arch Gen Psychiatry;67(10):1025-1032

NICE 2004. Eating Disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. CG9 Eating disorders: full guideline. Available: www.nice.org.uk/CG009.

Fairburn, C.G., Harrison, P.J. (2003). Eating disorders. Lancet; 361:407–416.

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The Eden Unit

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