CLINICAL PATHWAY: SERVES AS A GUIDE Eating …...THIS PATHWAY SERVES AS A GUIDE AND DOES NOT REPLACE CLINICAL JUDGMENT. CLINICAL PATHWAY: Eating Disorder Pre-treatment evaluation Chem

THIS PATHWAY SERVES AS A GUIDE AND DOES NOT REPLACE CLINICAL JUDGMENT.

CLINICAL PATHWAY:

Eating Disorder

Pre-

treat

men

t eva

luat

ion

Chem

10,

AST

/ALT

, GG

T, a

lkal

ine

phos

phat

ase,

ferr

itin,

% ir

on sa

tura

tion,

T4

& T

SH, a

lbum

in, p

re-a

lbum

in, t

rigly

cerid

es, C

BC w

/di

ffere

ntia

l, U

A, u

rine

for h

CG, 1

2-le

ad E

KG(if

test

s wer

e re

cent

ly co

mpl

eted

, use

pro

vide

r disc

retio

n w

heth

er o

r not

to re

peat

)

Adm

issio

n Cr

iteria

1

(1 o

r mor

e)

Patie

nt d

oes n

ot m

eet

inpa

tient

crit

eria

Cons

ider

beh

avio

ral h

ealth

co

nsul

t for

par

tial

hosp

italiz

atio

n pr

ogra

ms o

r ou

tpat

ient

coun

selin

g, a

nd

notif

y PC

P

May

alw

ays c

all P

sych

iatr

y or

Hos

pita

l Med

icin

e to

di

scus

s

Adm

it to

Hos

pita

l Med

icine

PC

P or

ED

prov

ider

revi

ews c

linic

al p

athw

ay m

anag

emen

t w

ith p

atie

nt a

nd fa

mily

2

ED

pro

vide

r giv

es p

atie

nt a

nd fa

mily

the

Patie

nt H

ando

ut

that

out

lines

exp

ecta

tions

dur

ing

the

adm

issio

n (s

ee

Appe

ndix

C)

If

patie

nt 1

8 ye

ars,

mus

t cal

l hos

pita

list t

o di

scus

s ad

miss

ion

Initi

al M

anag

emen

t

Patie

nt h

ando

ut to

be

revi

ewed

and

sign

ed b

y th

e pa

tient

an

d fa

mily

at t

ime

of a

dmiss

ion

(see

App

endi

x C)

Pl

ace

patie

nt in

1:1

obs

erva

tion

Pl

ace

patie

nt o

n co

ntin

uous

CR

mon

itorin

g

Ord

er st

rict I

/O s

Pl

ace

appr

opria

te c

onsu

lts. C

alls

for c

onsu

lts m

ay n

eed

tobe

pla

ced

the

follo

win

g m

orni

ng if

late

adm

issio

n.

Psyc

hiat

ry c

onsu

lt

Nut

ritio

n co

nsul

t

PCA

to p

rint N

ursin

g/PC

A Jo

b Ai

d (A

ppen

dix B

) and

N

ursi

ng/P

CA P

roto

col W

orks

heet

(App

endi

x I)

Plea

se co

ntin

ue to

pag

e 2

for s

peci

fics o

f inp

atie

nt

man

agem

ent.

1 Adm

issio

n Cr

iteria

<7

5% m

BMI O

R <8

0%m

BMI i

f < 1

0 ye

ar o

f age

or

pre-

men

arch

al

Acut

e fo

od re

fusa

l > 2

4hrs

HR

4

0 bp

m su

pine

&

rest

ing

(con

sider

if

45

with

oth

er c

riter

ia)

S y

stol

ic B

P <8

0 m

mH

g

Ort

host

atic

chan

ges i

n SB

P(>

20 m

mH

g)

Sync

ope

or p

re-s

ynco

pew

ith st

andi

ng

Elec

trol

yte

dist

urba

nces

(e

.g. h

ypok

alem

ia,

hypo

phos

phat

emia

, hy

pom

agne

sem

ia,

hypo

chlo

rem

ia)

De

hydr

atio

n

Tem

pera

ture

<36

°C

Arrh

ythm

ia (p

rolo

nged

Q

Tc)

In

trac

tabl

e vo

miti

ng o

r he

mat

emes

is

Failu

re o

f out

patie

nttr

eatm

ent

No

Yes

2 Exa

mpl

e sc

ript f

or E

D w

hen

notif

ying

of a

dmiss

ion:

You

r chi

ld is

bei

ng a

dmitt

ed

for m

edic

al st

abili

zatio

n fo

r m

alnu

triti

on d

ue to

di

sord

ered

eat

ing.

The

tr

eatm

ent r

equi

res a

st

ruct

ured

app

roac

h, w

ith

slow

and

gra

dual

re-

intr

oduc

tion

of n

utrit

ion

in a

sa

fe w

ay.

Ther

e is

an

initi

al

rest

rictio

n of

act

ivity

and

pr

ivile

ges

are

gain

ed th

roug

h co

mpl

ianc

e w

ith th

e tr

eatm

ent p

lan.

Inclu

sion

Crite

ria: D

isord

ered

eat

ing

and

mal

nutr

ition

Exclu

sion

Crite

ria: A

ctiv

e ga

stro

inte

stin

al p

atho

logy

cau

sing

mal

nutr

ition

PCP

and/

or ED

Ass

essm

ent

Hist

ory o

f: w

eigh

t los

s, bi

ngin

g/pu

rgin

g, d

iet (

inta

ke),

alco

hol o

r sub

stan

ce u

se, m

edic

atio

ns, e

xerc

ise,

sync

ope,

men

stru

al p

erio

ds

Phys

ical:

heig

ht &

wei

ght w

ith %

med

ian

BMI (

% m

BMI -

see

Appe

ndix

A),

orth

osta

tic B

P an

d HR

, hyd

ratio

n st

atus

, car

diac

and

pe

riphe

ral e

xam

, sig

ns o

f int

entio

nal v

omiti

ng (d

enta

l ero

sion,

knu

ckle

abr

asio

ns)

©2019 Connecticut Children’s. All rights reserved. 19-004

NEXT PAGE

CONTACTS: ALYSSA BENNETT, MD | CHRISTINE SKURKIS, MD | LISA NAMEROW, MD | DIANE SIEGEL, RD

LAST UPDATED: 05.22.19


CLINICAL PATHWAY:

Eating Disorder

VITA

L SI

GN

SQ

4HR

LABS

& D

IAGN

OST

ICS

ACTI

VITY

& 1

:1

OBS

ERVA

TIO

N S

TATU

S

Ort

host

atic

s:

Obt

ain

1st se

t on

adm

issio

n

If or

thos

tatic

for B

Por

HR,

take

dai

ly

until

nor

mal

ized

Wei

ght:

W

eigh

pat

ient

QAM

af

ter 1

st v

oid

and

befo

re b

reak

fast

Wei

ght t

o be

don

ein

hos

pita

l gow

n on

ly (n

o so

cks,

un

derw

ear e

tc.)

N

eith

er p

atie

nt n

or

fam

ily a

re to

be

told

th

e w

eigh

t (m

ay b

e to

ld u

p, d

own

or

sam

e)

Obt

ain

grow

th

char

ts fr

om P

CP

Day

1:

Echo

card

iogr

am fo

r Ea

ting

Diso

rder

pa

tient

s

If no

t pre

viou

sly o

btai

ned

in

the

ED:

U

A

Urin

e hC

G (fe

mal

e pt

s)

Days

2-5

:

i-STA

T Ch

em 1

0 da

ilyfo

r 5 d

ays,

then

PRN

ba

sed

on ri

sk o

f re

feed

ing

synd

rom

e

Adva

ncem

ent b

ased

on

incr

easin

g m

edica

l sta

bilit

y.U

se o

rder

set t

o ch

ange

act

ivity

leve

l.

Leve

l 1 (s

tart

at a

dmis

sion

):

Stric

t bed

rest

due

to V

S in

stab

ility

O

OB

for b

athr

oom

use

onl

y

Plac

e on

1:1

obs

erva

tion

Leve

l 2:

Ad

vanc

e to

this

leve

l onc

e BP

and

orth

osta

tic sy

mpt

oms s

tabi

lize

O

OB

in ro

om fo

r mea

ls

OO

B in

whe

el c

hair

for l

imite

d sc

hedu

led

activ

ities

as

dete

rmin

ed b

y m

edic

al te

am

Show

er b

ased

on

med

ical &

psy

ch

clea

ranc

e

Cont

inue

1:1

obs

erva

tion;

co

nsid

er q

15 m

in c

heck

s ov

erni

ght w

hile

asle

ep

Leve

l 3:

Ad

vanc

e to

this

leve

l onc

e or

al

inta

ke p

rom

otes

wei

ght g

ain

or

wei

ght s

tabi

lity

Fi

rst,

ad li

b ac

tivity

in th

e ro

om

Then

, adv

ance

to 1

-3 fi

ve-m

inut

e w

alks

per

day

(may

adv

ance

mor

e slo

wly

or r

apid

ly b

ased

upo

n m

edic

al st

abili

ty)

Co

nsid

er 1

:1 o

bser

vatio

n on

ly

with

mea

ls an

d 1

hour

aft

er

MED

ICAT

ION

S

Anor

exia

& A

RFID

:

Com

plet

e m

ultiv

itam

in 1

ta

blet

dai

ly

Thia

min

e 10

0 m

g/da

y x7

day

sto

tal

Co

nsid

er T

ums f

or lo

wca

lcium

leve

ls

Cons

ider

ora

l pho

spho

rus

[Pho

s-N

aK co

ntai

ns 2

50m

g Ph

os, 1

60m

g (7

mEq

) Na,

28

0mg

(7.2

mEq

) K]

Co

nsid

er IV

pho

s su

pple

men

tif

phos

phat

e le

vel ≤

2m

g/dL

Bulim

ia:

Co

nsid

er IV

pho

s su

pple

men

tif

phos

phat

e le

vel ≤

2m

g/dL

Co

nsid

er so

dium

bic

arbo

nate

or o

ral B

icitr

a if

bica

rbon

ate

leve

ls ar

e lo

w

Cons

ider

pot

assiu

m

supp

lem

ent i

f low

seru

m K

and

norm

al p

H (i

ndic

ates

da

nger

ous

redu

ctio

n of

tota

l bo

dy K

)

NU

TRIT

ION

& F

LUID

S

Nut

ritio

n:Se

e Ap

pend

ix D

for A

nore

xia,

Ap

pend

ix E

for B

ulim

ia d

iet p

lans

, Ap

pend

ix F

for A

RFID

pla

ns

In

itiat

e m

eal p

lan

imm

edia

tely

afte

r adm

issio

nla

b re

sults

revi

ewed

Di

et a

dvan

ced

per R

D re

com

men

datio

ns

Afte

r eve

ning

sna

ck

com

plet

e, p

lace

nex

t day

’s di

et o

rder

St

art w

ith 2

4oz o

f fre

e w

ater

an

d th

en a

djus

t per

RD

reco

mm

enda

tions

Pl

ace

naso

gast

ric tu

be (N

GT)

afte

r sna

cks i

f not

100

%

com

plia

nt w

ith ca

loric

goa

ls

(per

App

endi

ces

D &

E &

F

rega

rdin

g N

GT fe

edin

gs)

Se

e Ap

pend

ix G

for E

nsur

e re

plac

emen

t gui

delin

e

IV F

luid

s:

Cons

ider

NS

bolu

s and

/or

cont

inuo

us IV

Fs if

mod

erat

e to

seve

re d

ehyd

ratio

n or

pa

tient

refu

sing

PO

flui

ds

PRIV

ILEG

ES

Adva

ncem

ent b

ased

on

com

plia

nce

with

the

diet

pl

an.

Use

ord

er se

t to

add

priv

ilege

s.

See

Appe

ndix

H fo

r list

of

priv

ilege

s;Se

e Ap

pend

ix I

for n

ursin

g/PC

A pr

otoc

ol w

orks

heet

Di

scus

s the

pat

ient

’sco

mpl

ianc

e fo

r the

day

af

ter 8

:30p

m sn

ack

If

100%

com

plia

nt w

ithbo

th so

lids &

liqu

ids

(incl

udes

wat

er a

nd

mak

e-up

liqu

id

nutr

ition

supp

lem

ent)

, pa

tient

can

iden

tify

the

next

day

’s p

rivile

ge

Ord

er th

e ne

xt d

ay’s

pr

ivile

ge to

beg

in th

e fo

llow

ing

day

at 9

am

Do n

ot s

tart

ho

mew

ork;

will

be

cons

ider

ed p

er P

sych

te

am

Disc

harg

e Cr

iteria

/Med

icat

ions

:

Med

ical

ly c

lear

ed w

ith st

able

labs

and

vita

l sig

ns

Patie

nt a

dher

ent t

o pr

escr

ibed

nut

ritio

n pl

an w

ith w

eigh

t gai

n, e

spec

ially

with

ad

lib a

ctiv

ity

Appr

opria

te p

lace

men

t arr

ange

d in

inpa

tient

, PHP

or o

utpa

tient

pro

gram

with

psy

chia

try

team

inpu

t

Med

icat

ions

at d

ischa

rge:

com

plet

e m

ultiv

itam

in; t

hiam

ine

(if 7

day

s not

com

plet

e)


RETURN TOTHE BEGINNING




CLINICAL PATHWAY:Eating DisorderAppendix A: Guide to Calculating % Median BMI

APPENDIX A: Guide to Calculating % Median BMI

Steps:

1. Find patient’s BMI using the following link (need patient’s height & weight):https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

2. Using a CDC growth/BMI chart (or one of the links below):BOYS:

http://www.cdc.gov/growthcharts/data/set2clinical/cj41c073.pdfGIRLS:

http://www.cdc.gov/growthcharts/data/set1clinical/cj41l024.pdf

Find the BMI at the 50th percentile* for the patient’s age.

3. % Median BMI (mBMI) = Patient’s BMI ÷ BMI at 50th %* for age

Example:15 year old girl has a BMI of 14 (based on entering her height & weight in Step #1)BMI at 50th percentile for age = 20 (based on BMI chart in Step #2)

% mBMI = 14 ÷ 20 = 70%

* The dietitian and/or medical team may adjust the patient’s % mBMI to a different BMI %ile (other than 50th%ile)based on the patient’s previous growth history (e.g. if the patient has tracked at the 25th percentile prior to weightloss, use this for mBMI calculation).





https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

http://www.cdc.gov/growthcharts/data/set2clinical/cj41c073.pdf

http://www.cdc.gov/growthcharts/data/set1clinical/cj41l024.pdf


CLINICAL PATHWAY:Eating DisorderAppendix B: Nursing/PCA Job Aid

APPENDIX B: Nursing/PCA Job Aid

Vital Signs: q4hr Orthostatic vital signs (“Orthostatics”) HR and BP when supine, sitting and standing:

• Obtain 1st set on admission• If Orthostatic for BP or HR, take daily until normalized

Weight: • Weigh patient qAM after 1st void and before breakfast• Weigh patient in hospital gown only (no socks, underwear etc.)• Neither patient nor family are to be told the weight (may be told up, down or the same)

Lowest heart rate per shift • PCA document the lowest heart rate noted each shift in the vital signs flowsheet in Epic

Nutrition and Fluids: • See Appendix C (Patient Handout) for detailed Meal Guidelines. See Appendix D for Anorexia meal

plan, Appendix E for Bulimia meal plan, & Appendix F for Avoidant Restrictive Food Intake Disorder(ARFID)

• Make-up liquid nutrition supplement will be offered with snacks 3 times per day as needed if not100% compliant with meals

• NG tube will be placed after each snack if not 100% compliant with make-up• NGT exceptions: Consider waiting in patients <11 years. Consider not removing/replacing if NGT is

needed twice or more regardless of age.

Activity Status: Patient will be admitted to Activity Level 1. Activity level is advanced based on increasing medical stability. Providers use the eating disorder order set to change activity level.

Level 1: • Strict bed rest due to vital sign instability• Out of Bed for bathroom use only• On 1:1 observation

Level 2: Advance to this level once BP and orthostatic symptoms stabilize • Out of bed in room for meals• Out of bed in wheelchair for scheduled floor activities as determined by medical team• Shower based on medical and psychiatric team clearance• Continue 1:1 observation; consider q15 min checks overnight while asleep

Level 3: Advance to this level once oral intake promotes weight gain • First, ad lib activity in room• Then, advance to 1-3 five-min walks per day (advancement based on medical stability)• Consider 1:1 observation only with meals and 1 hour after

Privileges: Advancement based on compliance with the diet plan. Order set used to add privilege. See Appendix H for list of privileges, see Appendix I for nursing/PCA protocol worksheet.

• Determine the patient’s compliance for that day right after the 8:30pm snack• If 100% compliant with both solids and liquids (includes water & make-up Ensure), patient can

identify the next day’s privilege in the evening to begin the following day at 9am• Do not start homework. Will be considered per psych team






CLINICAL PATHWAY: Eating Disorder Appendix C: Patient Handout





APPENDIX C

Patient Handout You have been admitted to the hospital because your physician determined that it was medically necessary to hospitalize you to ensure your safety and restore your physical health. This protocol was developed to assure that your hospitalization achieves these goals. If you have any questions about this protocol, please discuss with your nurse or doctor. Your team will keep you up to date with your progress during your hospital stay.

Patient Protocol Wake Up/Dress Guidelines:

1. At the time of admission, you will be asked to dress in a hospital gown.2. You need to wake up, get weighed and be dressed prior to breakfast.3. Clothing per medical team determination.

Weight Guidelines: 1. You will need to be weighed daily before breakfast, after the first morning urination, in a hospital gown

only. No other clothing (i.e. underwear, socks, slippers, or shoes) will be worn.2. You will use the bathroom to urinate prior to being weighed.3. No jewelry is to be worn.4. You may not eat, drink, bathe, or brush your teeth before getting weighed.5. You must stand on the scale with your back toward the weight.6. Neither you nor your family will be told your actual weight, but you will be told the general trend of up,

down, or the same.

Meal Guidelines: 1. There will be 6 mini-meals per day. Each day, if you are 100% compliant, your meals will be advanced

through a system, as directed by your Registered Dietician (RD), who will be in charge of creatingbalanced meal plans that meet your nutritional and caloric needs. You will be allowed to pick 3 fooddislikes with the RD on the first full day, which will take into effect on the following day’s meal plan. Allmeals will be supervised by staff.

a. Food meal plans will be provided starting on the first full day on the protocol. If you are admittedin the evening hours or overnight, you will be provided crackers and liquid nutrition supplementsuch as Ensure for that meal time until the following morning. If you are admitted in the morningor mid-day, it will be determined by the medical team if you can start with food mealsimmediately.

2. There will be no visitors and no activities allowed during mealtime, unless receiving meal support from afamily member or the Patient Care Assistant (PCA). The readiness of a family member to provide mealsupport will be determined by the psychiatry team after initial evaluation, observation and education withthe family.

3. Staff will check your tray for accuracy prior to each meal. No food substitutions are allowed.4. You will have 30 minutes to complete each mini-meal. After that time, the tray will be removed from your

room.5. Approximate meal times are:

Breakfast = 8:00am – 8:30am Snack = 10:00am – 10:30am Lunch = 12:00pm – 12:30pm Snack = 2:30pm – 3:00pm Dinner = 5:00pm – 5:30pm Snack = 8:30pm – 9:00pm

6. Staff will record food intake on a protocol worksheet.7. No food, beverages, cups, or dishes are allowed in your room, including the food/beverage of family

members.

8. Meal plans are advanced in the evening based on compliance and will begin at breakfast the nextmorning.

9. 100% compliance with daily nutrition (food & water) is expected.10. If you are unable to meet 100% compliance, you will have the opportunity to take in the missed calories

from a meal at the next snack by drinking a nutrition supplement.11. If you are unable to make up the calories from the liquid nutrition supplement, a feeding tube, called a

Nasogastric Tube (NGT) will be considered. An NGT will be placed at the end of each snack time if youdo not consume the goal calories for that snack and the prior meal. The remainder of the calories will beprovided with a nutrition supplement via the NGT. The NGT will be taken out when it is completed. Youwill then have a “fresh start” to be able to achieve 100% compliance with the next meal and snack.

Unit Environment: 1. The family kitchen is off limits.2. Bedside curtains must be kept open, except when dressing.3. There is no bathroom use for 1 hour after all meals.4. Bathroom use is supervised by staff.5. Staff will measure urinary output after each void.6. You will be placed on constant observation on admission. This means there will be a PCA who sits

outside your door to provide safety and support, and monitor for any disordered eating behaviors.7. Inappropriate language or threatening behavior is not acceptable.8. All medications brought from home must be given to your nurse upon admission.9. We ask that families do not discuss meals, weight, or other eating-related topics, as these topics may

raise anxiety. The treatment team will help guide the family as to appropriate discussions and mealsupport.

Visiting: 1. Immediate family and clergy may visit at any time, except mealtime, unless otherwise ordered by the

team.2. Friends and extended family members may only visit after the privilege has been obtained per this

protocol.

Activity: 1. All patients are admitted on bedrest.2. You will be placed on a cardiac monitor upon admission. This means stickers on your chest will measure

your heart rate and breathing. The duration of cardiac monitoring depends on your medical condition.3. Vital signs (blood pressure, heart rate, breathing rate and temperature) will be taken at least every 4

hours, or more frequently, if your medical condition warrants.4. Any transports for medical care off the unit must be via wheelchair or stretcher.5. The patient and family will be updated daily regarding advancements in activity level. Activity level will be

advanced as the medical status improves. All patients are admitted on Activity 1 (bed rest) and activity isprogressed as nutritional status stabilizes and will be identified by level 1, 2, and 3 with increasing abilityto leave the room in a wheelchair and move about the room out of bed. Medical stability requirements foreach activity level can be described by the medical team in the sequence per protocol. If the family and/orpatient need clarification of a privilege or activity level, they are encouraged to check with the medicalteam, nurse, or PCA.

Privileges: 1. You will be admitted to a room without TV, phone, or other in-room activities. Throughout your hospital

stay, you may earn these “privileges” based upon 100% compliance with your daily meal plan. If you havebeen 100% compliant with all food and drink (includes water and make-up liquid nutrition supplement) forthe entire day, you will be able to earn a privilege (listed on the Privilege Menu) for the following day.


CLINICAL PATHWAY:Eating DisorderAppendix C






CLINICAL PATHWAY:Eating DisorderAppendix C





2. On any given day, if you are not 100% compliant, then you will not obtain an additional privilege.Previously obtained privileges will not be lost.

3. Privileges for the next day must be selected and communicated to the staff by 10:00pm and the staff willdocument the choice on the care plan.

4. Privileges advance at 9:00am the following day.

Date Reviewed with Patient:

Patient Signature: (signature indicates patient received a copy of this handout)


CLINICAL PATHWAY:Eating DisorderAppendix D: Meal Plan for a Child with Anorexia Nervosa

APPENDIX D: Meal Plan for a Child with Anorexia Nervosa

The goal of the meal plan for the first 4 days is to prevent further weight loss and to encourage patient to eat by mouth. The patient may not gain weight initially. Do not share calorie levels with patient.

No additional coffee, tea, diet soda, or juice. Free water as below.

Step One: (1500 total calories per day) 6 standardized meals. Meal plans per Clinical Nutrition to be determined on the first morning following admission. Prior to Clinical Nutrition consultation, each meal will be 230 ml of Ensure + 1 packet of saltine crackers which can be initiated and provided in ED or upon arrival to the floor. Minimum of 24oz of water per 24-hour period. Continue until patient complies with Step One. During Step One, the patient will be allowed to choose 3 food dislikes, but will be told that the Registered Dietician (RD) will choose the meal plan to meet the patient’s nutritional needs. The dislikes will be included on the next day’s meal plan.

Step Two: (1800 total calories per day) 6 standardized meals per Clinical Nutrition. Minimum of 24oz of water per 24-hour period. Continue until patient complies with Step Two.

Step Three: (2100 total calories per day) 6 standardized meals per Clinical Nutrition. Minimum of 24oz of water per 24-hour period.

Step Four: Increase intake by 20% or 200-300 kcal/day to a goal set by Clinical Nutrition. Step number continues to advance until reaching adequate intake, as determined by Clinical Nutrition.

The decision to begin nasogastric tube (NGT) feedings is based on medical necessity as determined by the multi-disciplinary team. If a patient does not finish an entire meal (breakfast, lunch, dinner), he/she will have the opportunity to take in the missed calories at the next snack by drinking a liquid nutrition supplement (Refer to Appendix G; consult with Diet Tech if needed). An NGT will be placed at the end of each snack time if the patient does not consume the goal calories for that snack and the prior meal. The remainder of the calories will be provided via the NGT. The NGT will then be removed when the feeding is completed. The patient will then be allowed a “fresh start” to be able to achieve 100% compliance with the next meal.

The decision to place an NGT in a patient < 11 years old will be determined by the multi-disciplinary team.

If a patient has needed an NGT more than twice, in consultation with psychiatry, consideration should be made to keep the NGT in place, particularly if there has been no progress in PO feeds after the NGT is pulled.






CLINICAL PATHWAY:Eating DisorderAppendix E: Meal Plan for a Child with Bulimia Nervosa

APPENDIX E: Meal Plan for a Child with Bulimia Nervosa

All meals/snacks should contain adequate fat and fiber to prevent excessive feelings of hunger.

The goal of the meal plan for the first 4 days is to prevent further weight loss and to encourage patient compliance. The patient may not gain weight initially. Do not share calorie levels with patient.

Allow additional fluids after eating the meal as planned. Restrictions on patients who are meeting meal goals are not recommended.

Step One: Starts with the first meal after admission (1500 total calories per day). Three meals + three snacks. Minimum of 24oz of water per 24-hour period. Patient selects foods from modified menu. Continue until patient complies with Step One.

Step Two: (1750 total calories per day) Three meals + three snacks. Minimum of 24oz of water per 24-hour period. Patient selects foods from modified menu. Continue until patient complies with Step Two.

Step Three: (2000 total calories per day) Three meals + three snacks. Minimum of 24oz of water per 24-hour period. Patient selects foods from modified menu.

Step Four through discharge: Increase intake by 20% or 100-200 kcal/day to achieve goal established by Clinical Nutrition.

The decision to begin nasogastric tube (NGT) feedings is based on medical necessity as determined by the multi-disciplinary team. If a patient does not finish an entire meal (breakfast, lunch, dinner), he/she will have the opportunity to take in the missed calories at the next snack by drinking a liquid nutrition supplement (Refer to Appendix G; consult with Diet Tech if needed). An NGT will be placed at the end of each snack time if the patient does not consume the goal calories for that snack and the prior meal. The remainder of the calories will be provided via the NGT. The NGT will then be taken out when the feeding is completed. The patient will then be allowed a “fresh start” to be able to achieve 100% compliance with the next meal.







CLINICAL PATHWAY:Eating DisorderAppendix F: Meal Plan for a Child with Avoidant Restrictive Food Intake Disorder (ARFID)

APPENDIX F: Meal Plan for a Child with Avoidant Restrictive Food Intake Disorder (ARFID)

The goal of the meal plan for the first 4 days is to prevent further weight loss and to encourage patient to eat by mouth. The patient may not gain weight initially. Do not share calorie levels with patient.

No additional coffee, tea, diet soda, or juice. Free water as below.

Step One: (1500 total calories per day) 6 standardized meals. Meal plans per Clinical Nutrition to be determined on the first morning following admission. Prior to Clinical Nutrition consultation, each meal will be 230 ml of Ensure + 1 packet of saltine crackers which can be initiated and provided in ED or upon arrival to the floor. Minimum of 24oz of water per 24-hour period. Continue until patient complies with Step One. During Step One, the patient will be allowed to choose 3 food dislikes, but will be told that the Registered Dietician (RD) will choose the meal plan to meet the patient’s nutritional needs. The dislikes will be included on the next day’s meal plan.

Step Two: (1800 total calories per day) 6 standardized meals per Clinical Nutrition. Minimum of 24oz of water per 24-hour period. Continue until patient complies with Step Two.

Step Three: (2100 total calories per day) 6 standardized meals per Clinical Nutrition. Minimum of 24oz of water per 24-hour period.

Step Four: Increase intake by 20% or 200-300 kcal/day to a goal set by Clinical Nutrition. Step number continues to advance until reaching adequate intake, as determined by Clinical Nutrition.

The decision to begin nasogastric tube (NGT) feedings is based on medical necessity as determined by the multi-disciplinary team. If a patient does not finish an entire meal (breakfast, lunch, dinner), he/she will have the opportunity to take in the missed calories at the next snack by drinking a liquid nutrition supplement (Refer to Appendix G; consult with Diet Tech if needed). An NGT will be placed at the end of each snack time if the patient does not consume the goal calories for that snack and the prior meal. The remainder of the calories will be provided via the NGT. The NGT will then be removed when the feeding is completed. The patient will then be allowed a “fresh start” to be able to achieve 100% compliance with the next meal.

The decision to place an NGT in a patient < 11 years old will be determined by the multi-disciplinary team.







CLINICAL PATHWAY:Eating DisorderAppendix G: Meal Plan Calorie Key for Ensure Replacement

APPENDIX G: Meal Plan Calorie Key for Ensure Replacement

For each food item not consumed, please replace with the following Ensure (30 kcal/oz) equivalent:

1 starch = 80 ml Ensure

1 protein = 45 ml Ensure

1 fat = 45 ml Ensure

1 dairy = 120 ml Ensure

1 fruit = 60 ml Ensure

1 vegetable = 30 ml Ensure

1 packet saltine crackers = 25 ml Ensure

* 1 calorie is equivalent to 1 ml of Ensure (30 kcal/oz)






CLINICAL PATHWAY:Eating DisorderAppendix H: Privilege Menu

APPENDIX H: Privilege Menu

Patient Name: Date:

One privilege may be added for each day of 100% compliance with all 6 mini-meals (this includes make-up Ensure). Please circle your choice by 10:00pm today. Your privilege will begin at 9:00am tomorrow.

Arts & Crafts Hospital phone in room (not personal mobile phone)

Writing Reading

TV & Movies Visitors

Games & Video Games Music (No wireless devices) (CD player, Keyboard, other)

(No wireless devices)

Wheelchair rides (Once medically stable = activity level 2 or greater) (Three 5-minute rides per day)






CLINICAL PATHWAY:Eating DisorderAppendix I: PCA Protocol Worksheet

APPENDIX I: PCA Protocol Worksheet

Patient Name: Date: Unit:

Date Day Wt (kg) Meal Plan Calories

100% Compliance

Privileges (*Patient Choice)

Activity Level (Assigned)

Comments Eating behaviors/exercise/other

Admit Yes / No Begin on Day 2 at 9:00am, if compliant

Advancement requires

physiologic stability +

weight neutrality or gain w/o IV

fluids

1 Yes / No N/A All patients start at Activity

Level 1

2 Yes / No

3 Yes / No

4 Yes / No

5 Yes / No

6 Yes / No

7 Yes / No

*PRIVILEGES are chosen by the patient. See Pathway and Appendix H for guidance.





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