Physicians' perspectives on the treatment of patients with eating disorders in the acute setting

Abstract Background Hospitalisation for an eating disorder is rare, however treatment in the acute medical setting can be a life-saving admission. While the multidisciplinary team delivers overall patient care, medical decisions are the responsibility of the treating physicians. Treatment decisions directly impact on patient care and outcomes. This study aimed to explore the considerations that influence the medical decisions of physicians when treating patients with eating disorders in the acute setting. Method Semi-structured interviews were conducted with ten medical physicians who had previously treated eating disorders on a general medical unit in two Australian tertiary hospitals. An interview schedule, based on the literature and four relevant domains from the Consolidated Framework for Implementation Research, was developed. Interviews were audio recorded, transcribed verbatim and analyzed thematically. Coding and interim themes and sub-themes were developed by two dietitian researchers; these were further refined through researcher discussion and triangulation with two additional dietitian researchers. Results Ten doctors were interviewed (3 consultants (1 adult general medical and 2 paediatricians: 13–16 years medical experience), 2 registrars (4–7 years experience), 1 resident (1 year experience), and 4 interns (< 1 year experience). Doctors described memorable patient cases, related to hospital stays over several weeks. Interviews ranged in length from 58 min to 91 min. Four themes (with five sub-themes) were developed: 1) navigating uncertainty (focusing on processes and goals and seeking information), 2) being “the good doctor” (doing the right thing), 3) seeing the big picture (depending on key players and considering short and long-term), and 4) involving family and patient. Conclusions Non-specialist physicians described challenges in the treatment of eating disorders in the inpatient setting. They take a holistic approach that considers both short and longer-term goals, relying on specialist colleagues, the wider multidisciplinary team and sometimes family members to guide treatment decisions during admissions on general medical wards. Additional support, education and training centered on the key themes may increase physicians’ confidence and ability to make effective treatment decisions for this patient group. The results are relevant to all health professionals working in this field to better understand the priorities of medical physicians and to support them to achieve positive outcomes in the inpatient treatment of patients with eating disorders

MALNUTRITION SCREENING IN AN IN-CENTRE HAEMODIALYSIS UNIT: APPETITE FOR CHANGE?

Best Practice Guidelines recommend regular nutrition assessment of patients receiving haemodialysis, with priority to those with poorly controlled co-morbidities or malnutrition. On a nurse-led monthly care plan, serum albumin is currently being used to identify patients requiring referral to a dietitian. It is well documented that the specificity of serum albumin as a nutritional marker is limited by the presence of inflammation. The purpose was to compare albumin with an alternative screening tool. An annual malnutrition audit was conducted with 100 patients attending in-centre Haemodialysis across two centres. Each were assessed using the PG-SGA or SGA, and asked to rate their appetite on a five point scale (very poor, poor, fair, good or very good). Pre dialysis serum albumin levels were noted. Of the 100 patients assessed, 28% were classified as malnourished. 61% of all patients had a serum albumin of 35 g/L or less. 31% of all patients rated their appetite as being fair, poor or very poor. The sensitivity, specificity, positive predictive values and negative predictive values of albumin and appetite as a screening tool for malnutrition can be seen in the table. Albumin (≤35 g/L) Appetite (≤fair) Sensitivity 0.86 0.78 Specificity 0.49 0.86 Positive Predictive Value 0.39 0.68 Negative Predictive Value 0.90 0.91 If albumin is used as a screen for malnutrition and referral to a dietitian, 61% of those referrals will be assessed by the dietitian as well nourished, and 14% of malnourished patients would be missed. If appetite was used as a screen for malnutrition, 32% of those referrals will be assessed by the dietitian as well nourished, and 22% of malnourished patients would be missed. Asking patients to rate their appetite on a five point scale appears to be an effective way to screen for malnutrition in the haemodialysis population. In centres with limited dietitian support, this may be preferable to screening with albumin due to the reduced number of inappropriate referrals and therefore enabling the priority to lie with the patients with malnutrition

ASSESSMENT OF MALNUTRITION IN AN INCENTRE HAEMODIALYSIS UNIT- SINGLE CENTRE EXPERIENCE

Malnutrition is highly prevalent among haemodialysis patients, but the best method for assessing nutritional status remains unclear. Historically, Dietitians’ use the Subjective Global Assessment (SGA) or Patient Generated Subjective Global Assessment (PG-SGA) tool to assess nutritional status of in centre haemodialysis patients. In 2001 a new tool called the Malnutrition Inflammation Score (MIS) was developed by Zadeh et al. We conducted an annual malnutrition audit on patients who regularly attend the in-centre haemodialysis units at Gold Coast Hospital District using MIS and SGA/PG-SGA. An annual malnutrition audit was conducted over a 2 month period with 100 in centre Haemodialysis patients across 2 centres. For each patient a nutritional assessment was conducted using SGA or PG-SGA and MIS assessment tool. The MIS tool was adapted to suit Australian laboratory measurements and units (Alb, TIBC); and the BMI scale adapted to be inline with current guideline recommendations. Overall the malnutrition rate using PG-SGA/SGA was 28% of patients classified as “malnourished” (26% scored B- moderate malnutrition and 2% scored C-severe malnutrition). According to MIS the rate of malnutrition was 94% (39%-mild malnutrition; 22% moderate malnutrition; 33% severe malnutrition). In conclusion there is discrepancy in the rate of malnutrition when assessed according to different tools. MIS has been shown to be a better predictor of survival in dialysis patients. We need interventional studies to assess the utility of MIS in improving patient outcome and survival in dialysis patient