ACUTE’s Statement on Standards of Care for Severe and Extreme Eating Disorders
Expertise and experience matter when seeking medical care for a severe eating disorder. All care at ACUTE is overseen by Dr. Philip S. Mehler, the world’s leading expert in the medical treatment of eating disorders and the founder of ACUTE.
The integrity of ACUTE’s commitment to patients is unimpeachable. Our efforts buoy the spirits of our patients and their families and give them good reason to reclaim life; the beneficence, largess and acumen of our multidisciplinary team of skilled providers saves the lives of people, daily, who are afflicted with these highly lethal diseases. Every day, the ACUTE team shows our best, with deep empathy for these medically fragile patients, many of whom travel great distances to trust our care. In fact, almost 95% of admissions to ACUTE are from states outside of Colorado.
– Philip S. Mehler, MD, FACP, FAED, CEDS, CEO of ACUTE.
Given this, we understand the anxiety providers feel when an individual has a life-threatening medical emergency due to an extreme eating disorder. For these patients, all medical care is not created equal. Finding effective treatment — and the experts experienced at treating these issues — can be a matter of life or death. Sadly, too few physicians understand the nuances surrounding medical care for severe eating disorders and many patients just won’t make it in subpar treatment settings. While some eating disorder treatment programs offer a degree of internal medicine and/or nursing support to manage medical issues, many individuals are so medically compromised by their illnesses that they must be swiftly referred for hospitalization and medical stabilization prior to entering an eating disorder treatment program. This level of care is necessary to adequately address severe and life-threatening medical complications, “Immediate hospitalization is indicated in some patients because of profound hypotension and dehydration, severe electrolyte abnormalities, arrythmias or severe bradycardia and suicide risk” (Mitchell & Peterson, 2020).
Let’s be clear: the ACUTE Center for Eating Disorders & Severe Malnutrition at Denver Health is the only dedicated hospital-based, medical stabilization unit in the country with the full gamut of medical resources, environment and experience to treat patients with the most life-threatening medical complications due to severe eating disorders. This important distinction makes a difference when it comes to survival and recovery.
When Life-Saving Medical Care is Needed, Experience Matters; Volume = Quality
As healthcare providers, we are all ethically bound to ensure that each patient receives the right type of care at the right time. Consider these questions when determining where to refer:
- Is a free-standing inpatient eating disorder program equipped to handle the risks associated with all levels of refeeding?
- Is an inpatient eating disorder treatment center equipped with requisite and continuous vital sign and cardiac monitoring with telemetry and do they have a cardiology service immediately available to intervene for life-threatening cardiac complications?
- Does your patient need medical care right now, or do they only need behavioral care? (i.e., Are they ready and able to engage in eating disorder treatment programming or are they too medically frail to engage in a meaningful way?) Many patients with low BMI will need to weight restore up to the 70 percent IBW range before they are able to engage in therapeutic eating disorder treatment interventions.
The tragic dearth of expertise to successfully treat severe eating disorders is made even more alarming by the fact that anorexia nervosa has the highest mortality rate of any mental disorder aside from opioid abuse. Most premature deaths from anorexia nervosa stem from medical complications, highlighting the need to place the sickest patients in a medical intensive care-type environment with 24/7 medical monitoring, where they can get the stabilization and refeeding they need, supervised by experts in the field, and respond urgently to any serious medical complication that may arise.
Medical complications stemming from eating disorders demand careful oversight by knowledgeable and experienced physicians. Progressive malnutrition, purging behaviors and blood chemistry abnormalities can all lead to medical instability, compromising virtually all the body’s vital organs and systems. Additionally, providers must be wary of refeeding syndrome — a dangerous metabolic disturbance that can occur following uninformed and inadequately monitored initiation of nutritional rehabilitation. The lower the patient’s BMI, the greater the risk for refeeding syndrome. Thus, medical providers must ensure that each patient in need of refeeding undergo a thorough assessment of all clinical data, receive ongoing monitoring and receive test results within an hour of drawing labs. Care must always center around what is best for each unique individual in need of refeeding.
Unfortunately, many medical providers are not trained to identify or address refeeding syndrome in patients with extreme anorexia and ARFID. While patients can survive when severely emaciated, misguided refeeding efforts and mishandling of medical complications by those without adequate training can be deadly. To keep patients safe, the American Psychiatric Association’s (APA) practice guidelines for treating patients with eating disorders proposes a number of necessary evaluations. Timely laboratory assessments, electrocardiogram, echocardiogram, endoscopy, X-ray and CT scans may all be warranted for those who are gravely ill.
The APA guidelines for treating eating disorders also advise providers to pay particular interest to weight and cardiac status when determining the appropriate level of care for a patient. An extremely severe low body weight is defined as BMI < 15. At this low weight, patients must be moved to a medical setting in an inpatient, hospital-based unit. As BMI falls even lower, complications can and will increase dramatically.
If the Risk for Complications is High, Err on the Side of Caution
When treating medical complexities of severe/extreme eating disorders, it is critical to seek out a medical stabilization unit that provides comprehensive care so the patient can receive appropriate and necessary medical oversight by physicians trained in eating disorders along with psychiatric, nutritional, nursing and physical therapy support by professions with levels of expertise in their perspective discipline.
The APA recommends that one “hospitalize before a patient becomes medically unstable.” Once hospitalized, the goal of the providers offering medical stabilization will include:
- Improving and normalizing the patient’s vital signs, cardiovascular system and bowel function
- Restoring levels of key electrolytes including phosphorus, potassium, magnesium and calcium in a timely manner; and correcting acid-base disorders
- Providing nutritional rehabilitation to support weight restoration in a safe manner
If there is any ambiguity regarding medical stabilization, err on the side of admitting the patient to a higher level of care. If your patient is experiencing any existing medical comorbidities, including co-occurring illnesses, like a substance use disorder or a seizure disorder, the need for hospitalization is increased. Once the patient is stable, they can transition to a lower level of care.
No Patient is Too Sick for ACUTE
We’re highly aware of the fact that few medical stabilization units exist to save the lives of patients suffering from severe and extreme eating disorders. Access to out of state care should never be a limiting factor for any patient. Should an individual require urgent medical transport, ACUTE works with elite air ambulance providers to provide bedside-to-bedside transfers on medically configured aircraft to ensure safe, comfortable air travel (domestic or international) to our unit at Denver Health Medical Center. These companies utilize ACUTE’s air-transport medical protocols in flight. Once medically stabilized and sufficiently weight restored, your patient can step down to a lower level of care or return home to continue the important work of recovery.
As the pioneer in research and professional education in this field, ACUTE has the experience and specialty expertise built around almost 20 years of caring for the sickest of the sick. When you refer to ACUTE, you can expect:
- Unmatched formal medical training in treating eating disorders and malnutrition
- Oversight by Dr. Philip S. Mehler, a pioneer in the medical complications of eating disorders, with over 500 scientific writings, medical textbooks and decades of experience
- Tube feeding, if rarely needed, and any refeeding intervention (oral, enteral, parenteral)
- Concurrent medical care on the unit for any co-occurring medical condition (diabetes, cardiac arrythmias, cancer, infection, NTM aka MAI, liver failure, etc.)
- Safe detox from purging and substance use and 24/7 1:1 nursing personnel supervision
- 7 days a week, 365 days a year rounding by full-time, on-site academic medical doctors
- Individual 1:1 meetings with a registered dietitian, 6 days a week
Everyone Deserves a Chance to Survive and Recover — We Can Help.
To summarize, initial medical stabilization in a hospital-based unit is recommended for eating disorder patients who are severely low weight, seriously medically compromised or at risk for major complications from refeeding syndrome. Choosing the right level of care at the right time gives your patient a real chance at a rewarding future to return home to. Should you need us, we are here around the clock to help you navigate every aspect of assessment, insurance authorization and air ambulance transport (if needed).
Bringing you lifesaving medical treatment when all other care has failed, the ACUTE Center for Eating Disorders & Severe Malnutrition at Denver Health was honored once again by Anthem Health in 2021 as a Center of Excellence for Medical Treatment of Severe and Extreme Eating Disorders, the first medical unit ever to achieve this designation in the field of eating disorders. Our providers are thoughtfully trained in culturally responsive care with the goal of helping all patients live a healthy and affirmed life.
Mitchell, J. E., & Peterson, C. B. (2020). Anorexia nervosa. New England Journal of Medicine, 382(14), 1343–1351. https://doi.org/10.1056/nejmcp1803175