PWE-116 evaluating the management of inpatients with anorexia nervosa: retrospective audit using marsipan guidelines. (8th June 2018) - Majeed, Buland
Abstract : Introduction: The MARSIPAN guidelines were produced in response to evidence that anorexic patients on medical wards have sub-optimal outcomes. We aim to evaluate whether the care provided by a Gastroenterology ward in a busy teaching hospital meets recommendations provided by the most recent MARSIPAN guidelines. Methods: Retrospective case note analysis of patients admitted with severe anorexia nervosa (BMI <15) over 12 months. 9 patients meeting the inclusion criteria were identified, and their care was audited against a pro-forma that was crafted according to the MARSIPAN guidelines, discussion with clinicians and the wider evidence base. Results: Our findings suggest that there is variability in compliance with the recommendations set out in the MARSIPAN guidelines. Some recommendations were met consistently; 100% of patients were seen by a dietitian and a senior psychiatrist at least once a week and had some common initial laboratory investigations (e. g. Full Blood Count, Urea and Electrolytes and Liver Function Tests). However, a number of important baseline investigations (such as the Sit-Up-Squat-Stand test [11.1%], serum amylase [0%], creatinine kinase [0%], serum ferritin and iron [33.3%], B12 and folate [33.3%]) were often missed. It was also rare for a full MSE to be documented (44.4%), or for a patient to see a senior psychiatrist twice a week or more (44.4%). Other important risk stratifying tools such as a baseline ECG (monitoring for prolonged QT) (66.6%) and sitting and standing blood pressure (33.3%) were also inconsistently carried out. In regards to nursing recommendations, the majority of patients were recommended bed rest (77.7%) and 100% had regular checks for pressure sores. However, only 22.2% were supervised for washes. 88.8% were supervised while they ate but only 22.2% were supervised for 30 min after (important to monitor for purging). Every patient received thiamine replacement as well as vitamin supplementation. The majority of patients were monitored daily for the first week of their admission for most markers of refeeding syndrome (U and Es [88.8%], calcium, magnesium and phosphate [77.7%]); however, only 33.3% had daily blood glucose measurements. Conclusions: Our findings, in the context of the wider evidence base, substantiate previous findings that anorexic patients on medical wards may receive sub-optimal care. In particular, important baseline investigations that are necessary to stratify risk are often missed and their importance needs to be better stressed. As the MARSIPAN guidelines state, 'patients near to death often look well', so being able to identify high-risk patients through rigorous investigation is key to optimising outcomes.