Risk Management in Eating Disorders Dr Phil Crockett.
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Transcript of Risk Management in Eating Disorders Dr Phil Crockett.
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Risk Management in Eating DisordersDr Phil Crockett
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Risk Management
• Risk in Eating Disorders-Why Worry?• Risk Assessment vs Risk Management• The Physical, Psychological, Social• Context• Transitions • Communication• Networks and Frameworks• Taking advice• Summary
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Risk in Eating Disorders-Why Worry?
• For A.N.: 5-30% long term mortality(Theander, Halmi(1992))
• Difficulties in psychological adjustment up to 50% (Pike, 1998)
• Wide variation outcome-depends on study centre e.g. Korndorfer (2003), Johnson et al (2003) more benign
• Keski-Rahkonen, (2008): Finnish nationwide• N=2880: 5yr recovery 67%
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Risk in Eating Disorders-Why Worry?
• B.N. sig psychological impairment and physical morbidity
• AN can:– Sudden death– Cardiac failure– GI bleeds– Sepsis– Suicide
» (Millar,2005)
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Risk Assessment vs Risk Management
• Risk Assessment: an estimation of the likelihood of particular adverse events occurring under particular circumstances. Within a specified period of time
• Risk Management: organised attempts to minimise the likelihood of adverse events
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Risk Assessment vs Risk Management
• Approaches to risk assessment broadly grouped into ‘clinical’ versus ‘actuarial’ .
• The actuarial approach: clues to broad populations at risk, but informs us inadequately on the individual
• The clinical perspective: “individualised and contextualised assessment” , vulnerable to poor inter-rater reliability and influence of other considerations
• Remember the protective…• Only tells you about the current situation
From Feenay, A
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Five-step structured professional judgement approach to Five-step structured professional judgement approach to
risk management risk management (Doyle and Duffy (2006))(Doyle and Duffy (2006)) Step 1:
Step 2 :
Step 3 :
Step 4 :
Step 5:
Case information
History, mental state, substance use, physical parameters
Presence of risk factors
Historical, current, contextual, physical
Presence of protective factors
Historical, current, contextual, physical
Risk formulation
Nature, severity, imminence, likelihood, risk reducing/enhancing
Management plan
Treatment, management, monitoring, supervision,
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The Physical• Starvation and Malnutrition
• Other Behaviours
• Co-morbidities and complications
• Self Harm and Suicide
• Re-feeding Syndrome
• Past history and factors
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Re-Feeding Syndrome
• The major physical risk of treatment• Cascade of metabolic and electrolyte changes• Hypophosphataemia, hypomagnesaemia,
hypokalaemia major risks• Raised risk with n.g. re-feeding• Very slow initiation feeding• Take advice• “Have you considered re-feeding syndrome”
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The Psychological• Depression
• Anxiety
• Personality Disorder
• Obsessionality (OCD)
• Hopelessness and Frustration
• Past history and individual
factors
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The Social
• Families and Friends
• Work and studies
• Home environment
• Professionals
• The In-Patient Environment
• The Unexpected
• Past history and factors
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Context
• Context always important
• Major influence on risk for individual
• Major influence on judgement of risk
• Part of risk assessment
• Will alter most appropriate course of action
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Transitions
• Geographical and Developmental
• Life cycle challenges
• In-patient units
• Travel and relocation
• The Scottish Ombudsmen's Report, 2006
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Communication
• Ensuring care plans are a team effort
• Note limitations of them
• Liaison between areas important
• Patients and carers involved
• Recording
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Networks
• For patients protective and maladaptive
•A way for professionals to gain guidance
•EDSECT
•MCNs
•Benchmarking and audit
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Guidelines and Frameworks• NICE and QIS
• APA
• Specific for context
• Crisis planning
• Consistently reviewed/revised
• CPA/MHA
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Taking Advice•Role of the Gastroenterologist/Physician
•Especially when very high risk
•Co-morbidities
•Second opinions and consultations
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Conclusions• No simple methods to quantify risk in EDs
• Physical/Psychological complications common including resulting from intervention
• Broad assessment important
• Principles risk assessment/management useful
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Conclusions
• Developing appropriate frameworks to the context you are based in
• Applying the guidelines
• Making use of containing networks and maintain communication
• Take advice
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