NEDA TOOLKIT for Parents
In determining a patient’s initial level of care or
whether a change to a different level of care is
appropriate, it is important to consider the patient’s
overall physical condition, psychology, behaviors, and
social circumstances rather than simply rely on one or
more physical parameters, such as weight [I]. Weight
in relation to estimated individually healthy weight,
the rate of weight loss, cardiac function, and
metabolic status are the most important physical
parameters to be considered when choosing a
treatment setting; other psychosocial parameters are
also important [I]. Healthy weight estimates for a
given individual must be determined by that person’s
physicians [I]. Such estimates may be based on
historical considerations (often including that person’s
growth charts) and, for women, the weight at which
healthy menstruation and ovulation resume, which
may be higher than the weight at which menstruation
and ovulation became impaired. Admission to or
continuation of an intensive level of care (e.g.,
hospitalization) may be necessary when access to a
less intensive level of care (e.g., partial hospitalization)
is absent because of geography or a lack of resources
[I]. Generally, adult patients who weigh less than
approximately 85% of their individually estimated
healthy weights have considerable difficulty gaining
weight outside of a highly structured program [II].
Such programs, including inpatient care, may be
medically and psychiatrically necessary even for some
patients who are above 85% of their individually
estimated healthy weight [I]. Factors suggesting that
hospitalization may be appropriate include rapid or
persistent decline in oral intake, a decline in weight
despite maximally intensive outpatient or partial
hospitalization interventions, the presence of
additional stressors that may interfere with the
patient’s ability to eat, knowledge of the weight at
which instability previously occurred in the patient,
co-occurring psychiatric problems that merit
hospitalization, and the degree of the patient’s denial
and resistance to participate in his or her own care in
less intensively supervised settings [I].
Hospitalization should occur before the onset of
medical instability as manifested by abnormalities in
vital signs (e.g., marked orthostatic hypotension with
an increase in pulse of 20 beats per minute (bpm) or a
drop in standing blood pressure of 20 millimeters of
mercury (mmHg), bradycardia <40 bpm, tachycardia
>110 bpm, or an inability to sustain core body
temperature), physical findings, or laboratory tests [I].
To avert potentially irreversible effects on physical
growth and development, many children and
adolescents require inpatient medical treatment, even
when weight loss, although rapid, has not been as
severe as that suggesting a need for hospitalization in
adult patients [I].
Patients who are physiologically stabilized on acute
medical units will still require specific inpatient
treatment for eating disorders if they do not meet
biopsychosocial criteria for less intensive levels of
care and/or if no suitable less intensive levels of care
are accessible because of geographic or other reasons
[I]. Weight level per se should never be used as the
sole criterion for discharge from inpatient care [I].
Assisting patients in determining and practicing
appropriate food intake at a healthy body weight is
likely to decrease the chances of their relapsing after
discharge [I].
Most patients with uncomplicated bulimia nervosa do
not require hospitalization; indications for the
hospitalization of such patients include severe
disabling symptoms that have not responded to
adequate trials of outpatient treatment, serious
concurrent general medical problems (e.g., metabolic
abnormalities, hematemesis, vital sign changes,
uncontrolled vomiting), suicidality, psychiatric
disturbances that would warrant the patient’s
hospitalization independent of the eating disorder
diagnosis, or severe concurrent alcohol or drug
dependence or abuse [I].
Legal interventions, including involuntary
hospitalization and legal guardianship, may be
necessary to address the safety of treatment-reluctant
patients whose general medical conditions are life
threatening [I].
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