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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]. Page | 46