1
The Eden Unit
Operational
Policy
The Eden Unit
Block C
Clerkseat Building
Royal Cornhill Hospital
Cornhill Road
ABERDEEN AB25 2ZH
Tel: 01224 557769/557758
COMPLETED JUNE 2009
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Contents
Page 3 to 6 Aims of the Unit
Criteria for Admission
Page 6
On Admission
Page 7
Refeeding
Page 8
Therapeutic Programme
Page 9
Pre-Discharge
Page 10
Social Work Involvement
Liaison with Local Eating Disorder
Services
Intermediate/Outreach Care
Page 11
Communication
Page 12
Out-of-Hours and Holiday Cover for
Psychiatrists
Review of Operational Policy
Page 13/14 Appendix – Service Flowchart
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North of Scotland Inpatient Unit for Eating Disorders
The Eden Unit
Operational Policy
This is a 10 bed inpatient unit for the treatment of patients with eating
disorders for the North of Scotland ie to take patients from Tayside,
Grampian, Highland, Orkney, Shetland and the Western Isles. The Argyll and
Bute area which is now part of Highland Health Board has not been included
because they will continue to look to west central Scotland for provision of
specialist services. The in-patient unit will operate alongside a 4 place day
patient facility for Grampian patients, which will help facilitate rehabilitation
and make re-admission less likely.
This operational policy has been informed by the regular meeting of the
Project Steering Group, and developed in conjunction with the Clinical Project
Group for the unit. It will be reviewed by those groups and representatives of
medical management bodies and informed by the MCN North of Scotland for
Eating Disorders.
1. Aims of the Unit
The unit will provide intensive inpatient treatment for patients with severe
eating disorders. These will be predominately patients with severe anorexia
nervosa who are dangerously underweight and/or have not responded to less
intensive forms of treatment.
The unit will aim to provide
1. A safe environment in which to manage severe eating disorders.
2. A broad range of expertise and therapeutic options for the treatment of
severe eating disorders.
3. A detailed assessment of the physical, nutritional, psychological and social
needs of the patient.
4. An individually tailored combination of nutritional, psychological, physical
and social treatment of the eating disorder.
5. Smooth transitions between the unit and other treatment settings before
and following admission to hospital.
2. Criteria for Admission

The unit will primarily cater for adult patients aged 18 years and over.
4

Patients younger than 16 would be admitted to specialist inpatient units
designed for adolescents or children. This will usually be the case for
the 16-18 age group.

In exceptional circumstances, where the patient’s maturity,
circumstances, and emotional and physical needs would be best
served by the Eden Unit, then admission will be considered for the 1618 age group. The unit is funded as an adult unit; hence admission out
with this parameter will be uncommon. Likewise the unit does not have
access to the correct range of resources that a children’s unit would
have to provide usually.

Prior to admission patients will have had a comprehensive assessment
by local specialist services (local means from the service for the local
health board i.e. Tayside, Highland, Grampian, Orkney, Shetland,
Western Isles).
Normally this would include assessment by a
consultant psychiatrist with a special interest in eating disorders from
the local specialist services in eating disorders, but where that is not
possible then the psychiatric assessment will include detailed input
from the consultant psychiatrist from the Eden Unit. Other members of
the multidisciplinary team such as specialist nurses, dieticians, clinical
psychologists and local general psychiatrists will contribute to the
assessment as appropriate.

The Eden Unit consultant will include the Nursing ward manager in
discussions about the possible admission.

This prior to admission assessment will include a full psychiatric history
and mental state examination, physical assessment, assessment of the
family and social situation and a summary risk assessment.

This assessment will take account of all the special considerations
relevant to the assessment of an eating disorder, including those
outlined in the Quality Improvement Scotland guidance on the
assessment and treatment of patients with eating disorders.

The assessment will include a consideration of alternative options to
admission to hospital. Agreement for admission will be between local
specialists, or Multidisciplinary team and the Eden Unit representatives.

Prior to admission there would be detailed liaison between the inpatient
unit and the local specialist services to clarify the expectations and
aims of the admission, including expected duration of the admission.

A key worker will be allocated to each patient, on referral, prior to
admission to hospital. The key worker will familiarise him/herself with
the details of the patient’s problems prior to admission.
5

Transfer of patients into the regional inpatient unit will be the
responsibility of the local health board service.

Responsibility for the care and treatment of the patient following
discharge from hospital will be clarified in advance of admission so that
the transition from inpatient care to community care is not disrupted or
delayed.

See Appendix 1, figures 1 and 2 for clarification of Admission Process.

The risk assessment will include a consideration of psychiatric risk
such as suicide risk as well as physical risk. See Clinical protocol,
information on risk management policies

Admissions will be arranged for normal working hours to prevent
difficulties in transfer, initial unit based assessment and treatment
arising. Thus Emergency admissions will not be accepted. If a patient
is considered to be at extreme physical risk, then local (to the patients
home) admission to a medical ward is advisable for physical
stabilisation. See Clinical Protocol for guidance on physical risk.

If suicidality is considered to be the major risk factor out of hours, then
emergency admission to a (local to the patient) general psychiatric
ward for initial assessment and stabilisation will be most appropriate,
obviously from there transfer to the Eden Unit can be facilitated if
considered the best course of management.

Not all patients with suicidal or impulsive self harm features, who have
eating disorder symptomology or diagnoses, will be appropriate for the
unit, which provides a service to those with severe eating disorders and
their treatment.

Urgent admissions, i.e. those needing admission in the next one to two
weeks, should be managed by in normal working hour’s procedures.

As previously indicated patients assessed at high physical risk will be
considered for initial stabilisation in a local Health Board medical unit in
consultation with the consultant physician with responsibilities for the
regional inpatient unit. There will be cases where patients at physical
high risk can be managed safely at the Eden unit with appropriate
guidance.

The consultant psychiatrist and other senior staff of the unit will be
available to discuss and plan the admission with local specialist
services, the patient and carers.

Arrangements will be in place for informal visiting of patients and carers
to meet staff, to see round the unit and to be given oral and written
information about the programme.
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
Admissions under the terms of the Mental Health (Care and Treatment)
(Scotland) Act 2003 will be accepted.
Local councils will be
responsible for providing a mental health officer for their patients.
While the patient is in the inpatient unit their Responsible Medical
Officer (RMO) will be the inpatient unit consultant and RMO
responsibility will revert to the local consultant psychiatrist on discharge
from hospital. There might be exceptions to this in the case of the
under 18 age group, where RMO status might well be best retained by
specialist Child and Adolescent psychiatrists.

Special attention will be given to referrals coming from patients moving
from the child and adolescent age range into the adult age range.
These are often difficult transitions in service provision and there will be
a careful negotiated overlap of care between child and adolescent
services and the adult eating disorders services in these cases.

The care pathway leading to admission is summarised in Figures 1 and
2.
3. On Admission

All patients will be assessed by the inpatient team and an individual
treatment programme designed for them. The assessment will take
account of physical, psychological and social (including family) factors
and will include a psychological formulation and risk assessment. This
biopsychosocial approach will help inform all stages of management.

Usual Psychiatric clerking will take place, which will be the remit often
of the Speciality doctor (Staff Grade) in psychiatry (.5 WTE) appointed
to the unit, or other junior staff with a remit on the ward at that time.
There are no training placements currently available to the ward.
When not available then the duty junior team will provide cover for
this, with a full senior review of this being provided within the first 24
hours of admission. The on-call medical staff will be provided with
clear guidance as to areas of particular importance in the initial
clerking.

The management plan will be built up from this and the initial nursing
review. The Eden unit consultant psychiatrist will play a key role,
especially since they will have knowledge from initial discussions and
even review prior to admission.

The consultant psychiatrist and records staff will review the legal
status of patients and for those subject to procedures of the mental
health act they will review the requirements for review and other
documentation.
7

This programme will include expert implementation of a re-feeding
programme in order to address the starvation state in the majority of
the patients, see Clinical protocol.

This could include the use of intravenous fluids and nasogastric
feeding where appropriate.

There will be close liaison and proximity to general medical services
with the availability of a consultant physician with special responsibility
for patients with severe eating disorders in the unit and the availability
of transfer acutely to general medical services in extreme physical
distress needing the close expert physical management of the
Gastroenterology service in Aberdeen. Ideally patients will be
manageable on the Eden Unit throughout their admission. See
Clinical Protocol for further guidance.

Direct involvement at initial assessment can be requested from the
Gastroenterology team for examination and management advice.

There will be the ability (where deemed necessary) to provide one to
one psychiatric nursing cover for patients whether they are on the
regional inpatient eating disorders unit or in a medical unit.

On-going assessment will then follow the pathway as outlined in the
Clinical Protocol.

An integrated formulation will encompass the individual professional
assessments involved, using a biopsychosocial emphasis as
previously stated. See Appendix to the Clinical Protocol.
4. Re-Feeding

The use of normal food would be the preferred option when re-feeding
although the use of nutritional supplements and nasogastric feeding
will be available when necessary.

Close supervision will be provided at meal times in the early stages of
re-feeding.

The diet will be balanced and sufficient to ensure weight gain except in
the first week or two when intake will be introduced gradually to avoid
re-feeding syndrome. The food will be of high quality and appetising.

Arrangements will be in place to restrict activity and reduce access to
toilets where appropriate and this will be done with due respect of the
dignity and privacy of the patient.
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
There will be close medical monitoring to avoid, or note early signs of,
re-feeding syndrome. Re-feeding syndromes will be dealt with by
reference to the in-patient units supporting physician. Risks are
particularly high in the first week of re-feeding, necessitating twice
weekly bloods and twice daily physical observations as a minimum.
Greater observation, and daily bloods, than that maybe required in high
risk patients. See Appendix on risk management, Clinical Protocol.

The unit consultant physician will advise on the detailed management
of re-feeding.

On occasion feeding without consent of the patient will be required.
This will be giving in accordance with Mental Health Act requirements
and guidance provided by the Mental Welfare Commission.

The treatment programme will be flexible and tailored to the individual
needs of patients. This will include flexibility about the overall aims of
admission. Some patients will aim to have weight restored to a healthy
weight while others will have more limited aims to stabilise at a lower
but safe weight.

For those with a significant duration history of low weight or
malnutrition, a DEXA bone scan will be considered.
5. Therapeutic programme

All patients will have a key nurse who will meet regularly with them and
who will have responsibility for overall implementation of the care plan.
This maybe, when appropriate, the same individual who responded to
the initial referral by helping organise the admission.

On-going individual therapy is seen as an important part of the
program.

All patients will attend group based therapeutic programmes, as far as
they are physically able. These will be designed to cater for patients at
different stages in their recovery.

Treatment approaches, where possible, will be used according to
evidence based criteria and guidelines produced by NICE and QIS.

Normal Weight restoration whilst an in-patient will not be seen as the
only or even most necessary target in all cases. Many patients may
benefit from a shorter admission with recovery of function and a period
of more intense therapy being the primary goal. Aims of the treatment
should be clear from the outset, but should be regularly reviewed.
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
The following therapeutic modalities will be available in group, family or
individual settings.
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

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Cognitive Behaviour therapy
Motivational enhancement therapy
Body image work
Eating skills development
Attention to excess exercise, vomiting, laxative misuse and
other abnormal behaviours associated with eating disorders
Self-esteem work
Mindfulness work
Nutritional education
Family work. This will depend on individual patient need and
where appropriate will include formal family therapy.
Art Psychotherapy
Occupational therapy
Social therapy
Physiotherapy including Body Awareness therapy.

Patients will be able to keep in touch with relatives and friends by
videolink and telephone subject t an assessment of therapeutic benefit.

Family work can also be done via videolink. Doing such work should be
seen as expected, to help reduce transition issues back into the
community.
6. Pre-discharge

Patients will have opportunities
independent living skills.

These will include self preparation of food, eating out and eating with
others, and other activities such as clothes shopping essential to good
rehabilitation.

There will be an ability to offer patients a trial period at home prior to
discharge.

There will be possible use of the day-patient (transitional care) facilities
for Grampian patients at this stage, once this unit is staffed and
opened.

There will be close liaison and discussion with local specialist teams to
ensure the setting up of a continuing therapeutic programme
immediately on discharge.

There will be full assessment of areas of social and family need prior to
discharge (see social work involvement also).
to
develop
age
appropriate
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7. Social Work Involvement

Where the need for an assessment of social care needs is identified
during the patients stay in hospital, and there is no existing social work
involvement, this will be arranged at an early stage via the local
specialist teams who will have the necessary knowledge of local social
work services and referral mechanisms.

Social work staff involved in the care of patients will be engaged in
discharge planning via the local specialist services and attendance at
discharge planning meetings.

Where a patient has been admitted from one of the Island Health
Boards, such social work involvement that is required will be arranged
in collaboration with the referring clinician.

Social work input will be vital in sustaining rehabilitative measure postdischarge.

Where patients are subject to compulsion under the Mental Health
(Care and Treatment) Act a designated Mental Health Officer shall be
appointed by the Local Authority where the patient is normally resident.
8. Liaison with Local Eating Disorder Services

There will be regular meetings with the local clinical team throughout
the period of admission. This could include local clinicians attending
ward meetings and if travel is a problem there will be video
conferencing facilities available to enable the local specialist service to
be involved. Continuing direct clinical contact between local clinicians
and patients will be encouraged with the aid of video conferencing
facilities if necessary.

There will be prompt reporting to the local clinical team on significant
developments e.g. urgent plans to discharge the patient or to have the
patient taking timeout of the programme, serious self-harm or failure to
progress. There will be facilities in place for local eating disorders and
other specialist staff to visit and speak to the patient and staff.

There will be progress summaries by letter at 1 month, full assessment
reports and 3 months and discharge. These will contain information as
collected by the clinical protocol.
9. Intermediate/Outreach Care

The transition from inpatient to community care will be a crucial stage
in the patient’s treatment.
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
There will be a specially designated group of staff who will have
responsibility for ensuring good liaison and planning both before and
after admission and for the provision of transitional care while patients
move to a locally based outpatient programme. Individual key workers
will also be involved.

The transitional care arrangements will vary depending on where the
patient lives and other local factors such as the intensity of service
available from the local specialist service.

In Grampian it is anticipated that most patients will make significant
use of the transitional care service and will attend as day patients for a
month or two following discharge from inpatient care.

It is also expected that some patients from Tayside/Highland will be
able to make use of day patient attendance.

For the remainder of Tayside patients and the most of Highland
patients it is expected that the transitional care will be provided more
locally, but there will be the option of continuing appointments at the
regional unit, telephone advice and video conferencing.

The aim will be maximum flexibility to meet the very individual
circumstances of each patient.
10. Communication

Patients will not be considered for admission without a referral letter
giving an adequate assessment of the patient’s history and setting out
the reasons for requesting admission. Communication by telephone,
e-mail and other means would be welcomed but would not substitute
for a formal written referral letter.

Initial communication needs to present a full picture of the physical
status of the patient and any areas of other significant risk. See Clinical
Protocol on pre-admission information.

Liaison might need to include discussion with the in-patient unit’s
attached physician to help draw up a safe plan for admission.

The admitting team will write to the referrer confirming whether
admission is to be offered and giving some idea when a bed would be
available.

By four weeks following admission there will be a detailed admission
care plan a copy of which will be made available to the patient and to
the referring clinician. This will have been prepared in consultation with
the patient, carers where appropriate and with the referring team.
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
At three months of admission a detailed assessment report and
progress update will be sent to the referring region, this may in some
cases be a detailed discharge report.

Prior to planned discharge the local eating disorders or other specialist
team will be given at least two weeks notice in order to prepare
appropriate follow up arrangement.

If there is an acute unplanned discharge then information about this
happening and the reasons will be conveyed urgently by telephone to
the local service.

On discharge a note of immediate treatment recommendations
including medication will be sent to the local general practitioner and
the local specialist service on the day of discharge.

A full typed discharge summary (see above) will be sent to the local
general practitioner within two weeks of discharge.

All patients will be reviewed by the clinical team regularly ie at least
weekly and any significant changes in the management plan will be
discussed with the local specialist team.
11. Out-of-Hours and Holiday cover for Psychiatrists

The out of hours doctors, including the Consultant rota, will provide
cover for the unit for medical and Psychiatric situations that arise. They
are likely to involve the need for usual medical and psychiatric
assessment for situations that will usually involve predictable physical
or psychiatric complications. These are covered in the Clinical Protocol.
The expectation is that not taking emergency admissions and usual
daytime practice will greatly reduce the need for out of hour’s
involvement.
12. Review of Operational Policy

Once agreed this policy will be fully reviewed after 12 months in
conjunction with the involved regions, Project Steering group, Clinical
project group and the MCN for Eating disorders.
Date of Review:
Appendix 1
1
Figure
Inpatient Treatment for Severe Eating Disorders
Under 16’s
16 – 18 year olds
Full assessment &
consideration of
alternatives by area
CAMHs’ Service
16 – 18 year olds
Decision to admit
Regional
adolescent
inpatient unit
Decision of where to admit for
16 – 18 year olds to depend on
maturity, educational needs,
family situation geography,
physical and psychological
need. Exceptionally will be to
the Eden Unit.
Over 18’s
Full assessment and consideration
of alternatives by area eating
disorder team and where
appropriate local adult mental
health service.
Liaison when required with Eden
unit Consultant.
Eden Unit
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Referral to IP Unit from Tertiary
Services or Secondary
Services (over 18 years of age)
Comprehensive Assessment*
by local specialist services
(including assessment by
Consultant Psychiatrist from
local specialist service or
Consultant from Regional ED
Unit in liaison with local
Consultant Psychiatrist and
Multidisciplinary Team.)
Consider alternative
options to admission
Decision to admit Discussion to plan
admission between IP Unit
& Local Specialist Services:
Eden Unit Consultant and
Ward manager
Admission
** See Below
Risk Assessment – both
physical & psychiatric risk
High Physical Risk –
consider stabilisation in
medical unit in the first
instance. Liaison with
Consultant Physician.
Informal Visit by
Patients/Carers to Unit.
Supply Patient with oral &
written information re unit.
*To include full Psychiatric History and MSE, Physical Assessment, risk assessment & assessment of family situation
** Responsibility for care and treatment of the patient following admission to hospital will be clarified in advance of admission so that transition from IP Care to Community Care is not disrupted