This guidance is for eating disorder services during the COVID-19 epidemic. It covers outpatient and inpatient services as well as the effect of COVID-19 on eating disorders patients and infection control in services.
COVID-19 is a new virus, and at this stage we have insufficient information as to whether people with eating disorders are more likely to develop serious complications than the general population. Although those with eating disorders are not included as one of the ‘shielded’ groups, there does need to be increased monitoring/awareness as patients with ED may have atypical COVID-19 presentation.
Those who are severely malnourished, and people with significant comorbidities, such as asthma or diabetes, should consult their treatment team about the best strategy to avoid infection (such as shielding) to reduce the risk of infection and other physical health complications while also considering the potential impact on their mental health and eating disorder of such approaches. The following indicators may be helpful when advising patients about shielding (we will update the advice as new evidence emerges):
- severe malnutrition (BMI <15 in adults, or below 5th centile in children and young people)
- severe obesity (BMI >40)
- electrolyte imbalances due to purging
- bone marrow suppression (including low lymphocyte levels)
- physical comorbidities, such as severe asthma, diabetes, kidney disease, pancreatitis
- male gender (due to the higher risk of severe COVID-19 presentation among men)
- potential risks of mental health harms caused by isolation of shielding.
Patients with eating disorders may have atypical response to infections (such as lack of fever in a malnourished patient), which can delay recognition, treatment and the necessary isolation of the patient. New symptoms, such as fatigue, lack of energy, should be followed up even in the absence of temperature or cough. It may be recommended to patients to monitors their own temp if they suspect COVID-19, so if there is a change it can be responded to accordingly.
For people with eating disorders, the risk of contracting Covid-19 is accompanied by additional stress and anxieties. Social distancing policies are likely to increase isolation and result in loss of support networks such as friends and family. Young people living at home continue have parental support, although family relations can often already be strained. The economic consequences of the lockdown may further increase stress and high expressed emotions or even lead to abuse in some families.
It is important for specialist eating disorder services to be aware of this risk, and offer the young person a safe way of expressing their difficulties. Adults with eating disorders often live alone and the isolation is likely to get worse during the current lockdown. Many adults may also experience significant financial difficulties, and they may worry about job and accommodation security. Young people with eating disorders who are in education may also worry excessively about the impact on their academic progress.
Furthermore, the lockdown disrupts safe routines, such as access to specific foods and options for exercise, and, all of which could worsen eating disorder psychopathology and behaviours. For example, if people with EDs have severe restriction to certain ‘safe’ foods which aren’t easily available, this could mean visiting numerous food outlets, with increased risk of COVID-19 infection. If the patient is unable to be more flexible using alternatives, it may be helpful for specialist services to consider write a letter explaining the situation which the individual can carry with them.
Raised general anxiety due to the pandemic may translate into agitation and distress which may further interfere with eating, and can trigger unhelpful coping mechanisms, such as bingeing and purging or excessive exercise. These can be reinforced by unhelpful narrative about food/meals and fitness on social media and on the news, which encourages exercise and prevention of weight gain during lockdown. Increased alcohol consumption is an additional risk, and can lead to severe consequences, particularly in binge-purging anorexia subtype,
It is important to encourage patients to continue keeping in touch with their friends and family (even if it is only possible remotely) as they are important resource for emotional and for practical support, such as helping with routines, shopping and activities.
Most psychological interventions can continue to be offered via online platforms. Systematic reviews of telehealth interventions have consistently found that there is strong evidence of high acceptability, feasibility and sustainability as well as good evidence of non-inferiority as compared to face to face contact, although there is less robust evidence of effectiveness. There is more research regarding remote psychological treatment for eating disorders than for other patient groups in psychiatry. NICE approved treatments, such as cognitive behavioural therapy, can be effectively delivered remotely. Please refer to NHSE IAPT guidance here and NICE guidance on recognising and treating eating disorders here.
Video technologies are helpful for remote assessments in a significant number of cases, where the assessment consists of a clinical interview and collection of baseline outcome measures. Most patients with eating disorders use mobile technologies and are familiar with video chats and in our experience find it helpful to discuss their difficulties with a clinician. Remote technologies can also be helpful for interviewing young people and their families, and may be preferable to face to face contact where the clinician would need to wear PPE covering their face and impairing non-verbal communication. If the patient does not have a smart phone, tablet or computer, telephone consultation may be an alternative. For further information on this, please refer to RCPsych’s guidance on remote consultations.
Physical examination and blood test
These interventions require PPE according to national guidance. RCPsych have also provided a summary of PPE guidelines as relevant to those working in mental health settings. Physical examination is an important part of assessment, particularly if the patient is malnourished. The decision about blood tests and ECG need to be made between the consultant psychiatrist and the patients GP depending on the level of risk and local arrangements.
Thisis part of CBT-E and can be arranged remotely with a cooperative patient. For those patients, who are likely to falsify their weights a specific care plan needs to be agreed with the GP, the eating disorder team and carers depending on local availability and risk.
Medication may be used to manage significant comorbidities These should be done via telephone/video reviews where feasible and prescribing continued via shared care where possible. Electronic prescription is only available in some parts of the country, and therefore local solutions need to be generated to avoid delay. Please see RCPsych’s guidance on providing medication during the COIV-19 pandemic for more information.
Working from home or clinical base
It is possible for eating disorder clinicians to work from home during the majority of time, as this helps to ensure effective social distancing. Clinical team meetings and supervision should be arranged remotely, by using MS Teams/Skype. If office space is used, staff should ensure 2m physical distancing, handwashing, cleaning of environment, and self isolation if symptomatic. Testing is recommended, as above, if a member of staff becomes ill.
The COVID-19 crisis has necessarily meant the cessation of all day patient services for patients with eating disorders, and also the discharge of many patients who would ordinarily benefit from intensive support. This, and the impaired ability to conduct home visits or face to face consultations, has meant that it is very difficult to support patients with eating disorders and their families who may be struggling with maintaining their mealtimes and nutritional intake.
Alternative ways of supporting patients should include more frequent remote support by staff, or if possible, the encouragement of telehealth alternatives for groups.
It is paramount that mental health services and medical wards (paediatric or adult acute wards for medical stabilisation of an eating disorder) focus on preventing COVID-19 infection in inpatient settings, where the virus could be spread very rapidly, due to the close proximity of staff and patients, and enclosed environments. This requires different ways of working from usual practices in the UK, but would prevent significant morbidity and mortality, and would reduce the pressure on acute services.
As a general principle, clinicians need to carefully consider and balance benefits and drawbacks of admitting to inpatient services due to the increased risks in inpatient settings.
Providers should consider whether it is possible to reconfigure the inpatient estate to create ‘cohorted’ wards to reduce the risk of contagion. Wherever possible inpatient settings should ‘cohort’ all patients into:
- those with confirmed COVID-19;
- those without confirmed COVID-19
- where an individual is admitted who meets the government criteria for ‘shielding’ they should be prioritised for an en-suite facility.
Providers should continue to consider the vulnerabilities of all patients they are caring for when reconfiguring the inpatient estate to reduce the risk of contagion among specific, vulnerable groups.
Current UK infection control guidance relating to symptomatic patients is based on a risk stratification technique.
The guidance regarding symptoms is specific to viral load shedding being higher in those that are symptomatic. However, this does not necessarily mean that asymptomatic people are not infectious: since they are not currently screened, the risk of transmission cannot be excluded. High level infection control strategies are helpful for morale, allowing staff and patients to feel safe.
Suggestions for prevention in inpatient eating disorders settings and medical wards (paediatric or adult acute wards for medical stabilisation of an eating disorder) in addition to existing measures such as regular hand washing.
- Enhanced cleaning of hard surfaces, particularly door furniture, shared computers etc, is necessary to remove potential viruses.
- Alternative ways of keeping in touch with friends and family should be encouraged (access to telephone and mobile technologies). Visits that must go ahead should be restricted to essential visitors only and for children and young people it is recommended that only one parent is in attendance. Local arrangements are likely to be made according to the need and risk of the population they serve, bearing in mind the general principles outlined in national guidance on visitors.
- Clinicians should follow Public Health England guidance on investigation and initial clinical management of possible cases of COVID-19.
- If the patient tests positive, they should be nursed in a COVID-19 ward setting until the symptoms resolve or acute hospital treatment is required. More guidance on this can be found here. A separate COVID-19 ward may be necessary for those who are at the end of life requiring high level of medical or palliative interventions. Such wards should be regarded as higher risk acute inpatient areas and staff should be cohorted as an additional infection control measure as per current guidelines. Please refer to cohorting guidance above. High level of infection control is necessary in such environments to reduce the risk of transmission and viral load to ensure patient and staff safety. As much as possible, patients should be cared for in their individual bedrooms, and additional consideration should be given to how to ensure the maximum distance between patients in common places, such as dining rooms. The environment should be well ventilated with fresh air.
- Access to fresh air should be facilitated depending on psychiatric risks (e.g. hospital grounds/ gardens, parks as long as 2 m distance from others is maintained).
- Smoking should be stopped as much as possible, and each persistent smoker should be advised to stop and have access to nicotine replacement therapy.
- Psychological support should be provided remotely or, if this is not possible, with 2 m distance.
- Ward rounds and CPA meetings can be facilitated remotely, by using appropriate technologies, such as MS Teams
- Standard infection control precautions require staff to assess any risk of body fluid contamination prior to undertaking an activity. As detailed in current national guidance, the recommended PPE to be used by healthcare workers within one metre of a patient with possible or confirmed COVID-19 is a fluid repellent facemask (FRSM), a single use plastic apron and gloves, and eye protection if there is a risk of splashing or exposure to respiratory droplets. Also, guidance should be followed on patient use of PPE (including guidance that patients who are confirmed COVID-19 positive wear a surgical face mask if this can be tolerated).
- With specific regard to delivering NG feeding under restraint, or other issues such as staff exposure to spitting during restraint activity, the same risk assessment and level of PPE should be worn. Transmission of COVID-19 is via respiratory droplets and so face protection should be worn during restraint activity in possible or confirmed COVID-19 individuals. According to PHE ‘NG feeding under restraint and spitting will not result in aerosolisation of particles of less than 5 micrometres in size and a review of the literature (UK and WHO) does not class this procedure or exposure as aerosol generating, thus FFP3 respirators are not required. Evidence suggests that the use of FRSM and FFP3 respirators offer the same level of protection against respiratory droplets.’ However, several other organisations have stated that naso-gastric (NG) tube placement may be an aerosol generating procedure (AGP) and requiring full PPE. This includes the British Dietician Association and BAPEN.
- A high level of caution should be maintained. If there is sufficient evidence that the patient is COVID-19 free, then NG feeding can be used as normal, but if there is a risk that the patient is COVID-19 positive, full PPE is advised.
- The main challenge may be ensuring that staff maintain their PPE, particularly face and mucosal protection, during the restrain activity on possible or confirmed COVID-19 individuals. This should be considered prior to undertaking the restraint activity. After the activity, PPE should be removed and disposed of carefully to reduce the risk of self-contamination and good hand hygiene carried out.
The above suggestions are highly restrictive. However, they are part of infection control, and designed to reduce iatrogenic morbidity and mortality in inpatient settings. For further information on legal and ethical issues, please refer to the below.