Managing Eating Disorders on a General Pediatrics Unit: A Centralized Video Monitoring Pilot

Hospitalizations for nutritional rehabilitation of patients with restrictive eating disorders are increasing.¹ Among primary mental health admissions at free-standing children’s hospitals, eating disorders represent 5.5% of hospitalizations and are associated with the longest length of stay (LOS; mean 14.3 days) and costliest care (mean $46,130).² Admission is necessary to ensure initial weight restoration and monitoring for symptoms of refeeding syndrome, including electrolyte shifts and vital sign abnormalities.^3-5

Supervision is generally considered an essential element of caring for hospitalized patients with eating disorders, who may experience difficulty adhering to nutritional treatment, perform excessive movement or exercise, or demonstrate purging or self-harming behaviors. Supervision is presumed to prevent counterproductive behaviors, facilitating weight gain and earlier discharge to psychiatric treatment. Best practices for patient supervision to address these challenges have not been established but often include meal time or continuous one-to-one supervision by nursing assistants (NAs) or other staff.^6,7 While meal supervision has been shown to decrease medical LOS, it is costly, reduces staff availability for the care of other patient care, and can be a barrier to caring for patients with eating disorders in many institutions.⁸

Although not previously used in patients with eating disorders, centralized video monitoring (CVM) may provide an additional mode of supervision. CVM is an emerging technology consisting of real-time video streaming, without video recording, enabling tracking of patient movement, redirection of behaviors, and communication with unit nurses when necessary. CVM has been used in multiple patient safety initiatives to reduce falls, address staffing shortages, reduce costs,^9,10 supervise patients at risk for self-harm or elopement, and prevent controlled medication diversion.^10,11

We sought to pilot a novel use of CVM to replace our institution’s standard practice of continuous one-to-one nursing assistant (NA) supervision of patients admitted for medical stabilization of an eating disorder. Our objective was to evaluate the supervision cost and feasibility of CVM, using LOS and days to weight gain as balancing measures.

Setting and Participants

This retrospective cohort study included patients 12-18 years old admitted to the pediatric hospital medicine service on a general unit of an academic quaternary care children’s hospital for medical stabilization of an eating disorder between September 2013 and March 2017. Patients were identified using administrative data based on primary or secondary diagnosis of anorexia nervosa, eating disorder not other wise specified, or another specified eating disorder (ICD 9 3071, 20759, or ICD 10 f5000, 5001, f5089, f509).^12,13 This research study was considered exempt by the University of Wisconsin School of Medicine and Public Health’s Institutional Review Board.

Supervision Interventions

A standard medical stabilization protocol was used for patients admitted with an eating disorder throughout the study period (Appendix). All patients received continuous one-to-one NA supervision until they reached the target calorie intake and demonstrated the ability to follow the nutritional meal protocol. Beginning July 2015, patients received continuous CVM supervision unless they expressed suicidal ideation (SI), which triggered one-to-one NA supervision until they no longer endorsed suicidality.