Consistent indications for hospitalization have been defined in published practice guidelines.

It is often in the patient’s best interest to exhaust medical benefits before using mental health benefits. It is therefore essential for the medical professional to document medical complications and indications for treatment. Medical hospitalizations should carry medical diagnoses and diagnostic codes. Make certain that documentation reports caloric intake, vital sign, laboratory, and other abnormalities. Several practice guidelines define generally consistent criteria for medical hospitalization:

• Committee on Adolescence, American Academy of Pediatrics. Policy Statement: Identifying and Treating Eating Disorders. Pediatrics. 2003; 111:204-211.
  
• Society for Adolescent Medicine. Eating Disorders in Adolescents: Position
  Paper of the Society for Adolescent Medicine. J Adolescent Health. 1995; 16:476-480.
  
• American Psychiatric Association. Treatment Recommendations for Patients with Eating Disorders. Am J Psychiatry. 2006; 163(7 suppl):1-54.
  
• American Dietetic Association. Position of the American Dietetic Association: Nutritional Intervention in the Treatment of Anorexia Nervosa, Bulimia Nervosa, and Other Eating Disorders. Journal of the Am Dietetic Association. 2006; 106:2073-2082
  
• National Collaborating Center for Mental Health, National Institute for Clinical Excellence. Eating Disorders: Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa, and elated Eating Disorders. London: NICE, 2004.


• Committee on Adolescence, American Academy of Pediatrics. Policy Statement: Identifying and Treating Eating Disorders. Pediatrics. 2003; 111:204-211.
  
  Criteria for Hospital Admission for Children, Adolescents, and Young Adults with Eating Disorders (Table 6)
  
  Anorexia Nervosa
  
  • < 75% of ideal body weight, or ongoing weight loss despite intensive management
  • Refusal to eat
  • Body fat < 10%
  • Heart rate < 50 beats/min daytime; < 45 beats/min nighttime
  • Systolic pressure < 90
  • Orthostatic changes in pulse (> 20 beats/min) or blood pressure (> 10mm Hg)
  • Temperature < 96 degrees F
  • Arrhythmia
  
  Bulimia Nervosa
  
  • Syncope
  • Serum potassium concentration < 3.2 mmol/L
  • Serum chloride concentration < 88 mmol/L
  • Esophageal tears
  • Cardiac arrhythmias, including long QTc
  • Hypothermia
  • Suicide risk
  • Intractable vomiting
  • Hematemesis
  • Failure to respond to outpatient treatment


• Society for Adolescent Medicine. Eating Disorders in Adolescents: Position Paper of the Society for Adolescent Medicine. J Adolescent Health. 1995; 16:476-480.
  
  "Factors that would justify inpatient treatment include: significant malnutrition, physiologic or physical evidenced of medical compromise (such as vital sign instability, dehydration, or electrolyte disturbances) even in the absence of significant weight loss, arrested growth and development, failure of outpatient treatment, acute food refusal, uncontrollable bingeing, vomiting, or purging, family dysfunction that prevents effective treatment, and acute medical or psychiatric emergencies."



• American Psychiatric Association. Treatment Recommendations for Patients with Eating Disorders. Am J Psychiatry. 2006; 163(7 suppl):1-54.
  
  "Hospitalization should occur before the onset of medical instability as manifested by abnormalities in vital signs... physical findings, or laboratory tests."
  
  " patients who weigh less than approximately 85% of their individually estimated healthy weights have considerable difficulty gaining weight outside of a highly structured program that includes inpatient care... It is important to underscore that these are individually estimated healthy weights, not weights simply listed in a standard insurance table. Healthy weight estimates for a given individual must be determined by that person’s physician on the basis of historical data(e.g., growth charts), and for women, the weight at which menstruation and ovulation became impaired."
  
  "Vital sign changes that indicate a need for immediate hospitalization include marked orthostatic hypotension, with an increase in pulse of 20 beats/min or a drop in blood pressure of 20 mm Hg standing; bradycardia, with a heart rate < 40 beats/min; tachycardia, with a heart rate > 110 beats/min; or the patient’s inability to sustain his or her body core temperature (e.g., body temperatures < 97.o degrees F)."
  
  "It is equally important that the decision to hospitalize a patient be based on psychiatric and behavioral factors, including a rapid or persistent decline in oral intake..."
  
  "Weight level per se should never be used as the sole criterion for discharge from inpatient care."
  
  "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."
  


• Fisher M, Golden NH, Katzman DK, et al. Eating Disorders in Adolescents. J Adolescent Health. 1995; 16:420-437.
  
  Adolescents with AN need hospitalization when weight loss has been so prolonged or so rapid that life-threatening complications must be averted, or when weight loss continues despite outpatient treatment.
  
  Table 3: Indications for Hospitalization in an Adolescent with an Eating Disorder
  
  
  1. Severe malnutrition
  2. Dehydration
  3. Electrolyte disturbances
  4. Cardiac dysrhythmias
  5. Physiologic instability (Severe bradycardia; hypotension; hypothermia; orthostatic changes)
  6. Arrested growth and development
  7. Failure of outpatient treatment
  8. Acute food refusal
  9. Uncontrollable bingeing and purging
  10. Acute medical complications of malnutrition (e.g., syncope, seizures, cardiac failure, pancreatitis, etc.)
  11. Acute psychiatric emergencies (e.g., suicidal ideation, acute psychosis)
  12. Co-morbid diagnoses that interfere with the treatment of the eating disorder (e.g., severe depression, OCD, severe family dysfunction)


• American Dietetic Association. Position of the American Dietetic Association: Nutritional Intervention in the Treatment of Anorexia Nervosa, Bulimia Nervosa, and Other Eating Disorders. Journal of the Am Dietetic Association. 2006; 106:2073-2082
  
  "Nutritional treatment goals, typically referred to as nutritional rehabilitation, relate to restoration of healthful weight and normalization of eating patterns.... Individuals with acute medical needs may have shorter hospitalizations because of economic restraints with health insurance limitations and consequently may leave the hospital without progress toward medical nutrition therapy goals."



• Academy of Eating Disorders. Position Statement on Equity in Insurance Coverage for Eating Disorders. 1997.
  
  "Given the medical complications associated with AN in particular, in several instances the courts have ruled that the treatment of this disorder should be covered by medical insurance to the same extent as other sever medical illnesses. The courts have reasoned that medical coverage for treating the malnutrition resulting from AN is no different than the medical coverage for physical damage associated with other conditions such as alcoholism or for orthopedic injuries resulting from drunk driving or from failed attempts at suicide."



• Becker AE, Grinspoon SK, Klibanski A, and Herzog, DB. Current Concepts: Eating Disorders. New England Journal of Medicine 1999; 340:1092-1098.
  
  "Indications for inpatient care include extremely low weight or rapid weight loss, severe electrolyte imbalances, cardiac disturbances or other acute medical disorders, severe or intractable purging, psychosis or high risk of suicide, and symptoms refractory to outpatient treatment ."