Operationalising adult eating disorders admission criteria in Australian emergency departments: a clinical decision-support approach

Abstract

Emergency departments operate under conditions that constrain clinical decision-making, including high patient volume, time pressure, workflow disruption, frequent interruptions, and variability in clinician experience. Eating disorders present a particular challenge within these settings because assessment requires integration of physiological, biochemical, behavioural, nutritional, mental health, and psychosocial risk factors, many of which may not be immediately apparent even during acute presentations. Although guideline-based admission criteria exist, their application requires clinicians to synthesise and cross-reference heterogeneous clinical information in real time, which may contribute to variability in decision-making and risk of unsafe discharge. This paper examines eating disorder-related emergency department practice as an operational implementation problem, drawing on existing literature, clinical guidelines, and lived experience perspectives to identify why established adult eating disorder admission criteria may be difficult to apply consistently in acute care settings. Based on this analysis, a clinical decision-support framework is proposed to operationalise existing guideline-based admission criteria within emergency department workflow. The framework is intended for use after initial triage, when clinical observations, biochemical findings, behavioural information, mental health risk, psychosocial context, and response to outpatient treatment are reviewed, and before final admission or discharge decisions are made. It is designed to support more consistent and transparent assessment of risk by organising clinical input across key domains and mapping these inputs directly to established admission criteria. This is intended to support clinical judgement by increasing visibility of clinically significant risk factors and prompting documentation when decisions diverge from guideline-based recommendations. As a proposed framework, empirical evaluation is required to determine feasibility, usability, implementation barriers, clinician acceptability, and potential effects on decision-making, clinical outcomes, and patient safety.

Plain language summary

This is the Plain English Summary:Emergency departments need a safer and more consistent way to decide when adults with eating disordersshould be admitted to hospital. Although admission guidelines already exist, they can be difficult to apply consistently in busy emergency departments,where clinicians often work under time pressure, with incomplete information and many competing demands. Eating disorders are particularly challengingbecause a person may appear medically stable while still being at serious medical risk. Important warning signs may involve a wide range of factors,including blood pressure, heart rate, blood sugar, heart abnormalities, dehydration, rapid weight loss, purging, low food intake, suicidal thoughts, or unsafehome circumstances. This paper proposes a clinical decision-support tool, similar to a structured checklist. Clinicians would enter key information aboutthe patient’s physical health, eating disorder behaviours, mental health, and social situation. The tool would compare this information with existingadmission guidelines and show when hospital admission criteria are met. The tool would not replace clinical judgement. Instead, it would help makeserious risks more visible, reduce missed information, and lower the risk of unsafe discharge.

Introduction

Emergency department pressures and decision-making constraints

Emergency departments operate under conditions that constrain clinical decision-making, including high patient volume, time pressure, frequent interruptions, incomplete information, workflow disruption, and variability in clinician experience. These pressures are structural rather than incidental, reflecting the role of emergency departments as continuously operating systems with unpredictable demand and constrained staffing, space, and resources. Overcrowding is widely recognised as a persistent issue in emergency care, arising when demand exceeds available physical and staffing capacity [1, 2]. In Australia, rising emergency department presentations have intensified these pressures, contributing to longer waiting times, reduced throughput, and constraints on timely care delivery [3].

Overcrowding is associated with delays in assessment and treatment initiation, and these delays are linked to adverse clinical outcomes [4]. These pressures may also affect clinical reasoning. Emergency clinicians frequently make decisions under conditions of time pressure, uncertainty, interruptions, and incomplete information, all of which may increase cognitive load and the risk of diagnostic error or omission [5–7]. This context is especially important for presentations in which severity is not immediately apparent, and clinicians must identify immediate risk before all information is available [7].

Within this context, applying clinical guidelines can be difficult. Emergency care decisions often require integration of physiological, biochemical, behavioural, and contextual variables, distributed across observations, investigations, clinical notes, patient history, collateral information (e.g., observations from carers or family members), and psychosocial assessment. This creates a mismatch between the complexity of guideline-based criteria and the cognitive and operational constraints of emergency practice [5–7]. From a systems perspective, the problem is not simply absence of guidance, but difficulty translating established guidance into consistent real-time action at the point of care.

Eating disorders in emergency department care: complexity and under-recognition

Eating disorders represent a growing public health concern, with increasing prevalence, substantial disease burden, and significant impacts on quality of life [8]. They are associated with high levels of chronic disability and among the highest mortality rates of any mental health condition [9]. Despite this, eating disorders may be under-recognised within emergency department settings, particularly when individuals present with non-specific complaints [10]. Individuals with eating disorders may also appear outwardly medically stable despite significant underlying risk, requiring active clinical assessment and proactive risk recognition [11]. However, emergency clinicians report limited training, knowledge, and familiarity with eating disorder assessment and management, which may further contribute to difficulties in identification and appropriate care [12].

Eating disorder risk assessment requires synthesis across multiple domains. Physiological instability (e.g., postural tachycardia, postural drop in blood pressure, hypovolaemia), electrolyte disturbance (e.g., hypokalaemia, hypomagnesaemia, metabolic acidosis or alkalosis), rapid weight loss, severe nutritional restriction, dehydration, compensatory behaviours (e.g., self-induced vomiting, excessive exercise, laxative use), mental health risk (e.g., suicide ideation, self-harm, psychosis), psychosocial difficulties (e.g., abusive or toxic family environments, domestic violence, food insecurity), and limited response to outpatient treatment may each indicate need for escalation. These indicators may emerge from different sources, including clinical observations, blood test results, electrocardiogram findings, patient history, collateral information, clinical notes, and psychosocial assessment. They may also be minimised, concealed, disclosed incompletely, or interpreted in isolation from each other. Lived experience and qualitative research help explain why this information may be difficult to elicit: stigma, prior dismissal of risk (e.g., ‘not sick enough’) [13, 14], systemic barriers to appropriate care, prior negative treatment experiences, including iatrogenic harm, and erosion of trust in healthcare systems can shape whether, when, and how people disclose eating disorder behaviours and physiological symptoms indicating medical risk [15–19]. This creates a clinical context in which significant eating disorder-related risk may be missed.

International frameworks provide important guidance for identifying and managing medical risk in eating disorders, although they differ by population, healthcare system, and clinical setting. The Society for Adolescent Health and Medicine position paper outlines consensus-based criteria for medical hospitalisation in adolescents and young adults with restrictive eating disorders [20]. Earlier United Kingdom guidance, including Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN), supported recognition and management of severe anorexia nervosa within adult and general medical settings [21], and the MARSIPAN-derived Modified Early Warning Score was developed to structure physiological deterioration monitoring in inpatient anorexia nervosa care [22]. More recently, Medical Emergencies in Eating Disorders: Guidance on Recognition and Management (MEED) replaced MARSIPAN and Junior MARSIPAN and provides guidance across the age range, while distinguishing risk considerations and thresholds for children and adolescents from those for adults [23]. For example, MEED notes that weight loss in children and adolescents may be more acute because of lower body fat stores, whereas adults with more long-standing eating disorders may present later and be medically compromised despite serum electrolyte levels that do not reflect severely depleted intracellular stores, such as potassium [23]. MEED also emphasises that patients may be medically high risk despite appearing outwardly well or having blood results within reference ranges, and that assessment should integrate nutritional status, physical examination, blood tests, electrocardiography, eating disorder behaviours, mental health risk, engagement with treatment, and social context [23].

State-specific admission criteria for eating disorders exist in Australia, including the New South Wales guidelines [24]. However, these criteria require clinicians to synthesise heterogeneous clinical information rapidly and consistently within high-pressure emergency department environments. No prospectively validated eating disorder-specific emergency department disposition rule currently exists, and limited work has focused on operationalising existing criteria into workflow-integrated clinical decision-support systems for adult emergency department practice.

Healthcare utilisation data indicate marked increases in Australian eating disorder presentations, hospital admissions, and outpatient contacts over the past decade, particularly among young people [25]. Care pathways are often fragmented and non-linear, with individuals moving between emergency, inpatient, and community settings without consistent continuity of care [25]. Limited service availability, long waiting times, underdiagnosis, stigma, fear, and low mental health literacy may further delay treatment-seeking [26, 27]. Such delays are clinically significant because prolonged untreated illness is associated with increased severity, chronicity, and reduced likelihood of recovery [27].

Evidence that individuals with eating disorders may be discharged from emergency departments despite significant medical risk indicates potential gaps in risk identification, escalation of care, and application of admission criteria [10, 28, 29]. From a lived experience and quality improvement perspective, these gaps reflect broader systemic shortcomings, including misalignment between patient needs and service responses and challenges in recognising the seriousness of eating disorder presentations in acute settings [16, 30].

Operationalising admission criteria as a decision-support problem

The present paper focuses on adult eating disorder presentations within an Australian emergency care context. Paediatric and adolescent eating disorder assessment involves additional developmental, family-based, and growth-related considerations that are beyond the scope of this paper. The proposed framework is intended to operationalise existing guideline-based adult admission criteria into a clinical decision-support approach for emergency department practice (Fig. 1). It is intended for use after initial triage and before final admission or discharge decisions are made. It is therefore not proposed as a triage-screening tool, but as a support for synthesising and cross-referencing heterogeneous clinical information with admission criteria once observations, investigations, history, mental health risk, psychosocial context, and treatment history are available. Where relevant information is absent or incomplete, the framework would also make this visible, prompting clinicians to obtain, document, or explicitly account for missing information before final decisions are made.

Fig. 1.

Adult emergency department eating disorder risk assessment (New South Wales, Australia).

BMI = body mass index; kcal = kilocalories; mmHg = millimetres of mercury; ECG = electrocardiogram; QTc = corrected QT interval; mmol/L = millimoles per litre; g/L = grams per litre; AST = aspartate aminotransferase; ALT = alanine aminotransferase; ×10⁹/L = cells per litre. This tool is an adapted clinical decision-support framework derived from the Guidelines for the Inpatient Management of Adult Eating Disorders in General Medical and Psychiatric Settings in New South Wales. Available from: https://www.health.nsw.gov.au/mentalhealth/resources/Publications/inpatient-adult-eating-disorders.pdf

The central problem addressed here is not the absence of admission criteria, but the difficulty of cross-referencing and applying multi-domain criteria reliably under emergency department conditions. Eating disorder admission decisions require clinicians to integrate a wide range of heterogeneous clinical information. In routine emergency department workflow, these data may become available at different times, may be documented in different places, and may require interpretation by clinicians with varying levels of eating disorder expertise. This creates opportunities for omission, inconsistent weighting of risk indicators, or failure to escalate care when guideline thresholds are met.

Clinical decision-support tools, checklists, and cognitive aids have been used in emergency care to organise assessment, reduce omission of key steps, improve communication, and support consistency in high-pressure environments [5, 31, 32]. The proposed framework draws on this broader logic while addressing the specific operational challenge of mapping adult eating disorder risk indicators to established admission criteria during emergency department assessment. The framework is therefore introduced as clinical decision-support designed to make relevant criteria visible, support clinical synthesis, and preserve clinician judgement.

Proposed clinical decision-support framework

This paper proposes a clinical decision-support framework to operationalise existing adult eating disorder admission criteria within emergency department practice (Fig. 1).

Intended point of use within emergency department workflow

The framework is designed for the clinician-led assessment phase of emergency department care, when disposition planning is underway and relevant clinical information is being assembled. This timing reflects the type of information required to apply adult eating disorder admission criteria, including postural observations, examination findings, blood glucose, electrolyte results, electrocardiogram findings, nutritional and behavioural history, suicide and self-harm risk, psychosocial context, and response to outpatient treatment. Many of these data are unlikely to be available at initial triage alone and may become available at different points during the emergency department encounter.

The framework therefore supports the synthesis of available information before final admission or discharge decisions are made. It also makes absent or incomplete information visible, prompting clinicians to obtain, document, or explicitly account for missing data where relevant to risk assessment and disposition planning.

Framework structure and clinical domains

The framework translates guideline-based adult eating disorder admission criteria into a questionnaire-based format. Clinicians would complete mandatory fields across domains relevant to medical, mental health, and psychosocial risk.

These domains are included because adult eating disorder risk assessment requires integration of multiple forms of information. Severe risk may not be apparent from appearance, weight, or a single physiological marker. Individuals may be medically unstable across a range of body weights [33–35], may conceal disordered eating behaviours, or may have clinically significant biochemical or cardiac risk that is only identified through active assessment.

Mapping clinical inputs to admission criteria

Clinician-entered data would be mapped directly to established adult admission criteria, using the Guidelines for the Inpatient Management of Adult Eating Disorders in General Medical and Psychiatric Settings in New South Wales as the source framework [24]. Where entered data meet guideline-based thresholds for admission, the framework would generate an output identifying that admission criteria have been met and specifying the relevant criteria involved.

This mapping process is intended to reduce reliance on memory and repeated manual cross-referencing between clinical data and external guideline documents. It also aims to make clinical reasoning more transparent by showing which risk indicators have triggered the recommendation. In this way, the framework supports, rather than replaces, clinical judgement.

Recommendation output, clinical judgement, and documentation

Where entered information meets criteria indicating medical instability, acute mental health risk, severe behavioural risk, or unsafe psychosocial context, the framework would generate a recommendation for admission or senior clinical review. Clinicians would retain discretion to admit, discharge, seek specialist advice, or pursue further assessment based on the full clinical context. However, where a clinician decides to discharge a patient despite guideline-based indicators for admission, the framework would prompt documentation of the clinical rationale, including how identified risks have been considered and what follow-up, safety planning, or escalation arrangements have been made.

This documentation prompt supports transparency and audit. It may assist information-sharing between emergency department clinicians, eating disorder services, inpatient teams, general practitioners, and community providers, and may support quality improvement by identifying patterns in admission decisions, discharge decisions, and divergence from guideline-based recommendations.

Format and implementation considerations

For clinical utility, the framework would ideally be embedded within existing hospital electronic medical record systems rather than used as a standalone document. Electronic integration could support accessibility within routine emergency department workflow, reduce reliance on separate forms, and provide a structured location for documenting relevant observations, pathology results, electrocardiogram findings, clinical history, psychosocial context, and decision rationale. However, the extent and form of integration would depend on local electronic medical record infrastructure, interoperability, governance requirements, and available implementation resources.

Implementation would need to be adapted to local workflows, information systems, staffing models, clinical governance processes, and escalation pathways. Such adaptation is necessary because admission criteria, referral pathways, electronic medical record infrastructure, and specialist eating disorder service availability may differ across jurisdictions and hospitals. The framework should therefore be understood as a conceptual implementation proposal rather than a validated clinical instrument. Its reliability, validity, usability, feasibility, implementation requirements, and effects on clinical decision-making, patient safety, and outcomes require empirical evaluation before clinical use.

Discussion

This paper positions variability in adult eating disorder admission decisions as an implementation problem within emergency department practice. Admission criteria and clinical guidance already identify important markers of risk, but their practical value depends on whether they can be applied consistently during real-time assessment and disposition decisions. The proposed framework therefore addresses the gap between guideline availability and guideline use. Its contribution is not to introduce new admission criteria, but to explore how existing criteria might be made more usable, transparent, and auditable within emergency department workflow.

Emergency department decision-making is vulnerable to omission because clinicians often work under time pressure, uncertainty, interruptions, incomplete information, and competing demands [5–7]. Eating disorder presentations amplify this problem because clinically significant risk may not be visually apparent, may be minimised or concealed by patients, and may only become evident when information from multiple sources is considered together. A decision-support approach may therefore be valuable if it helps clinicians recognise risk, locate missing information, and make the reasoning behind decisions more explicit.

Emergency medicine literature suggests that clinical decision-support tools, checklists, and cognitive aids can support care processes when they are well designed and aligned with clinical workflow, but their effectiveness cannot be assumed [5, 31, 32, 36]. Poorly designed or poorly implemented tools may be used inconsistently, ignored, or experienced as burdensome, particularly if they are too long, ambiguous, poorly integrated, or perceived as replacing clinical judgement [32, 37, 38]. Electronic integration may improve accessibility, but may also introduce usability, interoperability, cost, and implementation barriers [39]. The relevant question is therefore not simply whether a decision-support framework is desirable, but whether it can be designed and implemented in a way that supports clinical reasoning without adding avoidable burden.

Lived experience and qualitative research indicate that people with eating disorders may delay help-seeking, minimise symptoms, or avoid disclosure when care has previously involved stigma, dismissal, iatrogenic harm, or not being believed [13–19]. A decision-support framework cannot resolve these systemic problems alone, but it may help make risk harder to overlook and make discharge decisions more accountable when guideline-based indicators are present. Future development should therefore involve people with lived experience, emergency clinicians, eating disorder specialists, service managers, and information technology teams, so that the framework is usable, co-designed, and responsive to the realities of emergency care.

This paper presents a conceptual implementation proposal and does not provide evidence that the framework improves admission decisions, reduces unsafe discharge, or improves patient outcomes. Empirical work is required to examine validity, usability, acceptability, workflow fit, documentation burden, and feasibility before clinical use. Subsequent evaluation should assess effects on admission and discharge decisions and patient safety outcomes, while also monitoring unintended consequences such as over-reliance, inequitable implementation, or false reassurance when risk is not captured by predefined fields.

Conclusion

Adult eating disorder admission decisions in emergency departments require clinicians to integrate complex and often dispersed information under conditions of time pressure, uncertainty, and variable eating disorder expertise. Existing admission criteria provide essential guidance, but their consistent use depends on whether they can be operationalised within emergency department workflow at the point where disposition decisions are made.

The proposed clinical decision-support framework offers an approach for making guideline-based risk indicators more visible, supporting synthesis of heterogeneous clinical information, and improving transparency when admission or discharge decisions are made. Its intended role is not to replace clinical judgement or create a new admission rule, but to support more consistent application of existing admission criteria and strengthen documentation of clinical reasoning.

Before clinical implementation, the framework requires empirical evaluation of feasibility, usability, acceptability, reliability, workflow fit, and potential effects on admission decisions, escalation pathways, patient safety, and unintended consequences. Future development should involve emergency clinicians, eating disorder specialists, people with lived experience, service managers, and information technology teams to ensure that the framework is clinically useful, locally adaptable, and aligned with person-centred emergency care.

Abbreviations

BMI

Body mass index

ECG

Electrocardiogram

MARSIPAN

Management of really sick patients with anorexia nervosa

MEED

Medical emergencies in eating disorders

NSW

New South Wales

Author contributions

LC: Conceptualisation, Formal analysis, Investigation, Project administration, Writing – original draft, Writing – review and editing.

Funding

No funding was obtained for this work.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This work does not involve the collection of human data.

Competing interests

The authors declare no competing interests.