A decade ago, Dr. Laird Birmingham saw the writing on the wall. Because of reductions in the number of hospital beds, he began shifting the Eating Disorders Program at Vancouver's St. Paul's Hospital away from inpatient care and toward outpatient therapy. In the process, he cut the average length of stay from about 54 days to 19 days, and by prioritizing patients with the most serious cases of anorexia nervosa for hospital admission, the time patients had to spend on the waiting list dropped drastically. FIGURE
Birmingham's latest initiative is to add 3 beds to the inpatient unit, allowing the sickest patients to stay at St. Paul's for longer periods instead of paying $1500 a day at a facility in the US or UK. At a cost of about $500 000 per year, the beds will become part of a new 7-bed unit.
Birmingham, who sees 300 patients annually, says there has been a "gigantic increase" in the number of anorexia nervosa patients during the last 10 years. The initial inpatient therapy is on a par with intensive care, with 1 nurse for every 2 patients. Intensive vitamin and mineral therapy is supplemented by low levels of calories. Patients are discharged when their body fat is about 10%, and there is weekly follow-up to provide psychological support and to review meal plans. Some patients enter a residential program at the 10 bed Vista House on Vancouver's west side. They live here for about 3 months; there is 24-hour nursing care, and residents attend a day program at the hospital 4 days a week. Meal support-having a staff member with patients whenever they eat and afterwards-is one of the most important parts of the program. After leaving it, most people need therapy for another 2 years.
For the 1 in 5 anorexic patients who become chronically disabled, staff set up support services in their communities to provide follow-up. This is different from the approach taken by many centres, which offer only palliative care. Eighteen percent of Birmingham's patients die because of the illness, half by committing suicide. He is currently developing a range of educational materials to help provide better care in BC communities, including a Web site (www.anorexianervosa.org) and Internet teleconferencing.