CAE and CPD

Henry the Harris Hawk, May 2012

Well, we have swapped wards, on the first day following the three-day week. During that previous week I worked all three full days, colleague #1 worked two days, and colleague #2 worked one and a half which included an outpatient clinic (and therefore she was not available for ward work for half a day). I handed over my patients all up to date and tidy, and received wards in return that contained all sorts of loose ends (and the wards in question have not stopped referring patients since Monday).

Then two specific things happened. Firstly, a Clinical Adverse Event (CAE) was recorded about a patient on one of my (new) wards who had not been seen despite having been referred and then chased. Secondly, it became clear that the referrals continued to come in at a rate of two new patients for every one I was able to actually see. Add the fact that my outpatient clinic on Tuesday was the biggest ever (full clinic, no gaps, ten patients! Only one DNA!) so there was much letter-writing to be done, and I had a day's professional development course all day Thursday when I wouldn't be able to see any patients at all.

At this point, I had to ask for help from our new clinical manager, who is covering for maternity leave and has been in post for less than a month. I have to say that she took the load of referrals away from me in a matter of minutes, and I was able to go for my CPD with a clear conscience. I did make the small mistake of looking in the referrals book before I went off on the course, and the relentless stream of new patients didn't seem to be diminishing at all. Of course the nature of referrals is that they do not necessarily come in at an ideal rate, sometimes too many and sometimes too few, but I know which I prefer.

By the way, I am not in the least concerned about the CAE. When I did go to see the patient, he was not in a particularly bad state, and I wouldn't have prioritised him over many of the other patients needing nutrition support. He had been looked after as I would have wished, offered snacks and supplements, and his intake (mostly) recorded along with his weight and other details that form the evidence base for my intervention. As this is a ward that is wholly unfamiliar to me, I can make no judgement about why the CAE was raised and by whom, but I hold no grudges - presumably someone thought that the poor nutritional state of a patient was important enough to complain about, and that is generally a good thing. I can't take it personally, given that nobody on the ward knows who I am yet.

The course I went on for a day was part of something called 'Preceptorship', which is supposed to provide a framework for supported ongoing learning within the first year post-qualification. The organised forums are mostly aimed at nurses, with a couple of session suitable for other healthcare professionals. This one was mostly about patient safety and brief behavioural interventions, and was much more relevant than I was expecting it to be, especially the session about Motivational Interviewing. This is an evidence-based technique for promoting behaviour change, which turns out to be the part of the job of a Dietitian that I like the best, although I'd never have guessed it before I started. I actually like weight management! Up until very recently indeed, I was claiming that this was an area of Dietetics that really didn't interest me.

I have also spent a short time with a Specialist Diabetes Dietitian, planning how I might gain an insight into what they do. This is for the enhancement of my CV, my professional development portfolio (which at the moment is rather in the nature of a virtual portfolio until I get round to actually writing things down and filing them) and for brandishing at a future job interview to show how interested in diabetes I am. Among the wealth of practice-related matters that I gleaned from this session, I also took away the abiding impression that all the Dietitians currently in the Diabetes service are young, committed, and unlikely to move away to leave any room for me in the near future. There are also many impediments to expanding the service, so it may be some time before any vacancies appear. The last Dietitian recruited into the Diabetes team had remained at my current level for seven years before the opportunity arose for her to move upwards. But you never know.

[I have also looked into volunteering at Diabetes UK weekend events, and the only thing currently putting me off applying is the need to express enthusiasm about working with and/or supporting children. Being a truthful person, I have yet to contrive a convincing response for this area of the form.]

The good news was that thanks to my manager I was able to leave at the end of Friday with most of the new referrals seen, although there are still a few that are having to wait until Monday. As for the type of interventions I'm seeing on the new wards, that will have to wait for a future blog post.

Prioritisation

Jephson Gardens, Feb 2012

My main weakness over the first weeks of my first dietetic job has been the tendency to accept referrals and agree to review patients that a more experienced Dietitian would discharge from their care. Without the experience to be certain that my practice is safe and correct, I have tended to want to review patients to make sure that all is well, and to find out whether my recommendations worked. This is commonly found with new Dietitians, and a sign of increasing confidence is to reject a referral or discharge a patient from dietetic care.

What this has meant is that my caseload is rather too big, and I wasn't able to review all my patients last week. This is fine, because if there had been any cause for concern, the ward staff would have bleeped me or called the office, which they actually did once or twice. New referrals kept coming in, and those patients have to come first.

When you are interviewed for a job as a Dietitian, invariably there is a question about prioritisation, which goes like this:

"It is Friday afternoon and four referrals have been received in the dietetic office. What do you do?"

Then they describe the four different patients, who usually are as follows: one overweight patient on a ward wanting healthy eating advice, one person with newly-diagnosed diabetes about to be discharged home, one malnourished in-patient with poor appetite, and someone who has just had a nasogastric (NG) tube placed and needs a regimen for feeding through the tube. What you do is offer the overweight patient an outpatient appointment, go and see the person with diabetes before they go, tell the ward staff to give the malnourished patient food, snacks and supplements and re-refer if things don't improve, and tell them to use the emergency regimen for NG tube feeding that has been drawn up for just such contingencies, until you can see the patient on Monday.

Up until last Friday I had thought it was a useful exercise to ensure that candidates can make the right choices when demand for dietetic input exceeds the number of hours in the working week. Last Friday I discovered that it is actually a very accurate description of real life. I had new referrals for a patient with type 1 diabetes, another who was obese, a third with Crohn's disease, another with a reported BMI of 15 kg/m² (which is seriously underweight), and I was on a ward reviewing a patient receiving an NG feed. And it was 2 o'clock on Friday afternoon.

It all went to pieces through an unprecedented chain of events that meant I had to spend a long time on the ward sorting out a potentially harmful situation, and then reporting a 'Clinical Adverse Event'. It's interesting to find that as the end of the working week approaches, priorities sort themselves out - three of the referrals ended up being somehow much less important than I had originally imagined, and, for the first time, I rejected a referral. It felt good.