Diabetes services

Greek sunset, June 2014

I've got a half-written blog post that I've been trying to finish, but it's taking ages because it needs a bit of thinking time and I'm just not getting round to it. So I'll do some writing off the top of my head, just to keep things ticking over.

I'm still working five days a week, being paid for about five hours on that fifth day doing general dietetics on the wards, which means mostly nutrition support. The hospital is a small one with only six wards, and holds patients who are not acutely ill and/or who live in the area. They are generally old and not actually needing further treatment but cannot go home until some sort of provision is arranged to make sure they can cope (a 'Package of Care'). Nearly all those who need dietetic input are not eating or drinking well, usually because they have dementia. I absolutely hate it. I have two weeks to go before the Dietitian who has been off sick is due to return, and I shall do everything in my power after that to be completely unavailable for this type of work in future, although there will be a lot of moral pressure to 'help out' if a similar situation happens again.

My real job is still very interesting. I have managed to start two people on the very low carb plan, but unfortunately one did not return for the follow up appointment and wasn't answering the phone when I rang. My first Structured Education course for people with Type 1 Diabetes finished this week. This is designed to give people a lot of information and practical experience of how to best manage their diabetes, and we run it one day a week for four weeks. We had eight attendees, and all of them seemed to get a lot out of it. I found it a little stressful to have so much responsibility for delivering material that is so critical to the course.

At least half of the course is about carbohydrate counting. This is a skill that is fundamental to good control of Type 1 Diabetes for those who want to have the flexibility of eating what they like when they want to. Teaching carb counting is a core skill for a Diabetes Specialist Dietitian, and I would say I have reached an intermediate skill level - not too bad, but I've only been doing it in earnest for a few years. Nearly all of the people on the course have had diabetes for much longer than that.

Despite my nervousness, it went quite well, although I think I can improve with practice. We cover all sorts of ways of estimating the carbohydrate content of food - using food labels, weighing food and using reference tables, using apps, websites and pictures, and plain and simple educated guesswork. The part that makes me a little bit uncomfortable is that while my estimates are based on my experience with a number of different people as a day job, I don't actually act on the data and inject insulin, so I don't get any personal feedback about the accuracy of my estimates. When I get it wrong, it's someone else that suffers. I take this responsibility very seriously, so I often lose sleep worrying about whether someone I've seen in the day is going to end up with very high or very low blood glucose as a result of something I've said.

As well as the course and the individual consultations, there has been some discussion in the Trust and the Clinical Commissioning Group about funding to expand the very low carb programme that we offer. This has caused some controversy, because we haven't any solid evidence for its value in our service. We have lots of anecdotal evidence of patients who have found it life-changing (in a positive way), and we have a spreadsheet with lots of data, but the data hasn't been analysed and there's been no data collection from those who haven't found it helpful, nor have we sought views from anyone who may have experienced negative effects.

There are a number of healthcare professionals in our Diabetes service who are positively messianic about the plan, and they are all in favour of the expansion in funding because they have seen so many people find it beneficial. Having joined the service so recently I am more sceptical, and feel that we must carry out some analysis of our data to provide evidence of benefit and investigate any negative aspects properly. Our Team Leader has very sensibly defused the situation with an eminently rational proposal, including the view that we should be offering people choices rather than putting all our energies into selling the low carb idea.

Whenever I have met up with other Diabetes Dietitians, I have asked them their views on very low carb diets. So far I haven't met any that are offering anything like our plan, but they have all been very interested in hearing about what we do. I would like our next stage to be a proper audit of what we have, if not a research project culminating in a peer-reviewed publication, but I'm not volunteering for the job.

Nutrition Team

Brixham, August 2012

One of the roles of the senior Dietitian is to take part in the Nutrition Team ward rounds. The Nutrition Team is a multi-disciplinary group that takes referrals for more complex nutritional issues, such as parenteral nutrition (PN) - feeding a person intravenously. They are also called in when there are difficult judgements to be made about other types of feeding - an example might be when someone with a number of serious conditions is no longer able to manage normal or textured food. It might be neurological, such as Motor Neurone Disease, or due to a stroke or dementia, or an obstruction or non-functioning bowel, or some other restriction to intake. It might be a patient who is simply not eating, because of nausea, vomiting, diarrhoea or other effects of a disease, or possibly because of a psychological disturbance - we find these cases very difficult to deal with, because the patient can eat, but doesn't. Is it appropriate to intervene? If so, how invasive should we be? If not, how do we justify our inaction?

The core members of the Nutrition Team are a Gastroenterology Consultant, a Nutrition Nurse, a Dietitian and a Pharmacist. The round that I joined also had a number of others in attendance: a Specialist Registrar, a Senior House Officer, two medical students, and me. It was a pity that I'd chosen that particular day to join the round, because the group was really too big and unwieldy, and the Consultant had to attend a meeting so was missing for most of the round, which led to a bit of a leadership vacuum.

All of the cases on this round were for PN. A couple of the patients were in Intensive Care, and I'd never been there before in this hospital. It seemed less spacious than the equivalent wards I'd seen on placements (although this might have been because of the size of the group), but otherwise equally well equipped with a myriad of machines that go 'ping' keeping people alive in various states of incapacity. The rest of the patients we saw were on other wards where PN can be supported, which are more familiar environments, but still difficult to manage with a group of nine people.

In terms of what was dealt with, these were far more complex cases than I've been expected to deal with so far as a lowly graduate with little experience. The patients had mostly had gastrointestinal (GI) surgery or an inflammatory bowel disorder like Crohn's Disease or other complication of the GI tract. One or two were in hospital because their intravenous lines had become infected, which raises the risk of serious illness given that pathogens might be introduced directly into the bloodstream. The parenteral feed has to be treated much more carefully than standard intravenous fluids (which is why not every ward can support PN) and nursing staff must be properly trained to administer it aseptically. The Pharmacist was part of the group because of the need to tailor the composition of the feed in terms of nutrients and electrolytes, which is their job. We can either buy standard bags of parenteral feed, or have them made up specially in the Pharmacy department.

So I mostly hung around at the back of the group, watching and listening and trying to understand the reasoning behind some of the discussion about rates and timing and composition of feed and bowels and surgical procedures and how blood test results related to everything, drawing on my knowledge of the forms and functions of the different parts of the GI tract. The senior Dietitian and the Nutrition Nurse tried to help me out by explaining some of what was going on, but that just added to the noise and chaos of the huge group milling about the nursing station on the ward.

The main thing I learned was: given that the small intestine is mostly used for nutrient absorption and the colon for water absorption, there is a difference in nutritional impact if different sections of the gut are removed or non-functioning. If an opening (ileostomy) is made at the far end of the small bowel, nutrient absorption may be unaffected but the patient may lose a lot of fluid and electrolytes. Higher up, and PN may be needed because there isn't enough absorptive capacity to meet the nutritional requirement. Nutritional supplements may actually make things worse by drawing water into the bowel to counteract their high concentration (osmolarity).

I found the experience a little too chaotic for comfort, but I should be able to observe again another time when the group is smaller.

Doubts

Sissinghurst, June 2012

Last week was a difficult week at work, for a number of reasons. Firstly, both of my peers were on holiday, leaving me and the two seniors covering their wards as well as our own. Luckily, things were quiet, otherwise I'd have had a worse week than I did. I had to give up my outpatient clinic, though, and I missed it.

As well as the greater workload, I had some challenging patients. Not that they were challenging people, but their situations were complex, difficult and depressing. And a patient that I'd spent a lot of time with, and really tried to help in many different ways, died. I'm not usually affected by this, but on this occasion I spent a minute in silent contemplation when I found out.

I'm also annoyed at having so little time for thinking, and when I did stop to think this week, I was assailed with doubts. Was that the right treatment? Should I have considered other alternatives? Did I really do my best for that individual, or am I just going through the motions? Am I doing a good job?

I have to admit that this job has not improved with time, and my original thought when I started the whole process of retraining for this new career still holds true: the hospital setting is not where I want to end up. I look forward to my outpatient clinic with eager anticipation that I don't feel for another day on the wards. I am frustrated by my role in nutrition support, which doesn't seem to utilise much of the enormous body of knowledge that I acquired during the degree, and gives me little opportunity to promote behaviour change, which it turns out is what I am really interested in. Working on the wards does not inspire me.

I was discussing this preference with a colleague, who described a similar level of frustration with outpatient work. She finds it frustrating that outpatients come to the Dietitian for advice, but then often don't follow that advice and either don't return, or come back without improvement. She is much happier to work in the ward environment, where we might have a little more influence over whether our advice is put into practice or not.

I feel the opposite: an outpatient has the choice whether or not to follow my advice, and my job is to help them find the right path, tailoring and tweaking my advice to take account of their lifestyle and supporting them in reaching goals that I may have helped them to choose. I find the ward environment frustrating because there are so many institutional variables that prevent patients from achieving nutritional objectives, which are mostly imposed upon them. I acknowledge that I have no control over how a free-living individual chooses to eat and drink, but we ought to be able to do better on the wards, and often we don't.

I have applied for another job in a different NHS Trust, and have told the Dietetic Manager (because I had to list her name as a referee). The good news is that I have been offered an interview; the bad news is that it is scheduled in the middle of our planned holiday in the South West. We are adjusting our plans so it shouldn't disrupt the holiday too much.

I think that it is appreciated that when one has a temporary post covering maternity leave (or in my case, two days permanent and three days temporary per week), one has to take up opportunities when they present themselves. But I don't think that the Dietetic Manager is aware of the main reason for me applying for the job: it is in Primary Care rather than the hospital setting. Finding myself in the position of anticipating an interview, only seven months after the end of the last round of interviews, makes me rather apprehensive and a little sad. Interviews really are painful, and not just because of the Lady-shoes. And this time I have to do a presentation.

It is also for a job that is a higher grade than the one I have at present, and this seems very precocious given than I have only completed six months in a Dietetics role. The same Trust is recruiting for posts at my current level as well, but because the students in the year below mine have now graduated and are looking for their first jobs, the vacancies at that grade closed almost immediately, well before I could put together my application. If I am given the role I have applied for, it is possible that I will be senior to Dietitians who have more dietetic experience than I do. That is a sobering thought.

Looking on the bright side, there are many positives to offset the negatives in my current job. My colleagues really are the nicest people I have ever worked with, without exception - if I get the new job, I shall be truly sorry to leave them behind. And aside from work, when we happened to mention to Smurf that it was my birthday on Monday, he offered us a free meal in the pub, which we had on Tuesday. I've played badminton twice this week, watched two films, we had dinner in Wofon, and while writing this I'm sitting on the sofa with Mr A opposite, in my pyjamas, with a nice cup of tea and some birthday chocolate. Things could be a lot worse.

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.

Feeds, food tasting and hand-washing

On the M40, May 2012. No, I have no idea.

Back at work to a three day week after a ten day holiday was challenging last week, and demanded all the prioritisation skills I have. My colleagues dealt with the urgent referrals on my wards while I was away, but there were plenty of non-urgent cases, and other colleagues were away when I was back at work, and I had to reciprocate and cover their urgent referrals. Added to that, I had a food tasting session, a department meeting and compulsory training on hand-washing to squeeze into those three days.

So I prioritised the tube-fed people - those who can manage to eat just had to get along somehow until I could get round to them. And, of course, they were all slightly 'interesting' cases that needed extra time and attention, rather than the quick, straightforward, 'just calculate the total requirement and divide by the number of hours the feed is delivered' cases.

There was one whose feed rate had been reduced to a bare minimum because of unpleasant side effects, so I had to try and consider how to tweak the feed schedule to meet the patient's nutritional requirements. Another was a patient who was frail and elderly, and one of the reasons for admission was because he'd stopped eating - in this case, the purpose of artificial nutrition has to be clarified, because the patient was not suitable for a permanent PEG tube but wouldn't be able to go back to the nursing home with an NG tube. This is one of the worst possible situations - do we allow the patient to remain on the ward indefinitely just so that he can be fed? If not, what is the alternative? Ultimately it's the doctor's decision, but my job to raise the issue to try to ensure that a decision is made.

Another patient had received a trauma injury and had come from Intensive Care where they had placed an oro-gastric tube, which is an alternative when the naso-gastric route is not appropriate - but the tube had come out and nobody on the ward quite knew whether another oro-gastric tube was needed (which would have to be put in place by a doctor) or whether an NG tube would do (which could be placed by a suitably-qualified nurse). Then just as I thought it was all over, there seemed to be another new NG feed schedule needed, except when I got to the ward there was no NG tube in place and some confusion about whether one was needed or not. I didn't hang around to find out - if they'd decided to go ahead there were options they could implement for the weekend and I could re-visit the patient on Monday.

The food-tasting happens about four times a year, and had been scheduled by the hospital Catering department before the Bank Holiday had been moved. This is probably why it had ended up in a three-day week, and that was why only three of us turned up: me, the manager of the Dietetic service, and a member of the lay panel that represents the interests of patients. We were outnumbered by the catering staff hosting the tasting session.

There being no such thing as a free lunch, our job was to rate all the available foodstuffs by appearance, smell, texture, taste, temperature, and anything else we could think of. All the day's standard main course menu items were there, plus a few extras: a 'fork-mashable' option, two from the 'ethnic' menu, one of the 'Lite bites' that are available outside regular mealtimes, plus a couple of puddings. Served at the perfect temperature in this calm, controlled setting, all the meals were pretty good, with a couple of really outstanding options and a couple that were just OK. Served in the normal overworked ward environment, where they may have been heated up for too long or not long enough, and may take a little while to actually reach the patient, I imagine some options may in reality be less attractive.

The compulsory hand-washing training was fairly straightforward, except that I refused to have the UV-fluorescent liquid applied thanks to its paraben content. So the infection control nurse just watched me washing my hands. And he was delighted when it turned out that we had their missing UV light box, which had been loaned to our department and then forgotten about to the extent that they'd given it up as lost.

With my holiday just a dim and distant memory, so the week ended. Some time has passed without me managing to get this blog updated, and much has happened - Sister D celebrated her silver wedding anniversary, Mr A is spending three weeks on 'work experience' in Manchester, and all my wards were swapped for different ones. More to come as soon as I can manage it.

Texture and consistency - in practice

A ski bar, Austria, February 2011

I left you in a quandary: we need to supplement the diet of patients on texture-modified diets, but we don't have texture-modified supplements...

So what do we do? Up to now, working on the stroke ward as a newly qualified Dietitian with zero prior experience, I have done what others have shown me and what I can cobble together from resources lying around. For Texture C and Stage 2 fluids we have a 'pudding' consistency supplement and thick yogurts, as well as the puree menu itself and a powder thickener for drinks. For Stage 1 fluids I have been offering a standard concentrated supplement, which may or may not be acceptable but one of the senior Dietitians uses it in the community so that's good enough for me. We also have milkshakes and soups made up from powder that can simply have less liquid added to make them thicker.

The new Dietitian who joined us last week has some previous experience, and has been asking some very interesting questions, mostly along the lines of "...and why do you do it this way?" My somewhat lame answer has been along the lines of "...because that's how I was shown, and I'm only three and a half months old, and I've had your ward and four other wards to cover so limited time to spend thinking about other ways to do it."

So far she has questioned the way that we start new enteral feeds, the way that blood tests are ordered, and now, the range of supplements that we can offer to patients on texture-modified diets. We did a small experiment, mixing two together to try and achieve an intermediate texture, which I promptly poured down my front in a particularly inept tasting session. But that is beside the point - it looks as though some fresh eyes are going to come up with useful tools for the rest of us to adopt. I've already changed the way I start enteral feeds and order blood tests following her suggestions, so I look forward to a Stage 1 thickened fluid supplement option very soon.

Our newest Dietitian is also going to liaise with the SLT team about other aspects of our collaborative working. Exactly how thick should Stage 1 and Stage 2 fluids be? How much fluid should be added to a soup or shake to make it the right consistency? And I'd like her to talk to the SLTs about the 'Texture E' Fork Mashable menu, which is relatively new, and is currently in a different format compared with the other 'special' menu options. The Texture E food is apparently also more expensive to produce, and there are more appetising choices, which means that the kitchen has restricted this menu to patients who have specifically been put on it by a Speech and Language Therapist.

Introducing a new menu within a hospital is no mean feat, mainly because the hospital is a 24/7 full-time operation, but the staff within it obviously don't work 24 hours a day. So you have to roll out any changes multiple times in order to catch those on different shifts or who are on holiday. Done incompletely, there is nothing but confusion, as some ward staff are aware of the change while some are not. And as time goes by, even those who used to know what was going on become unsure of themselves or forget completely what they were shown.

The Texture E menu is an example of this situation. The SLTs who assess patients' swallow have a special sign that they put up over a patient's bed if texture modification is required, and the sign clearly indicates 'Texture E Fork Mashable' among the options. In the medical notes and when talking to nurses, however, they are less consistent, recording for the same patient that 'soft' or 'soft, moist' food is indicated. The nursing staff and Health Care Assistants, who are used to people needing soft options, often offer the same soft meals for these patients as they would for those without good teeth, from the normal menu.

This is the situation I encountered as a new Dietitian on the ward, and to start with, I didn't realise what was going on - I read the notes more often than I look on the wall above the patients, and didn't notice that these 'soft' recommendations actually meant Texture E. Since it became clear (which happened with the help of the more experienced Dietetic Assistant who worked out what was going on) we have been trying to work out how best to make the ward staff aware of the situation and get them to use the correct menu, without having the resources that were available when the new menu was introduced hospital-wide. Our tactic has mostly consisted of keeping an eye out for people being put on the Texture E menu, and providing multiple copies of the menu to the nurses at that point, while making sure that as many people as possible are told about the Texture E menu option, including the patient. Ideally, I'd like to see the SLTs use the same terminology throughout - in the notes, on their notice and when talking to the nursing staff, but it's not up to me.

The last hurdle is on discharge, if someone is still on puree or Texture E food when they go home, especially if they aren't going to a nursing or residential home. The SLTs have a team providing follow-up in the community, but we don't have any Community Dietitians for this sort of follow-up. We rely on providing written information. a telephone follow-up and/or inviting the patient back for an outpatient appointment. If they aren't able to manage any of these, which is going to be those patients in the most difficult circumstances, then all we can do is let the GP know, and hope for the best.

Texture and consistency - the theory

Norfolk, July 2011

The hospital job that I do involves quite a lot of consideration of texture modification, of both food and drink. This is due to many reasons - poor dentition and dysfunctional swallow being the main ones. Hospital food is obviously not a gourmet delight, and you would be crazy to expect a rare steak (we can't even offer runny egg yolk), but without proper teeth it can be tricky to get through even the softest cut of meat. So there are a lot of soft and wet options on the menu, using minced meat, fish in sauce and stews as well as baked potatoes and sandwiches.

Sometimes the process of swallowing is damaged, either by a stroke or a neurological condition like Parkinsons Disease, Motor Neurone Disease or Multiple Sclerosis, or surgically due to something like head and neck cancer. We learned quite early on in my course that 'Swallowing is the most complex reflex in the body, employs about 25 separate muscles, and once initiated it cannot be stopped.' If any part of the reflex is damaged, whether by a brain injury or surgery to tissue and muscles in the mouth or neck, there is a risk that the swallow will fail, and food will either remain in the mouth, or pass into the lungs (called 'aspiration').

Speech and Language Therapists (SLTs) not only deal with communication in these patients, but are also in charge of the pathway from the mouth to the stomach, which is not reflected in their professional title. Maybe one day they will become Speech, Language and Swallow Therapists. Anyway, they are the ones who investigate and assess the risk of aspiration, using sips of fluid and bites of food, cameras put down the throat (FEES = Fibre-optic Endoscopic Examination of Swallow) and videofluoroscopy using barium drinks, where the internal process of swallowing and route of a liquid can be watched 'live' from various angles.

The treatment they have at their disposal includes both exercise (if the problem is muscular or neurological) and texture modification of food and fluids. Fluid is easier to control in the mouth and to swallow when it is thickened, and presents a lower risk of aspiration. Similarly, removing the lumps from food and reducing it to a puree consistency can reduce the risk of choking. It is not an exact science, and sometimes things 'go down the wrong way.' For many patients, this would provoke a fit of coughing, alerting onlookers that something is wrong. Some do not cough, however, and this 'silent aspiration' manifests itself as a wet voice, 'chestiness', or a drastic drop in blood oxygen saturation as the lungs fill with food or fluid.

Not that long ago, an attempt was made to standardise the classifications of texture modified food and fluids, and the latest reference document is freely available. It contains only the descriptors for food - those for fluids are still under review, although previous standards are still available. The two sets meet in the middle - food is progressively softened and pureed into something approaching a liquid, while drinks are progressively thickened to something approaching a solid.

In the hospital where I work, alongside the normal menu are two 'texture modified' menus, offering Texture C (thick puree) and Texture E (fork mashable) food. Fluids can be thickened to Stage 1 (thin custard) and Stage 2 (thick custard). Each patient is assessed by an SLT, and the most suitable texture is recommended. When any such texture modification of food or fluid is advised, a referral to a Dietitian should ensue (but it doesn't always happen).

The main reason for the Dietitian getting involved is because it is almost impossible for a patient to meet his or her full nutritional requirements on a texture-modified diet or fluids. The thought of thickened fluids - imagine a custard-thick cup of tea or coffee - is enough to put most people off drinking anything, although fruit juice and squash seem much more acceptable in a thickened form. If food is pureed to the right consistency it often has to have water or other liquid added, which dilutes the nutrient content, and many patients who have a compromised swallow will have a small appetite to start with. They simply can't eat enough to provide the protein and energy they need, and again, pureed food on a plate is not the most appetising sight (although I would contend that the taste isn't too bad if you can get past the look of it).

So we ride to the rescue, the Dietitian on the steed of food fortification and nutritional supplements. But hang on - most of the supplements we use are in liquid form, and by virtue of the complex composition which makes them nutritionally complete (i.e. containing all the essential protein, carbs, fat, vitamins and minerals), they are impossible to thicken successfully. There are pre-thickened supplements on the market, but they are not available in the hospital on our contract with the supplier, due to their high price. And the kitchen in this hospital doesn't provide a fortified menu, let alone a fortified puree menu...

To be continued

Nutrition support

All Saint's Church, Leamington Spa, Feb 2012

The vast majority of the patients I have been seeing on the wards are one of two types: a) not eating well and requiring either food- or supplement-based prescribing, or b) needing to be fed through a naso-gastric (NG) tube to the stomach via the nose and throat, or percutaneous endoscopic gastrostomy (PEG) tube to the stomach directly through the stomach wall.

A regimen for tube feeding requires a calculation of the patient's likely nutritional requirements for energy, protein and fluid based on their age, sex, likely level of activity, a stress factor according to their clinical condition, and their weight (or more usually an estimated weight because they haven't been weighed as they're supposed to be). Other considerations may be taken into account, such as a prolonged high sodium level in the blood biochemical results, or impaired kidney function. All of this leads to the dietitian making a choice of a type of feed, the amount that the patient should receive, and the rate at which it should be delivered via a pump, which will start at a low level and then increase over a number of days. I document all this in the notes, and all the nurses have to do is follow the instructions.

Compared with drawing up a feed regimen, oral nutritional supplementation is much more complicated. Where the feed, fluid and pump settings are very much under the control of the nursing staff, when it comes to trying to increase a patient's intake in hospital by getting them to eat and drink, there are a whole lot more variables to deal with. The catering department, the food service staff, support workers and nurses all have to come together at mealtimes to provide appetising food and to help frail and sometimes confused and/or recalcitrant patients to eat it. In theory, snacks and drinks are available between meals, including such wonders as cheese and crackers (8g protein and 130 kcal), but the patients are more likely to get a couple of ordinary biscuits (negligible protein and about 70 kcal).

Worse still is if the patient has an impaired swallow, and cannot be given normal food and fluids because of the risk that it will enter the lungs instead of the stomach. Food with modified texture is usually preferable to tube feeding, but trying to maintain sufficient intake from pureed food and fluids thickened to the consistency of custard or syrup is difficult. The very thought of thickened water or tea is enough to put most of us off drinking as much as we should. If this situation persists and the patient is otherwise medically fit for discharge, it may be necessary to draw up a fluid-only plan for their full nutritional requirement of anything up to and sometimes beyond 2000 kcal. This will rely to a great extent on nutritionally complete supplements in order to ensure that vitamin and mineral requirements are covered, because ordinary everyday fluids rarely contain iron, for example.

Even more difficult are those patients who are eating almost nothing but are deemed unsuitable for artificial feeding through a tube. This may be because of a medical condition that makes the endoscopic placing of an NG or PEG tube inappropriate (e.g. oesophageal varices or abdominal ascites), or a condition where artificial feeding has not been found to improve quality of life or clinical outcomes (e.g. dementia). Or because the patient just doesn't want to eat, which is, after all, their right. A referral is often made to a dietitian, because not to do so might be considered neglectful, but a dietitian can't wave a magic wand and make patients eat if they don't want to.

Towards the end of life it is often the case that a patient will stop eating and drinking, and the evidence suggests that clinical dehydration is actually likely to make the process of dying less traumatic. But the ethical dilemmas that arise are no less intractable because of the evidence - what if a patient with dementia starts to have an impaired swallow? Is tube feeding indicated, contributing little to quality of life and likely to cause distress and confusion and be pulled out, or do we offer food and drink orally that may be aspirated and cause chest infections, or will we allow them to starve? Unfortunately there are no easy answers.

Working life

Hospital corridor, 2012

The week ended well, even though I made the slight error of seeing my last patient in a ward that didn't have a clock, so I was late home on Friday. Then straight out for another badminton match, which we won. This full time work lark really leaves no time for much else, especially because this weekend we went south for visits to family and friends (I shall blog about that trip in due course). There is just NOT ENOUGH TIME.

As promised, however, here's some dietetic news, although it's still all about admin because I'm not risking writing about patients except in the most general terms. Believe me, I'm spending a lot of time seeing patients on wards as well as all this other stuff. I'll probably describe the job in more detail at some point.

Despite claiming to have finished all the necessary shopping for clothes, I had to do a bit more. This was because of the 'bare below elbows' rule on the wards, which is supposed to facilitate hand-washing and reduce risk of hospital-acquired infection. So now I've got a few more short-sleeved tops, and a serious problem with static when walking about the corridors. I now have the list of ingredients of the alcohol rub, but no answer from the Infection Prevention and Control department telling me what I should do about the fact that it contains one of the allergens that I react to.

My workplace is a brand new hospital built with the aid of PFI (Private Finance Initiative) money, whereby the capital funding to build the hospital came from the private sector. This means that there are some very hard-nosed commercial aspects to the infrastructure, like parking. Both patients and staff have to pay to park, and there is a waiting list for staff permits that is ranked by need and priority - on-call and night-shift staff along with people with disabilities are much more likely to get permits than perfectly fit Allied Health Professionals who work from 8.30 to 4.30 Monday to Friday. I haven't even bothered to apply for a permit, and I drive for about 25 minutes to a nearby housing estate, park there, and walk for about 15 minutes to the hospital.

This new hospital was built on the same site as the old one, which had a poor reputation in the city. With the new build it acquired a very clunky and long-winded new name, presumably in the hope that it would have the 'Sellafield effect' (when the nuclear reprocessing plant at Windscale acquired a new name in the hope that it would no longer be associated with safety concerns). I have no idea whether this worked, since I hardly know anyone who has needed treatment there except for our neighbours over the road who are going to have their baby there. I visited the old hospital only once, to play a badminton match in a gym with a ridiculously low ceiling.

Since my working day starts at 8.30 a.m., it should be possible to leave home around 7.45 a.m. Unfortunately, that pitches me into the heaviest traffic, so I leave half an hour earlier and spend the time in the hospital library catching up with my online life - emails and blogs and Facebook. I'd rather do that than get up a bit later but spend an extra 20 minutes in traffic. My actual job comprises 80% ward work, one half-day outpatient clinic and a bit of time for admin and professional development. I have been allocated to four wards: stroke, elderly medicine, and two others. Pretty much everything I do is about 'nutrition support' - helping people who can't eat or don't want to eat - through the use of modified menus, snacks, nutritional supplements and tube feeding.

That's all I've got time for at the moment - back to work tomorrow, badminton, work, and then maybe time for a bit more blogging. I'm hoping to put together a picture story similar to the 'Camping holiday - in pictures' post, but covering (among other things) the replacement of the car windscreen on our trip south. Watch this space...