Festive seasoning

Thank you, Judging Covers!

The run-up to Christmas has been in turn stressful, enjoyable, frustrating and, at last, relaxing.

At work, there's been a lot to do, and fewer people than usual to do it. Last week was busy, and I was working with a student, which made it quite difficult to keep track of what had and hadn't been done, and what needed doing next. I was out on Tuesday at a study day (more about this in a future post), then on Thursday my clinic was relatively quiet, allowing me to enjoy a social Christmas lunch in the canteen. It was proposed as a leaving party for me and a colleague who is going on maternity leave, but my departure had become a little uncertain. I do now have a confirmed start date in the new job, towards the end of January, but both my current and future managers were fighting over me for a day or two! It was a little disconcerting, and not at all welcome.

I was at work yesterday (Monday), and was interested to find that nothing special was happening on the wards, although I spotted a tired-looking man in a Santa outfit reading some medical notes, who might have been one of the junior doctors. Otherwise, there were a few nurses wearing antlers or halos, but patients' stories today were so sad that it was difficult to spread any festive cheer, because who would choose to be in hospital over Christmas unless they were so unwell that they were forced to?

I'm told that some years there's very little to do in the hospital on Christmas Eve. That wasn't the case this year - there were more referrals than usual. We blitzed it in the morning, only to find that more had come in by lunchtime. Some were, frankly, taking the mickey, like the patient who just wanted a cooked breakfast, and another referred because they had been transferred from another hospital on supplements and the nurse didn't want them to become 'lost in the system'. An admirable sentiment, but not today. Diabetics struggling with blood sugar control and patients who had lost a bit too much weight had to give way to patients not able to swallow who needed tube feeding or textured diet and thickened fluids.

I am having nearly two weeks off work, so I also need to ensure all the information about my current patients and their priorities is made available to the Dietitians who'll be looking after my caseload while I'm away. I feel lucky that I was only 30 minutes late leaving the hospital after work.

At home, the build-up to Christmas has been steady, with some notable highlights. We thought we would like to spend our TV watching points on a tablet PC, so we went to review the options at the only high street electronics retailer that allows our points to be converted to vouchers. The experience was underwhelming, but never mind, we ordered the vouchers and returned to the shop at the weekend - the last weekend before Christmas. We were prepared for crowds, but there were none - neither were there any shop assistants. When we finally found one, and indicated what we'd like to buy, we were told: "There aren't any. We're sold out."

On the weekend before Christmas? The busiest shopping weekend there's likely to be in the year? Not only were they sold out, they refused to accept our money against an advance order, because this is impossible if there are no products in the warehouse, or some other nonsense. So we took our vouchers home, and thought about it.

A similar high street electronics retailer has recently gone bust. If this large retailer is unable to take our money at this critical time of year, we were very reluctant to hang on to the vouchers, which would turn to dust should the retailer join its close competitor in liquidation. So we considered our options.

Mr A's mother is now in a nursing home, and his dad asked our advice on a basic DVD player that she could have. Our DVD player is a suitable one, so we thought we would give her that one and upgrade our own system - but we had more money in vouchers than the cost of a new and better DVD player.

I've never had a printer of my own, and although I've been able to connect to Mr A's printer some of the time, his setup changes so frequently that mostly I have to go up and ask him to print stuff for me (or print personal things at work). So as well as the DVD player, I now have a lovely all-in-one printer and scanner - and there was some money left for a new toner cartridge for Mr A's printer too.

Unfortunately, now that we've had time to look at installing the new DVD player, our TV is such an ancient model that the all-powerful new DVD player doesn't have the ancient connectors that are needed to connect it up. Mr A has spent some time looking at various options, including buying a new TV, but we're most likely to buy just a SCART-HDMI converter and wait until the ancient TV breaks down before replacing it.

Lastly, I know it's a little vulgar to boast about one's Christmas presents, but... I WON ANOTHER BLOG PRIZE! On one of the book review blogs I read, a prize of 12 books for Christmas was on offer. I thought twice about entering, because despite reading every post on the blog, very few books that they review are ones that I think I might read. But I entered anyway, and not long ago a very large box arrived containing my prize. I put it under the Christmas camera-tree to await the big day, and this morning Mr A and I opened it, only to find that the wonderful people at Judging Covers had wrapped each book individually!

I'm looking forward to a completely different type of reading for a few weeks - much less weighty than my usual selections. And in the New Year I'll be driving far more miles every week, so I might at last start to get through more audio books in the car. Happy holidays to everyone, and lots of good reading for 2013!

Work, food, birds

Cotswold Falconry Centre, July 2012

I always want to start posts nowadays with excuses - no, reasons - explaining why there's been such a long gap, I've been busy, blah blah blah. I should just accept that I haven't got the same amount of time nowadays, and an awful lot less that I'm allowed to write. If only I could tell you about some of the patients. There's a lot to tell, but what makes them interesting is also what makes it impossible for me to write about them. Even the woman who came to my clinic thinking that it was another clinic would recognise herself if I gave any more details, and that's my test nowadays for whether I can or can't relate the story. So, I can't. Even if it was a man.

Generalities are fine. So I can say that two weeks ago was extraordinary - I had almost no referrals all week, to the extent that I could spend half a day in the library reading about diabetes, and catching up with paperwork, and throwing a lot of accumulated stuff out. Then last week, the tables were turned. One of my colleagues was off sick, and we were just keeping our heads above water even when we discovered at very short notice that she was supposed to be giving a talk on Wednesday, and even though I had a full clinic (11 patients) booked in on Thursday morning (4 DNAs in the end). But on Thursday, the wards decided to go into overdrive, and we received 15 referrals (I think it was 15 - my other colleague had to deal with the inundation during the morning - I was in clinic).

For some reason, Thursday was also the day that I found myself involved in three separate complaints about catering. Afterwards, we decided that in an ideal world I should have just said "This has nothing to do with me; you need to talk directly to catering yourselves." But, as a health professional trained to help people, my instinct is to try and help, even though one complaint was simply that the ward catering staff wouldn't give larger portions to a patient who clearly needed and wanted more to eat. It was very frustrating for all involved.

In the end, you can only do as much as a person can do, and our colleague returned on Friday, and we just about got through everything as best we could. But the team of six is down one anyway since our team leader left, and the most senior of the remaining five of us is covering not just that post but also providing paediatric cover, as we only have one paediatric dietitian for the whole hospital. And one of the remaining five isn't supposed to do anything except stroke, and she had a student with her all week as well. The end of the working week on Friday was a huge relief.

Mr A and I had a treat on Friday night - a return visit to Queans, the restaurant where we first went to celebrate our birthdays earlier in the year. This time we had a voucher which Mr A had earned by doing some work for a neighbour. It was a lot of money, too, enough for dry martinis and three courses for each of us and a bottle of wine. It is a lovely place to spend the evening.

Then on Saturday I volunteered to help out with end-of-season cleaning and clearing up at the Falconry Centre. As a Friend of the Centre, as well as not having to pay to get in, I am invited to a summer barbeque and two cleaning events, one at the end of the season in November when the Centre closes, and the other in February just before the Centre opens again. I'm not entirely sure why I volunteered for this, and most Friends do the sensible thing and just come to the barbeque, but there I was on Saturday, spending a few hours sweeping up leaves in the pouring rain, and getting almost as wet while cleaning the insides of the cages where some of the birds are kept overnight and through the winter.

The birds don't fly at all out of season, mostly because there aren't enough visitors to justify opening the Centre. They don't need to fly - given sufficient food, they are happy to just sit there for a month or two, growing new feathers and thinking whatever birds think when they have nothing to do. There were about six of us volunteers in all, a friendly group, and I'm kind of glad I did it, even though I really didn't have to. I might even volunteer for the February opening workout as well.

No fresh news about the new job. I know I'll almost definitely be leaving if all the bureaucracy gets completed to everyone's satisfaction, and it is likely to be at the end of December all being well, but there are no guarantees. Then another similar vacancy was advertised, much nearer to home, permanent, but only 4 days a week. I mentioned it at work, and was surprised when the consensus was that I should apply, despite being halfway through the process of moving to a different job. So that's my Sunday fully occupied, along with my usual treat of a trip to the greengrocer.

Electronic referrals

Sissinghurst, June 2012

We have a new computerised referral system. The old referral system involved the telephone and pieces of paper with words written on them. Nurses on the wards would phone our office, and the admin team would write some scanty and usually misleading details about the referral, on paper forms kept in a file. When each of us had seen a referral intended for us, we would tick the form to show we were dealing with it, and go off and deal with it. This involved the admin team in answering the phone quite a lot, but on the plus side, they would do some basic triage and reject inappropriate referrals or bleep us if they thought we needed to know about a referral straight away.

The new referral system has been added to one of the many hospital systems that exist. The most surprising things about the introduction of this system were a) that we were told on the Friday that it would start on the following Tuesday, and b) we were given no information about how it would work or what we should do to pick up referrals or manage them once we had them. You can imagine that it has been a pretty steep learning curve, both for us and for the nurses on the wards. The main people to benefit have been the admin staff, who no longer have to write anything on the referral forms, but do still have to tell the nurses who continue to call the office that we don't accept telephone referrals any longer.

It has been an interesting experience, working with a new computer system that has not been designed or adapted for our use. I am still ignorant of the purpose of the change - why ditch a paper system that worked perfectly well for a computerised system that seems to work no better? It is possible that some numbers can be extracted more easily from the computer than from reams of paper forms, but which numbers are they, and what do they mean? If numbers were at the bottom of the change, then surely we would be given some instruction on how the system should be used, so that the numbers extracted would mean what they were intended to mean.

As an example, the nurses on a ward complete one section of the online referral form, and we then open the entry and can see what they have written. The referral has three options for status: when it is created it is 'Open', then it can be 'Under Review', where it sits on a viewable list, or 'Closed' when it still exists and can be viewed and edited, but is no longer on the special list, which only shows referrals that are Open or Under Review.

So we can assume that 'Open' means the referral is a new one. The next thing that used to happen was that we would tick the referral form and do a bit of background research before seeing the patient. We might see the patient several times, before they either died, left the hospital, or didn't need our input any more. At which point should we change the status to Under Review, or Closed?

The system has been in use for nearly two weeks, and the consensus about this has shifted several times. The latest informal discussion concluded that ticking the form in the book corresponds to changing the status to Under Review and typing our initials as the first entry. Actually seeing the patient prompts a change to a status of 'Closed', even though we may continue to see the patient many more times. And now, each time we see a patient, we are supposed to write something on the electronic record as well as writing on the record card.

I imagine that someone will gather the numbers about how many of these referrals are made, and perhaps the time between the various changes of status. That 'someone' will have little information about what these numbers or times mean, otherwise they might have specified what they wanted and told us how to operate the system in advance of going live.

The overall effect of this new system, after nearly two weeks of operation, is that the admin staff have considerably less to do now that phone referrals have almost stopped, but there has been an equivalent increase in workload for nurses and doctors who are now making the referrals online, and we Dietitians having to make additional notes where we didn't before. And our head of service is getting some data that she didn't have before.

There is a positive side to this, however. In time, we will be able to see whether a patient has had previous contact with a Dietitian on a ward, which is very useful information that we don't have at present. We might also be able to see details of what was done on that previous occasion without having to track down a physical card that might be archived in a warehouse somewhere. The electronic referrals also have scope for the nurses to provide a good deal more relevant detail about a patient than they used to on the phone.

The negative aspects, apart from those outlined above, also include the fact that access to computers on the wards is very limited - the doctors are usually using them to look up blood results, scans and x-rays and results of investigations. This has made it quite difficult for nurses to actually do the referrals online.

If you have read this far, you either know me personally and imagine that this blog entry will get more interesting by the end, or sufficiently obsessive not to be able to stop reading until you have finished. Or, in the case of Lola II, you will have skipped the majority of the boring bits and reached here to finish off, which is not a criticism of Lola II, but in this case a very sensible way to deal with a fairly tedious text. Well done for getting here! Next time, perhaps there will be something more interesting. Unfortunately, the most interesting bits are about patients, and what makes them interesting is precisely what makes them impossible to write about.

Another week in hospital

Norfolk, October 2011

The wards allocated to me at the moment are tricky, and the patients are time-consuming. I don't know why they should be any more difficult, but somehow they are. The wards also seem less organised, and I trust the nurses less to do the things I need them to do, like ensuring that the supplements and feeds that I prescribe are available to give to the patients when they need them. The patients, as always, are rather poorly. There is, however, a much larger proportion that are able to speak, and a significant number that actually recover enough to come off tube feeds and supplements.

The clinics remain my favourite part of the week, and I can now add Russian and Polish to the list of languages spoken by patients that have needed interpreters in my clinic. None of us has yet earned the certificate and medal for a full clinic with no DNAs. In one clinic (not mine), there were just two patients, although at least they both turned up.

We have had some input from the Dietitians working in the morbid obesity service, describing what they do and the thresholds and criteria for referral and for surgery. The thresholds are pretty high to be eligible for surgery, and the waiting list is long. They expect to carry out between 100 and 150 bariatric operations during the year. We asked whether patients in their clinics are successful in losing weight, and the answer without hesitation was, depressingly, "no." I am not sure whether they meant patients who have surgery or those who don't.

There has also been an employee 'Wellbeing' event, where various stands were set up to publicise various health-related services to staff in the hospital. I volunteered to cover the dietetic stand for the Community Dietitian, for just a couple of hours while she was at a meeting. Among the stands describing counselling, orienteering, catering and much more, our little stand was in a cluster next to two gorgeous squaddies advertising British Military Fitness courses on one side (outdoor fitness training military-style) and Health At Every Size on the other side.

The HAES program originated in the US but has been taken up by a local Dietitian whose research contradicts established wisdom (aka evidence-based opinion) on weight reduction. She suggests that dieting has been proven not to work - the vast majority of those who lose weight gain it again shortly afterwards - and yo-yo dieting often leads to gradual increase in weight over time. So the HAES approach is to address the person, their self-worth, happiness and general health, and let the weight sort itself out once people start to appreciate the barriers to change that they face in their particular and individual circumstances.

I can certainly see some value in this approach, and can imagine pointing some people in their direction - people who are simply unable to lose weight by conventional means (eating differently) and are not likely to be helped by three-monthly appointments of 15 minutes with a well-meaning but ineffectual Dietitian. The other attraction to the HAES stand was their scales, which were covered in pink fluffy fabric and had descriptions rather than numbers for your weight: 'Hot', 'Ravishing', 'Beautiful'.

What else this week? Badminton, watching DVDs from the sofa, Lola II visiting last weekend and The Boy this weekend. I have had a cold developing since Saturday. We went to the Falconry Centre yesterday, the first genuinely warm and sunny day since May, and I am now rather pink, mostly on one side.

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.