observational placement

last week i did a 2-day observational placement at the Royal Adelaide Hospital (RAH). here's the reflection piece i wrote up for the placement:

Over the 2-day observational placement at RAH, I had to opportunity to observe the dietitian attend to new and review cases in inpatient and outpatient settings.

For inpatient cases, I observed the management of a variety of cases under the cardiology, orthopaedics, and general medicine wards. Most of the cases were seen due to a risk of malnutrition due to low energy intake from low appetite or high energy needs from sepsis, wound healing, or surgery. I also observed the management of tube feedings and a patient at risk of refeeding syndrome.

An inpatient referral goes to the dietitian when the patient is scored as High Risk under the Malnutrition Universal Screening Tool (MUST), which is completed by the nurses for all inpatients. Before seeing the patient, the dietitian would look through the patient's casenotes, the nursing observation charts and the biochemistry data. This process was similar for both new and review cases, but the information gathering process was quicker with review cases as the dietitian only needed to go through the casenote entries from the previous date the patient was seen. I was impressed with how quickly the dietitian was able to scan through the patient's case notes, nursing observation charts, medication list, and biochemical data to find the relevant information before interviewing the patient!

During the patient interview, I was surprised how the dietitian collected very brief information for the diet history. Generally, the patient was asked about appetite level and the amount of food consumed at each meal. If protein level was a concern, the dietitian would focus more on the protein foods and ask how much of the protein foods were consumed. However, the dietitian did not probe for much detail and just estimated the portion sizes consumed. The dietitian mentioned that for inpatient cases, a very detailed diet history is usually only conducted with renal patients as their potassium levels need to be tracked with accuracy. Otherwise for all other cases usually the diet history is kept brief and if detailed information is required, the food chart would be used for that purpose. For the nutrition plan, the dietitian would negotiate with the patient. As most patients seen by the dietitian were at risk for malnutrition, the plan was usually to increase the energy and protein intake of the patient. This was done by incorporating high protein snacks during morning and afternoon tea and also the use of nourishing fluids such as Resource and Ensure. The calculations and documentation also focused mainly on overall energy and protein intake.

The documentation part took the longest as the dietitian had to document in the patient case notes and also in a set of progress notes that was to be kept in the dietetics department. I also observed the dietitan filling out an enteral feeding discharge summary for a patient who was transferring to another hospital.

I observed how there has to be a lot of flexibility in seeing inpatient cases as certain times a patient may be out of the ward for procedures, the medical team may be having ward rounds, or the nursing staff may be having their handover with the nursing observation charts. During such situations where it is not possible to refer to necessary information or interview the patient, the dietitian simply changed her plan and went on to another ward to see another patient.

As for the outpatient setting, cases were observed for half a day during the obesity clinic. Patients who have to attend the obesity clinic are on the waitlist for bariatric surgery and had been referred by their surgeon to lose weight before they could undergo surgery. For the typical outpatient case, the dietitian collected diet history briefly to determine usual eating patterns and did not collect detailed information such as method of preparation or exact portion size. The dietitian then did some nutrition education and handed out some resources on portion control or how to reduce emotional eating. Changes to the diet were negotiated with the patient to reach an agreement and there were usually only one or two changes suggested for the session.

For a new outpatient case, I noted how the dietitian spent significant time trying to build rapport with the patient and when the patient was not very forthcoming with dietary patterns, the dietitian did not probe further and only suggested little changes in the diet during the first session.

Another outpatient case was a review case, but the management of the case ended up being unrelated to nutrition as the patient turned emotional and voiced suicidal thoughts during the session hence the dietitian had to attend to patient's emotions and do the necessary referral to a psychologist. I thought the dietitian managed the situation well by encouraging the patient and showing the patient how much progress had been made up to that point in time, while assuring the patient that the current priority was to take care of his emotions and not to think about losing weight until he is ready.

Observing outpatient cases was truly an eye opener for me as all the patients seen that day were very different and the content discussed differed with each patient. The sessions were more on counseling rather than nutrition education. Much flexibility is required and it can be rather unpredictable, as there can be variations in how each session is conducted and appointments may change due to patients not showing up for, or walk-in patients may need to be slotted in.

These 2 days of observational placement at RAH provided me with great insight to clinical dietetics. I feel that I still need to learn so much in this aspect, to increase my competency with doing nutritional assessments and in counseling, and to build up my knowledge with regards to the various medical conditions.