Posts Tagged With: hospital

Which Patients See a Dietitian in a Hospital?

Monongalia General Hospital is an 189 bed acute-care community hospital and level 4 West Virginia trauma center.  With only 2 FTE clinical dietitians working each day, it’s impossible (and unnecessary) for a dietitian to visit every patient in the hospital. But who gets to the see a dietitian, and how is that decided? While it may be different at other hospitals, this is the consult system Mon Gen uses:

1- A physician or nurse orders a consult.  This could be because the physician feels the patient needs nutrition education, the patient is high-risk, or any reason they see fit.

2- A system consult is automatically ordered.  On a patient’s chart, there is a section with several boxes of criteria. If one or more of these criteria is met, the charting system automatically orders a consult. The criteria include unintentional weight loss of more than 10 pounds in 3 months, constipation, bed sores, and more.

3- The patient meets nutrition screening criteria. Dietitians can see patients that meet a specific diagnosis and/or treatment with component of nutrition therapy, including but not limited to:

  • Malnutrition, cancer, undergoing chemotherapy, radiotherapy, major surgery, oncology unit patient
  • Newly diagnosed diabetes mellitus, or uncontrolled
  • Unstable chronic renal disease
  • Unstable liver disease
  • GI: Crohn’s disease, ulcerative colitis, short bowel syndrome, GI fistula, small bowel obstruction
  • Failure to thrive
  • CVA (cerebrovascular accident or stroke) with severe dysphagia
  • Significant education needs

When these methods of ordering a consult with a dietitian are used, clinical dietitians are able to use their time wisely to see the patients who need the most help.

You ordered a consult??

Categories: Clinical Nutrition | Tags: , , , , , , , , , , , | 3 Comments

In-Service: Celiac Disease & Gluten Cross-Contamination

I was assigned with designing, implementing, and summarizing a special in-service topic for the hostesses at Mon Gen. I picked the topic of celiac disease and gluten cross-contamination last week, and I conducted the in-service presentation this morning.  I decided to pick the topic of gluten, because once in a while there’ll be a gluten-free tray on the line, and the employees on the tray line will change their gloves like they are supposed to. But I thought that perhaps some of them don’t know much more than “gluten-free means they can’t have gluten.”  I wanted to give the why behind the reasoning.  So I researched the topic, using sources such as http://www.eatright.org and designed a handout as well as an 8-question quiz at the end to test their knowledge.

For a PDF of my handout, click here: Living Gluten-Free: Preventing Cross-Contamination

Celiac Disease & Gluten Cross-Contamination

  • Celiac disease is an autoimmune disease caused by sensitivity to gluten, a protein found in wheat, barley, and rye.
  • 1 out of every 133 Americans has celiac disease, or a little less than 1%. Since it is genetic, if you have an immediate family member that has celiac disease, your chances of having it become 1 in 22.
  • If gluten is consumed by a person with celiac disease, an immune response is triggered and damage is caused to the lining of the small intestine.
  • Symptoms of celiac disease include: gas, diarrhea, stomach pain, fatigue, joint pain, weight loss, and an itchy skin rash.
  • Since most of the nutrients in your food are absorbed in the small intestine, if it is damaged, nutrients cannot be fully absorbed which can lead to nutritional deficiencies and weight loss.

  • There is no cure for celiac disease.  The only treatment for celiac disease is to eat a gluten-free diet. When a gluten-free diet is followed well, the condition can be managed and the person can live a long, healthy life.
  • There are plenty of foods that are naturally gluten-free, such as: fruits, vegetables, beef, poultry, fish, nuts, eggs, and more.  There are also a growing number of gluten-free products available for the public.
  • Grains to include:
    • Amaranth, corn, quinoa, millet, rice, sorghum, teff
  • Plant foods/starches to include:
    • Arrowroot, buckwheat, flax, indian rice grass, lentils, potato, sago, soy, tapioca, wild rice, yucca
  • Grains to avoid:
      • Wheat
      • Barley
      • Rye
      • Other cross-bred varieties of grain including triticale (a cross between wheat and rye)
      • Oats—Those with celiac disease can tolerate small amounts of pure oats in their diet. However, gluten can get into oats during the processing and packaging of oats, so it’s best to look for “gluten-free” on food labels for any foods containing oats
  • If a package says “gluten-free,” it means the manufacturer has ensured there is no gluten in that food product. However, food products that seem like they would be gluten-free, such as a rice mix, may have traces of gluten if the manufacturer makes other products with gluten in the same facility. If a food does not have a “gluten-free” claim on the package, check directly with product manufacturers for more information.

When you see “gluten-free” on the packaging, you can have your cake and eat it too!

  • Some processed foods and ingredients that may contain wheat, rye and barley (check labels!):  beer, bouillon cubes, cold cuts, hot dogs, salami, sausage, French fries, gravy, imitation fish, malt, modified food starch, rice mixes, sauces, chips/snacks, soups, and soy sauce.

“For people with celiac disease, even just a microscopic amount of gluten can cause a reaction and damage to the intestines, such as a single bread crumb on a plate or speck of wheat flour on manufacturing equipment,” – Rachel Begun, MS, RD, Spokesperson for the Academy of Nutrition and Dietetics.”

  • The key is to keep things clean and separated.
    • Crumb-free food preparation surfaces
    • Separate or carefully clean cooking equipment and serving utensils for gluten-free foods.
    • Wash dishes, pots, pans, utensils & surfaces well
    • Identify gluten-free foods with permanent pen or stickers
    • Store gluten-free foods above gluten-containing products in fridge or pantry so gluten particles don’t fall or settle into gluten-free foods
    • Mon Gen policy: Gloves must be changed by all employees when there are gluten-free trays on the line.
  • Watch out:
    • Are eggs cooked on the same griddle as pancakes?
    • Are gluten-free grains being cooked in the same pot of water that pasta was just cooked in?
    • Are fried gluten-free items placed in the same fryer as breaded items?
    • Is the same toaster used to toast wheat bread as gluten-free bread?
    • Is the same cutting board and knife used to slice wheat bread as gluten-free bread?

Hostesses and other kitchen employees play a huge role in making sure that those with celiac disease do not eat food contaminated with gluten.  Employees are handling bread and flour and other food items containing gluten, so when there is a gluten-free tray on the line, it’s important for them to change gloves so that any gluten that may be on their gloves, does not get into a gluten-free tray.  Taking simple precautions like this in food storage and during tray assembly can prevent a patient from damaging their intestine, developing a rash, or experiencing gastrointestinal discomfort.

Categories: Clinical Nutrition, Education in the Community | Tags: , , , , , , , , , , , , , | 2 Comments

Tray Audits

Another part of my job as a dietetic intern with Patient Food Services, is to conduct several tray audits while I am here.  A tray audit means that I order a lunch “test tray” and then watch it being assembled, put onto the cart, follow it up to the room, and then when all the other meal trays on the cart have been delivered to the patients, I take my test tray and test it for temperature, portion size, appearance, quality & preparation, taste & aroma, missing items or subs, and tray completeness and cleanliness.

An example of what a tray audit form looks like

The digital internal thermometer I use

The scores are tallied and if it receives a 96%-100%, it is ranked as excellent, 90%-95% is satisfactory, and below 90% is unsatisfactory.  Of the three tray audits I conducted this week, I received all three ranks– excellent, satisfactory, and unsatisfactory.

The excellent tray took 25 minutes to get from assembly to delivery (goal is 30 minutes or less).  I ordered the ADA1800 diabetic diet, and the hot items — pulled pork sandwich, corn, and coffee were all above the standard temperature.  The cold items — coleslaw and gelatin were also all below their standard temperatures. Nothing was missing from the meal order and everything tasted of quality. It received a 100% excellent rating.

The unsatisfactory tray took 15 minutes to get from assembly to delivery.  I ordered the regular diet this time.  There were several temperature issues.  The soup and coffee were both a few degrees colder than standard temperature, and the milk and chicken salad sandwich were also a few degrees warmer than standard temperature.  The meal was missing a few things on the meal ticket– the ticket said 2 packets of salt and 1 packet of mayonnaise, but there was only 1 packet of salt and no packets of mayonnaise.  Because of the temperature issues and missing condiments, this tray received an 88% unsatisfactory rating.

And finally, yesterday I ordered  another diabetic (ADA1800) lunch tray. This one took 23 minutes to get from assembly to delivery, and I found it to be satisfactory.  The only issues were that the broccoli was colder than standard temperature (it was below the standard 130 degrees F), the tomato and cucumber salad was a few degrees too warm, and the milk was warmer than standard temperature as well.  Everything on the tray was accurate and lined up with the meal order ticket.  So this tray received a 92% satisfactory rating.

I have a few more tray audits to complete next week, and when all the tray audits have been done, I plan to write up a summary, including any suggestions I have for improving the average score of these tray audits.   Tray audits are important because they can uncover reoccuring issues with the meal trays so corrective action can be taken. For example, if the milks are always coming back too warm, then we would need to come up with a different food delivery system that would keep the milk below 41 degrees F every time.  If the condiments are consistently missing from the trays, then we could remind the hostesses and diet clerks about this.  If there is a food dish that always lacks in appearance, we could come up with a garnish to make it look more appealing.  I think that tray audits should be conducted several times a month, and in order to get a more accurate overall picture, I think the trays should vary– different diets, different meals (breakfast, lunch, dinner), and they should be delivered onto different floors.

Categories: Clinical Nutrition | Tags: , , , , , , , , | 2 Comments

Meal Rounds

This Monday I started my rotation at Mon General Hospital here in Morgantown.  My first 2 weeks will focus on Patient Food Service and Production. I’ll be conducting meal rounds, patient surveys, testing trays, observing tray line, presenting an employee in-service, testing a new 7-day lunch menu, among other things.

Meal rounds are fairly simple to conduct, but can be very important in heading-off any bad service experiences the patient may have had, as well as providing an opportunity to get their nutrition and diet questions answered.  I start off by receiving a list of patients on a few floors and a meal round record sheet.  I try to speak to a variety of patients on different diets. The different diets include:

  • ADA1800 (Diabetic diet, 1800 calories)
  • NCEP2 (National Cholesterol Education Program II diet, “Cardiac diet”)
  • Regular
  • 2gmNA (2000 mg sodium, sodium-restricted diet)
  • ClearLiq (clear liquid diet)
  • LoFat50gm (low-fat diet)
  • GlutenFree
  • NPO (nothing by mouth, I skip over these patients)

I start by knocking on the door and asking to come in, then introducing myself, asking for their name, and telling them I am here to see how their meals have been.  Most patients are very satisfied with the quality of the food and the temperature of the foods (hot foods arriving hot, cold foods arriving cold).  Although 90% of the comments are “fine” to “very good,” there were a few issues with the French toast for breakfast this morning;2 patients said it was lukewarm when it arrived, and another said it was soggy rather than crunchy. I imagine it can be difficult to keep French toast, in particular, piping hot from the point of production up until it is delivered to the patient’s room, which can be over a half an hour. I make sure to relay these comments (good and bad) to my preceptor.

I also ask the patients if they have any questions about the diet they are on, if they are on a special diet. Most patients know why they’re on a certain diet.  For example, a lot of the patients are diabetic, and so they obviously understand why they are on a diabetic diet, or the ADA1800.  If patients have any questions or concerns about their diet or any nutrition questions, I will follow-through by letting a dietitian know, so they can head up to the patient’s room that day and clear up their concerns.  This could be a patient who wants to know why they are limited to a certain number of calories, a patient that wants to know what snacks they can have on their diet, or a patient wanting to know why they are on a fat or sodium-restricted diet.

I observed a meal round on Monday and I conducted meal rounds on both Tuesday and today, Wednesday.  So far I have comments from 33 patients, and I have 3 more days of meal rounds scheduled, so I hope to get over 80 responses total.  It is good to hear directly from the patients about the quality of the food and the temperature of the food, so that patient satisfaction scores can be improved for the hospital and any possible problems in the production or delivery of the meals can be corrected.

Categories: Clinical Nutrition | Tags: , , , , , , , | 2 Comments

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