June 1, 2021 • 45 mins
Wednesday 2nd June 2021
Dietetics Digest
Should dietitians place NG tubes? feat. Sam Francis RD (Episode 8)
Sam Francis is a Specialist Stoke Dietitian who has extended his role to place nasogastric feeding tubes in patients. He has been pivotal in developing a new role in Bradford Teaching Hospitals NHS Foundation Trust and expanding the role of the stoke dietitian. He works on a national level with the BDA neurosciences Stoke sub-group and inputting into national policies. He recently won the Rising Star Award in the 2021 United Kingdom Advancing Healthcare Awards for his work as Specialist Stroke Dietitian.
Sam Francis (Twitter)
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Sam Francis (00:00):
nothing quite like the boss of being
(00:02):
part of the BD Ward environment,everybody getting on with
their jobs but working closelytogether in making sure you
know that patients are safe andthey're getting the treatment
that they need to reallythrive in an environment of
I felt so it was for me itwas exactly what I wanted
to do rather than sitting ata desk basically for
the majority of the day.
Aaron Boysen (00:21):
Welcome to the dietetics digest podcast
with your host and dietitianme Aaron Boysen dietetics
digest is a podcast createdand produced by dieticians for
dietitians, we interviewdieticians from around the
world to talk about theirjourney and their groundbreaking
work. This podcast willhelp inspire you and others
to become the best dieticianpossible.
(00:48):
Sam Francis, welcome to thedietetics digest podcast.
Sam Francis is a specialiststroke dietitian working at
Bradford teaching hospitals. Herecently actually started the
role in NHS terms and lastcouple of years. And he's really
developed this new role as aspecialist stroke dietitian in a
place where there wasn'tone previously he recently
published an article abouthis work in the CN magazine
(01:09):
around his practices of strokedietitian and the extended
role he's been able to do andthe benefits it's had to
patients, but also to theservice as a whole. Is there
anything I've missed there,Sam to sort of introduce us? I
don't think so.
And that summarise iswhat I've been up to quite
nicely. So thank you forinviting me on to the show.
It's a real pleasure. Noproblem. I think especially
(01:29):
since your cm magazinearticle on when you were able
to sort of display thekinds of things you've been
doing and the kind ofimprovements in patient care. I
think it really intrigued me.
And I think a lot of peopleare also interested in
this area, specificallythe area about extending
dietitians role and extendingthe role into placing
nasogastric feeding tubes.
But also, I know you do afew sip tests as well to help
(01:52):
support the nutrition ofpatients and help them be
identified as at risk early.
So that stuff can be done alittle bit about the
nutrition. But maybe we couldstart a little bit early on
sort of a little bit ofbackground of how you got
first into dietetics whereyour journey sort of
started. Yeah, absolutely isquite funny, really. In the
office and in our teams, Iseem to find every single
(02:14):
support and role within thehospital leading up to
becoming a registereddietitian. But my background
originally was in SportScience. I graduated in
2012, from the University ofSalford doing a degree in
sports science.
And I think it was kind ofthen that my interest in
nutrition sparked, whichI think is quite a typical
story for male dietitianactually is you know, coming
(02:34):
from a sports science sort ofbackground, I was quite
sporty myself growing up andbought, I sustained a few
injuries and put quite a lotof weight on in my sort of late
teenage years.
And it kind of got to a pointwhere I thought I needed to pay
a bit more attention to myhealth. And I think that's
where the actual reading aroundnutrition soul came to the
fore and sparked myinterest. So to speak. From
(02:57):
there, I started to lookat careers in nutrition. So
have a little look around,obviously leave loads, stuffing
NHS websites, there's lots ofthings about being a
nutritionist or a nutritionologists, or a nutrition
therapist and all those typesof things is really
important to me to have aregulated profession. So
that's where dietetics comesin. I then went on to do a post
(03:18):
grad certificate inhuman nutrition diplomas to do
a full Master's in humannutrition. The University of
Chester quickly found out thatthat would lead me probably no
further on down the line anddoing a degree in Sport
Science with regards to actuallygetting my foot in the door
anywhere. So I quit sure andjust did the 60 credits and did
the nutrition.
I applied them for dietetics.
(03:38):
And I was unsuccessful onmy first go, which was a
little bit disheartening.
So decided that that's not forme, I'm going to do that
because they didn't want meon the course anyway, so
definitely not something Iwant to do anymore. So
decided to take a job workingas a pharmacy assistant. So
I'd worked throughout myundergrad studies. I was
a community pharmacyanyway. And I took a job as a
(03:59):
pharmacy assistant andwithin short Hospital in
Manchester. So I did that fora short period of time before
a dietetic assistant jobcame up, I applied for
that. And I did that at Boltonfor for a good year, I was
going to then apply fordietetics again, and I
did we bought a job came up fora marketing part of Lucas
Lucas aid sport and decided tosay that instead that as
the pay was quite good, sothat was second attempt of
(04:21):
getting into dieteticsabandoned by herself when
travelling that typical stuffand then came back and worked
as a respiratory assistant. So atherapy assistant for a
key for a couple years asa band three, and four and
then eventually applied todietetics again and was
accepted in 2016. So quitea long way around houses
there. But obviously thenI did my two years. I did
(04:44):
some training abroad to dothe placement and blackmailer
really enjoyed it and it kindof set himself is where where
I would like to work andfortunately there was a
bonfire of opportunitywhen I was due to graduate so
I applied for that and wassuccessful. So that was kind
of the way around thecountry's way into dietetics
and things
Sam Francis (05:00):
So that's kind of my, my way into dietetics.
Aaron Boysen (05:03):
Do you ever find that those those previous
maybe they worked inclinical areas as a therapy
assistant or previous jobsyou've had outside of
dietetics help inform yourdietetics today and your
decisions around sort ofunderstanding what other
members of the team do andtheir their goals, more
than say, just sort of a sortof a cosmetic understanding
that sometimes we try to dolike read a job description and
(05:25):
try to try to empathiseempathise with empathise, but
try to see it from theirpoint of view?
Do you think that havingthose roles and being in that
team helps you better understandtheir goals and their purpose?
Really?
Sam Francis (05:36):
Yeah, definitely. I think it was invaluable,
invaluable.
It's funny because we, wetry and work in a holistic
manner. And we say, we'reholistic practitioners.
And we like to see that holisticviewpoint. But actually, you
know, how far does it go?
When it goes to actually, howholistic? Are we? Do we have
a true understanding?
Or is it just a nice triggerword that people like to
use application form? And Ithink, sometimes you only know a
(06:00):
certain amount by observingand sort of watching from
afar, but then you start to PGstart to come together. And
actually, how is that personinvolved in a patient's care
if you've done that jobyourself, and you start to
see some of the challenges thatare the allied health
professionals or healthcareprofessionals or healthcare
workers face, because you'vesort of I've done that
before. So certainly givesme a level of can relate to
(06:23):
it a little bit more. And I'mmore sensitive to the
pressures, I think, for sortof the members of the MDT. And
actually, you know,obviously, I'm a dietician
with the media.
So my sole purpose is to sort ofoptimise the nutrition of my
patients. But I think it'sreally important to have a true
understanding of where allthe members of the MDT and all
the healthcare professionalssit and what their roles are
(06:44):
and what you can do to helpthem and what they can do to
help you.
Ultimately, that's whereyou get the best patient
care and the best patientoutcomes. Is there anything
that dieticians who haven't hadthat experience? And
are currently dietitians canget that experience
without sort of quitting thejob and becoming therapy
assistants or working indifferent roles? Is there
any, any way they can dothat? I would say just be
(07:04):
proactive, where you can buildrelationships with other
members on the ward. And ifyou don't work in a ward are
the members of your MDT or youknow, any sort of healthcare
professionals that you workquite closely within
expressed an interest in toshadow spend a bit of time
with them, trying to sortof ask them to explain their
role to you, and even have aconversation and say, how do
(07:24):
you perceive my role? And whydo and how do we work linking
together and see what theirperceptions are, rather
than, you know, guessing whatyou think that perceptions
are. And he's actually havingthat conversation,
which sometimes can be a littlebit daunting, especially if
you're not really familiarwith the other ends up team.
But if you kind of sell it asa, I really want to upskill
(07:45):
myself, so I understand whatyou do and best help support
your role. No reason whypeople won't accommodate
you, I don't think I thinkwith every area sometimes the
plan can seem quite basic andquite simple.
But obviously the journey toget there and why that's so
crucial for the patient oftengets missed in talking to other
therapists actuallyunderstanding that I think
every every job can besimplified into it, just tell
(08:06):
us how many Mills you putdown an mg tube, or you
just tell me how many insertbrand here supplement
drinks that you need to put inor you just get a patient to
sit on the edge of bed andwrite in the notes and say
you've achieved something, butactually understanding
why they're doing that andwhat their processes i
think is, is crucial now.
Yeah, yeah, definitely. Youcame from a sports science
(08:27):
background that usually lendsitself to more of a weight
management or sort of morecommunity based or clinic based
role when you're talkingto patients in clinic. What
made you go for something soclinical is working on the
ward on a busy stroke Ward?
It's funny that isn't it? Asyou say, because, you know, you
traditionally you do seepeople going from, from the
(08:48):
squat science background moreinto more sort of either
personal training stylenutrition roles, exercise
type nutrition roles, or,excuse me, dietetics more
to weight managementgenerally, what I think working
as an assistant, bothin hospital, particularly as
a dietetic assistant,rather than any other, the any
of the other assistantroles. I've all it did, what I
(09:09):
found really interestingfrom the get go is reading
medical notes, and just havinga little look through about,
you know, what's going onwith the patient, what's
a diagnosis, what's thetreatment, what medication are
they on what other peopleare involved in, in their
care, and I just, I wasblown away by how interesting
it is. And for me, the acutesetting is is the most ideal
(09:31):
place to learn more aboutthose, you know, really
acute health problems thatpeople are presenting
with. So I just kind of wantedto get to know more and more
and more about that field. Andpersonally, I didn't think I
would be able to do that if Iwent into sort of a weight
management type role. And whatI really loved about working
on the walls was just howfast paced and hectic it was
(09:53):
nothing quite like the bossof being part of a busy Ward
environment.
Everybody getting on withtheir jobs, but working closely
together and making sure youknow that patients are
safe and they get thetreatment that they need to
really thrive in anenvironment of I felt. So it
was for me, it was exactlywhat I wanted to do rather
than sit in a desk basicallyfor the majority of the day.
Aaron Boysen (10:13):
And that leads us into the recent role that you
you have the extended role,which is a lot more physical
than say most dieticianswould you actually get a
bit more hands on withpatients than the average
dietitian would and obviously,that that extends to placing
nasogastric feeding tubes in theinpatients. Now Could you just
set us a scene like beforeyour role was created what
(10:34):
what was available, likewhat was the standard of
care that was given to thesepatients nutrition wise.
So
Sam Francis (10:41):
I first started working working on the acute
stroke Ward at Bradford asabandoned five so newly
qualified and it was part ofa general bonfire caseload
economy, a few different wardsand clinic every week, and
you cover us our communityhospital ward as well to
quite a heavy amount ofresponsibility.
And that would be part of sortof a bit of a rotational type
(11:01):
basis. But with a stroke unitbeing part of a bonafide
caseload, you couldn't reallyget stuck in you kind of got
to wait for the work to comein. And by waiting for the
worker by work, I mean,obviously we refer patient
referrals and things and bywaiting for that people
will get in missed I thought,although is believes in
initiation of nutrition orgetting people said to either
(11:24):
orally or actuallysooner. So I've found that set
a scene if you're apatient coming on to the
stroke Ward, he just had astroke in Brantford, he
ran into the hypercube unit,he wouldn't see a dietitian
until someone else deemed itnecessary for you to see a
dietitian. And that's sort ofthe background of having not
not much dietetic input.
So therefore, that theculture to refer off a dietitian
(11:46):
wasn't necessarily that strongscreening was slightly delayed,
because again, the train andthe culture wasn't really
implemented. Or it was whatjust in dribs and drabs as
you could do as part of a verybusy caseload cuz, obviously,
having done that myself, itis a very busy caseload,
having four or five inpatientacute wards, community
(12:06):
hospitals and the generalclinic to juggle it's almost in
hindsight, just gobsmacking,that there was never a dedicated
specialist stroke dietitian inthe first place. And I
think for me, that's whatreally stood out when I
first started at Bradforddesign, why didn't exist is
mind blowing.
And the amount of time that Iwould spend on Ward six, those
show unit Ward far exceededanywhere else, and it's
(12:28):
probably in part due to personalinterest. But then also, once
you start on pickingsomething, it just keeps
going, keeps going and keepgoing. And you think, wait a
minute, why isn't thatperson being seen or that
person or that person and youfind yourself being
overwhelmed by one Ward, youknow, to summarise prior
to this post I do now, youprobably would have left sides
(12:49):
as the Kimbo you'd have itlater on, you might go quite
a long time not being seen by adietician, you might not be
identified as needed, needinga dietitian soon enough, which
ultimately, you know, will havea knock on effect to your
recovery in your in yourrehab goals.
Essentially,
Aaron Boysen (13:02):
I think it's also important to acknowledge
like you said, sometimes theculture wasn't there. But
there was no dieticianthere. I mean, everyone, it's
a bit like a dieticianidentifying therapy needs
for a patient.
Obviously, a dietitian coulddefinitely recognise that
and therapy needs a patientwould need however, they're not
going to be anywhere nearas good as say, a
(13:22):
physiotherapist or anoccupational therapist,
identifying those crucialneeds that that patient has,
yeah, and then implementingthem or speech language
therapists, we might noticethat the patient's got
dysphasia, or they'restruggling to swallow. But a
lot of dietitians unless they'vedone external dysphasia
training, and because dysphasiapractitioner, they wouldn't
be able to identify thatas well as, say, a speech
(13:45):
language therapist, I thinkdefinitely probably helps
that you're a dietitian. Andthat's your main focus on
the ward. So while everyone'sworrying about their area, you
have to worry about nutritionas well as, as well as other
things too, but to work as partof the MDT. And I think, as it
comes up more it becomes partof the, as you said, the
culture is asked to getimplemented and it becomes more
(14:06):
standard practice.
Sam Francis (14:07):
That's it, I think, I think it's
really boils down to youdon't know what you don't know
yet. And I think that'sit. I don't I don't think
it's anybody's fault. It'ssort of I think it was just
history. And it's not at theforefront of somebody's
agenda if it's not beingtalked about very regularly.
And it won't be talked about award level, particularly
regularly. If there's nobodythere to talk about it.
(14:28):
Essentially,
Aaron Boysen (14:29):
your role is not just a stroke, dietitian, it's
it's a little bit more thansay, the sort of a specialist,
stroke, dietitian, yourrole has been extended. Why
does that need to happen? Whatwas the purpose in that?
Sam Francis (14:41):
So there's a couple of reasons why.
And there's a couple ofthoughts as to why she do
this. We've noticed quite afew occasions where referrals
of patients were coming in345 plus days down the line
where they had been no biomarfor a significant period of time
and energy hadn't beeninserted. So we were thinking,
you know Lie on the bean insertIs it because there's not
(15:01):
that many people to do itis it because it's not been
that important, you know, peoplestretched and pressures
elsewhere, meaning thatthey're not putting energy
in or if they do come out,they're not putting them
back in timely.
And I've always been of thetrain of thought that I think
upskilling yourself to doa job that would help the
wider workforce is moreproductive than complaining
about what's happening inthe workforce over and over
(15:24):
again, and not actuallychanging any of the outcome. So
that was kind of a personalpush for why I wanted to do
it. And then also the waythat the post by the my post
is funded, was a came about bythe closure of some beds,
patient beds, which releasedsome nursing fund money. So
on the release of that nursingon money, there is an
(15:46):
opportunity to diversify theskill mix of the ward. And
as some of that money wasreleased for therapy, some
of it was released for pharmacytechnicians on some of it will
release for a dietitian, sopart of it was taking that
post on, there was anagreement with the reward
basically no generalmanagement that we'd need to
help with the nursing sidejobs on the wards. We were
(16:07):
thinking, Okay, from whatexactly is it that they do
that we think we could do,and it's directly related to
Nutrition and Dietetics. Andit it just lightbulb
moment, very obvious thatyou know, if we upscaling in
passing energy tubes, nasalretention devices, and
testing, and if necessary,hanging, commencing feeds and
(16:28):
general tube care andtroubleshooting, when it comes
to enteral feeding, thenthat would save a lot of
nursing time.
And it's almost on the wall todo that. They wouldn't have
to contact the nutritionist,wait for them to come back
then if I'm there, thensomebody there a dietitian is
there to deal with all thesenutritional related issues,
essentially,
Aaron Boysen (16:47):
I think that definitely is a natural,
natural fit, because Iremember I started off as
a newly qualified dietician. AndI would get asked questions
around the things youmentioned about tube care, even
said, Can you place it tocng? And I was like, No, I
can't. And it's almost like anautomatic thing they they
suggest as a thing that youshould do. It's almost like an
(17:08):
obvious thing.
Well, you could start startthem off and then you should
get them go in and you shouldI think it does it death. I see
the thing everyone elsesaw saw the fit there,
especially in a place wherethey don't have nutrition
nurses, because not everyhospital has a dedicated
nutrition nurse even I mean,hospitals have multiple
nutrition nurses, andsome hospitals don't have any.
(17:29):
And often a lot of thatresponsibility informing the
ward or different staffabout care of enteral tubes
often falls on the dietitianYeah, absolutely.
Absolutely don't alwaysaren't given always that
specific training because it'snot really in there. Their
job role.
However, I think, as youmentioned, we are we are sort
of the the go to people fornutrition in especially in
(17:52):
an acute setting. Whydon't we know well about some
of these, especially sortof nutrition devices like at
least n g tube.
I know dieticians learn about itas they realise its usefulness,
but I think there definitelycould be more systematised
knowledge around care ofthose things, especially for
(18:12):
new dieticians.
Sam Francis (18:13):
Oh, yeah. 100% agree with that, I think
that my level of competence nowtroubleshooting, energy, peg
related issues is much betterthan it was when I was a
newly qualified dietician. AndI remember being asked a
question about somebody nggwhen I was on a ward and being
like, absolutely no idea and notfeeling confident to
(18:33):
say, you know, try and do thisor do that. Or it might be
because of this. And itjust be me feel like a little
bit like always lacking inknowledge or expertise. And
I always find it quite funnybecause you write enteral
feed regime, and then yougive it to the ward. And then
that's it. But then you'reassociated with that whole
process. And I've been in apatient and that whole sign
(18:55):
of their treatment, butactually all say all we've
done, but what we've done iswrite a feed regime, but we
can't answer questions aboutthe practical side of it.
Other than you know, yourtypical tolerance, issue type
stuff, making sure people arefed a certain angle brief, a
juice blocked, I wouldn't haveknown what to do, because
you've moved by two centimetres,absolutely no idea what to
do. The patient has beencoughing, no idea what to
(19:18):
do. And it's really nice nowto be able to say, Well, in
this situation, try and dothis, or actually, I'll
do this and sort this outfor you. And ultimately
reduces delays in provision ofnutrition, medication
hydration for that patient.
And it's something that could bedragged out by having to bring
the nutrition nurse to findout is actually streamlined and
(19:39):
cut down because I'm onthe ward there to deal with
those issues.
So
Aaron Boysen (19:43):
if you don't have a nutrition nurse, try to
find some, some individual outthere that knows how to
how to deal with that problem,either. As you've developed this
role, and as you've becomeyou've extended the role is
there anything else that'shappened as part of this
role apart from just placingthe nasogastric feed feeding
tubes.
Sam Francis (20:00):
So obviously with the DNR article for SSI, and we
looked at quite a lot of keyperformance indicators and
things to measure. So we basedeverything on Duke guidelines
that are out there at themoment. So things from the
Royal College of Physiciansstroke guidelines, some of the
stroke, Sentinel National Auditprogramme, the snap programme,
(20:21):
and looking at stroke, nicerehabilitation guidelines, and
it was really to try and puta family screening. So
that should be done within 24hours a CIT testing, which
I think I'll come back tothat should be done within
four hours. And thenconsideration of energy
assertions within 24hours. Using nasal bridle
and nasal retention devices,bridles, F and G tubes are
(20:42):
frequently dislodged andmore timely referral for
gastrostomy placement if you'restruggling, either to keep
in use in or if patients arepushing start sort of four
week ish sort of window ofneeding energies and the swallow
isn't looking like it's goingto rehab. So really, we've
tried to identify the need fordietetic intervention
(21:03):
and intervene as fast aspossible in the most effective
way. So I think that was ourreal goal and aim for this
service. And obviously, thatsort of shows in some of the
things that we do. So theextended roles, I think, with
regards to sip testing,genuinely is done by short
responders in our hospital.
So they get alerted whensomeone's coming into a&e
(21:24):
with a stroke.
And they will go and try andsettle in for hours. Or if
there's staffing issues, if theif it's overnight, or if it's a
weekend or a patient isn'tsuitable for us, because
it's your geology, thenyou might pick up alertness to
GCS might improve 24 hours afterthat. They can be reef tested,
but on occasion isn't isn'tanybody in on the water that
(21:45):
has a hypercube bit that cansit as somebody so I can come
on in the morning, andgenerally I'll have a gander
and a quick eyeball at thepatients who is using you who
don't know, who's nearbymark, who is on the Wi Fi
consistency diet, and ifthe patients are nil by
mouth, and they're alert,they're talking for sidewalk,
they look like they'reappropriate for a sip test.
I'll ask you know, is thereanyone available to
(22:06):
sit tests? And if there isn't,then I'll just I'll just do
it. Because I'm competencytrained to do that. And it's
been two occasions thisweek, actually, we're doing
patients or something nilby mouth, and they can link
it back to you know, our aimwas to get nutrition implemented
sooner rather than later. Iasked him you know, are you
happy for me to sit as theywere they passed and then
we got a drink a cup of teaand I've been a goal Weetabix
(22:28):
within 20 minutes of mecoming into the ward where it
could be hours later. And youknow, you don't become
malnourished in a space of fourhours walk the patient's
experience and quality oflife. And what is important to
them is to be able to have acup of tea or a bowl of
Weetabix. And that's thething that they'll remember, I
think is you know, beingseen sooner and being able to
(22:49):
get back to some form ofnormality, despite being
on a ward sooner ratherthan later. So for me, that's
sometimes as important aslooking at the more technical
scientific key performanceindicators is actually how
did the patient feel there. Andthen definitely, I
Aaron Boysen (23:04):
think if you add all those things
up, sometimes patients thathave been in a long time are
the most complex patients those,those experiences of
either being nil by mouthfor we were talking about
as dietitians, I've gotprocedures that have to go for
being nearby mouth, I've gotthings that have to do
being nil, by mouth, theyhave a period where they they're
struggling to tolerate theirfeed, or the food that's
being given.
(23:24):
And all of those experiences, ifthey are delayed or through
staffing issues or throughprioritisation, then obviously
that makes an impact on thepatient, whether it's
one acute event or they add upover time. And I think it's a
really good thing for sortof expanding our our scope
of practice. So we can supportthese patients and sort of
say, well, well, it's anutrition related thing.
(23:45):
I'm trained in that area.
Yeah, let me sort it foryou. Let me do that for you.
Sam Francis (23:49):
Yeah, definitely. And I think, you
know, I introduce myself, as I'msome on the stroke
dietitian, and I'm here todayto do a sit test this
morning, which you know, willhopefully enable you to
start eating and drinking again,normally, and patients, I'd
like to open it, it makessense to them in their head.
They're not thinking, Waita minute was my fifth dietitian
doing that.
That's, that's not somethingthat I expect them to do. But
(24:10):
it fits in quite nicelywith what, what our role is. So
I think it makes completesense, in my opinion.
Aaron Boysen (24:16):
Definitely.
I think I really lovedthe story that you gave, can
you Is there any sort ofexperiences you've had, where
everything sort of connectedtogether? Or it's all sort
of how would it work in inpractice a journey, you
just give us like a like acase study or a patient gets
admitted? How would thatprocess go with you there as a
stroke dietitian,
Sam Francis (24:35):
so I think, you know, there's been a number
of times where I've fallen tothe wall. So I come in first
and go to the office, youknow, sell a cup of tea, all
that stuff. And then I go tothe ward generally
around the time of the wardround, the hazard Ward
round. So when people are sortof newly admitted with a
stroke, they belong there.
And a lot of the timethey're the ones that are
(24:56):
new nearby miles and theyyou know, they might have to
draw the for even storageassessment, and it's not
looking like they're goingto become more alert anytime
soon as I go to the ward andidentify those patients stents
off to the side of the mainbulk of people and Ward around
and, you know, interject whereI think there might be a
question. So, you know, thesepatients know, why more? Is
(25:19):
there a plan for nutritionat this point?
You know, sometimes theconsultant says, No, I
don't think it's appropriate.
And obviously, you have torespect that medical
decision. But sometimes Isay, Actually, no, I think you
are right there is we shouldstart enteral feeding. And I
think that's a sensible thingto do. They go on to the next
patient, I've built arelationship to a point with
the consultants where I canjust say, you know, are you
happy for me to place an NGCfor this patient, obviously, as
(25:41):
probate patients concern andthings and do a capacity
assessment if necessary, theconsultant essentially,
now just rubber stamps itbecause he has that much sort
of faith and trust in me asa part of his MDT, I'll just
go off, get the stuff ready incertain energy to move on and
you know, either myselfor the nurse or on the feed.
And, you know, it goes fromtime to seen on water on site
(26:01):
time to initiate andnutrition is probably half
an hour, half an hour, 45minutes. That's probably a
seamless as it's going toget. I think I'm not sure
how I would optimise thatprocess. And he certainly
didn't have tried to optimise itright up
Aaron Boysen (26:15):
to the speed of delivery of nutrition is a
lot faster than previously. Andobviously, that we could gather
from that has an impact onpatient outcomes patient's life,
not just sort of the lengthof time they stay, but how
how well, their life ispoststroke as well.
Sam Francis (26:30):
Yeah, certainly, certainly, all the majority of
the evidence out theresuggests you know that if you're
malnourished, then your highermortality risk you're going to
be in hospital for for longer,you're going to have more risk
of infections, and generallyyour level of disability will
be larger. So if we canprevent or treat malnutrition
(26:50):
from the front door, then youwill have an effect on treatment
outcome. And
Aaron Boysen (26:54):
so you mentioned a little bit about your
recognise if, if a patient'son a modified consistency
diet or nil by mouth, wouldyou would you see those
patients? How would you reactto those patients? What
would you say a patient's beendim nearby mouth that
morning? Would you go see thatpatient? Or how would that work?
Sam Francis (27:12):
Yeah.
So I mean, my referral, ourreferral criteria for stroke,
dietetic service is being no I'moff having a must have to or
above, you know, which issimilar to a lot of other
dietetic services. Andalso anybody requiring a
modified consistencydiet, because there's strong
evidence, you know, the restof my interest is higher. If
(27:33):
you want to modify consistencydiet, for patients that
are nearby mark, I'd usuallyintroduce myself and just
sort of make some common ornod to the fact that they're
nearby mark.
And can you just give themthe reason why that they are?
Because I find that somebodyissued services before and
somebody is obviously anobserver of day to day practice
on wards is some thingshappen to patients and
(27:55):
sometimes it's not alwaysexplained why that is the
case. So people can be stuckthere. All he says on their
board is an n b. c, laypersonwhat not doesn't mean
anything at all. And they're notbeing told why but know why
mark, sometimes not always. Ifeel like being a person that
can you explain that tosomebody if they do understand
this? He knows simply reasonwhy you know why mark is
because you've had a stroke,and you fail the CIT test,
(28:18):
this is what I said, tested.
And at that point, I won'tgo all guns blazing, and
say, right, so I think we needto put an energy tube
down, I'll say, you know,there's somebody else
in the team that can comein, especially swallow and
their speech languagetherapist, and this is what
their role is, and then thepatient expects knows what to
expect, then they know who'scoming to see them next, then
it up found that a lot ofthe time it calms people
down and you know, it givesthem a bit of reassurance
(28:38):
that they need.
So it doesn't take hours andhours to do for referrals to
myself on the on the electronicsystem and write up that whole
conversation in literally justhave a passing comment and
say, you'll be seeing myspeech and language
therapist. If you pass that'sgreat. We can start eating
and drinking.
And if you fail, and youneed enteral feeding, then
obviously I can come in and dothe next step of that as
well. And they already know myface at that point. So when
(29:00):
it comes to see them again, I'mfamiliar. I'm not like oh,
like, wow, who's thisperson? I mean, you're more
scared?
Aaron Boysen (29:07):
Yeah, definitely. It helps to give
them a little bit ofknowledge and power in a time
where they probably feeltheir most vulnerable and
powerless.
Absolutely.
Sam Francis (29:14):
Empowering is a good word to you.
Aaron Boysen (29:16):
So you mentioned a little bit about how you
built the relationshipwith the MDT and the
consultant and things likethat. How did you do that?
Like it's obviously beenover a year, too. Yeah,
yeah. About 818 months is kindof an 18 months, we've
had 18 months to build thisrole. How have you done it? Is
there anything unique thatyou've done or any sort of
(29:38):
crucial, basically tipsand tricks should we say?
dietitians, tips, clickbaitretail tips for developing a
great relationshipwith the other members of the
MDT go?
Sam Francis (29:51):
No pressure. I think having a presence on the
ward is probably one ofmy number one tips or tricks
is be there.
You know, let people know whoyou are, what you do, and
what you can do to helppatients and also them,
rather than this is who Iam. This is how you can help me
and just get to know people,introduce yourself, be
(30:14):
friendly, try and relate topeople on preferred personal and
professional levels wherepossible, and just be
enthusiastic.
Ultimately, you can't justthink about things in terms
of what is the dieteticoutcome here is about thinking
about what is the ultimatetreatment aim for this
patient? So medically, youknow, therapy, socially,
(30:34):
personally, all of thosethings? And where do we fit
into that, thinking aboutthe bigger picture and you
know, I use the word before, inholistic way.
And that sort of reallyinstils, where you fit in a
team into other people's minds.
So I think that's reallyimportant. And for me, being
around being helpful, it hashelped particularly having an
(30:55):
extended role because youhave an immediate impact from
somebodies work within a team,which is a patient required an
energy tube, a patient now hasone thanks to a stroke
dietitian, rather than a patientrequires nutritional
intervention, hopefully, theydon't get malnourished
later on. So you do get animmediate impact in Irish
factories, I think hashelped quite a lot, I think.
Yeah, I think that's it. Youcan think of anything else.
Aaron Boysen (31:18):
I mean, you mentioned about being present
on the ward and things likethat. And that's wonderful. And
I think I obviously, obviouslyexperienced being present
and being on the ward. And Ithink, as times gone on,
obviously, with paper notes, itwas really, really easy,
because we had to write up onthe ward. And we wrote in
those paper notes, butoften with electronic
(31:40):
medical notes, I thinksometimes it can be quite
difficult for dietitians tobe as present as they were
before not in their presenceas in them talking and
relating to people on apersonal or professional
level. But they're actually justbeing a body on the water, just
sitting there available toanswer questions or
bounce things off? Likeshould this patient be
referred to you or I'm havingquestions about this? Or X or
(32:02):
Y? Do you think it has value?
Or do you think it's a waste oftime or nothing, there's
Sam Francis (32:06):
a massive value to physically being present
on a ward, I remember when Iwas a dietetic assistant
working with a few differenttypes of dietitians, and he had
different types of healthcareprofessionals everywhere you
go. And for whateverreason, there was some people
that would go to awards, stayon the ward right off, and
then do a lot of their workon the ward and all the people
who come on right as fastas they can when they get
(32:27):
off the ward.
And it is like a flat. And thediversion then was remembered
as someone who just slips inand out of the ward. And I
sort of vowed to myself thenalthough years ago that that
wasn't the type of dietitian Iwas going to be I wanted to be
somebody that was veryheavily Ward base and have a
presence on the ward it is canbe difficult logistically,
(32:47):
if you don't have any mobilekit, again, computers on a
ward and things like that, whenwhen those are electronic. So
when we sort of started thispost was one of my essential
bits of criteria wasto, to be able to have a
laptop and remote work,essentially, to be able to go
to a world with a laptop and doeverything from that laptop.
Aaron Boysen (33:06):
I mean, I made it possible with COVID. Now, I
mean, that was before COVIDaffected us and made a lot of
people work from home, doyou think it has enough
benefit to make it worthwhile,
Sam Francis (33:15):
I think having a laptop that was 100% then
benefits and make itworthwhile. And I think the
wider acuity and I work in aseen some of that benefit.
And I think majority if notall of those now have
laptops, you know, it couldbe seeing a duplication of
electronic equipment,because there are computers
on wards. But you know,anyone that's worked on a
ward knows how difficult it isto get a computer sometimes and
(33:36):
it's very much of this is mycomputer, you can't sort of
just view this as a computerfor the day or and inevitably,
at that point, you're going tohave to write your notes up
somewhere else but that thenhas a knock on effect the
presence you have on theward. And then like you say it
reduces your ability totroubleshoot unanswered
questions for patients aroundthe okay or or any prospective
referrals where people areconcerned about the nutritional
(33:58):
status of that patient. Soit's made a massive massive
difference I think just
Aaron Boysen (34:03):
almost be in that sign there to make
people go Oh, yeah, nutritionall the time. I just that
constant little reminder allthe time.
Little person sitting there.
Yeah. Over in wherever yousit. I don't know. It's
because you'll have to spendtime writing notes you just
that constant reminder of Oh,when's that patient do for
the most screen? When'sthe when's this do? When's this
jus when's my patients beennearby mouth for how long?
Sam Francis (34:26):
Yeah.
It's funny to visithealthcare on the ward who
commonly will walk past andas always accountable to
me will tell me I've done afood record chart for the
jackin bed fine. And I'llsay all thanks for that.
Anyway, just carry on.
Obviously, I've never expectedthat from him, but the IP in
there, that's what he feels,you know, he's accountable to
me, which, you know,ultimately is still a better
(34:48):
outcome for that patientbecause they haven't been
there inside and monitoredproperly.
Definitely.
Yeah.
Aaron Boysen (34:53):
I think I'm gonna ask you more philosophical
questions. Do you think goingforward as a benefit for
more dieticians bye Seeingmajor gastric feeding tubes.
I think it's helpful. Do youthink more dietitians
should do it?
Sam Francis (35:05):
I think it's certainly helpful. I
think, as with anything else,you need to sort of assess
the clinical need for you todo that. And whether there's
a need to do it because,obviously, you know, a
predominantly outpatientdietitian probably
wouldn't, well wouldn't needto train to place energy
tubes. I said, I say, well,because it depends why our
patient service your workflowdoesn't get bought
Aaron Boysen (35:27):
home.
enteral feeding? I
Sam Francis (35:28):
think it goes, Yeah, exactly. Why?
Well, you can either clearlyprevent admissions and
that's it.
Yeah, that's something thatcould definitely be a
lot of start, I think is a bigdevelopment area in the future
outpatient insertion ofenergy tubes for patients from a
dietician or other healthcareprofessionals to prevent
admissions for that patient?
Well, yeah, I think if youassess if you look at the
(35:49):
clinical need, and there'squite a high prevalence of
patients in an area that requireenteral, feeding specifically,
you know, nice gastricfeeding, or even nice, gentle
obviously, there arepeople that are trained out
there to place nj tubes atbedside, then I think it's
really worth at that point,exploring competency
based training through insertLowe's, N, G and G and j
(36:11):
tubes. If you think thatthere's a need for it, I
personally would recommendit. If there's any punch that
might be beneficial fora patient, I'd say, you know,
dieticians, should look attrying to focus skill in that
area, because it's really mydevelopment in the past 18
months, as a result of doingthat has been absolutely
astronomical, like it'smassive, my confidence for
(36:33):
dealing with patients thatare actually fed not just from a
tolerance perspective,but the wider treatment and
the wider enteral feedingtreatment is just much, much
bigger. And I think I'veshown in equilibrium,
and you know, it does have aknock on effect to patient
outcomes. If you can be there totroubleshoot, initiate,
(36:53):
become an expert in bothnutrition and also roots of
nutrition, it makes you amuch more well rounded
dietitian, in my opinion.
Aaron Boysen (37:00):
So you said something I'm just gonna pick
up, pick up what he said.
He said there's a clinicalneed. Now, your clinical need
was it saves nurses nursingtime. That was correct. Am I
Sam Francis (37:11):
not just that though, it was, obviously we
needed to prove that in termsof the funding, so money is
coming from nursing budget.
So therefore, we need to showthat we were having a
positive effect on receivingnursing time.
But the obviously theother clinical need is, you
know, initiating nutrition earlyfor patients that have had a
stroke. And the evidence doessuggest, you know, prevent
(37:31):
involving nutrition doeshave positive outcomes for
those patients.
Aaron Boysen (37:35):
What which clinical area, is that
not a clinical need?
Sam Francis (37:39):
Well, there isn't, is a, I think if
you had an establishedteam, that we're inserting
energy juice really efficientlydealing with any problems,
like straight away, and youfell Actually, I've actually
no need to get involved inthis because it is already a
very, very good enteral feedingservice, that at that point,
maybe you could say, you know,there's no real need to me to
(38:00):
upskill in the moment, Iguess, what is a big thing to
consider is if you train toplace, nga chiefs or
anything like that, and youcan't keep up with the
competencies, then you willbe going competent very
quickly. So it's somethingthat if you are going to train
to do that, you kind of need todo it regularly to get good at
it. And then also become anexpert in it, which I think
you should be striving tobecome an expert in it if
(38:21):
you want. If you want tostart doing that in the
first place.
Aaron Boysen (38:23):
Definitely.
So in an area where enoughenergy tubes, you would
insert enough energy tubes onyour daily job role to enable
to maintain a competencylevel so that you're safe to
place ngga there's nopoint training, placing a few
mg tubes going Whoo, yeah,taking a picture for
social media.
Yeah, and then go ahead andplace within a couple months.
(38:44):
Absolutely.
Sam Francis (38:45):
Absolutely.
You don't want to do and, youknow, you need to be confident
in doing it. We see patientswith energy tubes all the
time, as dietitians,obviously, but there is
actually quite a dangerousthing to do is to insert an mg
and to start feeding downit. So if you aren't
confident when you're whenyou're placing that tube, you
could really put the patientat quite a high risk, really.
Aaron Boysen (39:07):
So you need to ensure that you're placing
enough mg tubes that you remaincompetent. And I think there
is, as you mentioned,there's loads of different
areas where I mean, you'renot the only dietician in
the UK that does this ismultiple dietitians and
they don't all work in stroke.
There's so many different areaswhere this would be a
benefit to the wider MDT andsupporting them, but also
improving patient careand hopefully helping
(39:28):
outcomes. So what kind ofimpact what kind of
outcomes have you actuallymeasured during the
implementation of the serviceand what's been the areas that
you've looked at?
Sam Francis (39:37):
Yeah, so one of the outcomes we wanted to
measure was the amount ofpatients that were considered
for mg tube within 24hours, which is it falls in
line with the Royal Collegephysician guidelines for
stroke and at the start, wehad pulled a load of patient
data and we found that foronly 40% of patients were being
considered for energy tubeinsertion. And then you know,
12 months into the post, itwas up to 94%.
(39:59):
So Not every one of thosepatients is going to have
an energy issue for a varietyof reasons. But statistically
if more patients thatrequire energy feeding will
have an energy placed within24 hours as it's being
considered in the firstinstance. So that was a really
important outcome measurefor us. I think what we've
proved is that we can initiatenutrition quicker for
patients when you havesomebody with an extended role a
(40:21):
dietitian with an extendedrole, but what we want to do
next is to work out exactlywhat difference that makes to a
patient. So looking atfunctional outcomes,
obviously we look atanthropometry all the time,
we're being a bit morespecific with that. So rather
than looking at just BMI,looking at calfs conference,
Malappuram maybe bioelectricimpedance analysis, if that's
appropriate, and seeing whata wider anthropometrical
(40:45):
picture looks like when itcomes to people's physical
rehabilitation.
So what goals are being setor working towards with
Visio and occupationaltherapy, and, you know,
optimising their nutritionalstatus, what effect does
that have on their functional ontherapy, goals and outcomes?
On the flip side of that,if somebody is struggling to
maintain nutritional status, forwhatever reason, whether
(41:07):
that's, you know, nottolerating, and YouTube's not
tolerating all issues andsupport, losing weight becoming
weaker, those that have anegative effect on therapy, led
goals and outcomes,
Aaron Boysen (41:17):
have the MDT and enjoyed you're having they're
not just the consultant, butthe other members of the
MDT. So the nursing staffand what's been their feeling
behind it? Is anyone said,are you stealing my
job? I really want to placesmg tubes.
Sam Francis (41:29):
No, not at all.
It's, it's been quite theopposite. It's been a massive
help, I think, both, you know,actually physically
taking the job in terms ofinserting and ngg. And then
also part of the developmentof this extended role
is that I'm kind of the lead fortraining new doctors, new
nurses on the safe insertionof n g tubes, and safe
(41:51):
insertion of nasal retentiondevices on the wall. So it's
really freed up time thatotherwise might have been spent
elsewhere, safely, it'sbeen very well received even
so point a one point I'd kindof like, Listen, it's
not just my job to put nggtubes in, so we're gonna
have to start looking atthis. That's not all I'm
here for. Yeah, so in thatsituation, where there's
multiple patients eatingand then jishu, who kind of got
(42:12):
to a point where there wasan expectation for me to put
them all in and actually hadsort of a conversation.
And, you know, this isn't justmy job, I still need to write
fi plans, I still need toimplement all nutritional
support, I still need toreview all the vast all the
things that we do asdietitian, so I'd sit down
with some nurses and thedoctors and say, you know,
there are eight patients thatneed them, there are four
bodies do them.
(42:33):
So let's do to each occlusionquite a bit more of a
planning role, as well asphysically for him, and
YouTube and for patients. Sothat's kind of been the, you
know, the development andmaturation of this role.
Aaron Boysen (42:46):
Brian, have you got any tips for
any, any dieticiansinterested in this area? How
can they what are the whatare the first steps they need
to do?
Sam Francis (42:54):
So I think have a have a chat with your your
manager supervisor andsort of say this is kind of
what I want to do, I thinkthat that is something that
you want to do and whetherit's relevant in your area.
And then if you've got anutrition nursing team
within the trust, and that's afantastic resource to use
absolutely nowhere to bedoing what I'm doing, if it
weren't for the competencyframework that they'd already
(43:15):
devised, spend some time withthem to see, you know,
observe as many anglesassertions, as you can see,
that actually, is what youwant to do, because some of
them are quite traumatic, bothfor patients and for the
people doing them. Andalways sort of nice and easy
pictures that you see in thedietetics magazines and
things like that they're notparticularly pleasant at
(43:36):
times. So just making surethat it's something you
want to do, and kind of askyourself a question is why
you actually want to dothat. And then I think it's
priority area for where youwork, then sort of pursue it
and go ahead with it. Thereare a few governance thingies,
little hoops that you needto jump through with clinical
(43:56):
governance and things likethat. But I think if
there's a good enough clinicalreason to do it, and you can
demonstrate that you willhave a big impact, and you're
ultimately better for thepatient, then I think, you know,
absolutely pursue it wouldbe my advice.
Aaron Boysen (44:11):
Thank you. And I think I think I'd advise
everyone to get the copy ofthat CME magazine read
the article and understand moreabout Sam's role and he's
got some brilliant sortof numbers in there that you
can look at and see the massiveimpact he's had on patients
outcome and how it's actuallyimproved care and reduce
costs in the wider MDT andactually showing the impact.
(44:33):
dieticians can have when theirtheir roles extended in an
intentional way, looking atthe areas and I just want to
say nasal gastric tube isnot the only way that
dietitians can extend theirroles. So there's has
lots of other ways thatdietitians can be flexible and
learn to extend their roles.
And hopefully we'll have somemore of those on the podcast.
And I want to thank Sam forhis time. And that's it.
(44:53):
You're very welcome,everyone. It's been a quite
pleasant way to spend myevening. Thank you very much.
Thank you for joining us thisEpisode of the dietetics
digest podcast.
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(45:15):
telling a friend aboutthe podcast.
Finally, make sure that yousubscribe and follow the
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episodes.
nothing quite like the boss of being
(00:02):
part of the BD Ward environment,everybody getting on with
their jobs but working closelytogether in making sure you
know that patients are safe andthey're getting the treatment
that they need to reallythrive in an environment of
I felt so it was for me itwas exactly what I wanted
to do rather than sitting ata desk basically for
the majority of the day.
Aaron Boysen (00:21):
Welcome to the dietetics digest podcast
with your host and dietitianme Aaron Boysen dietetics
digest is a podcast createdand produced by dieticians for
dietitians, we interviewdieticians from around the
world to talk about theirjourney and their groundbreaking
work. This podcast willhelp inspire you and others
to become the best dieticianpossible.
(00:48):
Sam Francis, welcome to thedietetics digest podcast.
Sam Francis is a specialiststroke dietitian working at
Bradford teaching hospitals. Herecently actually started the
role in NHS terms and lastcouple of years. And he's really
developed this new role as aspecialist stroke dietitian in a
place where there wasn'tone previously he recently
published an article abouthis work in the CN magazine
(01:09):
around his practices of strokedietitian and the extended
role he's been able to do andthe benefits it's had to
patients, but also to theservice as a whole. Is there
anything I've missed there,Sam to sort of introduce us? I
don't think so.
And that summarise iswhat I've been up to quite
nicely. So thank you forinviting me on to the show.
It's a real pleasure. Noproblem. I think especially
(01:29):
since your cm magazinearticle on when you were able
to sort of display thekinds of things you've been
doing and the kind ofimprovements in patient care. I
think it really intrigued me.
And I think a lot of peopleare also interested in
this area, specificallythe area about extending
dietitians role and extendingthe role into placing
nasogastric feeding tubes.
But also, I know you do afew sip tests as well to help
(01:52):
support the nutrition ofpatients and help them be
identified as at risk early.
So that stuff can be done alittle bit about the
nutrition. But maybe we couldstart a little bit early on
sort of a little bit ofbackground of how you got
first into dietetics whereyour journey sort of
started. Yeah, absolutely isquite funny, really. In the
office and in our teams, Iseem to find every single
(02:14):
support and role within thehospital leading up to
becoming a registereddietitian. But my background
originally was in SportScience. I graduated in
2012, from the University ofSalford doing a degree in
sports science.
And I think it was kind ofthen that my interest in
nutrition sparked, whichI think is quite a typical
story for male dietitianactually is you know, coming
(02:34):
from a sports science sort ofbackground, I was quite
sporty myself growing up andbought, I sustained a few
injuries and put quite a lotof weight on in my sort of late
teenage years.
And it kind of got to a pointwhere I thought I needed to pay
a bit more attention to myhealth. And I think that's
where the actual reading aroundnutrition soul came to the
fore and sparked myinterest. So to speak. From
(02:57):
there, I started to lookat careers in nutrition. So
have a little look around,obviously leave loads, stuffing
NHS websites, there's lots ofthings about being a
nutritionist or a nutritionologists, or a nutrition
therapist and all those typesof things is really
important to me to have aregulated profession. So
that's where dietetics comesin. I then went on to do a post
(03:18):
grad certificate inhuman nutrition diplomas to do
a full Master's in humannutrition. The University of
Chester quickly found out thatthat would lead me probably no
further on down the line anddoing a degree in Sport
Science with regards to actuallygetting my foot in the door
anywhere. So I quit sure andjust did the 60 credits and did
the nutrition.
I applied them for dietetics.
(03:38):
And I was unsuccessful onmy first go, which was a
little bit disheartening.
So decided that that's not forme, I'm going to do that
because they didn't want meon the course anyway, so
definitely not something Iwant to do anymore. So
decided to take a job workingas a pharmacy assistant. So
I'd worked throughout myundergrad studies. I was
a community pharmacyanyway. And I took a job as a
(03:59):
pharmacy assistant andwithin short Hospital in
Manchester. So I did that fora short period of time before
a dietetic assistant jobcame up, I applied for
that. And I did that at Boltonfor for a good year, I was
going to then apply fordietetics again, and I
did we bought a job came up fora marketing part of Lucas
Lucas aid sport and decided tosay that instead that as
the pay was quite good, sothat was second attempt of
(04:21):
getting into dieteticsabandoned by herself when
travelling that typical stuffand then came back and worked
as a respiratory assistant. So atherapy assistant for a
key for a couple years asa band three, and four and
then eventually applied todietetics again and was
accepted in 2016. So quitea long way around houses
there. But obviously thenI did my two years. I did
(04:44):
some training abroad to dothe placement and blackmailer
really enjoyed it and it kindof set himself is where where
I would like to work andfortunately there was a
bonfire of opportunitywhen I was due to graduate so
I applied for that and wassuccessful. So that was kind
of the way around thecountry's way into dietetics
and things
Sam Francis (05:00):
So that's kind of my, my way into dietetics.
Aaron Boysen (05:03):
Do you ever find that those those previous
maybe they worked inclinical areas as a therapy
assistant or previous jobsyou've had outside of
dietetics help inform yourdietetics today and your
decisions around sort ofunderstanding what other
members of the team do andtheir their goals, more
than say, just sort of a sortof a cosmetic understanding
that sometimes we try to dolike read a job description and
(05:25):
try to try to empathiseempathise with empathise, but
try to see it from theirpoint of view?
Do you think that havingthose roles and being in that
team helps you better understandtheir goals and their purpose?
Really?
Sam Francis (05:36):
Yeah, definitely. I think it was invaluable,
invaluable.
It's funny because we, wetry and work in a holistic
manner. And we say, we'reholistic practitioners.
And we like to see that holisticviewpoint. But actually, you
know, how far does it go?
When it goes to actually, howholistic? Are we? Do we have
a true understanding?
Or is it just a nice triggerword that people like to
use application form? And Ithink, sometimes you only know a
(06:00):
certain amount by observingand sort of watching from
afar, but then you start to PGstart to come together. And
actually, how is that personinvolved in a patient's care
if you've done that jobyourself, and you start to
see some of the challenges thatare the allied health
professionals or healthcareprofessionals or healthcare
workers face, because you'vesort of I've done that
before. So certainly givesme a level of can relate to
(06:23):
it a little bit more. And I'mmore sensitive to the
pressures, I think, for sortof the members of the MDT. And
actually, you know,obviously, I'm a dietician
with the media.
So my sole purpose is to sort ofoptimise the nutrition of my
patients. But I think it'sreally important to have a true
understanding of where allthe members of the MDT and all
the healthcare professionalssit and what their roles are
(06:44):
and what you can do to helpthem and what they can do to
help you.
Ultimately, that's whereyou get the best patient
care and the best patientoutcomes. Is there anything
that dieticians who haven't hadthat experience? And
are currently dietitians canget that experience
without sort of quitting thejob and becoming therapy
assistants or working indifferent roles? Is there
any, any way they can dothat? I would say just be
(07:04):
proactive, where you can buildrelationships with other
members on the ward. And ifyou don't work in a ward are
the members of your MDT or youknow, any sort of healthcare
professionals that you workquite closely within
expressed an interest in toshadow spend a bit of time
with them, trying to sortof ask them to explain their
role to you, and even have aconversation and say, how do
(07:24):
you perceive my role? And whydo and how do we work linking
together and see what theirperceptions are, rather
than, you know, guessing whatyou think that perceptions
are. And he's actually havingthat conversation,
which sometimes can be a littlebit daunting, especially if
you're not really familiarwith the other ends up team.
But if you kind of sell it asa, I really want to upskill
(07:45):
myself, so I understand whatyou do and best help support
your role. No reason whypeople won't accommodate
you, I don't think I thinkwith every area sometimes the
plan can seem quite basic andquite simple.
But obviously the journey toget there and why that's so
crucial for the patient oftengets missed in talking to other
therapists actuallyunderstanding that I think
every every job can besimplified into it, just tell
(08:06):
us how many Mills you putdown an mg tube, or you
just tell me how many insertbrand here supplement
drinks that you need to put inor you just get a patient to
sit on the edge of bed andwrite in the notes and say
you've achieved something, butactually understanding
why they're doing that andwhat their processes i
think is, is crucial now.
Yeah, yeah, definitely. Youcame from a sports science
(08:27):
background that usually lendsitself to more of a weight
management or sort of morecommunity based or clinic based
role when you're talkingto patients in clinic. What
made you go for something soclinical is working on the
ward on a busy stroke Ward?
It's funny that isn't it? Asyou say, because, you know, you
traditionally you do seepeople going from, from the
(08:48):
squat science background moreinto more sort of either
personal training stylenutrition roles, exercise
type nutrition roles, or,excuse me, dietetics more
to weight managementgenerally, what I think working
as an assistant, bothin hospital, particularly as
a dietetic assistant,rather than any other, the any
of the other assistantroles. I've all it did, what I
(09:09):
found really interestingfrom the get go is reading
medical notes, and just havinga little look through about,
you know, what's going onwith the patient, what's
a diagnosis, what's thetreatment, what medication are
they on what other peopleare involved in, in their
care, and I just, I wasblown away by how interesting
it is. And for me, the acutesetting is is the most ideal
(09:31):
place to learn more aboutthose, you know, really
acute health problems thatpeople are presenting
with. So I just kind of wantedto get to know more and more
and more about that field. Andpersonally, I didn't think I
would be able to do that if Iwent into sort of a weight
management type role. And whatI really loved about working
on the walls was just howfast paced and hectic it was
(09:53):
nothing quite like the bossof being part of a busy Ward
environment.
Everybody getting on withtheir jobs, but working closely
together and making sure youknow that patients are
safe and they get thetreatment that they need to
really thrive in anenvironment of I felt. So it
was for me, it was exactlywhat I wanted to do rather
than sit in a desk basicallyfor the majority of the day.
Aaron Boysen (10:13):
And that leads us into the recent role that you
you have the extended role,which is a lot more physical
than say most dieticianswould you actually get a
bit more hands on withpatients than the average
dietitian would and obviously,that that extends to placing
nasogastric feeding tubes in theinpatients. Now Could you just
set us a scene like beforeyour role was created what
(10:34):
what was available, likewhat was the standard of
care that was given to thesepatients nutrition wise.
So
Sam Francis (10:41):
I first started working working on the acute
stroke Ward at Bradford asabandoned five so newly
qualified and it was part ofa general bonfire caseload
economy, a few different wardsand clinic every week, and
you cover us our communityhospital ward as well to
quite a heavy amount ofresponsibility.
And that would be part of sortof a bit of a rotational type
(11:01):
basis. But with a stroke unitbeing part of a bonafide
caseload, you couldn't reallyget stuck in you kind of got
to wait for the work to comein. And by waiting for the
worker by work, I mean,obviously we refer patient
referrals and things and bywaiting for that people
will get in missed I thought,although is believes in
initiation of nutrition orgetting people said to either
(11:24):
orally or actuallysooner. So I've found that set
a scene if you're apatient coming on to the
stroke Ward, he just had astroke in Brantford, he
ran into the hypercube unit,he wouldn't see a dietitian
until someone else deemed itnecessary for you to see a
dietitian. And that's sort ofthe background of having not
not much dietetic input.
So therefore, that theculture to refer off a dietitian
(11:46):
wasn't necessarily that strongscreening was slightly delayed,
because again, the train andthe culture wasn't really
implemented. Or it was whatjust in dribs and drabs as
you could do as part of a verybusy caseload cuz, obviously,
having done that myself, itis a very busy caseload,
having four or five inpatientacute wards, community
(12:06):
hospitals and the generalclinic to juggle it's almost in
hindsight, just gobsmacking,that there was never a dedicated
specialist stroke dietitian inthe first place. And I
think for me, that's whatreally stood out when I
first started at Bradforddesign, why didn't exist is
mind blowing.
And the amount of time that Iwould spend on Ward six, those
show unit Ward far exceededanywhere else, and it's
(12:28):
probably in part due to personalinterest. But then also, once
you start on pickingsomething, it just keeps
going, keeps going and keepgoing. And you think, wait a
minute, why isn't thatperson being seen or that
person or that person and youfind yourself being
overwhelmed by one Ward, youknow, to summarise prior
to this post I do now, youprobably would have left sides
(12:49):
as the Kimbo you'd have itlater on, you might go quite
a long time not being seen by adietician, you might not be
identified as needed, needinga dietitian soon enough, which
ultimately, you know, will havea knock on effect to your
recovery in your in yourrehab goals.
Essentially,
Aaron Boysen (13:02):
I think it's also important to acknowledge
like you said, sometimes theculture wasn't there. But
there was no dieticianthere. I mean, everyone, it's
a bit like a dieticianidentifying therapy needs
for a patient.
Obviously, a dietitian coulddefinitely recognise that
and therapy needs a patientwould need however, they're not
going to be anywhere nearas good as say, a
(13:22):
physiotherapist or anoccupational therapist,
identifying those crucialneeds that that patient has,
yeah, and then implementingthem or speech language
therapists, we might noticethat the patient's got
dysphasia, or they'restruggling to swallow. But a
lot of dietitians unless they'vedone external dysphasia
training, and because dysphasiapractitioner, they wouldn't
be able to identify thatas well as, say, a speech
(13:45):
language therapist, I thinkdefinitely probably helps
that you're a dietitian. Andthat's your main focus on
the ward. So while everyone'sworrying about their area, you
have to worry about nutritionas well as, as well as other
things too, but to work as partof the MDT. And I think, as it
comes up more it becomes partof the, as you said, the
culture is asked to getimplemented and it becomes more
(14:06):
standard practice.
Sam Francis (14:07):
That's it, I think, I think it's
really boils down to youdon't know what you don't know
yet. And I think that'sit. I don't I don't think
it's anybody's fault. It'ssort of I think it was just
history. And it's not at theforefront of somebody's
agenda if it's not beingtalked about very regularly.
And it won't be talked about award level, particularly
regularly. If there's nobodythere to talk about it.
(14:28):
Essentially,
Aaron Boysen (14:29):
your role is not just a stroke, dietitian, it's
it's a little bit more thansay, the sort of a specialist,
stroke, dietitian, yourrole has been extended. Why
does that need to happen? Whatwas the purpose in that?
Sam Francis (14:41):
So there's a couple of reasons why.
And there's a couple ofthoughts as to why she do
this. We've noticed quite afew occasions where referrals
of patients were coming in345 plus days down the line
where they had been no biomarfor a significant period of time
and energy hadn't beeninserted. So we were thinking,
you know Lie on the bean insertIs it because there's not
(15:01):
that many people to do itis it because it's not been
that important, you know, peoplestretched and pressures
elsewhere, meaning thatthey're not putting energy
in or if they do come out,they're not putting them
back in timely.
And I've always been of thetrain of thought that I think
upskilling yourself to doa job that would help the
wider workforce is moreproductive than complaining
about what's happening inthe workforce over and over
(15:24):
again, and not actuallychanging any of the outcome. So
that was kind of a personalpush for why I wanted to do
it. And then also the waythat the post by the my post
is funded, was a came about bythe closure of some beds,
patient beds, which releasedsome nursing fund money. So
on the release of that nursingon money, there is an
(15:46):
opportunity to diversify theskill mix of the ward. And
as some of that money wasreleased for therapy, some
of it was released for pharmacytechnicians on some of it will
release for a dietitian, sopart of it was taking that
post on, there was anagreement with the reward
basically no generalmanagement that we'd need to
help with the nursing sidejobs on the wards. We were
(16:07):
thinking, Okay, from whatexactly is it that they do
that we think we could do,and it's directly related to
Nutrition and Dietetics. Andit it just lightbulb
moment, very obvious thatyou know, if we upscaling in
passing energy tubes, nasalretention devices, and
testing, and if necessary,hanging, commencing feeds and
(16:28):
general tube care andtroubleshooting, when it comes
to enteral feeding, thenthat would save a lot of
nursing time.
And it's almost on the wall todo that. They wouldn't have
to contact the nutritionist,wait for them to come back
then if I'm there, thensomebody there a dietitian is
there to deal with all thesenutritional related issues,
essentially,
Aaron Boysen (16:47):
I think that definitely is a natural,
natural fit, because Iremember I started off as
a newly qualified dietician. AndI would get asked questions
around the things youmentioned about tube care, even
said, Can you place it tocng? And I was like, No, I
can't. And it's almost like anautomatic thing they they
suggest as a thing that youshould do. It's almost like an
(17:08):
obvious thing.
Well, you could start startthem off and then you should
get them go in and you shouldI think it does it death. I see
the thing everyone elsesaw saw the fit there,
especially in a place wherethey don't have nutrition
nurses, because not everyhospital has a dedicated
nutrition nurse even I mean,hospitals have multiple
nutrition nurses, andsome hospitals don't have any.
(17:29):
And often a lot of thatresponsibility informing the
ward or different staffabout care of enteral tubes
often falls on the dietitianYeah, absolutely.
Absolutely don't alwaysaren't given always that
specific training because it'snot really in there. Their
job role.
However, I think, as youmentioned, we are we are sort
of the the go to people fornutrition in especially in
(17:52):
an acute setting. Whydon't we know well about some
of these, especially sortof nutrition devices like at
least n g tube.
I know dieticians learn about itas they realise its usefulness,
but I think there definitelycould be more systematised
knowledge around care ofthose things, especially for
(18:12):
new dieticians.
Sam Francis (18:13):
Oh, yeah. 100% agree with that, I think
that my level of competence nowtroubleshooting, energy, peg
related issues is much betterthan it was when I was a
newly qualified dietician. AndI remember being asked a
question about somebody nggwhen I was on a ward and being
like, absolutely no idea and notfeeling confident to
(18:33):
say, you know, try and do thisor do that. Or it might be
because of this. And itjust be me feel like a little
bit like always lacking inknowledge or expertise. And
I always find it quite funnybecause you write enteral
feed regime, and then yougive it to the ward. And then
that's it. But then you'reassociated with that whole
process. And I've been in apatient and that whole sign
(18:55):
of their treatment, butactually all say all we've
done, but what we've done iswrite a feed regime, but we
can't answer questions aboutthe practical side of it.
Other than you know, yourtypical tolerance, issue type
stuff, making sure people arefed a certain angle brief, a
juice blocked, I wouldn't haveknown what to do, because
you've moved by two centimetres,absolutely no idea what to
do. The patient has beencoughing, no idea what to
(19:18):
do. And it's really nice nowto be able to say, Well, in
this situation, try and dothis, or actually, I'll
do this and sort this outfor you. And ultimately
reduces delays in provision ofnutrition, medication
hydration for that patient.
And it's something that could bedragged out by having to bring
the nutrition nurse to findout is actually streamlined and
(19:39):
cut down because I'm onthe ward there to deal with
those issues.
So
Aaron Boysen (19:43):
if you don't have a nutrition nurse, try to
find some, some individual outthere that knows how to
how to deal with that problem,either. As you've developed this
role, and as you've becomeyou've extended the role is
there anything else that'shappened as part of this
role apart from just placingthe nasogastric feed feeding
tubes.
Sam Francis (20:00):
So obviously with the DNR article for SSI, and we
looked at quite a lot of keyperformance indicators and
things to measure. So we basedeverything on Duke guidelines
that are out there at themoment. So things from the
Royal College of Physiciansstroke guidelines, some of the
stroke, Sentinel National Auditprogramme, the snap programme,
(20:21):
and looking at stroke, nicerehabilitation guidelines, and
it was really to try and puta family screening. So
that should be done within 24hours a CIT testing, which
I think I'll come back tothat should be done within
four hours. And thenconsideration of energy
assertions within 24hours. Using nasal bridle
and nasal retention devices,bridles, F and G tubes are
(20:42):
frequently dislodged andmore timely referral for
gastrostomy placement if you'restruggling, either to keep
in use in or if patients arepushing start sort of four
week ish sort of window ofneeding energies and the swallow
isn't looking like it's goingto rehab. So really, we've
tried to identify the need fordietetic intervention
(21:03):
and intervene as fast aspossible in the most effective
way. So I think that was ourreal goal and aim for this
service. And obviously, thatsort of shows in some of the
things that we do. So theextended roles, I think, with
regards to sip testing,genuinely is done by short
responders in our hospital.
So they get alerted whensomeone's coming into a&e
(21:24):
with a stroke.
And they will go and try andsettle in for hours. Or if
there's staffing issues, if theif it's overnight, or if it's a
weekend or a patient isn'tsuitable for us, because
it's your geology, thenyou might pick up alertness to
GCS might improve 24 hours afterthat. They can be reef tested,
but on occasion isn't isn'tanybody in on the water that
(21:45):
has a hypercube bit that cansit as somebody so I can come
on in the morning, andgenerally I'll have a gander
and a quick eyeball at thepatients who is using you who
don't know, who's nearbymark, who is on the Wi Fi
consistency diet, and ifthe patients are nil by
mouth, and they're alert,they're talking for sidewalk,
they look like they'reappropriate for a sip test.
I'll ask you know, is thereanyone available to
(22:06):
sit tests? And if there isn't,then I'll just I'll just do
it. Because I'm competencytrained to do that. And it's
been two occasions thisweek, actually, we're doing
patients or something nilby mouth, and they can link
it back to you know, our aimwas to get nutrition implemented
sooner rather than later. Iasked him you know, are you
happy for me to sit as theywere they passed and then
we got a drink a cup of teaand I've been a goal Weetabix
(22:28):
within 20 minutes of mecoming into the ward where it
could be hours later. And youknow, you don't become
malnourished in a space of fourhours walk the patient's
experience and quality oflife. And what is important to
them is to be able to have acup of tea or a bowl of
Weetabix. And that's thething that they'll remember, I
think is you know, beingseen sooner and being able to
(22:49):
get back to some form ofnormality, despite being
on a ward sooner ratherthan later. So for me, that's
sometimes as important aslooking at the more technical
scientific key performanceindicators is actually how
did the patient feel there. Andthen definitely, I
Aaron Boysen (23:04):
think if you add all those things
up, sometimes patients thathave been in a long time are
the most complex patients those,those experiences of
either being nil by mouthfor we were talking about
as dietitians, I've gotprocedures that have to go for
being nearby mouth, I've gotthings that have to do
being nil, by mouth, theyhave a period where they they're
struggling to tolerate theirfeed, or the food that's
being given.
(23:24):
And all of those experiences, ifthey are delayed or through
staffing issues or throughprioritisation, then obviously
that makes an impact on thepatient, whether it's
one acute event or they add upover time. And I think it's a
really good thing for sortof expanding our our scope
of practice. So we can supportthese patients and sort of
say, well, well, it's anutrition related thing.
(23:45):
I'm trained in that area.
Yeah, let me sort it foryou. Let me do that for you.
Sam Francis (23:49):
Yeah, definitely. And I think, you
know, I introduce myself, as I'msome on the stroke
dietitian, and I'm here todayto do a sit test this
morning, which you know, willhopefully enable you to
start eating and drinking again,normally, and patients, I'd
like to open it, it makessense to them in their head.
They're not thinking, Waita minute was my fifth dietitian
doing that.
That's, that's not somethingthat I expect them to do. But
(24:10):
it fits in quite nicelywith what, what our role is. So
I think it makes completesense, in my opinion.
Aaron Boysen (24:16):
Definitely.
I think I really lovedthe story that you gave, can
you Is there any sort ofexperiences you've had, where
everything sort of connectedtogether? Or it's all sort
of how would it work in inpractice a journey, you
just give us like a like acase study or a patient gets
admitted? How would thatprocess go with you there as a
stroke dietitian,
Sam Francis (24:35):
so I think, you know, there's been a number
of times where I've fallen tothe wall. So I come in first
and go to the office, youknow, sell a cup of tea, all
that stuff. And then I go tothe ward generally
around the time of the wardround, the hazard Ward
round. So when people are sortof newly admitted with a
stroke, they belong there.
And a lot of the timethey're the ones that are
(24:56):
new nearby miles and theyyou know, they might have to
draw the for even storageassessment, and it's not
looking like they're goingto become more alert anytime
soon as I go to the ward andidentify those patients stents
off to the side of the mainbulk of people and Ward around
and, you know, interject whereI think there might be a
question. So, you know, thesepatients know, why more? Is
(25:19):
there a plan for nutritionat this point?
You know, sometimes theconsultant says, No, I
don't think it's appropriate.
And obviously, you have torespect that medical
decision. But sometimes Isay, Actually, no, I think you
are right there is we shouldstart enteral feeding. And I
think that's a sensible thingto do. They go on to the next
patient, I've built arelationship to a point with
the consultants where I canjust say, you know, are you
happy for me to place an NGCfor this patient, obviously, as
(25:41):
probate patients concern andthings and do a capacity
assessment if necessary, theconsultant essentially,
now just rubber stamps itbecause he has that much sort
of faith and trust in me asa part of his MDT, I'll just
go off, get the stuff ready incertain energy to move on and
you know, either myselfor the nurse or on the feed.
And, you know, it goes fromtime to seen on water on site
(26:01):
time to initiate andnutrition is probably half
an hour, half an hour, 45minutes. That's probably a
seamless as it's going toget. I think I'm not sure
how I would optimise thatprocess. And he certainly
didn't have tried to optimise itright up
Aaron Boysen (26:15):
to the speed of delivery of nutrition is a
lot faster than previously. Andobviously, that we could gather
from that has an impact onpatient outcomes patient's life,
not just sort of the lengthof time they stay, but how
how well, their life ispoststroke as well.
Sam Francis (26:30):
Yeah, certainly, certainly, all the majority of
the evidence out theresuggests you know that if you're
malnourished, then your highermortality risk you're going to
be in hospital for for longer,you're going to have more risk
of infections, and generallyyour level of disability will
be larger. So if we canprevent or treat malnutrition
(26:50):
from the front door, then youwill have an effect on treatment
outcome. And
Aaron Boysen (26:54):
so you mentioned a little bit about your
recognise if, if a patient'son a modified consistency
diet or nil by mouth, wouldyou would you see those
patients? How would you reactto those patients? What
would you say a patient's beendim nearby mouth that
morning? Would you go see thatpatient? Or how would that work?
Sam Francis (27:12):
Yeah.
So I mean, my referral, ourreferral criteria for stroke,
dietetic service is being no I'moff having a must have to or
above, you know, which issimilar to a lot of other
dietetic services. Andalso anybody requiring a
modified consistencydiet, because there's strong
evidence, you know, the restof my interest is higher. If
(27:33):
you want to modify consistencydiet, for patients that
are nearby mark, I'd usuallyintroduce myself and just
sort of make some common ornod to the fact that they're
nearby mark.
And can you just give themthe reason why that they are?
Because I find that somebodyissued services before and
somebody is obviously anobserver of day to day practice
on wards is some thingshappen to patients and
(27:55):
sometimes it's not alwaysexplained why that is the
case. So people can be stuckthere. All he says on their
board is an n b. c, laypersonwhat not doesn't mean
anything at all. And they're notbeing told why but know why
mark, sometimes not always. Ifeel like being a person that
can you explain that tosomebody if they do understand
this? He knows simply reasonwhy you know why mark is
because you've had a stroke,and you fail the CIT test,
(28:18):
this is what I said, tested.
And at that point, I won'tgo all guns blazing, and
say, right, so I think we needto put an energy tube
down, I'll say, you know,there's somebody else
in the team that can comein, especially swallow and
their speech languagetherapist, and this is what
their role is, and then thepatient expects knows what to
expect, then they know who'scoming to see them next, then
it up found that a lot ofthe time it calms people
down and you know, it givesthem a bit of reassurance
(28:38):
that they need.
So it doesn't take hours andhours to do for referrals to
myself on the on the electronicsystem and write up that whole
conversation in literally justhave a passing comment and
say, you'll be seeing myspeech and language
therapist. If you pass that'sgreat. We can start eating
and drinking.
And if you fail, and youneed enteral feeding, then
obviously I can come in and dothe next step of that as
well. And they already know myface at that point. So when
(29:00):
it comes to see them again, I'mfamiliar. I'm not like oh,
like, wow, who's thisperson? I mean, you're more
scared?
Aaron Boysen (29:07):
Yeah, definitely. It helps to give
them a little bit ofknowledge and power in a time
where they probably feeltheir most vulnerable and
powerless.
Absolutely.
Sam Francis (29:14):
Empowering is a good word to you.
Aaron Boysen (29:16):
So you mentioned a little bit about how you
built the relationshipwith the MDT and the
consultant and things likethat. How did you do that?
Like it's obviously beenover a year, too. Yeah,
yeah. About 818 months is kindof an 18 months, we've
had 18 months to build thisrole. How have you done it? Is
there anything unique thatyou've done or any sort of
(29:38):
crucial, basically tipsand tricks should we say?
dietitians, tips, clickbaitretail tips for developing a
great relationshipwith the other members of the
MDT go?
Sam Francis (29:51):
No pressure. I think having a presence on the
ward is probably one ofmy number one tips or tricks
is be there.
You know, let people know whoyou are, what you do, and
what you can do to helppatients and also them,
rather than this is who Iam. This is how you can help me
and just get to know people,introduce yourself, be
(30:14):
friendly, try and relate topeople on preferred personal and
professional levels wherepossible, and just be
enthusiastic.
Ultimately, you can't justthink about things in terms
of what is the dieteticoutcome here is about thinking
about what is the ultimatetreatment aim for this
patient? So medically, youknow, therapy, socially,
(30:34):
personally, all of thosethings? And where do we fit
into that, thinking aboutthe bigger picture and you
know, I use the word before, inholistic way.
And that sort of reallyinstils, where you fit in a
team into other people's minds.
So I think that's reallyimportant. And for me, being
around being helpful, it hashelped particularly having an
(30:55):
extended role because youhave an immediate impact from
somebodies work within a team,which is a patient required an
energy tube, a patient now hasone thanks to a stroke
dietitian, rather than a patientrequires nutritional
intervention, hopefully, theydon't get malnourished
later on. So you do get animmediate impact in Irish
factories, I think hashelped quite a lot, I think.
Yeah, I think that's it. Youcan think of anything else.
Aaron Boysen (31:18):
I mean, you mentioned about being present
on the ward and things likethat. And that's wonderful. And
I think I obviously, obviouslyexperienced being present
and being on the ward. And Ithink, as times gone on,
obviously, with paper notes, itwas really, really easy,
because we had to write up onthe ward. And we wrote in
those paper notes, butoften with electronic
(31:40):
medical notes, I thinksometimes it can be quite
difficult for dietitians tobe as present as they were
before not in their presenceas in them talking and
relating to people on apersonal or professional
level. But they're actually justbeing a body on the water, just
sitting there available toanswer questions or
bounce things off? Likeshould this patient be
referred to you or I'm havingquestions about this? Or X or
(32:02):
Y? Do you think it has value?
Or do you think it's a waste oftime or nothing, there's
Sam Francis (32:06):
a massive value to physically being present
on a ward, I remember when Iwas a dietetic assistant
working with a few differenttypes of dietitians, and he had
different types of healthcareprofessionals everywhere you
go. And for whateverreason, there was some people
that would go to awards, stayon the ward right off, and
then do a lot of their workon the ward and all the people
who come on right as fastas they can when they get
(32:27):
off the ward.
And it is like a flat. And thediversion then was remembered
as someone who just slips inand out of the ward. And I
sort of vowed to myself thenalthough years ago that that
wasn't the type of dietitian Iwas going to be I wanted to be
somebody that was veryheavily Ward base and have a
presence on the ward it is canbe difficult logistically,
(32:47):
if you don't have any mobilekit, again, computers on a
ward and things like that, whenwhen those are electronic. So
when we sort of started thispost was one of my essential
bits of criteria wasto, to be able to have a
laptop and remote work,essentially, to be able to go
to a world with a laptop and doeverything from that laptop.
Aaron Boysen (33:06):
I mean, I made it possible with COVID. Now, I
mean, that was before COVIDaffected us and made a lot of
people work from home, doyou think it has enough
benefit to make it worthwhile,
Sam Francis (33:15):
I think having a laptop that was 100% then
benefits and make itworthwhile. And I think the
wider acuity and I work in aseen some of that benefit.
And I think majority if notall of those now have
laptops, you know, it couldbe seeing a duplication of
electronic equipment,because there are computers
on wards. But you know,anyone that's worked on a
ward knows how difficult it isto get a computer sometimes and
(33:36):
it's very much of this is mycomputer, you can't sort of
just view this as a computerfor the day or and inevitably,
at that point, you're going tohave to write your notes up
somewhere else but that thenhas a knock on effect the
presence you have on theward. And then like you say it
reduces your ability totroubleshoot unanswered
questions for patients aroundthe okay or or any prospective
referrals where people areconcerned about the nutritional
(33:58):
status of that patient. Soit's made a massive massive
difference I think just
Aaron Boysen (34:03):
almost be in that sign there to make
people go Oh, yeah, nutritionall the time. I just that
constant little reminder allthe time.
Little person sitting there.
Yeah. Over in wherever yousit. I don't know. It's
because you'll have to spendtime writing notes you just
that constant reminder of Oh,when's that patient do for
the most screen? When'sthe when's this do? When's this
jus when's my patients beennearby mouth for how long?
Sam Francis (34:26):
Yeah.
It's funny to visithealthcare on the ward who
commonly will walk past andas always accountable to
me will tell me I've done afood record chart for the
jackin bed fine. And I'llsay all thanks for that.
Anyway, just carry on.
Obviously, I've never expectedthat from him, but the IP in
there, that's what he feels,you know, he's accountable to
me, which, you know,ultimately is still a better
(34:48):
outcome for that patientbecause they haven't been
there inside and monitoredproperly.
Definitely.
Yeah.
Aaron Boysen (34:53):
I think I'm gonna ask you more philosophical
questions. Do you think goingforward as a benefit for
more dieticians bye Seeingmajor gastric feeding tubes.
I think it's helpful. Do youthink more dietitians
should do it?
Sam Francis (35:05):
I think it's certainly helpful. I
think, as with anything else,you need to sort of assess
the clinical need for you todo that. And whether there's
a need to do it because,obviously, you know, a
predominantly outpatientdietitian probably
wouldn't, well wouldn't needto train to place energy
tubes. I said, I say, well,because it depends why our
patient service your workflowdoesn't get bought
Aaron Boysen (35:27):
home.
enteral feeding? I
Sam Francis (35:28):
think it goes, Yeah, exactly. Why?
Well, you can either clearlyprevent admissions and
that's it.
Yeah, that's something thatcould definitely be a
lot of start, I think is a bigdevelopment area in the future
outpatient insertion ofenergy tubes for patients from a
dietician or other healthcareprofessionals to prevent
admissions for that patient?
Well, yeah, I think if youassess if you look at the
(35:49):
clinical need, and there'squite a high prevalence of
patients in an area that requireenteral, feeding specifically,
you know, nice gastricfeeding, or even nice, gentle
obviously, there arepeople that are trained out
there to place nj tubes atbedside, then I think it's
really worth at that point,exploring competency
based training through insertLowe's, N, G and G and j
(36:11):
tubes. If you think thatthere's a need for it, I
personally would recommendit. If there's any punch that
might be beneficial fora patient, I'd say, you know,
dieticians, should look attrying to focus skill in that
area, because it's really mydevelopment in the past 18
months, as a result of doingthat has been absolutely
astronomical, like it'smassive, my confidence for
(36:33):
dealing with patients thatare actually fed not just from a
tolerance perspective,but the wider treatment and
the wider enteral feedingtreatment is just much, much
bigger. And I think I'veshown in equilibrium,
and you know, it does have aknock on effect to patient
outcomes. If you can be there totroubleshoot, initiate,
(36:53):
become an expert in bothnutrition and also roots of
nutrition, it makes you amuch more well rounded
dietitian, in my opinion.
Aaron Boysen (37:00):
So you said something I'm just gonna pick
up, pick up what he said.
He said there's a clinicalneed. Now, your clinical need
was it saves nurses nursingtime. That was correct. Am I
Sam Francis (37:11):
not just that though, it was, obviously we
needed to prove that in termsof the funding, so money is
coming from nursing budget.
So therefore, we need to showthat we were having a
positive effect on receivingnursing time.
But the obviously theother clinical need is, you
know, initiating nutrition earlyfor patients that have had a
stroke. And the evidence doessuggest, you know, prevent
(37:31):
involving nutrition doeshave positive outcomes for
those patients.
Aaron Boysen (37:35):
What which clinical area, is that
not a clinical need?
Sam Francis (37:39):
Well, there isn't, is a, I think if
you had an establishedteam, that we're inserting
energy juice really efficientlydealing with any problems,
like straight away, and youfell Actually, I've actually
no need to get involved inthis because it is already a
very, very good enteral feedingservice, that at that point,
maybe you could say, you know,there's no real need to me to
(38:00):
upskill in the moment, Iguess, what is a big thing to
consider is if you train toplace, nga chiefs or
anything like that, and youcan't keep up with the
competencies, then you willbe going competent very
quickly. So it's somethingthat if you are going to train
to do that, you kind of need todo it regularly to get good at
it. And then also become anexpert in it, which I think
you should be striving tobecome an expert in it if
(38:21):
you want. If you want tostart doing that in the
first place.
Aaron Boysen (38:23):
Definitely.
So in an area where enoughenergy tubes, you would
insert enough energy tubes onyour daily job role to enable
to maintain a competencylevel so that you're safe to
place ngga there's nopoint training, placing a few
mg tubes going Whoo, yeah,taking a picture for
social media.
Yeah, and then go ahead andplace within a couple months.
(38:44):
Absolutely.
Sam Francis (38:45):
Absolutely.
You don't want to do and, youknow, you need to be confident
in doing it. We see patientswith energy tubes all the
time, as dietitians,obviously, but there is
actually quite a dangerousthing to do is to insert an mg
and to start feeding downit. So if you aren't
confident when you're whenyou're placing that tube, you
could really put the patientat quite a high risk, really.
Aaron Boysen (39:07):
So you need to ensure that you're placing
enough mg tubes that you remaincompetent. And I think there
is, as you mentioned,there's loads of different
areas where I mean, you'renot the only dietician in
the UK that does this ismultiple dietitians and
they don't all work in stroke.
There's so many different areaswhere this would be a
benefit to the wider MDT andsupporting them, but also
improving patient careand hopefully helping
(39:28):
outcomes. So what kind ofimpact what kind of
outcomes have you actuallymeasured during the
implementation of the serviceand what's been the areas that
you've looked at?
Sam Francis (39:37):
Yeah, so one of the outcomes we wanted to
measure was the amount ofpatients that were considered
for mg tube within 24hours, which is it falls in
line with the Royal Collegephysician guidelines for
stroke and at the start, wehad pulled a load of patient
data and we found that foronly 40% of patients were being
considered for energy tubeinsertion. And then you know,
12 months into the post, itwas up to 94%.
(39:59):
So Not every one of thosepatients is going to have
an energy issue for a varietyof reasons. But statistically
if more patients thatrequire energy feeding will
have an energy placed within24 hours as it's being
considered in the firstinstance. So that was a really
important outcome measurefor us. I think what we've
proved is that we can initiatenutrition quicker for
patients when you havesomebody with an extended role a
(40:21):
dietitian with an extendedrole, but what we want to do
next is to work out exactlywhat difference that makes to a
patient. So looking atfunctional outcomes,
obviously we look atanthropometry all the time,
we're being a bit morespecific with that. So rather
than looking at just BMI,looking at calfs conference,
Malappuram maybe bioelectricimpedance analysis, if that's
appropriate, and seeing whata wider anthropometrical
(40:45):
picture looks like when itcomes to people's physical
rehabilitation.
So what goals are being setor working towards with
Visio and occupationaltherapy, and, you know,
optimising their nutritionalstatus, what effect does
that have on their functional ontherapy, goals and outcomes?
On the flip side of that,if somebody is struggling to
maintain nutritional status, forwhatever reason, whether
(41:07):
that's, you know, nottolerating, and YouTube's not
tolerating all issues andsupport, losing weight becoming
weaker, those that have anegative effect on therapy, led
goals and outcomes,
Aaron Boysen (41:17):
have the MDT and enjoyed you're having they're
not just the consultant, butthe other members of the
MDT. So the nursing staffand what's been their feeling
behind it? Is anyone said,are you stealing my
job? I really want to placesmg tubes.
Sam Francis (41:29):
No, not at all.
It's, it's been quite theopposite. It's been a massive
help, I think, both, you know,actually physically
taking the job in terms ofinserting and ngg. And then
also part of the developmentof this extended role
is that I'm kind of the lead fortraining new doctors, new
nurses on the safe insertionof n g tubes, and safe
(41:51):
insertion of nasal retentiondevices on the wall. So it's
really freed up time thatotherwise might have been spent
elsewhere, safely, it'sbeen very well received even
so point a one point I'd kindof like, Listen, it's
not just my job to put nggtubes in, so we're gonna
have to start looking atthis. That's not all I'm
here for. Yeah, so in thatsituation, where there's
multiple patients eatingand then jishu, who kind of got
(42:12):
to a point where there wasan expectation for me to put
them all in and actually hadsort of a conversation.
And, you know, this isn't justmy job, I still need to write
fi plans, I still need toimplement all nutritional
support, I still need toreview all the vast all the
things that we do asdietitian, so I'd sit down
with some nurses and thedoctors and say, you know,
there are eight patients thatneed them, there are four
bodies do them.
(42:33):
So let's do to each occlusionquite a bit more of a
planning role, as well asphysically for him, and
YouTube and for patients. Sothat's kind of been the, you
know, the development andmaturation of this role.
Aaron Boysen (42:46):
Brian, have you got any tips for
any, any dieticiansinterested in this area? How
can they what are the whatare the first steps they need
to do?
Sam Francis (42:54):
So I think have a have a chat with your your
manager supervisor andsort of say this is kind of
what I want to do, I thinkthat that is something that
you want to do and whetherit's relevant in your area.
And then if you've got anutrition nursing team
within the trust, and that's afantastic resource to use
absolutely nowhere to bedoing what I'm doing, if it
weren't for the competencyframework that they'd already
(43:15):
devised, spend some time withthem to see, you know,
observe as many anglesassertions, as you can see,
that actually, is what youwant to do, because some of
them are quite traumatic, bothfor patients and for the
people doing them. Andalways sort of nice and easy
pictures that you see in thedietetics magazines and
things like that they're notparticularly pleasant at
(43:36):
times. So just making surethat it's something you
want to do, and kind of askyourself a question is why
you actually want to dothat. And then I think it's
priority area for where youwork, then sort of pursue it
and go ahead with it. Thereare a few governance thingies,
little hoops that you needto jump through with clinical
(43:56):
governance and things likethat. But I think if
there's a good enough clinicalreason to do it, and you can
demonstrate that you willhave a big impact, and you're
ultimately better for thepatient, then I think, you know,
absolutely pursue it wouldbe my advice.
Aaron Boysen (44:11):
Thank you. And I think I think I'd advise
everyone to get the copy ofthat CME magazine read
the article and understand moreabout Sam's role and he's
got some brilliant sortof numbers in there that you
can look at and see the massiveimpact he's had on patients
outcome and how it's actuallyimproved care and reduce
costs in the wider MDT andactually showing the impact.
(44:33):
dieticians can have when theirtheir roles extended in an
intentional way, looking atthe areas and I just want to
say nasal gastric tube isnot the only way that
dietitians can extend theirroles. So there's has
lots of other ways thatdietitians can be flexible and
learn to extend their roles.
And hopefully we'll have somemore of those on the podcast.
And I want to thank Sam forhis time. And that's it.
(44:53):
You're very welcome,everyone. It's been a quite
pleasant way to spend myevening. Thank you very much.
Thank you for joining us thisEpisode of the dietetics
digest podcast.
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