Should dietitians place NG tubes? feat. Sam Francis RD

Sam Francis: 0:00

nothing quite like the boss of being part of the BD Ward environment, everybody getting on with their jobs but working closely together in making sure you know that patients are safe and they're getting the treatment that they need to really thrive in an environment of I felt so it was for me it was exactly what I wanted to do rather than sitting at a desk basically for the majority of the day.

Aaron Boysen: 0:21

Welcome to the dietetics digest podcast with your host and dietitian me Aaron Boysen dietetics digest is a podcast created and produced by dieticians for dietitians, we interview dieticians from around the world to talk about their journey and their groundbreaking work. This podcast will help inspire you and others to become the best dietician possible. Sam Francis, welcome to the dietetics digest podcast. Sam Francis is a specialist stroke dietitian working at Bradford teaching hospitals. He recently actually started the role in NHS terms and last couple of years. And he's really developed this new role as a specialist stroke dietitian in a place where there wasn't one previously he recently published an article about his work in the CN magazine around his practices of stroke dietitian and the extended role he's been able to do and the benefits it's had to patients, but also to the service as a whole. Is there anything I've missed there, Sam to sort of introduce us? I don't think so. And that summarise is what I've been up to quite nicely. So thank you for inviting me on to the show. It's a real pleasure. No problem. I think especially since your cm magazine article on when you were able to sort of display the kinds of things you've been doing and the kind of improvements in patient care. I think it really intrigued me. And I think a lot of people are also interested in this area, specifically the area about extending dietitians role and extending the role into placing nasogastric feeding tubes. But also, I know you do a few sip tests as well to help support the nutrition of patients and help them be identified as at risk early. So that stuff can be done a little bit about the nutrition. But maybe we could start a little bit early on sort of a little bit of background of how you got first into dietetics where your journey sort of started. Yeah, absolutely is quite funny, really. In the office and in our teams, I seem to find every single support and role within the hospital leading up to becoming a registered dietitian. But my background originally was in Sport Science. I graduated in 2012, from the University of Salford doing a degree in sports science. And I think it was kind of then that my interest in nutrition sparked, which I think is quite a typical story for male dietitian actually is you know, coming from a sports science sort of background, I was quite sporty myself growing up and bought, I sustained a few injuries and put quite a lot of weight on in my sort of late teenage years. And it kind of got to a point where I thought I needed to pay a bit more attention to my health. And I think that's where the actual reading around nutrition soul came to the fore and sparked my interest. So to speak. From there, I started to look at careers in nutrition. So have a little look around, obviously leave loads, stuffing NHS websites, there's lots of things about being a nutritionist or a nutrition ologists, or a nutrition therapist and all those types of things is really important to me to have a regulated profession. So that's where dietetics comes in. I then went on to do a post grad certificate in human nutrition diplomas to do a full Master's in human nutrition. The University of Chester quickly found out that that would lead me probably no further on down the line and doing a degree in Sport Science with regards to actually getting my foot in the door anywhere. So I quit sure and just did the 60 credits and did the nutrition. I applied them for dietetics. And I was unsuccessful on my first go, which was a little bit disheartening. So decided that that's not for me, I'm going to do that because they didn't want me on the course anyway, so definitely not something I want to do anymore. So decided to take a job working as a pharmacy assistant. So I'd worked throughout my undergrad studies. I was a community pharmacy anyway. And I took a job as a pharmacy assistant and within short Hospital in Manchester. So I did that for a short period of time before a dietetic assistant job came up, I applied for that. And I did that at Bolton for for a good year, I was going to then apply for dietetics again, and I did we bought a job came up for a marketing part of Lucas Lucas aid sport and decided to say that instead that as the pay was quite good, so that was second attempt of getting into dietetics abandoned by herself when travelling that typical stuff and then came back and worked as a respiratory assistant. So a therapy assistant for a key for a couple years as a band three, and four and then eventually applied to dietetics again and was accepted in 2016. So quite a long way around houses there. But obviously then I did my two years. I did some training abroad to do the placement and blackmailer really enjoyed it and it kind of set himself is where where I would like to work and fortunately there was a bonfire of opportunity when I was due to graduate so I applied for that and was successful. So that was kind of the way around the country's way into dietetics and things

Sam Francis: 5:00

So that's kind of my, my way into dietetics.

Aaron Boysen: 5:03

Do you ever find that those those previous maybe they worked in clinical areas as a therapy assistant or previous jobs you've had outside of dietetics help inform your dietetics today and your decisions around sort of understanding what other members of the team do and their their goals, more than say, just sort of a sort of a cosmetic understanding that sometimes we try to do like read a job description and try to try to empathise empathise with empathise, but try to see it from their point of view? Do you think that having those roles and being in that team helps you better understand their goals and their purpose? Really?

Sam Francis: 5:36

Yeah, definitely. I think it was invaluable, invaluable. It's funny because we, we try and work in a holistic manner. And we say, we're holistic practitioners. And we like to see that holistic viewpoint. But actually, you know, how far does it go? When it goes to actually, how holistic? Are we? Do we have a true understanding? Or is it just a nice trigger word that people like to use application form? And I think, sometimes you only know a certain amount by observing and sort of watching from afar, but then you start to PG start to come together. And actually, how is that person involved in a patient's care if you've done that job yourself, and you start to see some of the challenges that are the allied health professionals or healthcare professionals or healthcare workers face, because you've sort of I've done that before. So certainly gives me a level of can relate to it a little bit more. And I'm more sensitive to the pressures, I think, for sort of the members of the MDT. And actually, you know, obviously, I'm a dietician with the media. So my sole purpose is to sort of optimise the nutrition of my patients. But I think it's really important to have a true understanding of where all the members of the MDT and all the healthcare professionals sit and what their roles are and what you can do to help them and what they can do to help you. Ultimately, that's where you get the best patient care and the best patient outcomes. Is there anything that dieticians who haven't had that experience? And are currently dietitians can get that experience without sort of quitting the job and becoming therapy assistants or working in different roles? Is there any, any way they can do that? I would say just be proactive, where you can build relationships with other members on the ward. And if you don't work in a ward are the members of your MDT or you know, any sort of healthcare professionals that you work quite closely within expressed an interest in to shadow spend a bit of time with them, trying to sort of ask them to explain their role to you, and even have a conversation and say, how do you perceive my role? And why do and how do we work linking together and see what their perceptions are, rather than, you know, guessing what you think that perceptions are. And he's actually having that conversation, which sometimes can be a little bit daunting, especially if you're not really familiar with the other ends up team. But if you kind of sell it as a, I really want to upskill myself, so I understand what you do and best help support your role. No reason why people won't accommodate you, I don't think I think with every area sometimes the plan can seem quite basic and quite simple. But obviously the journey to get there and why that's so crucial for the patient often gets missed in talking to other therapists actually understanding that I think every every job can be simplified into it, just tell us how many Mills you put down an mg tube, or you just tell me how many insert brand here supplement drinks that you need to put in or you just get a patient to sit on the edge of bed and write in the notes and say you've achieved something, but actually understanding why they're doing that and what their processes i think is, is crucial now. Yeah, yeah, definitely. You came from a sports science background that usually lends itself to more of a weight management or sort of more community based or clinic based role when you're talking to patients in clinic. What made you go for something so clinical is working on the ward on a busy stroke Ward? It's funny that isn't it? As you say, because, you know, you traditionally you do see people going from, from the squat science background more into more sort of either personal training style nutrition roles, exercise type nutrition roles, or, excuse me, dietetics more to weight management generally, what I think working as an assistant, both in hospital, particularly as a dietetic assistant, rather than any other, the any of the other assistant roles. I've all it did, what I found really interesting from the get go is reading medical notes, and just having a little look through about, you know, what's going on with the patient, what's a diagnosis, what's the treatment, what medication are they on what other people are involved in, in their care, and I just, I was blown away by how interesting it is. And for me, the acute setting is is the most ideal place to learn more about those, you know, really acute health problems that people are presenting with. So I just kind of wanted to get to know more and more and more about that field. And personally, I didn't think I would be able to do that if I went into sort of a weight management type role. And what I really loved about working on the walls was just how fast paced and hectic it was nothing quite like the boss of being part of a busy Ward environment. Everybody getting on with their jobs, but working closely together and making sure you know that patients are safe and they get the treatment that they need to really thrive in an environment of I felt. So it was for me, it was exactly what I wanted to do rather than sit in a desk basically for 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 dieticians would you actually get a bit more hands on with patients than the average dietitian would and obviously, that that extends to placing nasogastric feeding tubes in the inpatients. Now Could you just set us a scene like before your role was created what what was available, like what was the standard of care that was given to these patients nutrition wise. So

Sam Francis: 10:41

I first started working working on the acute stroke Ward at Bradford as abandoned five so newly qualified and it was part of a general bonfire caseload economy, a few different wards and clinic every week, and you cover us our community hospital ward as well to quite a heavy amount of responsibility. And that would be part of sort of a bit of a rotational type basis. But with a stroke unit being part of a bonafide caseload, you couldn't really get stuck in you kind of got to wait for the work to come in. And by waiting for the worker by work, I mean, obviously we refer patient referrals and things and by waiting for that people will get in missed I thought, although is believes in initiation of nutrition or getting people said to either orally or actually sooner. So I've found that set a scene if you're a patient coming on to the stroke Ward, he just had a stroke in Brantford, he ran into the hypercube unit, he wouldn't see a dietitian until someone else deemed it necessary for you to see a dietitian. And that's sort of the background of having not not much dietetic input. So therefore, that the culture to refer off a dietitian wasn't necessarily that strong screening was slightly delayed, because again, the train and the culture wasn't really implemented. Or it was what just in dribs and drabs as you could do as part of a very busy caseload cuz, obviously, having done that myself, it is a very busy caseload, having four or five inpatient acute wards, community hospitals and the general clinic to juggle it's almost in hindsight, just gobsmacking, that there was never a dedicated specialist stroke dietitian in the first place. And I think for me, that's what really stood out when I first started at Bradford design, why didn't exist is mind blowing. And the amount of time that I would spend on Ward six, those show unit Ward far exceeded anywhere else, and it's probably in part due to personal interest. But then also, once you start on picking something, it just keeps going, keeps going and keep going. And you think, wait a minute, why isn't that person being seen or that person or that person and you find yourself being overwhelmed by one Ward, you know, to summarise prior to this post I do now, you probably would have left sides as the Kimbo you'd have it later on, you might go quite a long time not being seen by a dietician, you might not be identified as needed, needing a dietitian soon enough, which ultimately, you know, will have a knock on effect to your recovery in your in your rehab goals. Essentially,

Aaron Boysen: 13:02

I think it's also important to acknowledge like you said, sometimes the culture wasn't there. But there was no dietician there. I mean, everyone, it's a bit like a dietician identifying therapy needs for a patient. Obviously, a dietitian could definitely recognise that and therapy needs a patient would need however, they're not going to be anywhere near as good as say, a physiotherapist or an occupational therapist, identifying those crucial needs that that patient has, yeah, and then implementing them or speech language therapists, we might notice that the patient's got dysphasia, or they're struggling to swallow. But a lot of dietitians unless they've done external dysphasia training, and because dysphasia practitioner, they wouldn't be able to identify that as well as, say, a speech language therapist, I think definitely probably helps that you're a dietitian. And that's your main focus on the ward. So while everyone's worrying about their area, you have to worry about nutrition as well as, as well as other things too, but to work as part of the MDT. And I think, as it comes up more it becomes part of the, as you said, the culture is asked to get implemented and it becomes more standard practice.

Sam Francis: 14:07

That's it, I think, I think it's really boils down to you don't know what you don't know yet. And I think that's it. I don't I don't think it's anybody's fault. It's sort of I think it was just history. And it's not at the forefront of somebody's agenda if it's not being talked about very regularly. And it won't be talked about a ward level, particularly regularly. If there's nobody there to talk about it. Essentially,

Aaron Boysen: 14:29

your role is not just a stroke, dietitian, it's it's a little bit more than say, the sort of a specialist, stroke, dietitian, your role has been extended. Why does that need to happen? What was the purpose in that?

Sam Francis: 14:41

So there's a couple of reasons why. And there's a couple of thoughts as to why she do this. We've noticed quite a few occasions where referrals of patients were coming in 345 plus days down the line where they had been no biomar for a significant period of time and energy hadn't been inserted. So we were thinking, you know Lie on the bean insert Is it because there's not that many people to do it is it because it's not been that important, you know, people stretched and pressures elsewhere, meaning that they'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 the train of thought that I think upskilling yourself to do a job that would help the wider workforce is more productive than complaining about what's happening in the workforce over and over again, and not actually changing any of the outcome. So that was kind of a personal push for why I wanted to do it. And then also the way that the post by the my post is funded, was a came about by the closure of some beds, patient beds, which released some nursing fund money. So on the release of that nursing on money, there is an opportunity to diversify the skill mix of the ward. And as some of that money was released for therapy, some of it was released for pharmacy technicians on some of it will release for a dietitian, so part of it was taking that post on, there was an agreement with the reward basically no general management that we'd need to help with the nursing side jobs on the wards. We were thinking, Okay, from what exactly is it that they do that we think we could do, and it's directly related to Nutrition and Dietetics. And it it just lightbulb moment, very obvious that you know, if we upscaling in passing energy tubes, nasal retention devices, and testing, and if necessary, hanging, commencing feeds and general tube care and troubleshooting, when it comes to enteral feeding, then that would save a lot of nursing time. And it's almost on the wall to do that. They wouldn't have to contact the nutritionist, wait for them to come back then if I'm there, then somebody there a dietitian is there to deal with all these nutritional related issues, essentially,

Aaron Boysen: 16:47

I think that definitely is a natural, natural fit, because I remember I started off as a newly qualified dietician. And I would get asked questions around the things you mentioned about tube care, even said, Can you place it to cng? And I was like, No, I can't. And it's almost like an automatic thing they they suggest as a thing that you should do. It's almost like an obvious thing. Well, you could start start them off and then you should get them go in and you should I think it does it death. I see the thing everyone else saw saw the fit there, especially in a place where they don't have nutrition nurses, because not every hospital has a dedicated nutrition nurse even I mean, hospitals have multiple nutrition nurses, and some hospitals don't have any. And often a lot of that responsibility informing the ward or different staff about care of enteral tubes often falls on the dietitian Yeah, absolutely. Absolutely don't always aren't given always that specific training because it's not really in there. Their job role. However, I think, as you mentioned, we are we are sort of the the go to people for nutrition in especially in an acute setting. Why don't we know well about some of these, especially sort of nutrition devices like at least n g tube. I know dieticians learn about it as they realise its usefulness, but I think there definitely could be more systematised knowledge around care of those things, especially for new dieticians.

Sam Francis: 18:13

Oh, yeah. 100% agree with that, I think that my level of competence now troubleshooting, energy, peg related issues is much better than it was when I was a newly qualified dietician. And I remember being asked a question about somebody ngg when I was on a ward and being like, absolutely no idea and not feeling confident to say, you know, try and do this or do that. Or it might be because of this. And it just be me feel like a little bit like always lacking in knowledge or expertise. And I always find it quite funny because you write enteral feed regime, and then you give it to the ward. And then that's it. But then you're associated with that whole process. And I've been in a patient and that whole sign of their treatment, but actually all say all we've done, but what we've done is write a feed regime, but we can't answer questions about the practical side of it. Other than you know, your typical tolerance, issue type stuff, making sure people are fed a certain angle brief, a juice blocked, I wouldn't have known what to do, because you've moved by two centimetres, absolutely no idea what to do. The patient has been coughing, no idea what to do. And it's really nice now to be able to say, Well, in this situation, try and do this, or actually, I'll do this and sort this out for you. And ultimately reduces delays in provision of nutrition, medication hydration for that patient. And it's something that could be dragged out by having to bring the nutrition nurse to find out is actually streamlined and cut down because I'm on the 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 out there that knows how to how to deal with that problem, either. As you've developed this role, and as you've become you've extended the role is there anything else that's happened as part of this role apart from just placing the nasogastric feed feeding tubes.

Sam Francis: 20:00

So obviously with the DNR article for SSI, and we looked at quite a lot of key performance indicators and things to measure. So we based everything on Duke guidelines that are out there at the moment. So things from the Royal College of Physicians stroke guidelines, some of the stroke, Sentinel National Audit programme, the snap programme, and looking at stroke, nice rehabilitation guidelines, and it was really to try and put a family screening. So that should be done within 24 hours a CIT testing, which I think I'll come back to that should be done within four hours. And then consideration of energy assertions within 24 hours. Using nasal bridle and nasal retention devices, bridles, F and G tubes are frequently dislodged and more timely referral for gastrostomy placement if you're struggling, either to keep in use in or if patients are pushing start sort of four week ish sort of window of needing energies and the swallow isn't looking like it's going to rehab. So really, we've tried to identify the need for dietetic intervention and intervene as fast as possible in the most effective way. So I think that was our real goal and aim for this service. And obviously, that sort of shows in some of the things that we do. So the extended roles, I think, with regards to sip testing, genuinely is done by short responders in our hospital. So they get alerted when someone's coming into a&e with a stroke. And they will go and try and settle in for hours. Or if there's staffing issues, if the if it's overnight, or if it's a weekend or a patient isn't suitable for us, because it's your geology, then you might pick up alertness to GCS might improve 24 hours after that. They can be reef tested, but on occasion isn't isn't anybody in on the water that has a hypercube bit that can sit as somebody so I can come on in the morning, and generally I'll have a gander and a quick eyeball at the patients who is using you who don't know, who's nearby mark, who is on the Wi Fi consistency diet, and if the patients are nil by mouth, and they're alert, they're talking for sidewalk, they look like they're appropriate for a sip test. I'll ask you know, is there anyone available to sit tests? And if there isn't, then I'll just I'll just do it. Because I'm competency trained to do that. And it's been two occasions this week, actually, we're doing patients or something nil by mouth, and they can link it back to you know, our aim was to get nutrition implemented sooner rather than later. I asked him you know, are you happy for me to sit as they were they passed and then we got a drink a cup of tea and I've been a goal Weetabix within 20 minutes of me coming into the ward where it could be hours later. And you know, you don't become malnourished in a space of four hours walk the patient's experience and quality of life. And what is important to them is to be able to have a cup of tea or a bowl of Weetabix. And that's the thing that they'll remember, I think is you know, being seen sooner and being able to get back to some form of normality, despite being on a ward sooner rather than later. So for me, that's sometimes as important as looking at the more technical scientific key performance indicators is actually how did the patient feel there. And then definitely, I

Aaron Boysen: 23:04

think if you add all those things up, sometimes patients that have been in a long time are the most complex patients those, those experiences of either being nil by mouth for we were talking about as dietitians, I've got procedures that have to go for being nearby mouth, I've got things that have to do being nil, by mouth, they have a period where they they're struggling to tolerate their feed, or the food that's being given. And all of those experiences, if they are delayed or through staffing issues or through prioritisation, then obviously that makes an impact on the patient, whether it's one acute event or they add up over time. And I think it's a really good thing for sort of expanding our our scope of practice. So we can support these patients and sort of say, well, well, it's a nutrition related thing. I'm trained in that area. Yeah, let me sort it for you. Let me do that for you.

Sam Francis: 23:49

Yeah, definitely. And I think, you know, I introduce myself, as I'm some on the stroke dietitian, and I'm here today to do a sit test this morning, which you know, will hopefully enable you to start eating and drinking again, normally, and patients, I'd like to open it, it makes sense to them in their head. They're not thinking, Wait a minute was my fifth dietitian doing that. That's, that's not something that I expect them to do. But it fits in quite nicely with what, what our role is. So I think it makes complete sense, in my opinion.

Aaron Boysen: 24:16

Definitely. I think I really loved the story that you gave, can you Is there any sort of experiences you've had, where everything sort of connected together? Or it's all sort of how would it work in in practice a journey, you just give us like a like a case study or a patient gets admitted? How would that process 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 to the wall. So I come in first and go to the office, you know, sell a cup of tea, all that stuff. And then I go to the ward generally around the time of the ward round, the hazard Ward round. So when people are sort of newly admitted with a stroke, they belong there. And a lot of the time they're the ones that are new nearby miles and they you know, they might have to draw the for even storage assessment, and it's not looking like they're going to become more alert anytime soon as I go to the ward and identify those patients stents off to the side of the main bulk of people and Ward around and, you know, interject where I think there might be a question. So, you know, these patients know, why more? Is there a plan for nutrition at this point? You know, sometimes the consultant says, No, I don't think it's appropriate. And obviously, you have to respect that medical decision. But sometimes I say, Actually, no, I think you are right there is we should start enteral feeding. And I think that's a sensible thing to do. They go on to the next patient, I've built a relationship to a point with the consultants where I can just say, you know, are you happy for me to place an NGC for this patient, obviously, as probate patients concern and things and do a capacity assessment if necessary, the consultant essentially, now just rubber stamps it because he has that much sort of faith and trust in me as a part of his MDT, I'll just go off, get the stuff ready in certain energy to move on and you know, either myself or the nurse or on the feed. And, you know, it goes from time to seen on water on site time to initiate and nutrition is probably half an hour, half an hour, 45 minutes. That's probably a seamless as it's going to get. I think I'm not sure how I would optimise that process. And he certainly didn't have tried to optimise it right up

Aaron Boysen: 26:15

to the speed of delivery of nutrition is a lot faster than previously. And obviously, that we could gather from that has an impact on patient outcomes patient's life, not just sort of the length of time they stay, but how how well, their life is poststroke as well.

Sam Francis: 26:30

Yeah, certainly, certainly, all the majority of the evidence out there suggests you know that if you're malnourished, then your higher mortality risk you're going to be in hospital for for longer, you're going to have more risk of infections, and generally your level of disability will be larger. So if we can prevent or treat malnutrition from the front door, then you will have an effect on treatment outcome. And

Aaron Boysen: 26:54

so you mentioned a little bit about your recognise if, if a patient's on a modified consistency diet or nil by mouth, would you would you see those patients? How would you react to those patients? What would you say a patient's been dim nearby mouth that morning? Would you go see that patient? Or how would that work?

Sam Francis: 27:12

Yeah. So I mean, my referral, our referral criteria for stroke, dietetic service is being no I'm off having a must have to or above, you know, which is similar to a lot of other dietetic services. And also anybody requiring a modified consistency diet, because there's strong evidence, you know, the rest of my interest is higher. If you want to modify consistency diet, for patients that are nearby mark, I'd usually introduce myself and just sort of make some common or nod to the fact that they're nearby mark. And can you just give them the reason why that they are? Because I find that somebody issued services before and somebody is obviously an observer of day to day practice on wards is some things happen to patients and sometimes it's not always explained why that is the case. So people can be stuck there. All he says on their board is an n b. c, layperson what not doesn't mean anything at all. And they're not being told why but know why mark, sometimes not always. I feel like being a person that can you explain that to somebody if they do understand this? He knows simply reason why you know why mark is because you've had a stroke, and you fail the CIT test, this is what I said, tested. And at that point, I won't go all guns blazing, and say, right, so I think we need to put an energy tube down, I'll say, you know, there's somebody else in the team that can come in, especially swallow and their speech language therapist, and this is what their role is, and then the patient expects knows what to expect, then they know who's coming to see them next, then it up found that a lot of the time it calms people down and you know, it gives them a bit of reassurance that they need. So it doesn't take hours and hours to do for referrals to myself on the on the electronic system and write up that whole conversation in literally just have a passing comment and say, you'll be seeing my speech and language therapist. If you pass that's great. We can start eating and drinking. And if you fail, and you need enteral feeding, then obviously I can come in and do the next step of that as well. And they already know my face at that point. So when it comes to see them again, I'm familiar. I'm not like oh, like, wow, who's this person? I mean, you're more scared?

Aaron Boysen: 29:07

Yeah, definitely. It helps to give them a little bit of knowledge and power in a time where they probably feel their 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 relationship with the MDT and the consultant and things like that. How did you do that? Like it's obviously been over a year, too. Yeah, yeah. About 818 months is kind of an 18 months, we've had 18 months to build this role. How have you done it? Is there anything unique that you've done or any sort of crucial, basically tips and tricks should we say? dietitians, tips, clickbait retail tips for developing a great relationship with the other members of the MDT go?

Sam Francis: 29:51

No pressure. I think having a presence on the ward is probably one of my number one tips or tricks is be there. You know, let people know who you are, what you do, and what you can do to help patients and also them, rather than this is who I am. This is how you can help me and just get to know people, introduce yourself, be friendly, try and relate to people on preferred personal and professional levels where possible, and just be enthusiastic. Ultimately, you can't just think about things in terms of what is the dietetic outcome here is about thinking about what is the ultimate treatment aim for this patient? So medically, you know, therapy, socially, personally, all of those things? And where do we fit into that, thinking about the bigger picture and you know, I use the word before, in holistic way. And that sort of really instils, where you fit in a team into other people's minds. So I think that's really important. And for me, being around being helpful, it has helped particularly having an extended role because you have an immediate impact from somebodies work within a team, which is a patient required an energy tube, a patient now has one thanks to a stroke dietitian, rather than a patient requires nutritional intervention, hopefully, they don't get malnourished later on. So you do get an immediate impact in Irish factories, I think has helped quite a lot, I think. Yeah, I think that's it. You can think of anything else.

Aaron Boysen: 31:18

I mean, you mentioned about being present on the ward and things like that. And that's wonderful. And I think I obviously, obviously experienced being present and being on the ward. And I think, as times gone on, obviously, with paper notes, it was really, really easy, because we had to write up on the ward. And we wrote in those paper notes, but often with electronic medical notes, I think sometimes it can be quite difficult for dietitians to be as present as they were before not in their presence as in them talking and relating to people on a personal or professional level. But they're actually just being a body on the water, just sitting there available to answer questions or bounce things off? Like should this patient be referred to you or I'm having questions about this? Or X or Y? Do you think it has value? Or do you think it's a waste of time or nothing, there's

Sam Francis: 32:06

a massive value to physically being present on a ward, I remember when I was a dietetic assistant working with a few different types of dietitians, and he had different types of healthcare professionals everywhere you go. And for whatever reason, there was some people that would go to awards, stay on the ward right off, and then do a lot of their work on the ward and all the people who come on right as fast as they can when they get off the ward. And it is like a flat. And the diversion then was remembered as someone who just slips in and out of the ward. And I sort of vowed to myself then although years ago that that wasn't the type of dietitian I was going to be I wanted to be somebody that was very heavily Ward base and have a presence on the ward it is can be difficult logistically, if you don't have any mobile kit, again, computers on a ward and things like that, when when those are electronic. So when we sort of started this post was one of my essential bits of criteria was to, to be able to have a laptop and remote work, essentially, to be able to go to a world with a laptop and do everything from that laptop.

Aaron Boysen: 33:06

I mean, I made it possible with COVID. Now, I mean, that was before COVID affected us and made a lot of people work from home, do you 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 it worthwhile. And I think the wider acuity and I work in a seen some of that benefit. And I think majority if not all of those now have laptops, you know, it could be 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 is to get a computer sometimes and it's very much of this is my computer, you can't sort of just view this as a computer for the day or and inevitably, at that point, you're going to have to write your notes up somewhere else but that then has a knock on effect the presence you have on the ward. And then like you say it reduces your ability to troubleshoot unanswered questions for patients around the okay or or any prospective referrals where people are concerned about the nutritional status of that patient. So it'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, nutrition all the time. I just that constant little reminder all the time. Little person sitting there. Yeah. Over in wherever you sit. I don't know. It's because you'll have to spend time writing notes you just that constant reminder of Oh, when's that patient do for the most screen? When's the when's this do? When's this jus when's my patients been nearby mouth for how long?

Sam Francis: 34:26

Yeah. It's funny to visit healthcare on the ward who commonly will walk past and as always accountable to me will tell me I've done a food record chart for the jackin bed fine. And I'll say all thanks for that. Anyway, just carry on. Obviously, I've never expected that 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 outcome for that patient because they haven't been there inside and monitored properly. Definitely. Yeah.

Aaron Boysen: 34:53

I think I'm gonna ask you more philosophical questions. Do you think going forward as a benefit for more dieticians bye Seeing major gastric feeding tubes. I think it's helpful. Do you think 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 to do that. And whether there's a need to do it because, obviously, you know, a predominantly outpatient dietitian probably wouldn't, well wouldn't need to train to place energy tubes. I said, I say, well, because it depends why our patient service your workflow doesn'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 clearly prevent admissions and that's it. Yeah, that's something that could definitely be a lot of start, I think is a big development area in the future outpatient insertion of energy tubes for patients from a dietician or other healthcare professionals to prevent admissions for that patient? Well, yeah, I think if you assess if you look at the clinical need, and there's quite a high prevalence of patients in an area that require enteral, feeding specifically, you know, nice gastric feeding, or even nice, gentle obviously, there are people that are trained out there to place nj tubes at bedside, then I think it's really worth at that point, exploring competency based training through insert Lowe's, N, G and G and j tubes. If you think that there's a need for it, I personally would recommend it. If there's any punch that might be beneficial for a patient, I'd say, you know, dieticians, should look at trying to focus skill in that area, because it's really my development in the past 18 months, as a result of doing that has been absolutely astronomical, like it's massive, my confidence for dealing with patients that are actually fed not just from a tolerance perspective, but the wider treatment and the wider enteral feeding treatment is just much, much bigger. And I think I've shown in equilibrium, and you know, it does have a knock on effect to patient outcomes. If you can be there to troubleshoot, initiate, become an expert in both nutrition and also roots of nutrition, it makes you a much 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 clinical need. Now, your clinical need was it saves nurses nursing time. That was correct. Am I

Sam Francis: 37:11

not just that though, it was, obviously we needed to prove that in terms of the funding, so money is coming from nursing budget. So therefore, we need to show that we were having a positive effect on receiving nursing time. But the obviously the other clinical need is, you know, initiating nutrition early for patients that have had a stroke. And the evidence does suggest, you know, prevent involving nutrition does have 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 established team, that we're inserting energy juice really efficiently dealing with any problems, like straight away, and you fell Actually, I've actually no need to get involved in this because it is already a very, very good enteral feeding service, that at that point, maybe you could say, you know, there's no real need to me to upskill in the moment, I guess, what is a big thing to consider is if you train to place, nga chiefs or anything like that, and you can't keep up with the competencies, then you will be going competent very quickly. So it's something that if you are going to train to do that, you kind of need to do it regularly to get good at it. And then also become an expert in it, which I think you should be striving to become an expert in it if you want. If you want to start doing that in the first place.

Aaron Boysen: 38:23

Definitely. So in an area where enough energy tubes, you would insert enough energy tubes on your daily job role to enable to maintain a competency level so that you're safe to place ngga there's no point training, placing a few mg tubes going Whoo, yeah, taking a picture for social media. Yeah, and then go ahead and place within a couple months. Absolutely.

Sam Francis: 38:45

Absolutely. You don't want to do and, you know, you need to be confident in doing it. We see patients with energy tubes all the time, as dietitians, obviously, but there is actually quite a dangerous thing to do is to insert an mg and to start feeding down it. So if you aren't confident when you're when you're placing that tube, you could really put the patient at quite a high risk, really.

Aaron Boysen: 39:07

So you need to ensure that you're placing enough mg tubes that you remain competent. And I think there is, as you mentioned, there's loads of different areas where I mean, you're not the only dietician in the UK that does this is multiple dietitians and they don't all work in stroke. There's so many different areas where this would be a benefit to the wider MDT and supporting them, but also improving patient care and hopefully helping outcomes. So what kind of impact what kind of outcomes have you actually measured during the implementation of the service and 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 of patients that were considered for mg tube within 24 hours, which is it falls in line with the Royal College physician guidelines for stroke and at the start, we had pulled a load of patient data and we found that for only 40% of patients were being considered for energy tube insertion. And then you know, 12 months into the post, it was up to 94%. So Not every one of those patients is going to have an energy issue for a variety of reasons. But statistically if more patients that require energy feeding will have an energy placed within 24 hours as it's being considered in the first instance. So that was a really important outcome measure for us. I think what we've proved is that we can initiate nutrition quicker for patients when you have somebody with an extended role a dietitian with an extended role, but what we want to do next is to work out exactly what difference that makes to a patient. So looking at functional outcomes, obviously we look at anthropometry all the time, we're being a bit more specific with that. So rather than looking at just BMI, looking at calfs conference, Malappuram maybe bioelectric impedance analysis, if that's appropriate, and seeing what a wider anthropometrical picture looks like when it comes to people's physical rehabilitation. So what goals are being set or working towards with Visio and occupational therapy, and, you know, optimising their nutritional status, what effect does that have on their functional on therapy, goals and outcomes? On the flip side of that, if somebody is struggling to maintain nutritional status, for whatever reason, whether that's, you know, not tolerating, and YouTube's not tolerating all issues and support, losing weight becoming weaker, those that have a negative 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, but the other members of the MDT. So the nursing staff and what's been their feeling behind it? Is anyone said, are you stealing my job? I really want to places mg tubes.

Sam Francis: 41:29

No, not at all. It's, it's been quite the opposite. It's been a massive help, I think, both, you know, actually physically taking the job in terms of inserting and ngg. And then also part of the development of this extended role is that I'm kind of the lead for training new doctors, new nurses on the safe insertion of n g tubes, and safe insertion of nasal retention devices on the wall. So it's really freed up time that otherwise might have been spent elsewhere, safely, it's been very well received even so point a one point I'd kind of like, Listen, it's not just my job to put ngg tubes in, so we're gonna have to start looking at this. That's not all I'm here for. Yeah, so in that situation, where there's multiple patients eating and then jishu, who kind of got to a point where there was an expectation for me to put them all in and actually had sort of a conversation. And, you know, this isn't just my job, I still need to write fi plans, I still need to implement all nutritional support, I still need to review all the vast all the things that we do as dietitian, so I'd sit down with some nurses and the doctors and say, you know, there are eight patients that need them, there are four bodies do them. So let's do to each occlusion quite a bit more of a planning role, as well as physically for him, and YouTube and for patients. So that's kind of been the, you know, the development and maturation of this role.

Aaron Boysen: 42:46

Brian, have you got any tips for any, any dieticians interested in this area? How can they what are the what are the first steps they need to do?

Sam Francis: 42:54

So I think have a have a chat with your your manager supervisor and sort of say this is kind of what I want to do, I think that that is something that you want to do and whether it's relevant in your area. And then if you've got a nutrition nursing team within the trust, and that's a fantastic resource to use absolutely nowhere to be doing what I'm doing, if it weren't for the competency framework that they'd already devised, spend some time with them to see, you know, observe as many angles assertions, as you can see, that actually, is what you want to do, because some of them are quite traumatic, both for patients and for the people doing them. And always sort of nice and easy pictures that you see in the dietetics magazines and things like that they're not particularly pleasant at times. So just making sure that it's something you want to do, and kind of ask yourself a question is why you actually want to do that. And then I think it's priority area for where you work, then sort of pursue it and go ahead with it. There are a few governance thingies, little hoops that you need to jump through with clinical governance and things like that. But I think if there's a good enough clinical reason to do it, and you can demonstrate that you will have a big impact, and you're ultimately better for the patient, then I think, you know, absolutely pursue it would be my advice.

Aaron Boysen: 44:11

Thank you. And I think I think I'd advise everyone to get the copy of that CME magazine read the article and understand more about Sam's role and he's got some brilliant sort of numbers in there that you can look at and see the massive impact he's had on patients outcome and how it's actually improved care and reduce costs in the wider MDT and actually showing the impact. dieticians can have when their their roles extended in an intentional way, looking at the areas and I just want to say nasal gastric tube is not the only way that dietitians can extend their roles. So there's has lots of other ways that dietitians can be flexible and learn to extend their roles. And hopefully we'll have some more of those on the podcast. And I want to thank Sam for his time. And that's it. You're very welcome, everyone. It's been a quite pleasant way to spend my evening. Thank you very much. Thank you for joining us this Episode of the dietetics digest podcast. To share your thoughts on today's episode, please visit our social media. Our main channels are Instagram and Twitter. Also, if you enjoyed the podcast Why not leave us a review on Apple podcasts or a podcast host of your choice or consider telling a friend about the podcast. Finally, make sure that you subscribe and follow the podcast so that you can stay up to date with our latest episodes.