SKILLS & LEARNING
EXTENDED ROLES IN DIETETICS: A CASE STUDY Kaylee Allan RD ICU Dietitian, Southmead Hospital Bristol Kaylee works as a Critical Care Dietitian in Bristol and is undertaking a MClinRes part time with Plymouth University. Her interests are ICU, research and sports nutrition.
Extended roles in the NHS have shown to boost job satisfaction, improve the dietetic profile, enhance multidisciplinary team learning and most importantly, provide better patient care.1,1a This article takes a look at a recent case study that highlights the positive outcomes of extended roles in dietetics. Within dietetics, there are many clinical specialists with extended roles as part of their day-to-day responsibilities. Roles which were traditionally held by nursing or medical professionals are now held by dietitians working beyond their recognised scope of practice. In an effort to modernise the NHS, extended roles were introduced amongst Allied Health Professionals (AHPs), which have been shown to boost job satisfaction, improve the dietetic profile, enhance multidisciplinary team learning and most importantly, provide better patient care.1 There is a gap within the available literature which firmly concludes that extended roles enhance patient care. However, it is well reported that patient outcomes are likely to be
improved due to earlier interventions, where traditionally procedures were performed by medical staff.2 There is little known about the effectiveness of AHP training programmes and competency frameworks which underpin extended scope of practice. Nevertheless, there are many examples within dietetics of highly skilled extended roles, like feeding tube insertion and requesting condition specific blood tests and scans, all of which require training and an awareness of the liability associated with the job.3 This article explores a recent case study and the impact of two dietitians with different extended roles, and the benefit to the patient care. To protect patient confidentiality, details have been adjusted.
CASE STUDY A 50-year-old gentleman admitted to the intensive care unit (ICU) following a road traffic collision. Injuries included multiple broken ribs, fractured sternum and pneumothorax. Due to chest injuries and the difficulties maintaining his oxygen requirements, the patient was ventilated and sedated on day one. The patients’ ability to ventilate worsened due to respiratory failure, and the decision was made to prone (ventilate the patient, face down instead of supine). At this stage, the ICU dietitian was asked to review the patient and make a decision about the feeding options. Assessment Table 1: Initial assessment made by ICU dietitian Assessment Baseline (weight, height, BMI*) Admission details PMH+ Discussions with medical team *BMI (body mass index) +PMH (Past Medical History) **NG (nasogastric) ++ NJ (nasojejunal)
Findings BMI >30kg/m2 Respiratory failure, prone position, vomiting, no NG** feeding tube in situ. Gastric band placed eight years ago to aid weight loss. Failing to ventilate, oesophageal dilation on CT, gastric band in situ, vomiting, unable to pass an NG tube. Team would like an NJ tube placed at bedside to prevent vomiting whilst patient is in a prone position. Patient desaturates quickly when returned to supine position, making NJ++ insertion difficult.
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SKILLS & LEARNING Placing patients who are obese into a face down (prone) position can have a lung protective effect by improving the functional residual capacity and prevent atelectasis.4 Locally, nearly one quarter of ICU patients admitted are obese (BMI >30kg/m2) and 4% of those patients are morbidly obese (BMI >40kg/m2). Table 2 looks at the challenges faced by the dietetic team in this case. Feeding issues Table 2: Issues with feeding this patient and questions asked by the ICU dietitian Issues Vomiting (risk of aspiration and inability to feed) Patient desaturates quickly when in the supine position, making an NJ placement difficult Inability to pass an NG
Questions Was the gastric band too tight causing the patient to vomit? Was the gastric band the cause of oesophageal dilation and poor ventilation? Is the gastric band too tight, making it difficult to place a feeding tube? Would inserting an NJ tube be challenging?
The patient’s inability to ventilate well in supine could be caused by the gastric band being overfilled (too tight). This causes pouch enlargement proximal to the band which can cause oesophageal dilation due to a build-up in pressure.5 To help answer the initial questions, help was sought from the dietitian working within the bariatric team as an advanced practitioner and expert in filling and adjusting gastric bands. Action plan On arrival to the ICU, the bariatric dietitian requested to see the CT scan to establish where the gastric band port was situated in the patient. The patient was turned supine to allow the bariatric dietitian to access the port which was situated within the fractured sternum. With support from consultant colleagues, the port was found and 5mls aspirated from the band. The ICU dietitian was able to successfully place a 10FG NJ feeding tube at bedside, using an electromagnetic tracing technique. An NG was also successfully placed and the patient could be repositioned into the prone position. Both tubes were bridled by the ICU dietitian to prevent tube dislodgement during turns. Outcome The next day, the patient was in supine and nursing staff reported that his ventilation had significantly improved. He no longer had any episodes of vomiting and he was successfully feeding via the NJ tube at the target rate. In the following few days, the patient was successfully extubated and repatriated to a hospital nearer to home. Learning points Advanced practice goes beyond being a good practitioner with extensive experience. The British Dietetic Association (BDA) career framework is based on the four pillars of practice.6 The four pillars are defined by the National Leadership and Innovation Agency for Healthcare (NLIAH)7 and are based on four key areas which advanced practitioners must encompass during their development. Contributions from each pillar of practice will vary depending on the type of job held (clinical, research, private sector). Table 3: Four pillars (as outlined specifically for dietitians by the BDA) adapted from the BDA advanced practice document, 20126 Pillar of practice Advanced dietetic practice Research and evidenced-based practice
Leadership and management
Education and facilitating learning
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Description Demonstrates expert knowledge and skill, manages a complex caseload and can influence practice (locally and nationally) to benefit the service users. Leads the development of research, audit and service evaluation within their remit, identifies gaps in knowledge, is up to date with current research within area of expertise and has a sound understanding of research methodologies. Demonstrates the capacity for shared leadership. Can negotiate and influence key stakeholders and provide information to recognise working is efficient and optimal. Facilitates learning of others, is recognised as an expert within the field, actively contributes to specialist groups and undertakes CPD in the form of reflection, feedback and supervision.
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CONCLUSION
Healthcare is by no means a static entity and is being forced to adapt to the current financial climate. Dietitians hoping to develop their service provision, will need to encompass the four pillars of practice (see Table 3) in order to become established advanced clinical practitioners. The AHPs into action drive, focuses on the breadth of skills and expertise AHPs have, making us ideally placed to lead and transform healthcare services. AHPs are the third biggest workforce within the NHS. The Five Year Forward View movement by NHS England is hoping to develop more advanced clinical practice posts suitable for AHPs.8
The case study reported on in this article demonstrates how two experienced dietitians, active within research and teaching, were able to successfully treat the patient, without much assistance from nursing or medical staff. They had the desirable expertise and knowledge to manage the situation, which resulted in a positive patient outcome. This is not an isolated case, many dietitians across the UK work in roles which are complex and innovative. It is important as a small profession to share these roles, the journeys people have taken to adopt those positions and inspire the next generation of dietitians to do the same.
References 1 Ryan D, Pelly F, Purcell E. Exploring extended scope of practice in dietetics: a systems approach. Nutrition & dietetics: the journal of the Dietitians Association of Australia. 2017; 74: 334 1a. The British Dietetic Association (BDA) Professional Development Guidance Document for Extended Scope Practice, available from: www.bda.uk.com/publications/ professional/extendedscope2015 [accessed 09/04/2018 2 Saxon RL, Gray MA, Oprescu FI. Extended roles for allied health professionals: an updated systematic review of the evidence. Journal of Multidisciplinary Healthcare. 2014; 7: 479 3 Marsland C. Dietitians and small bowel feeding tube placement. Nutrition in Clinical Practice. 2010; 25: 270-276 4 De Jong A, Molinari N, Sebbane M et al. Feasibility and effectiveness of prone position in morbidly obese patients with ARDS: A Case-Control Clinical Study. Chest. 2013; 143: 1554-1561 5 Eid I, Birch DW, Sharma AM, Sherman V, Karmali S. Complications associated with adjustable gastric banding for morbid obesity: a surgeon's guide.(Clinical report). Canadian Journal of Surgery. 2011; 54: 61 6 The British Dietetic Association (BDA) Advanced Practice: Capabilities for Advanced Practice in Dietetics, 2012. Birmingham. Available from: https://www.bda. uk.com/professional/practice/advanced [Accessed 25/04/2018] 7 National Leadership and Innovation Agency for Healthcare (2011). Framework for Advanced Nursing, Midwifery and Allied Health Professional Practice in Wales. www.wales.nhs.uk/sitesplus/documents/829/NLIAH%20Advanced%20Practice%20Framework.pdf [Accessed 25/4/18] 8 NHS England (2017). Next steps on the NHS five year forward view. London. www.england.nhs.uk/ahp/ahps-into-action/ [Accessed 16/05/2018]
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