Issue 147 Developing a dietetic service

SKILLS & LEARNING

DEVELOPING A DIETETIC SERVICE Trying to set up a new dietetic service or developing an existing one can seem overwhelming, and pressures in the NHS may mean that doing this isn’t always feasible. This article discusses the factors that I considered for setting up a dietetic service to high output stoma patients.

When I was a Band 5 dietitian working on the acute medical assessment unit, I became increasingly aware of high output stoma patients being admitted with dehydration. They were hydrated with intravenous fluids (IV) and sent home a day or two later, but would often find themselves back in within a few months. I wondered if the individuals had been given any information on how to manage a high output stoma: was it the ‘norm’ for them and did they know how to start to manage it? With these questions in mind, I started to capture data to identify any trends.

I started to screen for patients who were admitted with the presenting complaint of dehydration. I then looked to see who had a jejunostomy, ileostomy, or colostomy. This created my data collection patient sample.

Referral to the dietitian was often not made for the patients in this sample and if a referral was made, it was not guaranteed that the dietitian saw the patient prior to their discharge, due to prioritisation of caseload. Looking at this retrospective data, I had the idea that if all jejunostomy, ileostomy and colostomy patients were provided with education on ‘how to manage their stoma output’, it may help with preventing these hospital admissions with dehydration. That formed the initial aim of my service, to contribute to preventing recurring hospital admissions with dehydration due to a high output stoma. I realised

that in order to achieve this aim, I would need to work closely with key stakeholders.

ENGAGING WITH KEY STAKEHOLDERS

I arranged a meeting with the stoma nurses and a colorectal surgeon at the trust and discussed my data findings. We were all in agreement that multidisciplinary team (MDT) working to educate and support this group of patients could only be beneficial to their patient experience and would hopefully prevent admissions with problems associated with stoma management. We discussed that I would see all jejunostomy, ileostomy and colostomy patients for dietary advice.

(All jejunostomy patients were already seen by a senior dietitian due to the increased requirement for parenteral nutrition.) We realised that I would need to provide ‘troubleshooting’ information to all patients who had an ileostomy, on how to manage a high stoma output should it ever develop in the future, so that they were informed and prepared.

Louise Edwards Specialist Dietitian, Community Team Lead Louise is a Specialist Dietitian working for the Central Cheshire Integrated Care Partnership (CCICP). She is the Community Team Lead and is passionate about service improvement.

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MULTIDISCIPLINARY TEAM (MDT) WORKING

Previously, the stoma nurses and dietitians worked minimally together, with the dietitians providing education at a support group a couple of times a year. After discussing the data I had collected, we were all driven to improve the service to this patient group. It was agreed that the nurses would refer to www.NHDmag.com August/September 2019 - Issue 147

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SKILLS & LEARNING

As part of the service, it was agreed that dietetics would provide an urgent service clinic, so that patients could be reviewed within one week of discharge from hospital.

me when a new stoma was formed during bowel surgery and we would aim to do a joint visit to introduce our newly formed ‘MDT’ and for me to provide my newly designed diet sheet on ‘troubleshooting for your ileostomy’. This diet sheet aimed to recognise signs of dehydration, ways to thicken output and fluid management, etc.

Within the MDT, we had the support of a colorectal surgeon who was happy to be our ‘go to’ consultant when we needed to discuss any individuals who we were really concerned about post-operatively. As part of this newly formed MDT, we decided to implement a weekly ward round, seeing predominantly the high output ileostomy patients. Whilst doing the rounds, it became clear to me and the stoma nurse that the variability in the management plan for a high output ileostomy patient depended on the doctors that had seen them and what ward they were on, etc. Again, I data collected this information looking at: • the length of time before medication to reduce output was initiated; • the dosage of the medication and how many times a day it was prescribed; • the rate at which the medication dosage was increased, etc.

The colorectal surgeon was surprised by the variability in these management plans and asked that I present the findings to all the general and 40

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colorectal surgeons at the Trust, which I did. This presentation was well received and the consensus was to look at creating a standardised protocol for the management of a high output stoma.

BENCHMARKING

To consider creating a standardised guideline, I thought about the term ‘benchmarking’: seeking out and implementing best practice.1 I contacted local Trusts and specialist centres to see if they had a standardised pathway for management of high output stomas to create a guideline that they felt would work in the Trust. The surgeon and I reviewed literature around management plans of high output stomas with Baker et al (2010)2 being a great source of information. Once all this had been collated, I sat with the colorectal surgeon and a gastroenterologist to create a pathway that they felt would work in the Trust.

This guideline had to be ratified at the relevant governance meetings and input from pharmacy was essential for instruction on the medications involved. The surgeons felt that this guideline supported doctors at all levels in their training in prescribing medications for a high output stoma.

As part of the weekly MDT ward round, the stoma nurse and I were able to highlight to the medical/surgical team whether a management plan was put in place that differed from the guideline.

SKILLS & LEARNING OUTPATIENT CLINICS

Patients were often discharged from hospital with a management plan for a high output stoma. As part of the service, it was agreed that dietetics would provide an urgent service clinic, so that patients could be reviewed within one week of discharge from hospital. I had to locate an appropriate clinic room in the hospital and work with the administrative support to set up 30-minute clinic appointments for all patients.

Following the trust policy, as a Band 6 dietitian, I was able to order bloods to assess hydration status and magnesium levels and was able to discuss these results with the consultant surgeon. This close working ensured that any patient who the surgeon was concerned about could be brought through to the surgical assessment unit for further review. In this clinic, I saw all stoma patients post-discharge and I used outcome measures to capture the patient experience of the service.

OUTCOME MEASURES

An outcome measure is defined as the ‘change in the health of an individual, group of people, or a population which is attributable to an intervention, or series of interventions.3 Creating outcome measures for this service was important to support decision-making and to demonstrate that it was a key service that made a difference to an individual’s health and quality of life.3 Patient reported outcome measures (PROMS) were implemented with a LIKERT scale of 1-10 for patients to rate the degree of their symptoms.4 For some, wind was their main concern, for others constipation, or odour for some high output.

Reviewing these outcome measure results at

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the start of the consultation supported tailoring dietary advice to the individual’s priorities.

CONTINUING PROFESSIONAL DEVELOPMENT (CPD)

Once the outpatient clinic was well established, it formed a fundamental part of CPD for the Band 5 dietitian, who I supervised in the gastroenterology/surgical rotation. The Band 5 was invited to shadow me in clinic initially, and then progress to seeing patients with indirect supervision. Reflecting on the service was continuous and before I left the Trust, there was still potential to develop it, for example, the stoma nurses and I discussed setting up a ‘pre-op bowel school’ to provide education and awareness of what individuals could expect after bowel surgery.

My initial aim of the service was to contribute to preventing recurring hospital admissions with high output stomas. As the service developed, other aims were identified, such as standardising the medical management of a high output stoma patient and contributing to reducing length of hospital stays post-surgery. It is likely that this service will continue to evolve with feedback within the MDT and feedback from outcome measures.

It is my own professional value to strive for service improvement for patients and I have been fortunate in my working career so far that the Trusts I have worked for have strived for this also. I would like to thank the dietetic team, stoma nurses and surgeons at the Countess of Chester Hospital for their input and support on developing this service. I would also like to thank Melanie Baker, RD for her valuable clinical experience.

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