Coronary Artery Bypass Grafting (CABG)

Over the past two weeks of clinicals, the majority of patients I saw were either cardiology or oncology patients. Since I began shadowing the physician assistants at the Heart Institute I was introduced to various cardiac-related terms, but this week, from reviewing countless charts I am much more “well-versed” in the language. CABG (pronounced like cabbage) was one of the most common surgeries my patients recently underwent. CABG stands for Coronary Artery Bypass Graft and is usually followed by the number of vessels that were repaired (i.e. CABGx4). After hearing this term over and over and knowing little about it, besides the fact that is an open heart surgery, I decided to research it.

Physicians will recommend CABG procedure for individuals with severe coronary heart disease. Coronary heart disease is characterized by plaque build up in the coronary arteries that can harden and narrow the arteries which decreases the flow of oxygen-rich blood flow to the heart. Another consequence of plaque build up is that is can rupture and cause a blood clot to form. Blood clots can partially or completely block an artery stopping blood flow to the heart. This can be detected by an individual if they report experiencing angina, or chest pain. Blood clots are the most common causes of heart attacks.

In order to repair these arteries, a CABG is one of the procedures that can be used for treatment. During a CABG, a healthy artery or vein from the body is connected, or grafted, to the blocked coronary artery to bypass the blocked portion creating a clear pathway to improve oxygen-rich blood flow to the heart. The majority of the time CABG procedures are performed on multiple vessels during one operation.

While this seems like a very tedious procedure the outlook for these patients is typically very good. Patients often remain symptom free, with reduced angina and decreased risk for a heart attack, for 10-15 years. Patients who chose to engage in lifestyle modification will typically have the best outlook. View the video below for a visual explanation.

CABG Video

So, as a dietitian what do I tell these patients? Well, I start out by determining if this is a recent diagnosis or if they had had a similar procedure before. If this is new, they may have never heard of a cardiac (heart-healthy) diet but if this is something they have previously experienced they may have received prior education. After looking at the diet habits prior to surgery I can determine a nutrition diagnosis and help the patient set attainable goals and provide them with the education that they need.

The main focus of the cardiac diet is to prevent future plaque build-up and lowering blood pressure by decreasing cholesterol and sodium intake. The major changes that cardiac patients should make include:
• Limit saturated fats and trans fats
• Increase intake of omega-3 fats
• Limit the total amount of fat that you eat to 25-35% of total calories
• Limit cholesterol intake to less than 200 mg per day
• Limit sodium intake to less than 2,000 mg per day
• Get 20 to 30g of dietary fiber per day

In addition to these guidelines these patients can benefit from establishing and maintaining a healthy weight and engaging in physical activity. See an example handout here (HeartHealthyNutritionTherapy) from the Academy of Nutrition and Dietetics that I frequently provide my patients with.

While many patients are motivated by a recent cardiac event or surgery to make positive lifestyle changes, a large percentage of patients have no desire. Over the past few weeks I have heard comments such as, “What I eat doesn’t affect me, so why would I change?” or “I eat what I want, whenever I want and I am not going to change.” If patients are unwilling to accept the education and agree to making small changes then there is nothing I can do for these patients. It is really unfortunate to hear these comments but speaking with patients who are actively engaged and motivated to set and achieve their new goals can be extremely rewarding and make up for the noncompliant patients.

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My First Immersion into Clinical Nutrition!

I just finished up my first week of my clinical nutrition rotations! I have just one more week left at Monongalia General Hospital before I move on to my next set of rotations. I have learned so much this week on the overall role of clinical dietitians and how it is to really utilize the Nutrition Care Process on real patients.

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Monongalia General Hospital is one of two major hospitals in the Morgantown area – in fact they are practically right next to each other! These two hospitals serve very different needs in the community. Ruby Memorial Hospital is a large teaching hospital that is over 500 beds and is fully equipped with a cancer center, children’s hospital, and a level I trauma unit. Monongalia General Hospital is only 189 beds equipped with a level IV trauma unit. It is definitely more a community hospital with less high-risk patients, which makes it an ideal location to start for my clinical journey.

 

So, what exactly does a clinical dietitian do? This is a very common question that, unfortunately, not many know the answer to! While I knew the basics of what a clinical dietitian was responsible for, this week gave me a much deeper understanding what a typical day was like as a clinical RD. Each day there are two clinical dietitians that are available to assess and treat patients. The day begins by looking at the list of patients that have been given “consults.” These consults can be sent to the RD’s for multiple reasons. First, nursing staff always conducts a basic nutrition risk assessment on all newly admitted patients. If the patients are considered high risk, then a consult is sent to the dietitians. Physicians can also order consults on patients who they feel will benefit from a nutrition intervention, education, or that require monitoring. The final way that a consult can be sent to the RD’s is by what is called a “system consult.” System consults are triggered by the electronic medical database for patients with a length of stay greater than seven days, a stage II or greater pressure ulcer, recent cardiac surgery or diagnosis, or a variety of other scenarios. Once the dietitian receives the list of patients for the day, the assessment process beings.

 

The assessment process involves a very comprehensive reading of all the lab values, and medical notes from physicians, mid-levels, nurses, and other allied health fields. Even though dietitians deal with nutrition interventions, they are still required to understand all the lab values, medical terminology for the conditions, surgical procedures, medications, and the abbreviations that other medical professionals are required to know. Before any patient is seen there is an extensive review so that the patients’ condition can be fully understood. After preparing a preliminary chart note for the patient with the information from the electronic medical records the patient is then visited. During the visits with the patients the dietitian assesses current intake and collects any information to determine if the patient requires any education or additional nutritional intervention (i.e. Ensure, tube feeding, parenteral nutrition (IV feedings), supplements, etc.). After finishing up with the patient, chart notes must be written and entered into the electronic medical record system. In addition to visiting patients that have consults, dietitians also participate in interdisciplinary care meetings and grand rounds with the physicians, case managers, and nursing staff.

 

I always had imagined that I would end up in clinical nutrition and being able to actually assess patients, deliver nutrition education and interventions, and write chart notes on patients throughout this rotation has confirmed my desire to become a clinical dietitian! This past week I was able to assess and deliver nutrition education to a variety of cancer and cardiac patients and write the chart note! I am looking forward to this next week with Monongalia General Hospital to focus on more nutrition interventions!

 

 

Patient Services Rotation

My time for rotations is finally here! This past week I completed my very first rotation as a WVU Graduate Dietetic Intern at Monongalia General Hospital. Over the past week I have been busy conducting meal rounds, tray assessments, sanitation and quality audits, developing and conducting an employee in-service, developing menus, and conducting a plate waste study.

Meal Rounds

It is important to assess the patient’s view on the meals because consuming adequate nutrition is the only way for them to heal efficiently. At Monongalia General Hospital this is assessed and tracked by meal rounds. Meal rounds are conducted by the clinical dietitian, clinical nutrition manager, diet clerks, and of course – the interns. Meal rounds involve asking the patient’s the following questions:

Food Quality: “How would you rate the overall quality of the food at the hospital?”

Food Temperature: “How is the temperature of the food? Are the hot foods hot and the cold foods cold most of the time?”

Special Diet Understanding: “I see you are on a __________ diet. Do you have any questions about that? Would you like to speak with a dietitian to answer further questions”

Menu Needs: “Do you need any changes made to your menu?”

Additional Needs: “Is there anything else I can do today?”

This information is collected using a form (that can be seen by clicking here – Meal Rounding Form) and is compiled to assess trends and averages across the weeks.

Tray Assessments

Each day I would order a test through the diet clerks and have it sent a specific floor of my choosing. I chose a different diet for each meal to be able to taste and compare each diet. The trays were assessed on the following criteria: time in cart, temperature, portion size, appearance, quality, taste, aroma, and the completeness of the tray. The forms used can be seen by clicking this link – Tray Assessment Form. If any tray received below a 90% for an overall score then corrective action must take place immediately.

Sanitation and Quality Audit

In order to ensure that the Monongalia General’s Food Service Department was being compliant with guidelines, I conducted a quality checklist and a sanitation audit. The quality checklist (view here – Quality Checklist) was designed to assess employee hygiene, dry storage, refrigerator/freezer storage areas, and the serving areas. The sanitation audit (view here – Sanitation Checklist) was designed to look at the kitchen area, dish room, and the food transportation carts. Monongalia General had very minor issues that were noted on the quality checklist but performed quite well overall.

 

Employee In-Service

In order to education the hostesses on diet compliance, in-services are used as short educational lessons. It is important for the hostess to understand the basics on the diets that the patients are prescribed because they are delivering the meals and taking the orders from the patients directly. I chose to education the staff on neutropenic (low-microbial diets). The handout for the in-service can and the employee quiz be seen by following this link (Neutropenic Diet Inservice). I presented this in-service to all the hostesses on duty.

Neutropenic Precautions Sign

 

Menu Development

I was responsible for creating a three-day menu for every meal for the following diets:

  • Regular
  • Cardiac
  • 2g Potassium
  • 2g Sodium
  • Gluten Free
  • Consistent Carbohydrate
  • Clear Liquid
  • Full Liquid

In order to first design a menu, it is important to assess the needs and desires of the target population. I chose to specifically assess the patients on a cardiac diet. During meal rounding I conducted a brief patient survey regarding the flavor of the meals, what menu items they would like to see more of, and what items they would like to see less of. I took into account the comments made when I began to plan meals for the cardiac patients. When creating the meals I had to keep in mind diet needs, patient preferences, cost, and feasibility of production.

 

Plate Waste Study

As a special project, I chose to conduct a plate waste study on the returned trays from the lunch period. Plate waste studies are a quick method to assess intake from a large sample size in an efficient and effective manner. Typically, plate waste studies are used for school meals or large food service organizations. The importance of assessing plate waste for hospital patients is that these studies provide knowledge about food preferences, what foods are being consumed, and what is being thrown away. It is expected, that regardless of how good the food taste, that there will still be a significant amount of plate waste because the target population includes ill individuals who are likely to be on medications that may alter their appetite or ability to taste normally. For this study, plate waste data was collected on four consecutive days at Monongalia General Hospital. The cart from which the trays were selected from was chosen at random according to what was available at the time of the observation. Trays were excluded from the analysis if they did not have the original ticket to identify the diet and meal order or if they were on a liquid diet. Each day of the study 10 trays were analyzed and the percentages of each major item were recorded. The data collected and the forms used can all be seen here (Plate Waste Observation Sheet). The findings of this study can be found by following this link (Plate Waste Report).

Plate Waste Study