Hospital Food Service Rotation

I spent two weeks at Tallahassee Memorial Hospital for food service.The first day I was in the kitchen at TMH,  there NSF auditor came for their food service safety inspection. I was able to shadow the inspector.  It was neat to see what he observed, and also allowed me to become familiar with the huge kitchen.

The second day of this rotation, the hospital was implementing a new wellness program incorporating healthy menu options. The launch of this was perfect for my requirements for this rotation. I was able to help set up and plan during this event.

Throughout the two weeks at TMH, I assisted on tray line as well as conducted a tray accuracy and a tray assessment.

My preceptor showed me how scheduling is done. He showed me how each position breaks down into FTEs (Full time equivalents) and how it all works out into positions and the breakdown from there. He then showed me how he figured out manager schedule including weekends. It was interesting seeing the breakdown and how in depth is has to get some times. They are hiring a new manager which made the schedule a little difficult with training's and necessary staffing for this new hire.

Friday I conducted inventory  with the staff in the kitchen. The store room took a while but then I helped out in the cooler. It was freezing! There was three coolers, I made it through the last two- helped out writing the numbers down for the kitchen staff as they called out the product and number.

By the second week of this rotation, I had already finished most of my projects. My preceptor scheduled my in-service at the behavioral health center but Wednesday came and everyone forgot about it and we had to reschedule.

It was a good learning opportunity to see the hospital food service management side of being a dietitian.

Leon County CRE Rotation

Our division, Food, Nutrition, and Wellness through the Florida Department of Agriculture, conducts CRE reviews to all schools. CRE is a Coordinated Review Effort.This review observes the national school lunch program. Our division monitors the school lunch program in schools, reviews/validates their documentation and provides technical assistance. 

The CRE I participated in was for Leon County schools and was an 'additional review'. This just means it wasn't as in depth as a normal CRE. 

The first day we met with the food and nutrition services director for Leon County and other food and nutrition services staff who joined us for the meeting. We then reviewed 10% of the free and reduced priced school lunch applications. 

Part of my job this day was to review civil rights and make sure that  at least one person from each school in the county attended the training on civil rights. I also reviewed 10% of the direct certification list for students and verified them. Student eligibility for free meals is determined by application or by direct certification.
Although direct certification systems vary by State, all such systems substantially reduce the need for household applications. Many States certify eligible children through computer matching of SNAP, TANF, and FDPIR records against student enrollment lists. Those systems require no action by the children’s parents or guardians.

This CRE was used as a training for our division. In two days, collectively we observed 6 schools in two days. Four people went to each school per day (12 of us total as reviewers). 

The second day I went to an elementary school, which the director was helping out at. It was a wonderful school, almost brand new kitchen. The staff was VERY nice and great at their jobs. We had no findings of errors or problems. We had to check their storage areas and ensure their commodity goods were properly stored. We also watched breakfast and lunch for correct, complete meals. 

During this review, I was able to spend some time talking with the director. She use to be the director of food, nutrition, and wellness (my division that I am with through the department of agriculture- but she was head of the division when it was at Department of Education ). This director is also a dietitian, it was nice to hear her story of how she came into the job as director. It was awesome to be able to hear her stories.  After we went to the schools,  we had a meeting back at the office about what we found and saw at the schools.

The third day we were at second school. I was at a special needs school where they have pre-k students through high school ( students through the age of 22 years old). We walked into the kitchen, and found out this kitchen was one of the oldest kitchens in the county. We observed breakfast and started our inspection. 

We had some findings at this school started. We found some shelving was not within standards off the floor and there was some ice from the freezer fan. The staff was so nervous  while we were there that a an employee actually dropped a full pan of collard greens. We told them it was okay and accidents happen. We met back as a team (all 12 reviewers) and discussed our findings with everyone.

It was nice to understand the way a CRE works and how what our division at FDACS does. 

Manatee School Food Service

After working in Sarasota County, the next rotation was at Manatee County Food and Nutrition Services main office. The first day we went to the department's Monday Briefing meeting and learned what we would be doing the rest of that week.

We then sat through a KPI (financial) meeting which looked at the financials of the school food service and action plans were created. In the afternoon we spoke with Sandy Ford, the director of the program and also school nutrition association president.

The next day we went with Melissa to a couple Fresh Fruit and Vegetable Program schools (http://www.fns.usda.gov/cnd/ffvp/). We learned about the program and saw the actual implementation of the program and the difficulties associated with it.

During this rotation we shadowed an area supervisor. We were able to see the kitchens and staff interact at various schools in the district. We learned that the supervisors here in Manatee have 17-18 schools each whereas Sarasota only had 12-13 schools but also had other job requirements. That afternoon we attended a staff meeting and learned about the different projects the staff are working on.

Valentines day was during this rotation and I was able to go to a school and help serve  strawberry shortcake dish to all the students and parents at the school.

I then went with another area supervisor to schools again. I attended a staff meeting discussing ways to lower cost in the schools.

The second week of this rotation, FDACS came to do a summer food service program training- it was nice to see familiar faces!

For our internship we have to do a research project, while in Sarasota I gave surveys to students one day. Then at Manatee I gave surveys to students again.

We shadowed our preceptor who gave a breakfast component training at a high school.

The second to last day I went to an elementary school and gave a nutrition lesson. Our lesson was on fractions and nutrition. We created oatmeal bars and used the process of cutting them to teach fractions. We also used oranges to help teach fractions to 3rd grade students. We created the lesson plan as well as a parent handout which gave the recipe taught about breakfast, and incorporated Florida history into the handout.

Sarasota School Food Service Weeks 3 & 4

Week 3 was the last week actually in the school. I did the grocery list and put the orders in. On the last Friday,I was the "manager".

Throughout the week I learned how to do inventory. I also made a grocery list and then submitted the order online. I received food orders online. I also helped out each day during the service time by restocking items.

On my manager day, the dish machine broke. I do not know much about the dish machine so I had to ask the actual manager ( who was there). We had to call the repair man and get it fixed. We had to use disposable trays for lunch service.

The last week of this rotation I was at the Food and Nutrition Services main office. I shadowed an area supervisor, they supervise the school food service managers. We went around to some schools delivering new thermometers and also looking and correcting any issues in the schools. I got to see how vastly different every school kitchen was in the district. Some were brand new, while another kitchen I saw was very very old and waiting to be fixed (it was on the list to be fixed asap).

While at the main office we had one office day where I was able to finish up projects and print them. We also attended a staff meeting and also sat through a commodity order meeting with Coastal Foods.

One of my favorite parts about this rotation was working with the secondary nutrition educator. It was a wonderful experience. We did about 6 nutrition lessons and I wish we could have done more.

Sarasota School Food Service Week 1 & 2

My school food service rotation was at a middle school in Venice, Florida (about 5 1/2 hours from Tallahassee).

This rotation is actually in part with the Sarasota school food service internship (http://www.sarasotacountyschools.net/departments/fns/default.aspx?id=1628).

As an intern we are working with the kitchen managers to learn how to do their job so we fully understand the kitchen. I learned how to check people out at the register as well as count the money and make the deposits. I learned how to do the grocery orders and how to prep foods. I have a TON of assignments to do for this rotation- including a menu, a work schedule, and job position descriptions.

For this rotation, I had to at the school by 6am,  that means I had to get up absolutely no later than 4:30am to leave my uncle's house to get to the school on time. The first couple days I shadowed the manager. She was absolutely wonderful. She explained everything to me and showed me how to do it myself.

The second week I learned how to do grocery orders and how to receive orders. I attended a manager's meeting at the main office.  The third week of this rotation I will be at this school  again, but the 4th and final week of this rotation I will be at the Sarasota County Food and Nutrition main office.

TMH Case Study

Here is most of my case study... there was a lot more to the written document but I wanted to share most of the clinical part.. 

Introduction:

While working at the Tallahassee Memorial Hospital (TMH) I found many patients very interesting, however, most of these interesting patients had already been seen by the dietitians. After a few days of searching for a case study, I found a patient whose case involved complex digestive problems and a need for the use of total parenteral nutrition (TPN).

Nutrition care process was carried out for this patient per TMH and Sodexho protocol following the Sodexho medical nutrition therapy guidelines. Initial assessment for this patient was carried out by Brittany Pond. Patient was screened to be at risk due to NPO status times three days in the intensive care unit (ICU) using the TMH nutrition screening guidelines. The medical record was reviewed and patient was seen. The assessment was written using the PowerChart system. Once the initial assessment was completed with an RD who signed off on the assessment note. Due to Christmas break, the follow-ups were carried out by the TMH dietitians.

Patient’s History

The patient is an elderly 79 year old Caucasian female who was admitted for sudden abdominal pain with copious episodes of nausea and vomiting. The family was concerned the patient had an abdominal obstruction and brought her to the emergency room. A CT scan showed focal ileus in the right upper quadrant with air fluid levels in the small bowel but no focal transition, suggestive of a small bowel obstruction. Free fluid in the right upper quadrant raised a question of gastroenteritis versus peritonitis. Also present in the patient is diverticulosis without inflammation of the colon. Patient’s last bowel movement was the night prior to admission with no diarrhea.

Patient’s Past Medical History Includes:1. Hypertension2. Transient ischemic attack3. Spontaneous pneumothorax in 20094. Hyperlipidemia5. Partial small bowel obstruction in 20106. Microscopic colitis7. Stage I diastolic dysfunction and minimal aortic sclerosis in 20118. Cholecystectomy9. Multiple bladder surgeries10. Bilateral tubal ligation11. Appendectomy12. A-fibrillation
Past Surgical History:Patient had a partial small bowel obstruction requiring resection in 2010 at Emory University Hospital in Atlanta, Georgia.

Allergies: Atropine, Codeine, Sulfa Drugs.

Physical Exam:General: 79 year old, ill appearing, elderly Caucasian femaleVital Signs: Afebrile, temperature 97.4, heart rate 90, respirations 18, blood pressure 138/77,Neurologic: Alert and orientated to person, place, situation, time


Primary Diagnosis:Necrotic tissue was found in the patient’s small intestine leading to a small bowel resection this admission.

Patient’s course of stay prior to first nutrition visit:· 12/19/12: Patient arrived at TMH emergency room (ER), had contrast scan (CT) of abdomen and pelvis with contrast, admitted to the cardiac intensive care unit (CICU).· 12/20/12: Exploratory laparotomy revealed necrotic tissue in patient’s small bowel with removal of this section of the small bowel.· 12/21/12: Patient initially assessed by nutrition.

Nutrition Care Process: Assessment

In order to begin the nutrition care process for this patient, the patient’s medical charts and past history were reviewed. Initial nutrition assessment was on 12/21/12. Patient was on a clear liquid diet with instructions to sip clear liquid with NG in only.

Anthropometric Data:Height: 60 inches, 152.4 cmWeight: 116 pounds, 52.6 kgBMI: 23 kg/m2 (normal)Ideal Body Weight: 45.5 kg

Subjective Data:Patient assessed due to NPO x3 days. Patient is a small framed, pale, white female seen lying in bed with NG tube connected to suction with dark green/brown output. She had a partial small bowel resection in June 2010, after which, the patient had frequent vomiting and diarrhea resulting in weight loss. Uncertain how many pounds patient actually lost since this time, but patient was able to state her weight was 160 pounds prior to 2010. In 2011 she had a small bowel obstruction. Current admission is for abdominal pain, nausea, and vomiting. Patient had an ex lap 12/20/12 with results that showed an area of necrotic small bowel secondary to adhesions. This area of necrotic small bowel was removed this admission.

Objective Data:Laboratory Data: Sodium, Glucose, CalciumIVF: Amiodarone IV @ 17 mL/hrD5 ½ NS + KCl @150 mL/hr (Providing ~681 kcal/day)Braden Score: 14Urinary: Foley, amber colorBowel Status: hypoactive, last bowel movement was 2-3 days prior+ afebrile+nasal cannula+edema Ankle Bilateral+edema Arm Bilateral

Biochemical Data (Labs):Na 133 (L), Ca 7.3 (L), 97-172 BBGs past 48 hours

Estimated Nutritional Needs for Patient’s Ideal Body Weight of 45 kg:· 1242-1426 kcals based on 27-31 kcal/kg increased for wound healing needs.· 46-55 g protein based on 1.0-1.2 g/kg increased for wound healing needs.· 1150-1380 mL fluid based on 25-30 mL/kg.

Nutrition Care Process: Diagnosis

Moderate malnutrition related to current NPO status x 3 days with poor intake prior to admission as evidenced by review of diet order and patient report.

Increased nutrient needs for energy, protein, fluid, and micronutrients related to recent abdominal surgery as evidenced by review of operative note in medical record.
Inadequate protein-energy intake related to NPO status and no alternate nutrition yet initiated as evidenced by review of current diet order, visual observation, and medications/IVF providing minimal protein-sparing kcals.
Altered GI functions related to small bowel resection versus microscopic colitis as evidence by small bowel resection post-operative day #1, previous small bowel resection in 2010, NG tube output, and hypoactive bowel sounds.

Nutrition Care Process: Interventions

1. If patient has improvement in GI function and patient’s NG tube is discontinued, please add Enlive supplement and advance diet as able.2. If improvement in gut function not anticipated, recommend TPN to allow bowels to rest and heal.· Suggest Clinimix 5/20 with a goal rate of 42 mL/hr, 250 mL 20% lipids daily.i. To provide: 1008 mL total volume, 1385 kcals, 50g protein, 202g CHOii. 2.64 mg/kg/min dextrose infusion rate and 36% kcal from lipidsiii. Please add MVI and MTE, insulin per physician3. Monitor K, Mg, and Phos for signs of refeeding syndrome. If these labs are low, continue TPN at ½ rate of 21 mL/hr until labs normalize.4. Please monitor weights and labs per parenteral nutrition order set.5. Continue to provide anti-nausea medications as needed
6. Bowel Care per MD.

Nutrition Care Process: Monitor and Evaluation

1. Nutrition Goal: Patient to start oral diet or TPB within next 24 hours.2. Weight Goal: Patient to remain within 1-2% of admission weight.3. Bowel Goal: Patient to have evidence of improving function, i/e: decreased NG tube output, + bowel movement.4. Lab Goal: Maintain BBGs >70, <180; electrolytes WNL.

Free Text Nutrition Note: 12/22/12

TPN started per RD recommendations: Clinimix 5/20 @ 42 mL/hr + 200 mL 20% lipids daily + MVI 3x/week + MTE daily. Potassium dropped from 3.9-3.4, may be related to re-feeding syndrome. Check magnesium and phosphorus once-twice daily to appropriately manage possible re-feeding syndrome. If these values are not adequate, may continue TPN at ½ goal rate. Patient continues with clear liquid diet, drinking minimally. Encourage oral intake.

Follow Up Assessment- 12/24/12

Patient is seen in follow up. The patient was lying down in bed at time of visit with family present. Patient is post-operative day number 4 since the small bowel resection. The patient continues to have TPN support. RD spoke with patient who reported no nausea or emesis at this time. Patient indicated they have bouts of diarrhea. No alleviating factors during last bowel resection. RD discussed food preferences and need to advance diet slowly. Patient and family verbalized understanding.

TPN Regimen: Clinimix 5/20 @ 42 mL/hr with 250 mL of 20% lipids daily. Doctor ordered multivitamin on Monday, Wednesday, and Friday schedule and will monitor multi-trace elements.
PO Regimen: Mechanical soft, carbohydrate controlled. Patient was on a full liquid diet prior to interview.

Biochemical Data (Labs): Ca 7.6 (L), Phos 2.2 (L), Mg 1.3 (L), 92-370 BBGs past 48 hrs.
Nutrition Diagnosis:

Moderate malnutrition related to current NPO status x 3 days with poor intake prior to admission as evidenced by review of diet order and patient report. Progress: Continue/unresolved.
Increased nutrient needs for energy, protein, fluid, and micronutrients related to recent abdominal surgery as evidenced by review of operative note in medical record. Progress: Continue/unresolved.
Inadequate protein-energy intake related to previous NPO status x3 days and clear liquid diet as evidenced by review of current diet order, visual observation, and medications/IVF providing minimal protein-sparing kcals. Progress: Improving.
Altered GI functions related to small bowel resection versus microscopic colitis as evidence by small bowel resection post-operative day #4, previous small bowel resection in 2010, NG tube output, and hypoactive bowel sounds. Progress: Continue/unresolved.

Interventions1. Continue with mechanical soft, carbohydrate controlled regimen as medically appropriate/tolerated· Consider GI soft/bland restriction to promote diet tolerance· Consider Boost Glucose Control BID is PO regimen is well tolerated.2. Continue TPN to allow bowels to rest and heal as medically appropriate, wean per physician.3. If signs of refeeding syndrome present (low K, Mg, Phos) continue TPN as ½ rate (21mL/hr) until labs normalize and decrease PO regimen.4. Please monitor weights and labs per parenteral nutrition order set.5. Continue to provide anti-nausea medications as needed.6. Bowel Care per MD.

Final Follow-Up Assessment- 12/27/12

Patient is seen in follow-up. Patient complains of ongoing chronic diarrhea related to microcytic colitis. The Patient reports an okay appetite, she states she feels full quickly and portion sizes sent on meals are too large. RD discussed consuming small frequent meals. The patient drinks Boost at home and would like some sent to her with meals. The patient’s TPN was discontinued today due to lack of parenteral access. Diet: Healthy heart. PO intake: Fair.
Biochemical Data (Labs): Na 135 (L) Ca 7.6 (L, same), 101-121 BBGs
Nutrition Diagnosis:

Moderate malnutrition related to fair intake on current diet as evidenced by review of diet order and patient report. Progress: Improving
Increased nutrient needs for energy, protein, fluid, and micronutrients related to recent abdominal surgery as evidenced by review of operative note in medical record. Progress: Continue/unresolved.
Inadequate protein-energy intake related fair intake on current diet as evidenced by patient report, review of current diet order. Progress: Improving.
Altered GI functions related to small bowel resection versus microscopic colitis as evidence by small bowel resection post-operative day #7, previous small bowel resection in 2010, and ongoing diarrhea. Progress: Continue/unresolved.

Interventions1. Encourage intake of small frequent meals· Send Boost supplement per patient request2. Recommend a multivitamin with minerals to ensure micronutrient needs are met.3. Recommend Lactinex 1 packet BID to promote GI health.

Patient’s Course of Hospital Stay at TMH

· 12/19/12: Patient arrived at TMH ER, had CT of abdomen and pelvis with contrast, admitted to CICU.· 12/20/12: Ex lap revealed necrotic tissue in patient’s small bowel with removal of this section of the small bowel.· 12/21/12: Patient initially assessed by nutrition due to NPO x 3 days.· 12/22/12: Patient moved to 5B- Diabetes Floor. Free text nutrition note.· 12/24/12: Patient seen for nutrition follow up, on full liquid diet then moved to mechanical soft diet. 12/27/12: Patient seen for nutrition follow up, heart healthy diet with fair intake. TPN stopped.· 12/31/12: Patient tolerating small meals, waiting for a rehab bed.

Conclusion:

The patient was treated for 12.6 days at TMH. Initially she was moderately malnourished. Before transferring to TMRH, her nutrition had improved based on her lab values and her ability to eat a heart healthy diet. The RD’s had discussed future nutrition care for the patient by explaining the importance of eating small frequent meals and bland foods with the patient. The patient was transferred to TMRH on December 31st, 2012 for continued care and rehabilitation.

Last week of TMH Clinical

The last week of clinical was 'staff relief' week. I was able to cover one floor by myself and part of another floor. It was awesome to be 'on my own'. The dietitians still signed off on my notes but I really felt like my notes were a lot better from when I first started.

During this week I presented my case study. I was unable to follow this patient through her full course of stay at TMH due to Christmas break. However, I made it work and presented well. I was able to explain in enough detail for a few people who are not dietitian's or nutritionists to be able to follow along and understand what I did for the patient and why.

Overall TMH was a good rotation, I learned a lot and I hope to work in clinical for a few years before finding more of a community based job.