Am I Boring You?

Happy Halloween! Yum look at all those vegetable servings!

I was "viewing" my blog and noticed my recent posts have been on the more educational and informative side.  Sorry if that also means boring.  I've been lead to believe my beginning posts were entertaining and even considered quite funny on the hilarity scale.  Now that I'm working it seems the tone has changed.  Due to this contrast you might be lead to believe that joining the working world sucks any sense of fun and humor out of you.  This is not the case.  There are an embarrassing amount of things that happen to me at work that you might find funny (I can already count on two hands and almost one foot how many times I will look at a baby or a picture and say "Your son is adorable!" and get the reply, "She's a girl...").  The thing is that although I find things funny, I value and take my job more seriously than the need to share stories for laughs.  What I do at work is confidential.  You might think a patient's choice between short ribs or chicken picatta shouldn't be kept secret, but it is.  All patients have the right to 100% confidentiality, from their medical records to their dinner entree. 

On a different note, I had someone ask me what I was doing right now professionally.  I told them I would be starting diet technician training next week but I was currently a hostess at the hospital.  The person was kind of snooty to be honest with you.  They asked why I didn't just work in a restaurant and make tips.  I laughed it off, but it also made me think.

First.  When I was offered this job, my boss told me I would be starting at the bottom and that I was overqualified.  The other hosts I work with don't have degrees in nutrition and haven't finished college.  They still know A LOT about diet orders and could even teach some current nutrition students a thing or two from the things they have absorbed working in a hospital.  

Being in a professional environment and absorbing information and experience can apply to any field.  My mom told me a story about her first job in accounting at a CPA firm.  Her boss was holding a meeting and was putting an employee at the very bottom of the totem pole  responsible for making all photocopies.  This employee asked the boss, "I have a college degree, how is this task putting it to use or furthering my career?"  The boss replied, "You can turn any task into a learning experience.  Read the memos and reports, you can pick up language, terms, and policies.  Absorb everything you can and don't take a task for granted and turn it into a thoughtless process."

This totally applies to me.  I could go on robot mode with patient orders.  I don't.  I learn the diet order abbreviations and know what is allowed in each order.  This might be the responsibility of someone else (the tech/RD) but those are positions I will be doing someday.  Being exposed to it now gives me valuable knowledge.  So no, I won't be a host in a restaurant.  The exposure I have now is far more valuable than tips.

Patients love when the dogs visit!

Second.  I like that I'm called a host.  I like to think that I am the one person in the hospital (besides the therapeutic dogs* maybe, they're THE COOLEST!)  that can help the patient think they are somewhere else.  I like to think that maybe, just maybe, giving patients meal choices can help them think for a second they are sitting at a restaurant table instead of laying in their hospital bed.  I know other hospitals get a diet order (i.e. Cardiac, Renal, Mechanical Soft) and have a set menu already in place with a meal for the patient. I work at a spectacular facility that gives patients choices and these choices can only be made with hosts and hostesses.  

Working as a host in a restaurant might be more comfortable, but for me personally what I'm doing now has much value and purpose.  Working in inpatient, patients come and go.  I usually don't see them for more than a couple of days.  However, I do have my "regulars" like a waitress in a diner would have.  Of course, I would never wish it upon anyone to ever be a "regular" at a hospital.  I'd rather people be healthy and get discharged as soon as possible.  Regulars are patients in the hospital for several days that I build relationships with.  I remember their names, their juice of choice, and what college football game they're watching on Saturday.  Sometimes, I even let them order cheeseburgers or let them have ice cream and apple pie (if their diet allows it, of course).  They brighten my day and I like to think I brighten theirs.  

*Your dog can be a therapeutic dog too!  They are the dogs of volunteers that are friendly mellow dogs.  They are groomed appropriately and visit with patients.  All people that come in contact wear gloves.  

Pumpkin photo by Stephen St. John, National Geographic retrieved on 31 Oct 2012 from http://news.nationalgeographic.com/news/2011/10/111028-halloween-facts-costumes-history-nation-science/

Therapeutic dog photo retrieved on 31 Oct 2012 from http://www.petanim.com/6399/jlbenton/pet-therapy-pet/

 

Diet Order Abbrevs.

As you can imagine, there are many different diet orders in the hospital. Techs and clerks use abbreviation/s on tickets for patients' meal orders. The tickets are on the tray with the meal and have the patient name, DOB (date of birth), room number, diet order, and a list of all items on the tray.  Before trays are passed, diet orders are read off the tickets to the charge nurse or secretary in each unit.  This is done because a diet order may change after tickets are printed (i.e. a patient may move from a liquid to puree diet or from a regular diet to no food by mouth).  Keep in mind different staff or hospitals may use different abbreviations.  Do you know some abbreviations? Let's find out!

1. ClLiq
2. FlLiq
3. GBPs
4. LctOv Veg
5. LactI
6. CarbCont
7. LoFt
8. Viet
9. 18Cal
10. 15Fl
11. GERD
12. TF
13. NPO
14. GlutF
15.  MinFib
16. LoFib
17. Microb
18. NAS
19. 2gNA
20. Card
21. Lo Res
22. Veg
23. Kosh
24. Dys 1/2/3
25. HnyThc, NctThc
26. K
27. HiFib
28. Reg
29. RnlStnd

1.  ClLiq: Clear Liquid

taken from be-kind-have-faith.blogspot

Clear liquids include juice, tea, coffee, water, jello, broth, and popsicles (anything clear that melts at room temperature).  May be reserved for patients with digestive issues or prior to medical procedures.  Post-partum patients that have undergone a Cesarean section will be put on this diet post op.  Should be followed short term as it contains minimal energy, fat, and protein. (I had a patient this week on a Cl Liq who kept asking for a pitcher of beer, I mean he kind of has a point...)

taken from sparrowhawkseries.com

2.FlLiq: Full Liquid
Full liquids include cream based soup, pudding, custard, ice cream, milk, milkshake, supplemental shake, and creamer.  Patients usually transition from a clear liquid to a full liquid or may be on this diet prior to or after a procedure.  As you can imagine, a full diet can offer more energy, fat, and protein than a clear diet.






3. GBPs: Gastric Bypass
After a patient undergoes gastric bypass surgery it is absolutely essential that their intake is monitored.  A patient will start with a clear liquid diet, but only when the nurse allows them to begin eating.  In fact, a GBPs patient's first tray will not be delivered but put in the fridge.  A nurse/doctor will decide when the patient is ready.  This is because the body must heal and adjust to eating patterns.  Post op patients will transition from clear liquid, to full, to puree, to mechanical soft, to regular foods.  Straws are NOT allowed for GBPs patients because you don't want them to be in-taking anything too rapidly. 

4. LctOvVeg: Lacto Ovo Vegetarian
Does not eat any meat, including fish.  Does eat dairy and milk products.

5. LactInt: Lactose Intolerant
Does not eat dairy products.  This includes ice cream, milk, cheese, ranch dressing, some shakes, etc.

6. CarbCont: Carbohydrate Control
Usually for patients with diabetes.  Need to make sure patient has protein  with carbohydrates and encourage whole grain sources and fiber.  Limit fruits, juices, and other starches.

7.  LoFt: Low fat
Limit fat.  For example if a patient has had their gallbladder removed.

taken from Stanford School of Medicine: eCampus Gariatrics

 8.  Viet: Vietnamese food
Some hospitals may offer Vietnamese food for patients who are Vietnamese.  A nurse has to request this order.  Items may include a pork based porridge for breakfast, tofu, stir fry, chicken, won ton soup, fish, rice, soy milk, and tea.





9. 18Cal: 1800 calorie diet
May have any number (i.e. 20 for a 2000 kcal diet).  Patient may have to limit calories for weight loss or diabetes.   

10.  15Fl: Fluid Restricted to 1500 mL
A patient may be on a fluid restriction if suffering from edema or swelling.  Fluid may be distributed evenly (i.e. 8 oz at breakfast, 8 oz at lunch, 4 oz at dinner).  This includes soup, broth, beverages, jello, and popsicles.

Taken from gerdremedies.info

11. GERD: Gastroesophageal reflux disease
Want to discourage food from refluxing up from stomach.  No pepper! Avoid spices, caffeine, fat intake, chocolate, mint, carbonation, citrus, and tomato products.  Small frequent meals are encouraged over large meals.  




12.  TF: Tube Feed
Patient is intaking food via enteral or parenteral feeds.  The type and rate is calculated and orders by a doctor or Registered Dietitian. 

13. NPO: Nothing by Mouth
 These patients cannot have a tray of food, not even liquids.  Usually there will be a NPO sticker by their door number to alert food service workers not to bring them a tray if it was ordered.  These patients may be awaiting surgery or a medical test.  They also may be receiving a tube feed.

14.  GlutF: Gluten Free
Patients with gluten allergies cannot have many bread products.  Can consume corn or rice products.

15.  MinFib: Minimal Fiber
Extremely low fiber intake.  Very limited amount of wheat carbs, fruits, and vegetables.

16.  LoFib: Low Fiber
Low fiber intake.  Can intake a little more fiber than MinFib.  Again, limit wheat based carbs, fruits, and vegetables.

17.  Microb: Microbial

taken from http://tripsons.blogspot.com/2012_04_01_archive.html

For patients with compromised immune systems or have undergone intensive cancer therapy that may get sick easily from  microbes found in raw/fresh fruits and vegetables or undercooked meat.  These patients can eat canned products which have had microbes safely eliminated in the canning process.  It is highly likely that these patients will be in isolation rooms, which means visitors must wash hands and put on a gown, gloves, and mask before entering. 


18.  NAS: No Added Salt
No salt on tray; patient may get a no sodium seasoning packet instead.  Also limit processed meats and soups.

19. 2gNA: 2 grams of Sodium (or 2000 mg)
Again, could be 1gNA for 1 gram.  Patient's sodium is being limited, usually for cardiac patients.  Patient will not be allowed meat besides poultry or fish (no ham, sausage, bacon, or beef).

20. Card: Cardiac Diet
Patient will be limiting fat and sodium.  Usually will not be allowed sodas, coffee, tea, some red meats, margarine, butter, regular salad dressings.  May offer diet dressings, sugar free puddings, jellos, custards, and ice cream.

21.  LoRes: Low Residue
Limit fiber and other foods that are harder for your body to digest are restricted.  Usually for patients with Crohn's, Ulcerative Colitis, or Diverticulitis.  

22.  Veg: Vegetarian
Patient doesn't eat meat but does eat fish.

taken from http://www.theyeshivaworld.com/article.php?p=28664

23.  Kosh: Kosher
Follows Jewish guidelines.  Some patients may follow the guidelines stricter than others (i.e. will eat chicken or fish not killed in accordance to law but won't eat any pork).  A Kosher diet allows fruit and vegetables but not pork.  Dairy cannot be eaten with meat (flesh of animals).  Approved animal products must be killed in accordance to Kosher guidelines.  Some Kosher patients may also be concerned of utensils used with non-Kosher food used with Kosher food.  Some hospitals may have pre-prepared Kosher meal packs available that are ready to eat.  

24.  Dys 1/2/3: Dysphagia 1, Dysphagia 2, or Dysphagia 3
Different levels according to patient's ability to swallow.  Patients with dys1 especially will not be allowed any straws due to risk of aspiration which could cause pneumonia (largest concern).  Remember that 1 is pureed foods, 2 is usually mechanical soft foods, and 3 is no sticky or crunchy foods.

Taken from Hormelhealthlabs.com

25. HnyThc, NctThc: Honey Thickness, 
Nectar Thickness
Usually in addition to a liquid diet. Remember that honey thickness is thicker than nectar.  Thickening agents can be added to beverages for patients at risk for aspirating. 




26. K: Potassium
Some patients may need to increase certain minerals such as Potassium, which can be found in bananas, potatoes, orange juice, beets, white beans, yogurt, and tomatoes.  Grapefruit is a good source of potassium, however products such as grapefruit or grapefruit juice are typically not allowed in hospitals because it harmfully interacts with many drugs including Lipitor, Valium, and Xanax to name a few.

27. HiFib: High Fiber
Encourage wheat carbohydrates, fruits, and vegetables. 

28. Reg: Regular
Patient has no restrictions.

39.  RnlStnd: Renal Standard
There are 5 stages of Chronic Kidney Disease (CKD) and are defined by different glomerular filtration rates (GFR).  GFR is basically the rate at which wastes are cleared from the blood plasma by the glomeruli, which are capillaries surrounded by an epithelial membrane in the kidneys.  Patients in stage 5 usually undergo dialysis, which is a procedure that uses a machine (hemodialysis at a medical center or peritoneal dialysis which can be done at home).  Patients in the hospital that have any stage of CKD or undergoing dialysis must follow a very strict diet.  When the kidneys deteriorate, it becomes more difficult for it to remove products from protein, fluid, and minerals such as sodium, potassium, phosphorus, and calcium. 

• Stages 1 and 2: focus therapy on controlling diabetes, hypertension(blood pressure), and hyperlipidemia(cholesterol).  
• Stages 3 and 4: monitor and limit protein intake (as kidney function slows, it becomes harder to excrete protein products).
• Stage 5: differs between hemodialysis and peritoneal dialysis.  Hemodialysis patients have a diet high in protein and must limit foods containing potassium, phosphorous and sodium.  Must also limit fluids.  Peritoneal dialysis patients have a diet higher in protein, sodium, potassium, and fluid than hemodialysis because peritoneal have higher losses during the actual dialysis process.  Peritoneal patients still have to limit phosphorous.  

High sources of Potassium (avoid): bananas,orange juice, melon, spinach, tomatoes, beans, broccoli, bran, milk, nuts, yogurt, salt-free broth, potatoes
Low sources of Potassium (ok): apple, pears, pineapple, asparagus, carrots, corn, peas, squash, rice, noodles,

High Phosphorous sources (avoid): chocolate, coke, dairy, fish, organ meats, beans, bran, caramel, seeds, whole grain

**Post partum patients will not be allowed caffeine due to breast feeding and cardiac patients may also be restricted from caffeine due to heart defects or testing that needs to be done.


Keep in mind that many of these orders will be combined.  For example...

Viet, Veg, MS: Vietnamese, vegetarian, mechanical soft.  This patient could eat tofu, chopped steam vegetables, and possibly fish

MinFib, Veg, K: Minimal fiber, increase Potassium, vegetarian.  This is tricky because the patient needs to decrease sources of fiber (fruits and vegetables) but needs to increase potassium which is found in fruits and vegetables.  Patient will receive potato products (mashed, hashed browns) and orange juice.  Encourage eggs and cottage cheese for protein.

Card, CarbCount, 18Cal: Cardiac, carbohydrate control, 1800 kcal.  Encourage fruits and vegetables.  No red meat, pork, caffeine, butter.  Limited non-fat dairy.  Diet jellos, pudding, custard, and salad dressings.

LctI, GlutF, LoFib: Lactose intolerant, gluten free, low fiber.  No dairy, carbohydrates, fruits, or vegetables.  Encourage rice, corn products, and proteins.  Patient may need to be on a lactose free shake for supplemental calories due to limited choices.  

15Fl: Patient is limited to 1500 mL fluids per day.  Could do 8 oz at breakfast (4 oz juice and 4 oz milk for cereal), 8 oz at lunch (4 oz soup and 4 oz juice), and 4 oz at dinner (4 oz milk).

NPO: sorry Charlie.  No choices can be made because no meal delivered to patient. 

Elevator Etiquette

I wish I could count how many times I go up and down in an elevator each day at work.  If I didn't have 453948 work related things already going through my mind, maybe I would have room in my cerebellum to count.  If I had to guess, I would say I go up and down the elevator 40 times a day.  That's 200 times a week!  Thanks be to Vitamin C that I don't have claustrophobia or issues being inside elevators!  I'm going to keep this short and sweet (instead of doing more food service equations; bet you're thinking you dodged a bullet on that one) and give you some pointers on elevator do's and don'ts in a hospital.

I hate to burst any fantasy Grey's Anatomy based bubble you may have floating above your head containing images of two or more attractive medically licensed individuals steaming it up or oozing sexual tension in between floors.  If you want to keep on believing that doctors have ample free time for shmoozing shenanigans and elevator escapades while patients await care, go ahead.  In reality, hospital staff are far more focused on patients than anything else.  Sorry McSteamy.  You too McDreamy.  Patients are the priority.

DO know what floor you're going to.  This might sound dumb, but there are days so busy you forget where you're headed.
DON'T push every button because it is fun (Elf)
DO make sure if you want to be going up the elevator is in fact going up (again, we all have those days, myself more than others)
DON'T jump up when the elevator is moving down (Elf)
DO step out of the elevator if a patient needs to use it; patient=priority (everyone uses the same elevators; this means people being wheeled to surgery, carts full of food, doctors, nurses, visitors, etc.)
DON'T talk about patients or anyone else for that matter inside the elevator; confidentiality is extremely essential in a hospital.  Always.  In fact, never talk about a patient.  Ever.
DO ask other people in the elevator what number floor they need and push the button for them if you are closest.
DON'T be an elevator hog; move to the back when possible.
DO assist visitors in the elevator if they don't know where they're going.
DON'T stick your arm out when you see the door closing and you need to get in.  If the door goes far enough, your arm might not stop it.  Waiting a couple minutes for the next elevator is in fact more time efficient than losing an arm.
DO introduce yourself to nurses or doctors on the elevator, "Hi, how's your day going?  What department do you work in?"

Maybe most of that was common sense.  I don't know.  Today I realized I spend a large portion of my day in elevators.  I guess in summary, know where you're going, get off to let patients use the elevator, be courteous to everyone in the elevator, and don't do anything you saw in Elf while riding. PS 62 days until Christmas, but who's counting?

Food Service Equations: Portion Costs

I like math.  Correction; I like easy math.  I am eternally grateful the applied nutrition curriculum's highest level of required math was pre-calculus.  I aced my pre-calc classes with A+'s, mostly because it's pretty simple math.  My method of studying when it came to math was to do example problems over and over until the process was brutally ingrained into my brain.  Sometime I understood what I was doing, and other times I didn't understand.  In those circumstances I repeated the example problem over and over until I could automatically and basically thoughtlessly solve the problem.  I think there is a lot more thinking involved with higher level calculus; thank God I dodged that bullet or I would probably have a life sentence at Cal Poly trying to get through math.

Anyways, I was studying for the DTR and hit the math problems: Food Cost Percentages; Edible Cost/Portion and Edible Yield; Cost Factor; Meals/labor hours, min/meal, payroll cost/day, payroll cost/meal, labor cost.  If you remember from my previous post about food service systems, I didn't pay much attention in my food service classes because I seriously underestimated an RD's role within the system itself.  (If you didn't read that one, long story short I assumed RD's lived in Clinical La La Land and had nothing to do with food service.  Some RD's might not be as involved with food service as others in the system, however they still must thoroughly understand food service.)

Anyways-anyways, I decided to take the same approach I did with pre-calc studying for the food service math problems and equations.  I kinda just did the problems and hoped it would stick.  I've been doing that on and off since July and nothing has stuck.  I decided to suck it up and actually learn the equations and why they were being used.  I want this information to stick with me so I can use it.  This requires me to teach myself using my study guide and the Internet since I never really comprehended it during my food service classes (shocking).  If I'm teaching myself, I might as well teach anyone reading this.  They say when you are able to teach someone else a topic it shows you fully comprehend it.  So, here we go!

Standard Portion Cost  (how much an item costs to purchase, prepare, and present)

These methods are used to help determine the total cost of product needed to produce an item on the menu. 

• Cost per unit is basically the cost of one portion from the whole unit.  This mostly has to do with items bought ready made, which is called the edible product in the food service world.  Basically, anything that can be served without altering (i.e. removing bones, cutting off stems).  Examples of edible products would include a cake that just needs to be sliced, a pack of bottled water, skinless/boneless chicken breasts, or pre-cut lettuce for salad.  Basically anything that requires little further prep before service.  

          To determine the standard portion cost, simply divide the cost of the whole unit by the

          number of portions.  For example, a cheesecake was purchased for $18 and can serve 

          12 people.  $18 by 12 servings equals $1.50 standard portion cost. This tells the kitchen

          how much each portion is costing them.  This can help determine how much an item

          should cost to the customer to make adequate profit for the business. 

• Yield calculations are used to determine how much of a product is used and how much it costs.  Most products are bought as purchased.  This is different than the edible product.  Products that are as purchased need further preparation.  This would include whole heads of broccoli (needs to be trimmed) or meat with skin/bones/fat that needs to be removed.  Or think about a bell pepper.  Lots of cutting and trimming.  Items such as these have trim loss or waste.  For example, you might need to buy 24 lbs of carrots.  However you cut 2 lbs worth of stems off (2 lbs of waste or 8.3% waste loss) and are left with 22 lbs edible portion (91.7% edible product).  

          If you take the edible weight and divide it by the as purchased weight and multiply by 100,

          you get the edible yield percentage.  Let's look at the green bean example:

          22 lbs / 24 lbs x 100= 91.7% edible yield

     

         If you flip flop that and take the as purchased and divide it by the edible portion, you can 

         see the percentage of edible cost.

         24 lbs / 22 lbs x 100= 109% edible cost or in decimal form, 1.09, also known as the cost 

         factor.

       

        **It's also important to remember that a buyer might look at the edible portion and compare

           that cost to the cost of a ready made product.  Keeping in mind labor costs, a buyer

           might decide a ready made product could be more cost effective after looking at the 
           edible portion from the as purchased.

Did I lose you?  I hope not.  Let's look at some sample problems and see if we can apply the terms and concepts learned.  (These sample problems are taken from a study guide I am using written by Jonathon Brown)

You need to prepare 374 4 oz portions of broccoli.  You note broccoli has a waste of 19%.  How much broccoli do you need to purchase?
Did you say 1,496 oz or 93.5 lbs?  If you did, you were thinking of the edible portion, not the as purchased amount.  

Did you get 115.5 lbs? Good job!
100%-19% waste=81% edible product
4 oz (portion size) divided by .81=4.938 oz (this is the AP amount per each portion)
4.938 divided by 16= 0.308 lbs
0.308 lbs x 374 servings= 115.5 lbs, round up to 116 lbs

OR make a proportion
81/100 (edible portion over total) cross multiply with 93.5 lbs/X (total edible portion over the variable, the total as purchased)
(81)(X)=(100)(93.5)
81X=9350
X=115.5 lbs


The yield factor on green cabbage is 87%.  Approximately how much cabbage is needed to prepare 175 servings of coleslaw that requires 2.25 oz of cabbage in each serving?
This is similar to the broccoli question.  87% edible portion is given and we are finding the amount in pounds that should be bought.  You could made a proportion again:
87/100 cross multiply with 24.61 lbs/X [24.61 lbs was found by (175)(2.25oz)]
X=28.3 lbs to purchase, round up to 29 lbs


You have purchased 35 lbs of fresh green beans with a 23% waste.  How many 4 oz portions will be prepared?
First let's figure out how many ounces are in 35 lbs.  35 lbs x 16 oz in a lb = 560 oz purchased

Second let's figure out the yield/edible portion (77%) of 560 oz.  560 oz x 0.77 = 431.2 oz

Lastly, divide 431.2 oz by 4 oz portion = 107.8 portions, 107 portions


How many pounds of pork roast (with a 15% shrinkage factor) should be bought to serve 600 portions that each weigh 3 oz?
First let's find out the total edible amount needed for service : 600 x 3 oz=1800 oz or 112.5 lbs

Next make a proportion again since we are trying to figure out how much to purchase
85/100 cross multiply with 112.5 lbs/X
(112.5)(100)=(85)(X)
11,250=85X
=132.35 lbs, round up to 133 lbs


CURVE BALL!  I'm going to throw in a scooper problem at you since I explained the concept in an earlier post (see Buckeyes).  The Standard portion for gravy is served with a No. 8 scoop.  Three gallons of the product should yield how many servings?
Do you remember what the number means?  It is the amount of scoops the scooper can get from 1 quart.  Therefore this scooper can get 8 scoops from 1 quart.  The question is asking how many scoops you could get from 3 gallons.

Since there are 4 quarts in 1 gallon, 3 gallons=12 quarts.  8 scoops x 12 quarts = 96 servings


A 4 oz serving of soy cheese is used in one omelet.  How many 5 lb blocks of cheese do you need to make 400 omelets?
1600 oz or 100 lbs are needed total.  100 lb divided by 5 lb blocks equals 20 blocks




Well that wasn't too bad now was it!  Stay tuned for more math adventures regarding Food Cost Percentages, Meals/Labor hrs, and Payroll Costs!  



 

Food Systems Management & Organization

Last year, I would be sitting in my Food Systems Management class about this time of day.  When I say sitting, I purposely exclude the words "paying attention."  I didn't dislike my food service classes, but I definitely underestimated their usefulness.  I  underestimated it even more as my senioritis kicked into full gear that fourth and final fall quarter. At the time, I agreed a dietitian should be familiar with how a kitchen is run and know  time and temperature control.  However, I was more interested in learning about clinical nutrition and things  such as medical nutrition therapy, counseling, and education.. Needless to say those previous sentences were fluff to cushion this upcoming sentence: I did not pay attention in my food systems management class.  I had already taken a two part series about food service and had learned all I thought I needed to know about the topic.  Food systems management covered topics such food purchasing, HR/employee management, and inventory.  I was not amused.  

An educational film from the 1980's was brought into this class about the Disney Corporation's unique method of employee management.  I was literally banging my head on my desk wondering why I had to watch a movie about this-I was a nutrition major, not a business major.  To me this was something so unnecessary and outdated it needed to be rewound before watching.  I should be learning about the DASH diet* or metabolic syndrome**.  In hindsight and a safe distance away from my brooding senioritis, today I will tell you the film is actually pretty interesting and educational; Disney calls their employees "cast members" and treats them as such.  They must be doing something right because Disney employees are always extremely friendly, happy, and helpful.  The film might have been made in the 80's, but the system Disney uses is so successful it is still implemented today.  However back then I didn't realize the connection of employee management to dietetics. 

Now that I am part of a system, I see that management is essential.  RD's, techs, clerks, hosts, and kitchen staff are all part of a system.  Some of the RD's may never meet our prep cook or dishwasher.  I don't directly work with the a lot of the RD's .  However we are all still connected.  For example, an RD will meet with a patient in surgical who just had jaw surgery and puts them on a temporary clear liquid diet.  (Hosts don't see NPO or liquid patients because their meal is pretty much already selected) The tech will receive the diet order from the RD and create the patient's dinner order.  Kitchen workers on tray line will put this meal together (i.e. jello, juice, popsicle, tea).  The clerk will double check the appropriate items are on the tray.  The host will deliver it to the appropriate patient.  Maybe the RD meets with a patient in telemetry recovering from a heart attack and puts them on a cardiac diet.  The host would see this patient and help them choose a meal with minimal non-fat dairy products, lean meats, diet salad dressing, and no caffeine or margarine.  The tech gets the order in their computer, the tray is made by kitchen staff, clerk verifies tray, and full circle-host delivers the tray.

What I'm trying to get at here is even if you're not the dietitian that supervises the system, you must understand how it works if you are a part of it.  Without a system, the RD would have to meet the patient, make an order, cook the food, make a tray, and deliver it.  A system is much more efficient!  Said RD may not know the cook making the food or the host delivering it, but they are still connected by the system.  If you are the supervisor of the system, you definitely need to understand system management.  This includes managing employees' hours, wages, and work ethic.  It also includes meals made per day and accounting.  To get a better idea of employee organization in a hospital system, here is a possible outline of organization.  

I.  VP Operations: da boss

    A.  Dietary Department Director: usually an RD that is the face of the department.  The 

          director communicates with other vice presidents in the hospital and receives complaints   

          and praise from patients and other departments.  Oversees all activity in the cafeteria 

          and with patients.  The director is held responsible anything dietary/food related.  

          1.  Administrative Assistant: I like to think of this position as the eyes and ears in the 

               kitchen for the director.  While the director may be dealing with a patient complaint or 

               communicating with another department, the admin assistant will be keeping an eye   

               out in the kitchen or going through orientation with a new dietary employee.

          2.  Clinical Dietitian Supervisor: this RD sees patients but is also the supervisor for

                employees in the dietary office.  The supervisor holds meetings and creates the work

                schedule for hosts, techs, and clerks.  They will also make sure daily tasks are 

                completed in a timely manner and employees must inform their supervisor if they are 

                running behind and need to work overtime.

                a.  Registered Dietitians: see patients and gives consultations on diets (don't let that  

                     short description fool you, there's a TON more RD's do with the inpatient world)

                b.  Dietetic Technicians Registered: DTR's work in the dietary office and receive 

                     meal selections and requests from patients from the computer system via the

                     hosts.  They will verify that the selections and requests are appropriate to the

                     patient's diet order and will alter the meal if necessary.  For example, the host may

                     have input an inappropriate amount of carbs for a diabetes order or juice for a 

                     fluid restriction patient.  DTR's must have a certification for this position.

                c.  Host/Hostess: interact with patients to make meal selections and deliver trays.

                d.  Diet Clerk: assist technician with printing and balancing meal selections.  Runs

                      tray line and is the last person on tray line to make sure the tray is correct.

           3.  Kitchen Supervisor/Buyer: oversees cooks and food service workers, manages 

                inventory, and makes food purchases.

                a.  Lead Cook

                     i.  Cook

                     ii. Grill Cook

                     iii.  Floaters

                     iv.  Food Service Workers: assist in kitchen and restock snacks and juices in on

                           floor kitchens in each unit, work in tray line production

                     v.  Storeroom Clerk: organize store room, bring in new products following FIFO 

                          (first in first out), disposing of expired items

          4.  Evening Lead: the kitchen is busiest and has the most people working from 5 am 

               to  3 pm.  This is when orders are taken, food is prepped for the day, and breakfast 

               and lunch is served.  Patients tend to be discharged in the afternoon, so the hours 

               between 5-3 are when the bed count or patient quota is highest.  Therefore there is a 

               distinction for evening staff that don't work during peak hours.

               a.  Vietnamese Chef: depending on the location of the hospital, there may be a 

                     strong need for a specific cultural type of food (i.e. Vietnamese, Kosher, etc).  

                     Vietnamese food may have items such as porridge, won ton soup, tofu, stir fry, etc.

               b.  Food Service Workers: deliver dinner trays since hosts are not working

               c.  Dishwashers

               d.  Cleaners

          5.  Cafe Lead: In charge of cafeteria where hospital employees and visitors may choose 

               to eat their meals.  May also include catering for hospital events or conferences.

               a.  Food Service Workers/Cafe Staff: serve customers and use cash registers

My next post will be related to all of the fun management equations I didn't pay attention to in class last year that will now be on my DTR exam...long story short to all you seniors out there-pay attention in food systems! 

*DASH diet: recommended for stopping hypertension, focuses on eating more fruits and vegetables, whole grains, lean proteins, Mg, K, and Ca.  Eat less saturated fats, red meats, sweets.

**Metabolic Syndrome: three or more of the following symptoms-hyperglycemia (diabetes), abdominal obesity, hypertriglyceridemia (high cholesterol), reduced HDL (the "good"/you want it to be high) cholesterol <40 for men, or hypertension (high blood pressure) above 130/8- mm hg

http://www.theclassroompost.com/2010/03/is-there-cure-for-senioritis.html

Where I'm At

I am in my third week at my job and am happy to let the world know I am finished training!  I will be on my own starting this Friday working with the postpartum, medical, and surgical patients.  I am a little nervous, but I feel pretty comfortable especially since normal training lasts another week or so but my supervising dietitian thinks I am already ready.  In the meantime, I have FOUR days off during a surprisingly spectacular sunny October week. 

Although I would love to put in 8 hour days at the beach, I really need to study for my DTR exam.  Especially because (drum roll please) the supervising dietitian wants me to start training with the current diet tech in the office in about a month!  There are currently two diet techs on staff (makes sense because there needs to be one on duty everyday) and one is retiring after working at this hospital for 26 years, wow!  She has incredibly big shoes to fill, but I can't think of someone better to train me!  In the meantime, I want to get my certification ASAP so I have it done and out of the way.  From what I can observe, the diet tech on duty receives the patient's meal requests that the hostesses put into the computer.  It is the diet tech's responsibility to make sure the meal is balanced and appropriate to the patient's diet order (i.e. a patient with a carb control diet cannot have fruit and juice for breakfast therefore the tech will alter it to fruit and a diet cranberry juice). 

There is so much to study for the DTR test!  Of course there is a broad spectrum of clinical topics ranging from carb counting to diverticular disease to renal diets.  There are also topics from the food service category including management, temperature control, and costing.  And don't forget food science! I'm also brushing up on maillard reactions, egg coagulation and syneresis, and the differences between soluble and insoluble fiber.  These are all things I can think of off the top of my head; there are just so many different questions that could pop up on this test!  Luckily, I have a study guide a previous student gave to one of my teachers from college that I have been using.   

[Sidebar, can I tell you how happy I am right now!?  I don't want to jinx said happiness, but so many things in my life are amazing and I am cautiously waiting for it all to crash down.  Moving away from the city and friends I loved to doggy paddle to keep my head above the waters of uncertainty, unemployment, and unhappiness left me with some dark days this summer.  Now I feel happy and that I have a purpose.  I am on a path and can see hazy images of my life as a Registered Dietitian.  In fact, my supervising dietitians are hoping I can stay on as a tech on weekends if I start a local DI next year.  They even went so far as to say that if I stayed and showed commitment, they could add me to their staff of RD's once I was certified.  WHAT?! It's very far down the line, but who wouldn't want to hear that?!

I've also been unexpectedly losing weight since I started working.  I was trying to get in better shape this summer to lose my beer/fireball/wine/tritip/baconwrappedhotdog belly from my last crazy quarter of college.  I ate healthier, worked out, and monitored everything on a great ap called My Fitness Pal.  However, I didn't really see any results.  All of a sudden I start working full time and am down 7+ lbs.  I don't completely understand why this happened.  Maybe it does take a couple of months to get noticeable results.  I do think it is helpful that I am on my feet, delivering trays, and pushing carts for 8 hours.   Another factor would be waking up earlier and going to bed earlier.  If I'm not up late, I'm less likely to get late night munchies.  My weight loss has nothing to do with the amazing free hospital food either; last week alone I ate ceviche, blackened salmon, and carne asada tacos!  So, I guess if you need to lose weight, start waking up before the sun and find a job where you're on your feet 40 hours a week :) ]

Patients Deserve Your Patience

I apologize for not posting in a while, but this new job is making me (happily) busy.  I'm feeling comfortable working in a hospital environment, talking to patients, and collaborating with other people that work at the hospital (charge nurses, RN's, dietitians, etc). I wanted to share some wisdom that was shared with me about working with "difficult" patients. If you ever held a job in customer service you are familiar with the following phrase: the customer is always right.  They may be called patients in a hospital, but they are also considered customers. They are paying the hospital for healthcare/treatment, which includes the proper nutrition found in their meals.

When doing menu selections with patients at our hospital, it can be more similar to a restaurant selection than typical hospital food. The patients are given as many options that fit into their diet plan as possible. Sometimes the occasional patient will become very particular or picky about what they ordered, similar to a customer one might serve at a restaurant. Sometimes the occasional patient is difficult. Sometimes the occasional patient will be angry at you for something you don't deserve. Sometimes the occasional patient is a perfect storm of picky, particular, difficult, and angry.  Still, the patient is not only always correct, but needs to be reassured and comforted. The number one goal for every patient is recovery and wellness.  To help put things in perspective, someone at work shared the following fantastic advice with me: a lot of patients in the hospital find themselves with nothing to control.  Their bodies might be failing them. Their doctor may have them on medication they don't understand. They may be under a doctor's orders they don't want to follow. However, they do control their food choice. Some patients may take their food orders more seriously than others because it is the only thing left that they can control.  This means when someone asks you for 5 Splenda packets or gravy on the side or a completely new order you apologize, take a deep breath, keep smiling, and admit you're wrong even if you know you're not.  You need to be able to leave the room knowing the patient is satisfied  with their meal choices and not angry at you or the menu.

Our goal as nutrition employees at the hospital is to encourage the intake of adequate foods to get patients on the road to recovery. So the patient is always right.  A happy patient will be happy to see their meal when it arrives.  Meal satisfaction leads to adequate energy intake.  Adequate energy intake helps recovery.  Recovery puts the patient back into optimal health.  The patient is always right.  Simple as that.

These are a Few of My Favorite Things

As you already know, I love cooking and baking.  I always like to try new recipes, but there are several old faithful crowd pleasers I know I can always count on.  I pinkie promise I will do some DTR studying today, but after a long 40 hour week I wanted to post something  for you foodies.  I added pictures to entice you and provided a link to each recipe.



Grilled Chicken Thighs with Ancho-Tequila Glaze
This a BBQ recipe from the magazine Cooking Light.  If you've never checked out the magazine, I highly suggest you do!  The recipes are on the lighter side, but always deliver on taste and the "yum" factor.  These are AMAZING.  Since I've moved back home, we've probably had them at least five times.  We usually skip the wood chips, use honey instead of agave, and regular chile powder instead of ancho; do what you want!  Promise me you will try these.  I can guarantee you will come back to them again and again.  

http://www.myrecipes.com/recipe/grilled-chicken-thighs-50400000122078/


Avalanche Bars
This recipe comes from the Rocky Mountain Chocolate Factory.  They are extremely quick and only require a microwave, in fact the first time I made these was during the Super Bowl halftime this year.  If you are a fan of Rice Krispie treats and think they are easy, wait until you make and eat these.  When you cut them you are left with lots of yummy avalanche crumbs-don't even think about tossing them!  They are a great snack for the deserving cook. 

http://www.thesweetslife.com/2012/07/avalanche-bars.html



Pioneer Woman Restaurant Salsa
I'm completely obsessed with Ree Drummond, the "Pioneer Woman."  She is an unintentional cowgirl who lives on her family's cattle ranch.  Her food is simple yet satisfying and scrumptious.  Knock on wood, but everything I have made from her has been FANTASTIC!  I have tried her stuffed shells (delicious), shortbread cookies (the PERFECT recipe), dreamy apple pie (can you say whiskey whipped cream?)and tortilla soup (great to make for the whole week).  I have been on the wait list for her cookbook at the library, which is finally ready for me today.  I guess Christmas came early this year!  Anyways, this salsa is incredible and very easy to make; you will never buy pre-made salsa again.  This ingredients are mostly canned, with some fresh items that bring it to life.  Throw everything in the Cuisinart and you'll have about 2 jars of homemade salsa!  I hate spicy foods but accidentally doubled the jalapenos and didn't have a problem with the result.  I use this salsa everyday by mixing it with egg beaters, then scrambling them.  ¡Muy delicioso!

http://thepioneerwoman.com/cooking/2010/01/restaurant-style-salsa/



Baked Monster Cookies
Baked is a fantastic bakery in Brooklyn that makes these cookies containing peanut butter, oatmeal, chocolate chips, and M&M's.  This makes a ton of cookies, but they are a total crowd pleaser!  Just make sure people with nut allergies are aware they contain peanut butter.  I also think everyone should have a copy of at least one of their cookbooks.  They have fantastic classic dessert recipes.

http://www.annesage.com/blog/2009/01/to-die-for-recipe-monster-cookies.html


Green Goddess Tabbouleh 
This recipe looks and tastes healthy.  It's chock full of fresh herbs and I like to make it with quinoa for added protein.  I used to make it in college to have as a quick lunch or dinner during the week.  You can make it on Sunday and it holds very nicely throughout the week. 

http://www.greenlemonade.com/recipes-juices/green-goddess-quinoa-tabbouleh/


Vegan Blueberry Pie Pancakes 

These come from a great website called Chocolate Covered Katie which has tons of creative and yummy healthy dessert recipes.  I happen to love these with orange zest and toasted chopped almonds on top, yum!  Best thing (for me) about this recipe, is it only makes a single serving so you're not stuck standing over a stove and left with 27 extra pancakes.  You could make a couple little pancakes, but I like to make one huge and satisfying vegan blueberry masterpiece!

http://chocolatecoveredkatie.com/2011/06/09/blueberry-pie-pancakes/

Made these while nannying over the summer

Soft Pretzels
These are 100% impressive and from Alton Brown.  The recipe is surprisingly easy and produces the most beautiful pretzels you have seen, not to mention the smell that will fill your kitchen is going to make you think you died and went to heaven.  They look like pretzels you find on carts or at baseball games because they come out golden brown.  However, these taste ten times better than those you can buy from a vendor.  You actually boil these for about 30 seconds in water and baking soda prior to oven baking, similar to how bagels are made.  Don't hold the mustard either, it's a must for these golden beauties!  If you want, the link has a video from Alton's show where you can watch how the pretzels are made.

http://www.foodnetwork.com/recipes/alton-brown/homemade-soft-pretzels-recipe/index.html

A batch I made three weeks ago

Cake Mix Doctor's Mom's Layer Cake with Fluffy Chocolate Frosting
This has been my go to birthday cake and cupcake recipe for 5 years.  It's that good.  Yellow cake with chocolate frosting is the ultimate birthday cake to me, and this recipe has never failed me.  It's just as simple as making a cake with a cake mix, except you use whole milk (no other kind of milk will do) and melted butter instead of oil and water.  You also beat the batter until it is nice and fluffy.  The chocolate frosting is exceptionally fudgey and will cause you to turn your nose at those of the canned variety after you try it.  After I frost these cupcakes, I like to dip them in a plate full of rainbow sprinkles.  These will make you feel five years old and bring you back to a time where you looked forward to turning another year older.  

http://familyfun.go.com/recipes/moms-layer-cake-with-fluffy-chocolate-frosting-679347/


Ina Garten's Potato Salad
I have never been a fan of potato salad.  Whenever I saw it I always thought of mass amounts of mayonnaise .  This recipe was a game changer for me; Ina's recipe is light and tastes fresh with all of the herbs utilized.  You can also sub in Greek yogurt for the mayonnaise (Greek yogurt is absolutely amazing and full of protein, please please try it if you haven't!  In general yogurt is a great sub for sour cream or mayo in savory recipes.) http://www.food.com/recipe/ina-gartens-old-fashioned-salad-365727

Overuse I Love You

I'm going to keep this one short and sweet.  Unfortunately there are some people who don't get to leave hospitals and end up spending their last days there.  I knew this coming into my job, but it wasn't until I was confronted with the situation yesterday that it really hit me.  A patient with a terminal illness was alive for breakfast, but not for lunch.  The shocking situation was so blatantly  front of me as I looked at the undelivered tray in my hands and it made me really sad.  The overwhelming  feeling of emotion caused me to doubt my ability to work in a hospital.  I know there are many other people who work in hospitals and have faced similar situations too many times to count.  It even made me think, "Is that ok?  To see death and keep working as if nothing happened?"  

I think what made me feel even worse was that I didn't remember who that patient was.  There are so many patients to see that it becomes easy to do what needs to be done and move on to what is next.  I'm not saying that I act like a robot when I see patients because that's accurate at all.  I try to be as warm and helpful as possible.  I doubt it was the case, but what if I was the last face that patient saw before they passed away? This made me reflect on bedside manner and the balance between getting things done efficiently while still being personable and friendly to patients.  Also about treating all units the same.  It's sometimes easier to be more friendly during comfortable situations.  Labor and delivery and postpartum are always my favorite units.  I enjoy visiting with the new mothers and watching them with their new babies.  Other departments with critically ill patients or those that are hard to understand usually make me want to get through their orders quickly.  It became clear to me that I need to act comfortably with all patients.  I realized that sometimes the patients that might make me uncomfortable deserve and just might need more personal attention.  The question that runs through my mind now before I enter any room, and especially those in critical care, is this: What if I am the last face this person sees?  I hope this is never the case, but you never know.

I came home yesterday and gave my dad a big hug.  I was reminded me to tell loved ones  that I love them and to show it often.  In the words of Lee Brice and one of my favorite songs, "Be a best friend, tell the truth, and overuse I love you.  Go to work, do your best, don't outsmart your common sense."

Brain Dump: Liquid Diets & Dysphagia Diets

I'm mostly doing this  to review for the DTR exam.  Feel free to skip this post or learn a little something about some clinical diet orders

Let's start with the liquid diets.  Liquid diets may be utilized for patients who are NPO (nothing by mouth).  A diet progression for this would go from Clear Liquid (CL) to Full Liquid (FL) to a soft diet (pureed foods) to a regular diet.

• Clear Liquids: broth, clear juices, jello, popsicles, coffee (no cream), tea.  You might not think of jello or popsicles as a liquid, but since both can be liquid if not chilled they are considered a clear liquid. This diet is usually short term since it isn't nutritionally adequate (not much protein or fat).  Reserved for situations such as post-op or bowel rest since it doesn't require much digestion or work from the GI tract (low residual)
• Full Liquids: cream soups, cream of wheat, custard, all juice, plain ice cream, pudding, butter, margarine, milk, yogurt.  These are all also liquid at room temp.  It is usually used as a transition from CL to a regular diet.  It contains more protein and energy than CL but still may not be able to provide enough overall energy.  Since most of the protein in this diet comes from dairy products, may be a problem for those with an intolerance.  

Since working, I do see a lot of CL's (posicles, Italian icees, jello, and broth which is always a soup option for lunch and dinner.  (There is low Na broth for cardiac diets).  As far as FL's, I see ice cream (sugar free and regular, both when appropriate), yogurt, milk, cream of wheat, vanilla pudding.  

Dysphagia diets are for those who have difficulty swallowing.  The primary complication with dysphagia is aspiration (which could affect the lungs and cause pneumonia) although weight loss and malnutrition may also occur because the patient is physically unable to intake regular foods or may not have an appetite for dysphagia appropriate foods.

There are 3 levels in the National Dysphagia diet (standard as of 2002)

• National Dysphagia Diet 1 (NDD-1) "Dysphagia Pureed" (I see this as Dys-1 on charts or heard verbally as pureed at work): food is pureed or pudding like, for example pureed meat or veggies, mashed potatoes with gravy (gravy helps make it moist and easier to eat, also adds flavor), applesauce.  NOT ok: jello(too thin), yogurt with fruit pieces (choking hazard), eggs, chunky cottage cheese, fried/hard-boiled eggs 
• National Dysphagia Diet 2 (NDD-2) "Dysphagia Mechanically Altered"  meats have been cut up using mechanical means such as a grinder/knife, vegetables may be steamed, soft or canned fruit, moistened cereals.  For example scrambled eggs, pancakes with syrup, banana, cereal flakes with milk, thickened beverages (ie OJ plus a thickener suck as Thicken up) NOT ok: bread, cake, rice, corn, peas, cheese cubes

ALSO: "Dysphagia Mixed" is a diet that uses NDD-1 plus one NDD-2 item (example menu: OJ, yogurt, cream of wheat, scrambled egg)

ALSO: "Mechanical Soft" is NDD-2 that allows bread, cake, and rice (example menu diced chicken+gravy, steamed rice, beets, pound cake, strawberries)

• National Dysphagia Diet 3 (NDD-3) "Dysphagia Advanced" for the most part, a regular diet, except patient must stay away from hard/sticky/crunchy items.  I like to call this the braces or retainer diet (remember back in the day of orthodontics when you had to stay away from caramel, gum, popcorm, corn nuts)  For example vegetable soup, shredded lettuce salad, sanwhich, melon, cookie (no nuts).  NOT ok: hard fruits and vegetables (apples, carrots), corn skins, nuts, seeds

Also good to know the progression of liquid terminology from thickets to thinnest: spoon thick, honey-like, nectar-like, thing liquids. (Thin liquid= water, ice, milk, milk shakes, coffee, tea, ice cream, jello; basically CL and FL)