At Liverpool Heart and Chest Hospital, a small specialist cardiothoracic centre, surgical complexity increased and with no on‑site gastroenterology support, the service needed senior, autonomous dietetic decisions every day. As an Advanced Practitioner Ruth ensures safe decision‑making, stronger governance and alignment with NHS priorities.
Ruth completed the e-Portfolio (supported) route to gain recognition of the level at which she was practising. This promoted proactive structured care, safer PN pathways, clearer escalation processes, earlier metabolic decisions and smoother collaboration with consultants. As an AP dietitian, she has brought stability to her team, created space for education and research, and enabled innovations that ensure faster, more efficient patientcare.
Population:
- 35‑bed critical care unit (12 long‑term ITU beds + 23 post‑operative beds).
- Supports cardiothoracic surgical patients: coronary artery bypass graft (CABG) and complex aortic surgery, including supra‑regional referrals.
- Manages post–cardiac arrest patients admitted directly to critical care(bypassing ED).
- Covers patients who are ventilated, sedated, septic, or in multi‑organ failure.
- Supports increasing proportion of younger adults in population (around10–15 years younger than pre‑2020).
- Growing adult congenital heart disease (ACHD) population returning for repeat surgery.
- Manages gastrointestinal (GI) and metabolic complications that develop during cardiac care.
Intervention:
- Provides advanced autonomous decision‑making for high‑risk parenteral nutrition (PN), enteral feeding and metabolic instability in a hospital without on‑site gastroenterology.
- Manages complex bowel issues by coordinating specialist referrals while escalating safely when needed.
- Leads Trust‑wide nutrition governance, updating PN/enteral policies and establishing clear, safe escalation pathways.
- Redesigns nutrition pathways, including Band4 led follow‑up clinics, improved discharge processes and streamlined referral routes.
- Improves insulin‑feeding management in critical care, reducing costs and supporting safer practice.
- Acts as the senior point of contact for nutrition, strengthening MDT communication and decision‑making.
- Embeds education, quality improvement (QI)and research into routine practice to support a modern, sustainable service.
Outcomes/Impact
- Service impact – AP leadership directly contributing to increased capacity, reduced unmet need and enhanced responsiveness to patient demand
- Patient outcomes – earlier identification and management of metabolic and GI complications, more consistent support for PN
- Workforce outcomes – a successful business case enabled recruitment of a Band 4 assistant, saving over £20,000 in unnecessary community oral nutritional supplement (ONS) prescribing
- Quantitative data (2024 – 2025)
- Total dietetic contacts increased from 4251to 4399
- 26% increase in patient-facing time
- 69% reduction in unmet need (patients experiencing delayed dietetic review due to capacity constraints)
- ACHD contacts increased by 160%
Ruth incorporates the four pillars of practice in their role by:
Clinical
Delivering autonomous, high-level clinical practice by independently directing investigations, managing complex GI and high-risk PN cases, leading multidisciplinary metabolic decision-making, and introducing novel assessment tools
Leadership
Manager of acute dietetic team, implementing Trust-wide nutrition policies, developing business cases for workforce expansion and QI projects, providing faster decision-making with fewer delays
Education
Student training lead for pre-registration dietitians, internal teaching across the multidisciplinary team (MDT), contributes to regional and national education through research projects, PN and enteral feeding protocol development
Research
Annual conference poster production to strengthen research culture within the team, driving innovation for modern patient screening techniques (ultrasound muscle-mass assessment),project on ONS use that generated measurable clinical cost benefits
