Annie Cichocki Oral History
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Behind The Mask
December 3, 2021
Barr: Good afternoon. Today is December 3, 2021. My name is Gabrielle Barr, and I’m the archivist at the Office of NIH History and Stetten Museum. Today I have the pleasure of speaking with Annie Cichocki. She is the chief of the Nutrition Department at NIH’s Clinical Center. Today she’s going to be speaking about her experiences of providing food to the inpatients at NIH during the pandemic. Thank you very much for being with me.
Cichocki: Thank you for having me. It’s a pleasure.
Barr: Briefly, will you please introduce the various facets of the NIH Nutrition Department and your responsibilities as its director?
Cichocki: In the Nutrition Department, we actually have two sections. We have the clinical side of the house—the registered dietitians who actually deal with patients, whether it’s regular diet or therapeutic diets. Within that section, we also have what we call the dietetic internship program. We train future dietitians, so they know what we have here, and what we have to offer in the area of dietetics at NIH. Hopefully we can get them into research because we do need to get new employees. Also, as part of the clinical side of the house, we have the metabolic kitchen—it’s not the main kitchen, but it’s where we do most of the research protocols in terms of supporting the Clinical Center. On the other side of the department is the food service section, and that’s where we have the patient trays. We cook and serve food to patients, whether it will be a regular diet or therapeutic diets. We also have the call center. We’ve implemented what we call “food-to-order.” It’s like a hotel service. When patients are ready to eat, they call us and let us know what they want to have. Then we deliver that tray to them within 30 to 45 minutes once they place the order.
Barr: You make food for patients on demand in addition to the other food that you make during the day?
Cichocki: Let me put it this way: most of our inpatient feeding is on demand because we want to prepare the food fresh for them—with the exception of some study protocols, which may ask for other ways to serve the food to the patient. For our inpatient feeding, we mostly serve them when they’re ready to eat. That also helps in terms of quality of food and making it fresh for them. It also decreases waste because if a patient is not ready to eat, there is no reason to bring the food up to them.
Barr: How do you work with the doctors, nurses, and other research scientists on tailoring the meals for the patients, particularly those that have therapeutic regimens and the portioning for them?
Cichocki: That’s pretty much more on the clinical side of the house. The doctors or the provider will have a patient diet order. It depends on the patient’s medical issues—whether it be kidney issues or diabetes or any other medical issues. We tailor those foods we have in the kitchen to make sure we follow the diet recommendation or diet order from the providers. Right now, we have 150 different therapeutic diets that we offer in the Clinical Center. It’s a wide array of therapeutic diets that we have available for our patients.
Barr: What are some of the other needs that you have to be mindful of? Some people are vegans or vegetarians or have religious restrictions in terms of their diets. How do you accommodate that at the Clinical Center?
Cichocki: We actually have a program called CBORD. This is where we annotate the patient’s allergies, their food preferences, and their cultural and religious restrictions—whether it be kosher or any other diets that may require restriction that deals with religion and culture. When they call the call center, we have those annotated in their notes and we know what not to give them and can adjust those food trays to fit the patient’s needs. One of the things that we also have here is a chef in-house. We do get patients from everywhere in the world, as you may know, and sometimes their food preferences vary. We just send the chef up to talk to the patient. We try to accommodate a lot of those cultural food preferences in the kitchen as much as we can. We try to make it really nice, personal, and comforting for the patients.
Barr: Just to get an idea, what are some of your facilities like—your kitchens, fridges, and stockpiles of food?
Cichocki: Right now, we have food in-house that will last for at least 72 hours. If something happens—a supply issue or a huge natural disaster, like snow or heavy rain—that we can’t get food supply, then we have at least 72 hours’ worth of food for patients, including beverages, but we also have a contract with a food company. They’re supposed to be able to deliver food to us at least twice a week. With the supply chain issue, there are some foods that are not available at particular times, but we’re able to look at what they have to offer and see if that will substitute what they cannot offer at that point.
Barr: Is your department a 24/7 operation?
Cichocki: No. The kitchen actually opens at 5:30 in the morning, and we close at 8:00 in the evening. We pretty much start breakfast at 6:30. Nobody wants to eat earlier than 6:30. If I’m a patient and I’m sick, then I would like to be able to sleep in. We deliver food trays up to 8:00 in the evening.
Barr: Is your department in charge of providing nutrition to patients on ventilators? It’s a little different than other kinds of patients.
Cichocki: We do. It depends whether they’re on a regular diet or whether they are on enteral or parenteral nutrition. We do provide those, whether they’re eating orally or intravenously. We provide food for all the inpatients. One of the things that happened during the pandemic is that we are also providing a meal to their guests or to their caregiver. We’re allowing one food tray for each patient if they have a caregiver because there are other circumstances—they can’t go out and get their own food, so we also serve guests trays along with inpatient feeding.
Barr: That’s a lot of meals to prepare!
Cichocki: It is a lot of meals to prepare. If we have a patient—let’s say the census is at 79—then an additional 25% to 30% of that would be the guest trays, which is mostly the patients’ caregivers.
Barr: When did you begin thinking about how your department was going to prepare for the pandemic?
Cichocki: I don’t think we actually planned to prepare for the pandemic, because it just happened, right? March and April of last year was when we started making changes because of the pandemic. Initially, one of the departments that was actually affected was the Nutrition Department, because of quarantine issues. We’ve had some employees who tested positive. Then you have kind of a snowball effect. At the beginning of the pandemic, we were actually red on staffing in the kitchen. We quarantined about 80 to 85 percent of the kitchen employees, so we didn’t have anybody. We only had one cook, which [makes it] kind of impossible to be able to do all the cooking. We were able to cater food from outside to feed patients—because we have to feed them! Then you have to look at other ways that you can still accommodate those therapeutic diets in addition to the regular meals. It’s been really challenging for us. It comes and goes in terms of red staffing in the kitchen, but over time we were able to plan what we would do if this thing happened again. When it comes to available food, that wasn’t really an issue during the pandemic, it’s just a matter of losing people due to quarantine. You just have to adjust your menu and still be able to feed patients and meet their nutritional needs.
Barr: You said a couple of people tested positive in your department. Were the rest of the people just exposed to those people and that’s why they had to be quarantined?
Cichocki: Correct. They were exposed, and they needed to be quarantined.
Barr: That must have been really hard.
Cichocki: Yeah, it was very challenging—but it was the beginning of the pandemic. We didn’t quite know. Nobody really knew. I don’t think that anybody ever really planned how to deal with staffing shortages because of quarantine.
Barr: How did you go about contracting with the caterer on such short notice, and what was that like?
Cichocki: Fortunately, we’ve been able to establish a relationship with the cafeteria contracts in the hospital. They’ve been very gracious in terms of accommodating our needs during that time. I give it to them—we would not have been able to do what we were supposed to do without them. Contracting other restaurants from outside would have been a lot harder. When we lost the staff, there’s really not a meal we cannot feed. There’s never been a meal where patients weren’t fed, or we weren’t able to give them what they need nutritionally.
Barr: Did you learn that there are particular dietary needs or recommendations for patients with COVID-19, and if so, how do you tweak their diets depending on their symptoms and the stage of the disease that they’re in?
Cichocki: It usually depends on what their providers order for their diet. A lot of our COVID patients, if they’re on the ventilator, they obviously cannot eat. If they can, then most of them are on regular diets. Either way, we were able to accommodate that, whether it’s oral nutrition or artificial nutrition. There’s really not anything that our COVID patients needed that we weren’t able to provide. We were able to adjust [to] whatever it is that they needed during their stay here.
Barr: Did your dieticians ever have to counsel patients to eat? A lot of people lost their taste and smell with COVID and were not very inclined to eat because of that.
Cichocki: During that time, or even now, when dieticians need to talk to patients who are on isolation—whether it be a COVID patient or any other reason—they were able to telehealth with the patient. Not necessarily face-to-face. They can talk to the patient in terms of changes in their taste or smell or other things we could possibly do for the patient in order for them to meet their nutritional needs—or if we need to put the patient on enteral feeding or TPN [total parenteral nutrition] if their gut is not working or if they’re not able to eat by mouth.
Barr: How do you provide food for patients like those with COVID-19 who are highly infectious or are in special units?
Cichocki: For our patients in isolation, to include our COVID patients, we actually have a protocol in the Clinical Center. We still prepare their food in the kitchen, but we put them in disposable trays so that it doesn’t come back in the kitchen. Whatever we put in the patient’s room doesn’t come out and come back to us. For the food we prepare for them, we use all disposables. Then it just doesn’t come back in the kitchen, to make sure that our kitchen is not exposed to those viruses that our isolated patients may have. In addition to that, when we deliver the food to the patient, the nursing staff are actually the ones who go to the patient’s room to give it to the patient, especially for our COVID patients.
Barr: That makes sense. How did you try to ensure the safety of your staff who have to perform their jobs in person and have to work with others throughout the day, and how did you maintain their morale?
Cichocki: It’s more like it evolved overnight. We learned as time progressed. During the pandemic, in terms of having a workspace, it’s kind of hard in the kitchen to do that. You have to be six feet apart. It’s really very challenging. The tray line itself is not that big, so making sure that employees are six feet apart is, most of the time, very challenging. We try to go by that as much as we can. In terms of employee morale, [we maintain that] just by being with them and seeing what they need and listening to them. One of the things we’ve also done during this time is employee recognition, whether it be putting them in for awards—a time-off award or monetary award—or just recognizing their efforts and their loyalty to the organization. It goes a long way.
Barr: How did you maintain your own morale during such a stressful period, especially in the beginning?
Cichocki: It’s just going back to the mission of the department, which is to provide meals to patients and quality and safe patient-centered nutrition care. [For me, it was asking] “What am I doing here today?” We have patients to feed. Kind of like going back to your mission. Why do you go to work every day? That’s pretty much to take care of patients and their nutritional needs.
Barr: With the number and types of patients at the Clinical Center fluctuating throughout the pandemic—at some point, it was only essential patients, at one point it was only COVID patients, now we’re back to everybody being back—how have you strategized on how to order, what to order, staffing requirements on your end, and just how to prepare on a daily basis for the patients that are there?
Cichocki: We’re not unfamiliar when it comes to patient census fluctuation. In terms of staffing needs, we adjust those. Most of our employees are federal employees, so I can’t really say, “We only have 40 patients today, so you can’t come to work”, but there are a lot of things they can do in the kitchen—not just patient feeding. In terms of food supply, we order twice a week, so it’s very easy to make adjustments in terms of what we need two days from now based on the census. There’s very little food waste when we have a very low patient load.
Barr: I had imagined that you would have to order some things months in advance.
Cichocki: Oh no, we order twice a week. It’s very easy to adjust your food orders.
Barr: What has it been like to provide meals to patients given supply chain issues at the beginning of the pandemic and now?
Cichocki: In terms of supply chain issues at the beginning of the pandemic, it wasn’t really that problematic compared to now, when we have real supply issues. That’s because during the beginning of the pandemic and the year after that, there was definitely no supply issue—we just had to adjust how much we were ordering because of the low patient census. Recently, with the supply chain issues, there are a lot of things that our food suppliers are not able to supply. Most of those are fruits and vegetables. Sometimes it’s food that we actually need to have for the patients, but one of the things we can do in the department as well—which is really great—is we’re able to go to the local grocery store. Sometimes there are patients who only need one food item, and if we get that from our food supplier, it will come in cases and there is no way that we can use that for just one patient. So, we’re able to go to Harris Teeter or Giant and just buy small amounts of foods for a few patients. That saves us in terms of food waste and space in our limited storage spaces in the kitchen.
Barr: Have you had issues getting meat? Many people have complained about that.
Cichocki: Every now and then there are certain food items that are deemed to be patient favorites. One of their favorites is our chicken wings. I don’t know why—it must be really good. I haven’t tried it yet. At one time, we didn’t have any chicken wings, and a lot of our pediatric patients weren’t happy about that. I guess it’s just a comfort food for a lot of our patients. Most of the time our issues with the supply chain are mostly our fresh fruits and vegetables.
Barr: How have you had to contend with the rising cost of food? Has that been a problem for you all?
Cichocki: It has been, but the leadership in the Clinical Center has been really, really supportive in terms of me asking for more money for food costs. It kind of evens out because of the low census at the beginning of the year. During our busiest time, we could have up to 150 or 160 patients a day. We haven’t really been able to do that, so with our food budget, we’ve been able to kind of stay within that with the rising food costs. It kind of evens out because of the lower census.
Barr: Have you always been able to find substitutes for patients when what you would like for them is not readily available?
Cichocki: Most of the time, we do. There are certain foods that our supplier is not able to give us, and then we just have to explain to the patient that we’re sorry, we don’t have cantaloupe today [for example] and we don’t know when it’s coming. They understand. Our patients are very accommodating and understanding, especially during the turbulent times of not having enough staffing. We have to give them catering foods, and they fully understand. Nursing staff is phenomenal in terms of supporting the department when we get into these staffing and supply issues.
Barr: Have you heard anything from the patients, either complaints or compliments about your department at this time?
Cichocki: We get both but mostly compliments. I don’t mind complaints because that’s the only way we can make things better, right? The thing about those is when we have those patients who are not happy about their food, we want to make sure that they are—because we want them to eat. We just go upstairs and visit them—or I’ll go upstairs and bring the chef with me—and talk to the patient or their family member about what it is we can do so we can give them better food or accommodate their preferences. We take those things very personally when it comes to unhappy patients with regards to their food.
Barr: Do you get a lot of people in general who don’t like a healthier diet that they’re being put on, like less salt or less sugar or something like that?
Cichocki: We do, but that’s really when the dieticians come into place. They would go or call the patient and explain to them why we can’t give them this much salt, or why their diet is bland, or why they are on this very healthy diet with low fat and low carbohydrates—just explaining to them the rationale. Most of the time when patients are placed on those therapeutic diets, they already know the reasons why.
Barr: What do you feel you have learned over this past year and a half that you would implement during normal times or perhaps another crisis like the pandemic?
Cichocki: Definitely a modified menu. We actually have almost a 10-page menu to select from. Now we have the modified menu that we can easily prepare when there’s staffing shortages or even food supply shortages. We’ve actually increased our shelf-stable foods. We actually have meals ready to eat—they call it MRE. It’s a full package of food and has everything like carbohydrates, protein, and fat for the patient. We have those on hand just in case something happens so we can use those for our patients. We also have those meals ready to eat that are halal or kosher so we can accommodate those patients who may be on those diets. Also, more water in our storage area.
Barr: In recent years, you have developed a lot of electronic systems. Can you speak a little bit about that and also how you accelerated or improved on those systems during the pandemic?
Cichocki: The CBORD program is a nutrition program where we document everything with regard to the patient’s food allergies, food preferences, and religious and cultural preferences, so that when they call the call center, we can look at that patient’s [information] and know the patient is kosher or that they’re supposed to be on halal, or they’re on low sodium. Also, with the CBORD program, it actually will also let us know if the patient missed a meal. If someone didn’t order breakfast, it’ll allow us to ask if they’d like breakfast. We want to make sure that by certain times of the day, if a patient hasn’t called, then we call them. We also use that in terms of substitution, especially now that we have supply issues. If we’re running out of a type of food item, [it helps determine] what we can use that’s still equivalent to this food item that’s not available from our supplier. It’s been a really great program that we use to make sure we continue to deliver those high-quality food items for patients.
Barr: How do you feel that your previous training and experiences have prepared you for dealing with the pandemic? Before you came to NIH, you’d done a variety of different jobs in your career.
Cichocki: It’s just a matter of what I’ve learned over the years—being agile and able to adjust with what circumstances offer you. The thing with the pandemic is just a completely different experience for all of us because there is no playbook that says how to feed patients during COVID. Over time, it’s just looking at your experiences in the past. As military personnel, you’re presented with a lot of issues or challenges at times. It’s a matter of working together as a team and bringing your team back, in terms of reminding them what our mission is. I’m telling you—we have some of the greatest staff in the Clinical Center in the Nutrition Department. During the pandemic, when there’s red staffing in the kitchen, dieticians came down and we prepared food and put food together for patients. It was very hard; we worked long hours, but those were the times where you can look back and you know you actually built this strong team because of the challenge that was presented to you.
Barr: In the beginning of the pandemic, some people felt maybe it was spread through surfaces. How did you assure patients that their food and the trays were okay to touch and safe? Did you have anyone worried about that?
Cichocki: Not really. We do have a good quality assurance program. Before the trays leave the kitchen, we check them not just for accuracy, but to make sure the food is of high quality. In terms of infection control in the kitchen, it’s really very paramount for us that we practice that because we’re serving patients who are very sick. We want to make sure that the food we serve them is not just high quality, but it’s also safe for the patients.
Barr: What has been the most rewarding aspect of working at NIH for you during the pandemic?
Cichocki: It’s the sense of team effort. We worked so hard during that time, just like I stated earlier, but those were the times when we got to know each other. It’s very hard work and long hours, but when you survive that kind of challenge, you look back at it. We still talk about it—it’s something that none of us hopefully will ever experience or go through again, but we’ve learned a lot. In the past you always wondered what happens if we only have 30 employees out of 120 available to work. To make that happen is actually very fascinating because you just look at the staff and you’re just amazed. I’m just amazed, as the chief, at how dedicated they actually are when it comes to making sure the patient actually received what they ordered. That experience really bound us together as a department.
Barr: Do you have a particular memory from that time that you would want to share because it seems like it really meant a lot?
Cichocki: When we had that red staffing, of course, I talked to the Clinical Center leadership and told them I didn’t have cooks or enough food service workers to take food to the patients. We had food but nobody can cook. I can’t cook; I don’t know how to cook. That kind of collaboration—not just with Eurest [Dining Services] but also with the clinical leadership and nursing leadership—has been really very accommodating. They fully supported us during that time. The memorable part is not only do you have this team effort within your department, but people outside of your department who are willing to help you. Mind you, there were nursing staff leadership that actually asked what they can do—whether that was in the kitchen or helping bag meals. It’s one for all. What’s amazing is that patients were very understanding during those difficult times. I can’t remember anybody actually complaining about the food they received during that time.
Barr: Is there anything else you would like to share about your work during COVID or your experiences?
Cichocki: I pretty much said everything we thought about COVID. One of the greatest things that happened during the pandemic is [finding out that] you never know what you’re capable of until things like that happen. I tell the employees that we’ve done this, we were able to do it, and we’re able to meet the mission. We can handle it much better next time it happens because now we have a playbook.
Barr: Definitely. I wish you and all your staff continued success and of course continued health.
Cichocki: Thank you so much.