Emerging Trends Project: Registered Dietitians Order Writing Privileges

Katie Ruhmann, Pam Brill RD LD, Amy DeMage MS, RDN, LD

Aramark Distance Learning Dietetic Internship
ABSTRACT & OBJECTIVE
The Centers of Medicaid & Medicare Services is hoping to transition roles to give dietitians working in the clinical field more order-writing privileges. They believe that this will bring multiple benefits to the physicians, dietitians, patients and the overall hospital. Many hospitals have already made this transition of permitting dietitian ordering rights. The point of this study was to research a hospital in Kansas City, Missouri, where currently dietitians only have minimum ordering privileges, and to analyze if the medical staff is ready for more. The research was done by surveying all the clinical dietitians and participating physicians on their confidence in giving additional ordering rights to dietitians. The results showed that the dietitians are confident that they could handle this responsibility without physician supervision. The physicians had mixed results. There were areas such as changing diets and ordering supplements where they did not feel as comfortable. In addition, there were areas that the majority of physicians felt that the dietitians could handle ordering without their approval such as in nutrition support. Some physician comments made it clear that they are not ready for these changes and would rather continue to have the dietitians recommendations available to them. What was taken from this research is that dietitians and physicians need to work more closing so they can build trust. A registered dietitians knowledge can be greatly underestimated and underutilized. Dietitians given order-writing privileges have been integrated into many hospitals already and have shown many successes in patient care. The sole purpose of this study is to observe what order writing privileges registered dietitians already have at St. Josephs Medical Center and how comfortable they are on gaining more and then comparing these results to the opinions of the physicians

RESULTS
Dietitian Results Registered dietitians ranged 1 years- 15+ years while the average was ~7 years, only one MS Many different ideas of current ordering rights at the hospital Main consensus is ordering supplements and giving stricter diet 80% of them strongly agreed that they were confident they could order diet supplements for patients without physician consent 80% answered strongly agree or agree on liberalizing a diet, changing an oral diet, ordering enteral formulas/rates or macronutrients for parenteral nutrition without physician approval 100% strongly agree that more ordering would help save time and that strong communication with physicians is important Physician Results Range of 4-35 years in practice, average years of practice for all who participated was 19 years with expertise in internal medicine, nephrology, cardiology, family medicine and pulmonary. 44% of the physicians do not agree that an RD should be allowed to order patients supplements without their consent, while 33% of physician did 56% of physicians did not want an RD to liberalize a patients diet or change their oral diet at all 22% of physician strongly agree or agree with an RD ordering enteral nutrition formula but 44% of them feel confident with an RD ordering the rate of enteral nutrition 67% of physicians strongly agree or agree with an RD ordering macronutrients in parenteral nutrition for patients 33% physicians agreed on RD ordering would help save time, 44% are neutral and 22% of disagreed 100% of physicians strongly agree or agree that physicians and dietitians should have strong communication.

DISCUSSION & CONCLUSION

Physicians and dietitians at St. Josephs Medical Center are not in agreement with giving dietitians additional order-writing privileges Dietitians confident in all areas of ordering for patients Differed from that study of Habschmidt et al. (6) Physicians have mixed feelings and not all on common ground Both cardiologist confident in all areas while the nephrologist disagreed in all areas The most disagrees from the three physicians with more years of experience (35, 26, 21) Three physicians with most experience all left comments in concern box Most seem to feel confident in dietitians ordering with nutrition support Physicians lack knowledge in the depth of a dietitians education and practice One comment saying the medical aspect of sodium, potassium and fluid balances should be left for physicians Physicians that left comments did offer ways for dietitians to either gain their trust for ordering writing privileges or more efficient ways to contact them with recommendations Dietitian must gain physicians trust, prove they obtain this specialized knowledge and continue their education Weaknesses in Research Very small sample size, first used data collection tool, misconception of research In conclusion, the research was effective in analyzing and comparing results if the dietitians and physicians are in agreement about changing order-writing privileges for dietitians Physician education on recent research on positive outcomes of dietitians and education background of a registered dietitian
Physician Comments: I order dietician consults frequently and feel it is a very important part of the patients care. There are situations where although dieticians are more knowledgeable about diet and supplements than i am, but the medical aspect of sodium, potassium and fluid management should be left to the physician. Many times i leave management of diet and fluids to renal physician when the patient has renal insufficiency or esrd. A phone call or text ie RD recommends 2 gram na 1600 calorie ada with 2 liter fluid restrict on 206 Return text would read please proceed with order, thanks I feel the primary physician should know everything that is going on with his patient. I have numerous concerns regarding this infringement on my practice style. I appreciate, respect and need the assistance of the Titians. However, I don't always need this and the added effort in my already busy schedule is not likely to help me. Furthermore I prefer taking responsibility for my own mistakes and not having to supervise others. Will the Titians need malpractice insurance, as well? I hate to be negative. I just don't find this sort of intrusion necessary. Furthermore, the old rules weren't much better. I prefer government to stay out of our business. This would promote the greatest efficiency and the best care.

INTRODUCTION
Centers of Medicare and Medicaid Services are proposing to have dietitians gain more ordering writing privileges (2) This plan would allow qualified dietitians to order lab values when needed, order diets for patients, and order diet supplements. Most dietitians currently make recommendation for the doctors to order which can cause a delay in intervention, mistakes, confusion or sometimes not utilized. Many studies have been done to support the benefits of registered dietitian ordering rights Roberts (3) study showed that groups of patients in which RDs recommendations were followed were meeting their calculated needs, and their LOS was significantly reduced Franklin et al (4) study followed patients on NPO diet in which after 3 days dietitians would leave a note to recommend diet advancement. There was 40% compliance of physicians after first note and 59.5% compliance after second note. Imfeld et al (5) did a study to compare time delays and error before and after dietitians were given ordering rights There was a noteworthy reduction in time delays and errors after dietitians were given ordering rights Roberts (3) also gathered research on dietitians being effective when ordering nutritional supplements as a malnutrition intervention Peterson et al (5) showed that dietitians are more effective (decreased complications, prescriptions, decreased inappropriate usage, BG control, and saved hospital money) in ordering for parenteral nutrition Habschmidt et al. (6) surveyed dietitians on their opinions on what they would like to have ordering right on Only ordering high calorie/protein snacks, supplements and changing oral diets but no nutrition support Baylor University Medical Center dietitians gained order writing privileges by creating a strong relationship with physicians, commitment, continuing their education, and persistence over 4 years Years of positive research conducted at BUMC with RDs having ordering privileges
RESEARCH POSTER PRESENTATION DESIGN 2012

This study was approved by the Chief Medical Officer and Hospitalist at St. Josephs Medical Center Participants and Recruitment Physicians that work with in-patients were recruited by Chief Medical Officer Clinical registered dietitians were recruited by dietetic intern Final sample size from this convenience sample was 5 dietitians and 9 physicians All different expertise areas and years in practice Data Collection A cross-sectional design was used to assess the relationship between dietitians opinions on diet ordering privileges compared with physicians views on dietitians diet ordering Data collection tool was a 10-question survey made specifically for this research Participants emailed link to SurveyMonkey survey Years of practice and expertise asked in survey All questions answered with strongly agree, agree, neutral, disagree, strongly disagree and was same questions on dietitians and physician survey Survey Analysis Quantitative data was collected to interpret data Simple statistics were utilized for each question Microsoft Excel (version 12.1.7;2008 for Mac) was used to create graphs

METHODS & MATERIALS

Renal patients, over half of whom are diabetic have the most complicated dietary needs of any patients. When I have comfort with a dietitian, with whom I have worked these proposals may be helpful and/or beneficial.

REFERENCES
1. 2. 3. 4. 5. 6. Rhea M, Betteles MA. Future Changes Drive Dietetics Workforce Supply and Demand: Future Scan 2012-2022. J Acad Nutr Diet. 2012;112(suppl 1):S10-S24. Academy of Nutrition and Dietetics. FAQs- CMS Proposed Rule Related to Therapeutic Diet Orders. http://www.eatright.org/HealthProfessionals/content.aspx?id=6442474904 Accessed on November 25, 2013. 3. Roberts SR. Improving Patient Outcomes Through Registered Dietitian Order Writing. Nutr Clin Pract. 2013;28:556565. 4. Franklin GA, McClave SA, Hurt RT, et al. Physician-Delivered Malnutrition: Why Do Patients Receive Nothing by Mouth or a Clear Liquid Diet in a University Hospital Setting? Parenter Enteral Nutr. 2011 ;35:337-342. 5. Imfeld K, Keith M, Stoyanoff L, Fletcher H, Miles S, McLaughlin J. Diet Order Entry by Registered Dietitians Results in a Reduction in Error Rates and Time Delays Compared with Other Health Professionals. J Acad Nutr Diet. 2012;112: 1656-1661. 6. Habschmidt MG, Bacon CA, Gregoire MB, Rasmussen HE. Medical Nutrition Therapy Provided to Adult Hematapoietic Stem Cell Transplantation Patients. Nutr Clin Pract. 2012;27: 655-660. 7. SurveyMonkey. https://www.surveymonkey.com/home/. Accessed January 6th, 2014.

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CONTACT INFORMATION
Katie Ruhmann Aramark Dietetic Intern Ruhmann-Katie@aramark.com

www.PosterPresentations.com