Order Writing Competencies. Susan Roberts, MS, RDN, LD, CNSC

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1 Order Writing Competencies Susan Roberts, MS, RDN, LD, CNSC

2 Identify reasons for establishing order writing competencies Relate steps and tools for achieving order writing privileges and competency Objectives

3 Competence is a principle of professional practice, identifying the ability of the provider to administer safe and reliable services on a consistent basis. Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. 2003

4 Unconscious Incompetence: Unaware of skill and lack of proficiency Conscious Incompetence: Aware of skill but not yet proficient Hierarchy of Competence Conscious Competence: Able to use the skill but only with effort Unconscious Competence: Performing the skill becomes automatic

5 Change in CMS Regulation Code of Ethics Scope of Practice Patient Safety Improved Outcomes Cost Savings Reasons for Establishing Order Writing Privileges and Competence

6 Hospital RDNS are being permitted to be privileged to order patient diets under the hospital Conditions of Participation (CoPs). A hospital s medical staff may include other categories of non-physician practitioners Non-physician practitioners to be included in medical staff because these practitioners, while not physicians, add significant value as members of the medical staff and in improving the quality of medical care provided to the patients in the hospital CMS Rule s Major Provisions

7 Greater flexibility for hospitals and medical staff to enlist the services of non-physician practitioners to carry out the patient care duties for which they are trained and licensed. Qualified Dietitian: the term Registered Dietitian, RD is used to describe all qualified dietitians and any other clinically qualified nutrition professionals as long as each qualified dietitian or clinically qualified nutrition professional meets requirements of his or her respective state laws, regulations, or other appropriate professional standards. Non-physician practitioners: specifically include Advanced Practice Registered Nurse, Physician Assistants, Registered Dietitians, and Doctors of Pharmacy Definitions of qualified dietitian and non-physician practitioners in the CMS Rule

8 In states where State law or regulations limits appointments to certain categories of practitioners, privileges may still be granted without appointment to the medical staff as long as such privileges are: Recommended by the medical staff Approved by the governing body Are in accordance with State law The hospital and its medical staff are best qualified and best situated to exercise oversight, such as credentialing and competency review, of those practitioners to whom it grants privileges, just as it would for those practitioners appointed to its medical staff. Rule Considerations

9 Fundamental principles Accepts the obligation to protect clients, the public, and the profession by upholding the Code of Ethics for the Profession of Dietetics Responsibilities to clients or patients Recognizes and exercises professional judgment within the limits of his or her qualifications and collaborates with others, seeks counsel, or makes referrals as appropriate. Responsibilities to the profession Practices dietetics based on evidence-based principles and current information. Assumes a life-long responsibility and accountability for personal competence in practice, consistent with accepted professional standards, continually striving to increase professional knowledge and skills and to apply them in practice. Code of Ethics JADA 2009

10 Tool for credentialed dietetics practitioners to use in professional development. Serves as a guide for self-evaluation and to determine the education and skills needed to advance an individual s level of practice. Although not regulations, the standards may be used by regulatory agencies to determine competence for credentialed dietetics practitioners. Scope of Practice

11 Team collaboration Avoid inappropriate nutrition support orders Improve nutrition delivery Address malnutrition earlier and more effectively to avoid negative outcomes associated with malnutrition Reduce complications such as hyperglycemia, electrolyte abnormalities and consequences of refeeding syndrome Patient Safety

12 Improving Outcomes Early nutritional intervention is key to prevention and treatment of malnutrition Only 42% of 865 written RDN recommendations were implemented by MDs in one study 1 Research demonstrates improved outcomes when RDN recommendations are followed 2-5 Timely implementation of Medical Nutrition Therapy is often delayed due to: 5,6 Communication delays between RDN & physician Overlooked recommendations 1) Skipper et al. 1994, JADA 2) Weddel et al. 1995, JADA 3) Braga et al. 2006, JADA 4) Lee et al. 2012, Clin Biochem 5) Moreland et al. 2002, JADA 6) Silver et al. 2003, JADA

13 Creates savings and reduces burden in many areas. Creates measurable monetary savings for providers and suppliers, while others create savings of time and administrative burden. Proposed regulatory changes allow hospitals to grant appropriate ordering privileges to RDs Hospitals would not be able to effectively realize improved patient outcomes and overall cost savings The economic impact estimate for hospitals is $459 million reoccurring annually. Cost Savings

14 The Baylor Experience

15 From first attempts to obtain order writing privileges to implementation took ~4 years BUMC: Implementation Timeline

16 Long history of informal privileges writing nutrition-related orders using verbal order process Why change? CMS emphasis that verbal orders are only for emergency situations, not routine use Joint Commission has guidelines for appropriate use of verbal orders consistent with CMS Conditions of Participation Issues arise when physicians and nurses assume all staff are competent to write orders Liability for staff, MD, and hospital Nutrition-Order Writing

17 Parenteral Nutrition order-writing audit (2003 &2004) Sample size= 50 (in 2 years) Average # of days on PN= 12 days ~30% of PN orders had RDN involved with writing orders exclusively or part of the time Results showed RDN involvement with order writing led to improved electrolyte management and glucose control Information presented at Medical Nutrition Committee after both audits, but unable to obtain approval for RDN order writing protocol Parenteral Nutrition Order-Writing

June 2006: Reintroduced the ideas of RDNs having nutrition order-writing privileges to Medical Nutrition Committee Pilot study on a general medicine and a

18 June 2006: Reintroduced the ideas of RDNs having nutrition order-writing privileges to Medical Nutrition Committee Pilot study on a general medicine and a surgical unit for 2 months First month-usual care Second month- RDN management of nutrition orders Utilized RDNs with ~5 years of experience + CNSD RDN Order-Writing

19 Objective: To demonstrate RDNs ability to provide safe, effective care through independent nutrition-order (NO) writing privileges Prospective data on total of 190 patients Control group (Physician-managed NO): N=97, RDN assessment/recommendations documented and communicated as needed Study group (RDN-managed NO): N=93, RDN managed nutrition orders with automatic RDN assessment Nutrition Order Writing Pilot

20 Procedure for Study Group: MD orders Nutrition Management Consult MD still maintains direct control of patient care MD may discontinue RDN orders at his/her discretion RDN will not independently initiate PN or EN Nutrition Order-Writing Pilot

21 Nutrition Order Writing Pilot

22 90% 88% 80% 70% 60% 50% 40% 30% 20% 20% 10% 0% Control Group Study Group NO Writing Pilot: RDN recommendations implemented

23 NO Writing Pilot: Percent of Kcal Needs Met & Gastric Residual Volumes Percent EN & PN - % of needs w/in 48 hrs 6 EN - GVR > 300 ml Control Study

24 NO Writing Pilot: Glycemic Control & Electrolyte Management Percent PN - elevated BG PN - abnl lytes Control Study

25 RDN nutrition orders did not cause patient harm and were not discontinued by physicians RDN nutrition order management: Increases implementation of RD recommendations Improves tolerance to medical nutrition therapy Decreases time to achieve caloric goals This study demonstrated RD independent nutrition order writing provides not only safe, but improved patient care Conclusions

26 Support for RDNs writing nutrition-related orders Policy (Nutrition Management Protocol) drafted Final approval by 3 different governing physician committees obtained Competency of staff (PN vs. other types of orders) Staffing levels adjustments (weekends and weekdays) Ongoing data collection and reporting to appropriate committees Nutrition Order-Writing

27 Parenteral Enteral Monitoring Oral Diets Nutritional Supplements What kind of nutrition orders?

28 Daily parenteral nutrition orders including Macronutrients, micronutrients, electrolytes, medications including insulin Laboratory monitoring Alter IV fluid infusion rate Enteral nutrition orders including Formula type, rate, hours of infusion, modulars, probiotics, water flushes Laboratory monitoring KUB after tube placement Oral or enteral vitamin/mineral supplements PN and EN Nutrition Management

29 Height and/or weight measurement Add or change serum glucose monitoring Institute the Glycemic Management Order Set Measure energy expenditure via indirect calorimetry Bedside swallow evaluation Order or discontinue calorie count, as indicated Monitoring

30 Oral Diets Increase or decrease diet consistency (in collaboration with speech therapist, if needed) Change calorie levels on calorie-restricted diets Modify diet restrictions as needed Nutritional Supplements (oral) Add or delete oral liquid nutritional supplements Add or delete modular supplements (protein, glutamine, fat, banana flakes, fiber, calories) Add or delete oral vitamin/mineral supplements Add probiotic Oral Diets & Supplements

31 Expectation gives way to reality Assess competency and willingness of staff Implement training if needed Develop a Competency Assessment Program Involve other disciplines for education as needed The Neighborhood by Jerry Van Amerongen

32 Are all RDNs allowed to write orders? The following must be met for all RDNs writing nutrition support orders: Registered and Licensed RDN Demonstrate competency in writing orders for enteral nutrition and monitoring Initial and annual enteral nutrition competency will be demonstrated using BSWH Prescriber EN Competency Assessment. Initial and annual competency assessment requires a minimum of 5 enteral nutrition orders. Demonstrate ongoing documentation of relevant education activities to maintain registration and/or licensure. PN orders: RDN s must be a Certified Nutrition Support Clinician (CNSC) Initial and annual parenteral nutrition competency will be demonstrated using BSWH Prescriber PN Competency Assessment. Initial competency assessment requires a minimum of 10 PN orders and annual competency assessment requires a minimum of 5 PN orders.

33 Electrolyte replacement guidelines Reminder list for the RD s on medication interactions with tube feedings and PN, insulin, and glucose management and lab reports Physician-led presentation with tips for successful order writing through appropriate and effective interaction with physicians Competency check-off for EN and PN order writing Preparation for implementation

34 To justify the need for additional full-time RDN s, PRN protocol time and full-time RD overtime was tracked along with the following information: Number of protocol patients Number of PN and EN protocol patients Number of non-protocol patients Time for protocol patient care and data collection Time for non-protocol patient care A buddy list for the RDN s who are not a CNSC - designated CNSC manages their PN orders Preparation for Implementation

35 Data collection following implementation in November February 2008 Observational, non-randomized study Control group- EN/PN order written by MD N=65 Study group- EN/PN order written by RDN N=242 Post-implementation Study

36 Post-implementation Study

37 Post-implementation Study

38 Post-implementation Study: Met 85% of Kcal Needs

39 Post-implementation Study: Maximum Percent of Needs Met

40 Post-implementation Study: Glycemic Control p = 0.046

100 90 80 70 60 50 40 30 20 10 0 p = 0.023 p = 0.009 39.3 45 14.3 14.

41 p = p = Abnormal K Abnormal Phos Control Study Percent of days with abnormal electrolytes Post-implementation Study: Electrolyte Management

100 89.1 80 60 40 20 69.4 p = 0.0018 30.7 10.

42 p = Control Study 0 No complications One or more complication Percent of patients with and without nutrition-related complications Post-implementation Study: Nutrition-Support Related Complications

43 14 Hospitals in the North Division- Nutrition Management Protocol (NMP) implemented in all hospitals Time to implement ranged from 6-18 months Steps to implementation included Establishing the need for the service (to enhance quality, cost savings, patient safety)- may require baseline data collection to establish the need Approval from appropriate committees including the medical board Assessment of staffing/training needs, competency check-off Baylor Scott & White Health

44 Existing relationship between RDs and physicians and strong physician support Persistence- took ~4 years from concept to implementation Pilot study and ongoing data collection which demonstrate improvements when the RDN writes the PN versus the MD Administrative support for additional staffing Implementing: Keys to success at BUMC

45 Lengthy process for approval from committees Physician and nursing education Staffing for weekends and holidaysrequire CNSC for PN order writing Ensuring ongoing competency of staff, new and existing Monitoring for quality, avoidance of errors Barriers to Implementation and Ongoing Challenges

46 Ongoing data collection on glycemic control, electrolyte abnormalities, days on nutrition support, LOS Buddy system- pair a more experienced CNSC with a less experienced CNSC to act as a resource Error/near miss reporting process Actions taken to overcome challenges

47 Preparation and sitting for CNSC examination for many staff members Attending class on PN order writing, which included case studies and practice writing orders Successfully passing an internal Nutrition Support Exam 2-3 days of hands-on training and competency check-off: required to write minimum of 10 correct PN orders, including new PN starts and orders for critically ill patients Annual competency check-off Training and Competency

48 Considerations for the NMP in the Electronic Health Record Include NMP consult as option in Admission Order Sets- may be more feasible in smaller hospitals or for specific patient populations Ongoing order for patient s stay- must keep NMP consult active versus completing it in the EHR Incorporate into Enteral and Parenteral Protocols as default RDN consult Ensure the RDN has the capability to enter orders, including labs and x-rays in the EHRmay have to explain RDN scope of practice to other disciplines

49 Improves quality of care- the patient receives the right care in a more timely manner Maximizes the role of the RDN- RDN is able to use expertise and have a higher level of job satisfaction Saves time for other disciplines and RDN- and team feels more cohesive Cost savings- decreases LOS, avoidance of complications and repeat orders Benefits of a NMP

50 Check state licensure requirements and understand CMS guidelines related to order writing Obtain support from key physicians and other clinicians prior to submitting for approval Evaluate RD staff s experience level and willingness to accept responsibility associated with order writing privileges Conduct a pilot study to demonstrate effectiveness of the protocol Collect outcomes data and explore/report cost savings with improved patient outcomes Track staffing time to justify need for more staff Establish an effective system for ongoing communication with and amongst RD staff Recommendations for successful implementation

51 Communication- before implementation and ongoing- stress more collaboration between disciplines is needed, not less!! Understanding the hospital s culture, key physician and nurse champions and committee structure/process for approval If writing PN orders, most staff will need additional training about electrolyte management Planning carefully for adequate staffing and training RD commitment to a higher level of accountability- with privilege comes responsibility Must Haves for success

52 Developing advanced practice skills as a part of order writing is important Chart the course: set specific steps and goals Approval and implementation for performing certain skill or obtaining privileges cannot be accomplished alone Once implemented, RD staff must collaborate even more closely with other team members Collect data and share it!! Practice Applications

54 Texas Dietetics Practice Guidelines:Title 22, Texas Administrative Code, Chapter Academy of Nutrition and Dietetics Scope/Standards of Practice. Brantley SL, Russell MK, Mogensen KM, et al. American Society for Parenteral and Enteral Nutrition and Academy of Nutrition and Dietetics: Revised 2014 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nutrition Support. J Acad Nutr Diet. 2014;114: Guenter P, Boullata JI, Ayers P, et al. Standardized competencies for parenteral nutrition prescribing: The American Society for Parenteral and Enteral Nutrition Model. Nutr Clin Pract. 2015;30: Phillips W, Doley J. Granting order-writing privileges to registered dietitian nutritionists can decrease costs in acute care hospitals. J Acad Nutr Diet Peterson SJ, Chen Y, Sullivan CA, et al. Assessing the influence of registered dietitian order-writing privileges on parenteral nutrition use. J Am Diet Assoc Resources & References

Order Writing for the Dietitian in Wisconsin WENDY PHILLIPS, MS, RD, CNSC, CLE, FAND

Order Writing for the Dietitian in Wisconsin WENDY PHILLIPS, MS, RD, CNSC, CLE, FAND About the Speaker Wendy Phillips MS, RD, CNSC, CLE, FAND As a Division Director of Clinical Nutrition for Morrison Healthcare,