The Role of the Clinical Dietitian in an

Acute Care Setting Lauren Stierstorfer

ARAMARK Dietetic Intern

To gain a greater understanding of the role, responsibilities and impact of the clinical dietitian in an acute care setting

Objective

Academic Path to Becoming a Clinical Dietitian

Responsibilities of the Clinical Dietitian in a Hospital Setting

How Does Nutrition Influence Patient Status?

Impact on Patient Outcomes Expertise of the Clinical Dietitian on

Performing Nutritional Calculations Malnutrition Clinical Order Writing Privileges

Focus

Minimum of a bachelor's degree at a U.S. regionally accredited university or college ◦ course work approved by the Accreditation Council for Education in Nutrition &

Dietetics (ACEND) of the Academy of Nutrition & Dietetics (AND)

Complete ACEND supervised practice program at a healthcare facility, community agency, or a foodservice corporation, or combined with undergraduate or graduate studies ◦ ~1400 hours of supervised hours

Pass national examination administered by the Commission on Dietetic Registration (CDR).

Complete continuing professional educational requirements in order to maintain registration and licensure (75 CEU’s for RD every 5 years; 30 CEU’s for LDN every 2 years)

“The Commission on Dietetic Registration (CDR) in 2013 advised in their Entry-Level Registration Eligibility Requirements Update that by 2024, any student intending to become Registered Dietitian/Nutritionist will be required to complete a Master’s degree.  This will apply to incoming freshman in 2017.”

Registered Dietitian: Educational and Professional Requirements. Eat Right. Academy of Nutrition and Dietetics. 2014. http://www.eatright.org/BecomeanRDorDTR/content.aspx?id=8143

Didactic Program in Dietetics. Youngstown State University. 2014. http://web.ysu.edu/gen/bcohhs/Didactic_Program_in_Dietetics_m112.html

Academic Path to Becoming a Clinical Dietitian

Conduct Medical Nutrition Therapy for all patients screened at nutritional risk by either MD, RN or RD

Participates in interdisciplinary patient rounds for trauma/critical care/medical/surgical patients

Participates in committees (Project RED, Wellness, Dermal Defense, Infection Control, Diabetes Advisory)

Maintains open communication with other disciplinary team members including medical staff, RN, PT/OT, pharmacy, respiratory therapy, speech therapy, case management, and social work to determine appropriate plan of care for each patient.

Responsibilities of the Clinical Dietitian in a Hospital Setting

Recommends care plan based on changes in patients’ nutritional status and/or needs

Acts as a liaison between nutrition department and other hospital staff members

Act as a preceptor for dietetic internship programs

Responsibilities Continued

Optimal health of patients rely on good nutrition from all aspects. Nutrition plays a key role in the care of the critically ill, those with inadequate gut function, eating disorders, patients with food intolerances, the obese, and a vast range of other clinical problems.

Majority of illnesses are linked to nutrition either with nutrition being a potential causal factor, or in assisting the treatment

How Does Nutrition Influence Patient Status?

Increase wound healing Decrease number of days on a ventilator Reduce length of stay Aid in discharge planning Reduce readmission rates Decrease prevalence of malnutrition Decrease rate of hospital-acquired

infections

Positive Impact of Medical Nutrition Therapy

Clinical Dietitians are educated on how to perform nutritional calculations including:◦ Caloric needs◦ Protein, carbohydrate, and fat needs◦ Fluid needs◦ Tube feeding/TPN requirements◦ BMI/% weight changes

These calculations help determine the nutritional needs of patients and steer the clinical dietitian to efficiently make recommendations for PO diet advancement, supplement use, enteral and parenteral nutrition.

Nutritional Calculations

What is malnutrition?◦ “Malnutrition begins with inadequate intake of

protein and/or energy over prolonged periods of time which results in loss of fat stores and/or muscle stores. Malnutrition occurs in the presence of absence of inflammation and can be related to: Starvation Chronic illness Acute disease or illness

◦ Malnutrition causes adverse effects on body function and clinical outcomes and can occur at any BMI.”1

1. The facts on malnutriton. Alliance to Advance Patient Nutrition. (2014). http://static.abbottnutrition.com/cms- prod/malnutrition.com/img/Alliance_Malnutrition_Fact-Sheet_2014_v1.pdf.

Malnutrition

If patient has at least two of the following six criteria, they are diagnosed with malnutrition.

1. Insufficient food intake compared to nutrition requirements

2. Weight loss over time3. Decrease in muscle mass4. Decrease in fat mass5. Fluid accumulation6. Measurably decreased grip strength

1. The facts on malnutriton. Alliance to Advance Patient Nutrition. (2014). http://static.abbottnutrition.com/cms- prod/malnutrition.com/img/Alliance_Malnutrition_Fact-Sheet_2014_v1.pdf.

How is Malnutrition Diagnosed?

Complications of malnutrition can cause increased risk for:◦ Pressure ulcers◦ Falls◦ Hospital-acquired infections◦ Surgical site infections postoperative pneumonia◦ Morbidity and mortality◦ Anemia◦ Decreased cognition◦ Edema◦ Hip fractures◦ Immune dysfunction◦ Muscle loss◦ Osteoporosis

Rosenthal M. Malnutrition ‘skeleton’ still rattling in hospital closets. Gastroenterology and Endoscopic News. November 2014. Volume 65:11.

Malnutrition

Effective Treatment of Malnutrition can:◦ Reduce incidences of pressure ulcers◦ Reduce incidences of hospital-acquired infections◦ Reduce incidences of surgical site infections◦ Decrease readmission rates◦ Reduce length of hospital stay◦ Reduce risk of falls, hip fractures, and

osteoporosis◦ Decrease morbidity and mortality rates

Malnutrition

Currently, at MLHS, Registered Dietitians do not have clinical order writing privileges

A dietitian may make recommendations, and the MD may or may not consider them

MLHS dietitians are currently working to gain order writing privileges◦ This will include:

Changing diet orders/restrictions Ordering supplements/protein Ordering tube feedings Ordering labs

Clinical Order Writing Privileges

“Registered dietitians can play an important role in a multi-disciplinary team at the bedside to apply evidence-based nutritional intervention that can improve patient outcomes,” said Sylvia Escott-Stump, President of the American Dietetic Association (ADA)1

“MNT by RDs is an essential component of comprehensive healthcare that prevents or alters the course of diseases including diabetes, obesity, hypertension, disorders of lipid metabolism, heart failure, osteoporosis, celiac disease, and chronic kidney disease,” said the ADA’s Escott-Stump1

1. The Impact of Clinical Dietitians on New Healthcare Delivery Modes. Aramark Healthcare. http://www.aramarkhealthcare. com/ docs/default-source/position-papers/the-impact-of-clinical-dietitians-on-new-healthcare-delivery-models.pdf?sfvrsn=4.