Roberts, S. Advanced Practice - Taking on the … Susan Slides.pdfAdvanced Practice – Taking on the Challenge Susan Roberts, MS, RD, LD, ... RDs with expertise in pediatrics,

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Advanced Practice –Taking on the Challenge

Susan Roberts, MS, RD, LD, CNSD

Assistant Director of Clinical Nutrition

Baylor University Medical Center

Dallas, Texas

Learning Objectives

� Identify advanced practice skills and potential benefits for various groups

� Describe institution specific positive outcomes associated with implementing advanced practice skills

� Relate considerations in obtaining advanced practice skills and clinical privileges

Advanced Practice

•What is it?

•Why achieve it?

•Who can do it?

•How can I do it?

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What is an expert?� Experts: prolonged or intense experience through practice & education

�Webster’s definition of an expert: “having involved, or displaying special skill or knowledge derived from training or experience”

� An expert is widely recognized as

– Reliable source of knowledge, technique, or skill

– Judgment is accorded authority & status by their peers

Characteristics of an Expert or Advanced Practitioner in Dietetics?

� Bradley Model (JADA, 1993)

� Advanced Practitioners– Education & experience

� At least a Master’s degree

�≥ 8 years of experience

– Professional achievement

� At least 1 professional award or honor, OR

�One journal or book chapter publication, OR

�One conference presentation in the past 3 years

What is an Expert or Advanced Practitioner in Dietetics?

� Bradley Model (JADA, 1993)

–Approach to practice� Values innovation & learning

� Possesses in-depth & intuitive understanding

�Highly adaptable & process-oriented

–Professional role position� Complex & diverse roles

–Professional contacts�Networks with diverse types of professionals in different geographical locations

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� Skipper Model (JADA 2006)

� Cannot use characteristics alone – lacks a description of what advanced practitioners do

� Interviewed 21 RDs from 14 states and Canada from Feb – August 2004

� RDs with expertise in pediatrics, renal, diabetes, nutrition support

� Main theme of model: “using initiative to achieve autonomy”


�Skipper Model (JADA 2006)

�Five subthemes

–Aptitude

–Attitude

–Context:

–Expertise

–Approach

Aptitude

Advanced Practice Degree, Experience, and/or Credentials

Attitude

Breadth & Balance, Scientific Inquiry, Creativity

Context

Collaboration, Networking, Consultation,

Leadership, Awareness

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Expertise

Pharmacology, Advanced MNT, Pathophysiology, Research Basis of

Practice, Counseling, Co-Morbidities

Approach

Comprehensive, Integrated, Discerning, Simplified

Patients, Practice, Environment

The Expert Dietitian(caveat: Susan Roberts’ version)

� Knowledgeable about nutrition therapy AND the other aspects of care

� Understands financial, legal, regulatory issues

� Sought out by other dietitians and health care professionals for recommendations

� Involved in professional organizations

� Research involvement

� Presentations and publication experience

ADA SOP & SOPP

� Documents complement each other

� Not established as a legal standard of care

– Provides guideline for determining scope of practice

– Method for evaluating current level of practice/setting goals

� Standards of Practice: 4 steps of NCP

� Standards of Professional Performance

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ADA SOP & SOPP

�Standards of Professional Performance

describe competent level of behavior in the professional role

� Provision of services

� Application of research

� Communication & application of knowledge

�Utilization & management of resources

�Quality in practice

� Continued competence

� Professional accountability

ADA SOP & SOPP

� Areas completed and published– Diabetes

– Behavioral Health Care

– Oncology

– Nutrition Support

� Areas in process (SOP & SOPP)– Renal

– Pediatrics

� Areas in process (SOPP only)– Dietetic Educators

– Management

Generalist & Specialist Levels

�Generalist

–Still learning principles of a specialty area

�Specialist

–Develops deeper understanding of specialty area

–Becomes better equipped to apply best practice and evidence-based principles

–Modifies practice according to unique situations

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Advanced Level� Exhibit a range of highly developed clinical and technical skills

� Formulate judgments based on combination of experience and education

� Applies composite nutrition knowledge, drawing not only on clinical experience, but also on experience of other practitioners in various disciplines and practice settings

� Experts, with their extensive experience and ability to see the significance and meaning of nutrition therapy within a contextual whole, are fluid and flexible in practice.

Nutrition Support SOP

�SOP: Nutrition Assessment – Evaluates Physical Findings–Anthropometric measurements – all levels

–Nutrition focused physical exam (examples – fluid assessment, functional status, clinical signs of malnutrition) –Specialty & Advanced

–Potential access sites for delivery of nutrition support - Advanced

Advanced Practice Level

�Need a clear course to achieve

�Education

�Experience

�Certification

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Advanced Practice Skills

� Clinical activities may include:

–Nutrition-focused physical exam

–Order-writing (Clinical Privileges)

– Indirect calorimetry measurement

–Feeding tube placement

–Catheter and feeding tube care

– Insulin teaching

–Outcomes research

Nutritional Status of Hospitalized Patients(Braunschwieg et al, JADA 2000)

� Association between changes in nutritional status during hospitalization with outcomes

– Infections

– Complications

– Length of stay

– Hospital charges

� 404 adults inpatients with LOS > 7 days and

– Complete admission & discharge SGA, retrospective chart review, financial data


� Used SGA to determine nutritional status

� 54% malnourished at admit

� 59% malnourished at discharge

� 31% of patients declined– 38% normally nourished at admit

– 20% moderately malnourished at admit

– 33% severely malnourished at admit

� 30% of patients malnourished at admit had improved nutritional status at discharge

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NS2121Infection (%)

P≤.036250Complications (%)

P≤.0319 ± 1.316 ± 0.7LOS

P≤.00445,762 ±4,021

34,336 ±1,812

Charges ($)

P-valueDeclined

(n = 126)

No decline

(n = 278)

Variable

Conclusions

�Decline in nutritional status, not degree of malnutrition at admit, associated with ↑ hospital charges & rate of complications

�Reducing declines in nutritional status should be priority regardless of status at admission

Physicians’ implementation of RDs’recommendations (Skipper, JADA 1994)

� 35 hospitals and 98 RDs provided information about recommendations & implementation by MDs

� 865 recommendations – 363 (42%) implemented

� Higher implementation rates seen when MD had requested the RDs recommendation (50%) and when RD discussed recommendations with the MD (65%)

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Positive association between RD recommendations & TF outcomes

(Weddle, JADA 1995)

� 172 patients on enteral nutrition

� Facilities: 6 acute care & 1 rehabilitation

�When the RD recommendations were followed, more patients

– Reached energy intake goal

– Bridged to oral diet

– Increased or maintained body weight

Why change from current system?(Moreland, JADA 2002)

RD Recommendation in Medical Record

Old System New System

Personally locate MD Leave “sticky” note for MD Ask RN to ask or call MD

Time delay of 10 mins to days

Problems: Patient delayed in receiving care; time constraints of all staff; wasting time of staff; notes get lost or missed;RN forgets to call; MD forgets to write order

RD Verbal Order, MD Order, or RN Verbal Order Written

Order Received and Implemented

MD writes for protocol

RD writes order

Development & implementation of Clinical Privileges for RD Nutrition Order Writing (Moreland, JADA 2002)

� LTAC facility – review of 250 charts found MDs followed 95% of RD recommendations

�Wanted a more effective & efficient means of implementing RD recommendations

� Program developed for RD nutrition order-writing privileges

� After implementation, patients’ rate of improvement in nutritional status was increased from 55% to 75%

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Nutrition Diagnosing & Order Writing (Silver, JADA 2003)

� Informal order writing privileges

� 6 weeks of data revealed only 57% of recommendations followed

� Data presented to the Medical Staff –obtained letters of support from MDs for order writing privileges

� Presented same information at Medical Board meeting – discussed RD training, credentials, scope of practice, liability, types of orders – obtained privileges

Benefits for the patient

� Improved patient outcomes and access to nutrition care

� Continuity of care� Patient safety � Expedited order

implementation – in contrast to waiting hours to days for implementation

� Increased involvement in care resulting in improved patient satisfaction

Benefits for the RD may include:

� ↑↑↑↑ responsibility, job satisfaction & challenge

� Professional advancement

� Increased recognition of RD from other healthcare professionals – ↑↑↑↑ value, indispensability & respect

� Financial compensation

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Benefits for Physicians

� Promotes consistent treatment plans

� Less time spent returning pages, emails, and phone calls

� Avoidance of Verbal Orders

� No recommendations overlooked, which may put the physician at risk legally

Benefits for Nurses

�Orders can be obtained and problems addressed more quickly

�Certain practices can actually assist the nurse in providing patient care

�Provides a readily available resource for nutrition issues

Benefits for Hospital

� Improved quality of care with multidisciplinary team

� Improved documentation of patient outcomes

� Recruitment & retention of a more motivated & highly trained staff

� Decreased liability due to consistency within the institution’s policies and procedures

� Increased respect

� Cost savings

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Steps to Obtaining Advanced Practice Skills & Clinical Privileges:

Many Factors Affect Implementation

� Dietitian expertise and experience

� Competency – initial and ongoing

� Readiness to accept additional responsibility

� Physician, nursing, departmental and organizational collaboration & support

� State licensure laws and regulations– Dietitian/nutritionist licensure

– Facility licensure

– Other healthcare practitioners (physicians, nurses)

� Federal regulations – CMS, Joint Commission, HFAP

� Liability concerns

Baylor Experience

�Small bowel feeding tube placement

�Nutrition-order writing

�Outcomes research

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Small Bowel Feeding Tube Placement

� Opportunity for improvement identified by a multidisciplinary ICU committee (comprised of nursing managers and physicians)

� Mild resistance from a physician but nursing support was strong

� Provided literature showing RDs at other institutions were placing SBFT’s and ASPEN Standards of Practice for Nutrition Support Dietitians

Small Bowel Feeding Tube Placement

� Approval by the ICU Committee obtained

� ICU Dietitians & designated ICU RNs underwent SBFT placement/Cortrak training & competency check-off

� Initial data collection compared to previous process

� Ongoing data collection presented to several hospital committees to ensure patient safety and effectiveness

RD and RN placing SBFT in ICU

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Placement Success Rate Comparison

63%

78%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Successful Placement of the SBFT

Control Study

Last 70 placements:

81%

SBFT Timing Data

4.752.5

4.5 4

22.25

7.75

0

5

10

15

20

25

Ho

urs

Hours between

physician order

and tube

placement

(p=0.003)

Hours between

placement and

feeding

Total time

(p=.006)

Blind Placement Placement using ETPD

Implementing Tube Team

� Evaluate the need & collect data– Process in place?

– Process successful?

� Gather support (RDs?) & references– Publications

– SOP for Nutrition Support RD

� Staffing needs

� Licensure and liability coverage

� Present to appropriate groups for approval

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Implementing Tube Team

�After approval–Pilot study

–Training

–Competency check-off

�Initial

�Ongoing

�Same for all disciplines

–Ongoing data collection

Nutrition-Order Writing

– 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 and HFAP now have 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


�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 RD involved with writing orders exclusively or part of the time

� Information presented at Medical Nutrition Committee after both audits

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PN Order-Writing Audit

68%58%Correct electrolyte mgmt

79%97%Appropriate indication

21% Attending

58% Residents

21% RD

16% Attending

65% Residents

29% RD

Clinician writing PN order

1931No.

20042003Parameter

PN Order-Writing Audit

79%84%Appropriate protein provision

79%80%Appropriate caloric provision

79%90%??Appropriate measures to control blood glucose

1931No.

20042003Parameter

Nutrition-Order Writing� June 2006: Reintroduced the idea of RDs having nutrition order-writing privileges to Medical Nutrition Committee

� Pilot study on a general medicine floor for 2 months

– First month – usual care

– Second month – RD management of nutrition orders

– Utilized RDs with ~5 years of experience + CNSD

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� November 2006: Subcommittee and Medical Nutrition Committee recommend RD managing PN orders

� Officers of Medical Staff Committee –recommended repeating the pilot on a surgical floor

� Jan – Feb 2007: pilot on a general surgical floor – RD managed all patients on nutrition support

Nutrition-Order Writing Pilot

� Objective: To demonstrate RDs’ 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, RD assessment/recommendations documented and communicated as needed

� Study group (RD-managed NO):N = 93, RD managed nutrition orders w/automatic RD assessment

Nutrition Order-Writing Pilot

� Procedure for Study Group

–MD orders “Nutrition Management Consult”

–MD still maintains direct control of patient care

–MD may discontinue RD orders at his/her discretion

–RD will not independently initiate PN or EN

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Nutrition Order Writing Pilot Data

� Percent of caloric needs achieved

�85% of needs met within 48 hours

� Feeding complications

–Gastric residual volume cap >300ml (EN)

–Percent of days with ≥ one glucose level >150mg/dl (PN)

–Percent of days with ≥ one abnormal electrolyte (PN)

� RD recommendations implemented

–Control – 20%, Study – 88%

Nutrition Order Writing Pilot

�Average # of days - Enteral Nutrition

– Control Group : 7.6 days

– Study Group : 6.7 days

�Average # of days - Parenteral Nutrition

–Control Group : 3.5 days

–Study Group : 9.8 days


57

23

72

39

0

10

20

30

40

50

60

70

80

Perc

en

t

PN - elevated BG PN - abnl lytes

Control Study

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0

65

100

60

10

20

30

40

50

60

70

80

90

100

Perc

en

t

EN & PN - % of needs w/in 48

hrs

EN - GVR > 300 mL

Control Study


� Support for RD writing nutrition-related orders

� Policy drafted

� Final approval by governing physician committees

� Competency of staff (PN vs other types of orders)

� Staffing levels to be adjusted (weekends and weekdays)

� Ongoing data collection and reporting to appropriate committees

� Presentation and publication of results

What kind of nutrition orders?

�Parenteral

�Enteral

�Monitoring

�Oral diets

�Nutritional supplements

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Are all RDs allowed to write orders?� Registered & Licensed Dietitian, ≥ 1 year of experience

� At least 1 year of experience w/Nutrition Support� Demonstrate competency in writing orders for enteral nutrition, oral diets, oral supplements, & monitoring

� Earn ≥ 10 relevant (Enteral & Parenteral Nutrition Support) hours of CE every year

� RD’s writing PN orders:– Certified Nutrition Support Dietitian (CNSD)– Pass the Baylor Nutrition Support Competency Examination, and demonstrate competency with writing a minimum of 10 parenteral nutrition orders

� Skipper, Future Dimensions, CNM Fall 2006

Nutrition Protocol

� Implemented November 2007

� Main hospital – 15 RDs, 8 are CNSD RDs

� Average number of patients seen on protocol weekly

– ~120 total

– ~ 90 on parenteral nutrition

– ~ 30 on enteral nutrition

� Average number of patients seen off protocol weekly - ~240

Implementing a Nutrition Protocol

� Collect data to identify gaps

� Evaluate staff experience/competency

� Staff training

� Communication with other disciplines

� Ongoing data collection

� Training new staff

� Ongoing discussions with staff

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Legal Concerns:

� Minimize liability risks� Effective and efficient communications

� Establish clear roles that are aligned with legislated and regulated scopes of practice

� Create and follow policies to guide interdisciplinary interactions

� Review, at least annually, and comply with established clinical protocols, guidelines, treatment standards, or critical pathways for practice setting and/or clinical specialty

� Ensure that every member of the team has adequate liability protection.

Regulations (Hager, JADA 2006 & 2007)

� Federal & state regulations can impact RD

– Scope of practice

– Job responsibilities

– Professional growth opportunities

� Federal level – CMS

� State level – Facility licensure & RD licensure

� [email protected]

� www.eatright.org – Information about licensure status for each state under the Advocacy & Profession tab

CMS identified 2 methods (ADA White Paper*)

� A physician may choose to write an order for a patient that authorizes 1 of the followings 2 options:1. A qualified RD, working within their hospital-granted

privileges to perform a nutrition assessment on a specific patient and then follow-up with the following possible options:

� Consult directly with the physician to determine the patient’s diet/nutrition order

� Write a consultation report to the physician, or

� Write an appropriate diet/nutrition order for the patient

*August 30, 2006 http://www.eatright.org/ada/files/Therapeutic_Diet_Order_White_Paper_083006.pdf

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CMS identified 2 methods (ADA White Paper*)

� A physician may choose to write an order for a patient that authorizes 1 of the followings 2 options:

2. The implementation of a hospital-approved nutrition protocol which,

� Could include nutrition assessment & diagnosis by RD, development and implementation of care plans & therapeutic diet/nutrition orders, monitoring & ongoing evaluation of the patient’s nutrition status & needs by the RD, and

� Is carried out only in accordance with an order of the physician practitioner responsible for the patient

*August 30, 2006 http://www.eatright.org/ada/files/Therapeutic_Diet_Order_White_Paper_083006.pdf

Timing is everything!

� Proposal should include why the changes will improve patient care and benefit the organization

� Physician support during the proposal presentation is crucial

� Proposal may have to be re-defined and resubmitted

The Neighborhood by Jerry Van Amerongen

Expectation gives way to reality.Staff issues & responsibilities

� Assess competency and willingness of staff

� Implement training if needed

� Develop a Competency Assessment Program

� Involve educators & administrators in the institution

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Outcomes Research

� Collecting data to maximize quality of care

� Clinical outcomes – time on mechanical ventilation; blood glucose control

� Functional outcomes – patient satisfaction measures; quality of life

� Economic outcomes – actual costs of services

Outcomes Research – Sample Questions (Biesemeier, Support Line, 2003)

� Do inpatients on TF receive a greater % of estimated nutrient needs when the

RD communicates TF recs to MD both verbally and in the medical record compared with medical record alone?

� Do inpatients on TF who have daily monitoring meet a greater % of estimated nutrient needs than those who receive twice weekly monitoring by the RD?

Outcomes Research – Sample Questions (Biesemeier, Support Line, 2003)

� Are outpatients undergoing PEG placement more likely to meet estimated nutrient needs when they are referred for a RD consult vs similar patients who are not referred to the RD?

� Do patients discharged with TF have fewer complications when monitored after d/c by the RD compared with TF pts who receive standard monitoring?

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Baylor Clinical Nutrition Research

� Parenteral Nutrition vs Oral Diet in Autologous HSCT Patients*

� Nutrition Outcomes in ICU Patients*

� Survival Skills vs Traditional Diet Education*

� Nutritional outcomes after mini-allogeneictransplant*

� Impact of aggressive nutrition in NICU*

* Publication and/or poster/abstract presentation

Baylor Clinical Nutrition Research

� Omega 3 Fatty Acids in patients with GVHD

� Oxandrolone in GVHD + Weight Loss*

� RD/RN Feeding Tube Team Using Cortrak Device*

� Nutrition Protocol Pilot*

� Tolerance & Complications with NGT Feedings in ICU Patients*

� Appropriateness of the renal diet

� Incidence of Feeding Issues in NICU Graduates born < 29 weeks Gestation*

� RD Intervention and Weight gain in NICU Graduates born < 29 weeks

� [email protected]

�214-820-6751