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CMS Rule Change Empowers Dietitians, Could Lower Nurse Workload

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By Megan Murdock Krischke, contributor

May 16, 2014 - “No one disputes that nutrition is central to having and sustaining good health,” began Danielle Snider, MS, RD, manager of clinical nutrition for Scripps Health in California. “Even so, registered dietitians are still a more recent profession in the hospital atmosphere, and because of that we are some of the last clinicians to be privileged in responsible care for the patient.”

Snider refers to a recent ruling by the Centers for Medicare and Medicaid Services (CMS) which will allow registered dietitians (RDs) to order therapeutic diets and even nutrition-related laboratory tests beginning July 11, 2014.  Currently, RDs provide suggestions to physicians, physician assistants or nurse practitioners who then have the responsibility to write the orders.

Because these other practitioners are already carrying a significant load of patient care, dietary order changes are often delayed, sometimes by a day or more.

“This new ruling allows me to stop bugging other care team members, who readily agree that these therapies need to happen but don’t have time to implement them,” Snider commented. “Now no one has to run around doing my work for me.”

Rachael Dunn, RD, LDN, clinical dietitian at Loyola Medical Center in Maywood, Ill., points out that an RD must complete an undergraduate degree, a master’s degree and a supervised practice internship, and then pass an exam to be licensed. Because of this extensive training, it is appropriate to grant order-writing privileges.

“I do think it is important for clinicians to be aware that there is a significant difference between a registered dietitian and a nutritionist,” she added. “Almost anyone can be a nutritionist, but being an RD requires lots of education and training.”

CMS anticipates that the new rule will save individual hospitals an average of $45,600 each year.

“Getting a patient on the correct diet is often time-sensitive,” noted Snider “With the expanded responsibilities provided by the CMS ruling, we will be able to get patients on the right nutrition plan sooner. For instance, there are diets that can help a patient produce more CO2, or maybe part of their treatment is leveling out their blood glucose levels.”

“When I can get a patient on the right diet right away,” she continued, “the amount of time they spend in the ICU or in the hospital can be decreased. Decreasing stays by even half a day can save thousands of dollars.”

More expedient changes in diet also lead to increased patient satisfaction and increased patient education.

“When a patient makes a specific dietary request or when I talk with them about a certain dietary plan and they agree to it, they are more satisfied when they see changes take place immediately,” remarked Dunn.

“The longer a patient is on a therapeutic diet, the more they understand which foods fall into that diet,” said Snider. “It is significant for a patient to see what nine different low-sodium meals look like rather than just three.”

The role of an RD is to assess the nutritional needs of each patient and create a dietary plan, in consult with the rest of the team, that feeds the patient in a way which supports their recovery, she explained.

“My hope is that as nurses and dietitians partner together in patient care, that concerns about diet can be taken off of nurses,” reflected Dunn. “Nurses certainly have knowledge about nutrition, but it isn’t the main focus of their work. Dietitians have training to know what the most appropriate diet is for a patient. I hope that the nurses I work with have more freedom to work in their areas of expertise.”

Snider encourages nurses to communicate with dietitians about changes in a patient’s status. 

“So many body processes really depend on how you are fueling the body, so if you change a couple of things you can often see a different recovery,” she stated. “For instance, when a patient develops a wound, physicians and nurses often immediately think of medications and bandages, but closing a wound also requires vitamin C, protein and enough fluid.”

Like Dunn, Snider’s hope is to ease nurses’ workloads.

“Lean on us, use us, let us improve your workload by directing anything related to nutrition or dietary needs to a RD,” she encouraged nurses.

While the CMS federal ruling is set to take effect in July, states and hospitals will still have to provide recommendations.

“We have to have collaboration between the state and federal governments about what RDs can and can’t do, and hopefully we will be able to move forward,” commented Snider. “RDs are excited about receiving support from the federal side. This is one huge step, but we now have a few more steps before we can embrace and enjoy these privileges.”


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