1. Is It a Realistic Battle in California?

2.  Importance of RD recommendations  Research giving RDs privileges  Obstacles of achieving privileges

3.  Give one reason why RD recommendations are important  Give one reason supporting privileges  State one obstacle

4. Turn to your neighbor and tell them how often MDs take your recommendations and if the system in place is efficient

5.  Specialists  Article- Implementation of Dietitian Recommendations for Enteral Nutrition Results in Improved Outcomes - accepted RD recommendations vs. non accepted  Malnutrition  Decrease length of stay  Wound healing  Decrease infection

6.  How often are they taken?  Article – Physicians implementation of dietitian’s recommendations -Lack of knowledge of RDs role

7. Expand RD privileges

8.  Verbal Orders  Research – Diet Order Entry by Registered Dietitians Results in a Reduction in Error Rates and Time Delays Compared to Other Health Professionals - reduced error rates and time delays with RD order entry privileges

9.  Order Writing Privileges  Research – Assessing the Influence of Registered Dietitian Order-Writing Privileges on Parental Nutrition Use -decreased inappropriate PN use  Research – The Role of Dietitian Order-Writing Privileges in Improving Parental Nutrition Utilization in Neonatal Intensive Care Unit - Faster achievement of calorie, protein, and lipid goals with presence of RD and order writing privileges in NICU

10.  Regulations  Clinical privileging vs. prescriptive authority Must obtain license, relevant training and experience, demonstration under observance by practitioner and competencies  Medicare State Operations Manual Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals - LIPs - Dependent on hospital facility and state dietetics and nutrition licensure law - States that do not license or give statutory certification to RDs: CA, AZ, CO, NJ, WY  California’s current law

11.  Liability and malpractice insurance  Academy accused of monopolizing field Alliance for Natural Health USA “nutritionists” Homeopathic nutrition Alternative nutrition Those with higher degree but did not pursue RD  Opposition from American Nurses Association of California and California Nurses Association

12. Conclusions….

13.  RDs have the knowledge and skills – reduce error and hospital costs  More research needs to be done  Very complex issue with many obstacles

14.  RD recommendations: Decrease length of stay, decrease infection, wound healing, malnutrition- SAVE HOSPITAL MONEY  Research says RD privileges can reduce diet entry error and time delays, decrease PN use and decrease cost, help achieve goals faster  Obstacles: state licensure, opposing groups, liability

15. Give one reason supporting RD recommendations? Give one reason supporting RD privileging? State one obstacle hindering the achievement of RD privileging?

16.  Educate others - Medical staff on RDs role -Issue of licensure -Difference of MNT and nutrition advice  Stay informed -Contact legislators -Be involved with the CDA

19. 1. Braga J, Hunt A, Pope J, Molaison E. Implementation of dietitian recommendations for enteral nutrition results in improved outcomes. J Am Diet Assoc. 2006; 106:281-284. 2. Skipper A, Young M, Rotman N, Nagl H. Physician’s implementation of dietitians’ recommendations: a study of the effectiveness of dietitians. J Am Diet Assoc. 1994; 94:45-49. 3. Imfeld K, Keith M, Stoyanoff L, et al. Diet order entry by registered dietitians results a reduction in error rates and time delays compared with other health professionals. J Acad Nutr Diet. 2012; 112:1656-1661. 4. Peterson A, Chen Y, Sullivan C, et al. Assessing the influence of registered dietitian order- writing privileges on parenteral nutrition use. J Am Diet Assoc. 2010; 110:1703-1711. 5. Witowich G, Fogelman M, Tupesis S, et al. The role of dietitian order-writing privileges in improving parenteral nutrition utilization in the neonatal intensive care unit. J Am Diet Assoc. 2009; 109:A30. 6. History of licensure for RDs in California. http://blog.shopwell.com/files/history_of_licensure_in_california_feb2011-1.pdf http://blog.shopwell.com/files/history_of_licensure_in_california_feb2011-1.pdf 7. Hager M, McCauley S. Clinical privileging: what it is.. And isn’t. J Am Diet Assoc. 2009;109:400-402. 8. Hager M, McCauley S. Why are therapeutic diet orders an issue now and what does it have to do with legal scope of practice? J Am Diet Assoc. 2009; 109:1515-1519. 9. House of Delegates: Licensure initiatives. http://www.reallyeatright.org/wp- content/uploads/2012/05/HOD-Licensure-Backgrounder-2011-07-22-11.pdfhttp://www.reallyeatright.org/wp- content/uploads/2012/05/HOD-Licensure-Backgrounder-2011-07-22-11.pdf