Submitted by Lawrence Livornese, MD, Chairman, MLH Department of Medicine
In the Commonwealth of Pennsylvania, the Department of Health does not allow Registered Dietitians (technically known as Licensed Dietitian-Nutritionists) to write orders. In 2014, we requested, and were subsequently granted, an exception to this rule; we were the first hospitals in Pennsylvania to achieve this. Some of our reasons for pursuing this included the high acceptance rate of LDN recommendations at MLH and the significant delay in enacting these recommendations in the inpatient setting. In 2015, with broad physician support, the Medical Staff Rules and Regulations were revised to allow physicians to delegate order writing authority to LDNs on a patient by patient basis. Our LDNs are now in the process of being credentialed and privileged through the Department of Medicine. The first LDNs in this process have been approved by the Medical Executive Committee of the Medical Staff and by the Quality Patient Safety Committee of the Board of Trustees; others will follow in the coming months.
Next week, our electronic medical record will be updated to accommodate this new privilege. When a physician writes a dietary order, the EMR will allow them the option of delegating dietary order writing to LDNs. If the physician chooses this option the LDNs who have this privilege will be able to:
- change or alter diets including supplements or enteral tube feedings
- order calorie counts
- enter heights and weights into the medical record
Similarly, when a physician enters an order for total parenteral hyperalimentation (TPN) the emr will allow them the option of delegating TPN ordering authority to LDNs who have been approved for this specific privilege to modify and renew TPN orders.
Per the exception granted to us by the DOH, LDNs may NOT start diets in patients who are NPO, may NOT advance the diet of a patient on clear liquids and may NOT initiate TPN.
If the physician does not choose to delegate the dietary order writing authority they will continue to be responsible to all dietary orders and LDNs will continue to function as they do now. Physicians who choose to delegate may still write any orders they wish.
Please be aware, physicians who grant this authority are considered to be supervising the LDNs. Additionally, per the DOH exception this authority can only be delegated by a physician; an order by a CRNP or PA is not adequate even if counter-signed by a physician.
I believe this process will improve patient care by allowing our LDNs to operate at the top of their license and by providing our patients with more timely quality care. If you have questions or concerns about this process do not hesitate to contact me or one of the Department of Medicine Campus Chiefs – Drs. Andrew Pitman, Deebeanne Tavani, David Thomas or Drew Ulichney.