Registered dietitian therapeutic diet order writing privileges and timeliness of

patient care in an acute care setting

Mary Arnold; Ashley Chowansky, RD; Cindy Banta, MS, RDN, LD
ARAMARK Distance Learning Dietetic Internship Program, Woodbury, NJ
ABSTRACT

RESULTS

Registered Dietitians (RDs) are often required to obtain physician consent before implementing a
therapeutic diet order. The process for obtaining physician approval of diet orders can be time
consuming. This study examined the amount of time it takes for a physician to implement a
therapeutic diet order recommendation from the RD in an acute care setting. Data was selected from
electronic order sets in a computer database over a ten-week time span. There were 314 order sets
tracked and evaluated using a cohort study design. Descriptive statistics were used to evaluate each
type of therapeutic diet order including tube feeding orders, supplement orders, and diet change
recommendations. Results found it takes an average of 19.18 hours for a tube feeding order to be
implemented, 28.19 hours for a supplement to be implemented, and 20.74 hours for a diet change to
be implemented. Minimum, maximum and standard deviation within the data sets for the three order
types varied tremendously. Results also revealed that many RD order recommendations are not
implemented during a hospital stay for a patient. This study demonstrates that lack of RD order
writing privileges drastically affects timeliness and quality of patient care in an acute care setting.

Tube Feeding (TF) Order

Implementation

DISCUSSION
Supplement Order Implementation

Diet Change Order Implementation

This study examined the amount of time it takes for the nutrition order process to be completed
from recommendation to implementation.
The results are consistent with findings that lack of diet order writing privileges for the RD can
drastically increase the time period in which adequate nutrition is not met.
On average about three meal periods were missed before nutritional intervention.
The findings in this study are comparable to Imfeld et al, which compared the error rates and
meals missed before and after RDs were able to electronically input the orders and after. Errors
were reduced by %13 and meals missed were reduced by %39 after RD order writing was in
effect. I think this location would have a greater percentage for both.
Time delays accounted for 19.18 hours of tube feeding time missed, 28.19 hours before
supplements entered, or three meals, and 20.74 hours for a diet change to be entered, or three
meals. However, this data does not include the amount of time from order entry to product
delivery, further increasing meals and tube feeding time missed.
The very large minimum and maximum order entry times indicate very inconsistent patient care
delivered.
The routes of getting an order entered were similar to the findings Moreland et al. This study
found personally locating a physician can take ten minutes to hours, placing a note in the chart
can take 24 hours to several days, and asking a nurse to contact the physician can take an hour
or several hours.
Limitations:
There was not enough time invested to track paper order trail and match with the
electronic orders. Physicians often sign the paper recommendation, but forget to
implement it electronically.
It was not possible to get an exact number of each order type due to the infrequency of
tube feeding orders at Inspira.

OBJECTIVE & INTRODUCTION

Objective: Would the timeliness and quality of patient care improve if registered dietitians
independently wrote therapeutic diet orders without mandatory physician consultation?
The Centers of Medicare and Medicaid (CMS) proposed a rule change permitting RDs to order
therapeutic diet orders without physician approval, however this varies by state and facility. Inspira
does not have this privilege.
RDs recommend diet changes, supplements and tube feeding recommendations to physicians and
await approval to implement the order.
Awaiting physician approval can lead to missed meal trays and inappropriate or dangerous diet
orders. It also delays the time in which nutritional needs are inadequate.
Studies have reported strong correlations between nutritional status, nutrition intervention, length of
hospital stay, and patient survival rates. 4
Across the health care continuum, nutrition screening, assessment, counseling, treatments, and
monitoring can be inconsistent due to the limitations that an RD may have, which contributes to the
gap in communication between the healthcare team and the patient, and also treatment plans for
discharge. For example, an RD may be unable to move forward with patient goals and interventions if
a diet order was never entered.
It is expected that the results will indicate a large average time gap between recommendation and
implementation of the diet orders, spanning over many days. It is also expected that many orders will
not be implemented.

METHODOLOGY
Cohort study design using descriptive analysis of patient data using Soarian Electronic Medical
Records (EMR)
314 order sets evaluated over a ten week period; 281 were included in the study
Variables: tube feeding, supplement, diet change, discharge time for unacknowledged orders
Any patient with diet order recommendations were included in this study; if diet order changed and
recommendation was no longer appropriate, the order was taken out of the study.
Data focused on central tendency: mean, minimum, maximum, standard deviation of variable.
Resources: data collection tool, Soarian EMRs, Microsoft Excel

CONCLUSIONS

Tube Feed Order Implementation

Tube feeding orders were found to be the highest
priority for orders that are implemented by the
physicians.
Tube feeding orders accounted for 30 of the 281
orders evaluated, or %10.6 of total orders.

Supplement Order Implementation

Supplement orders were second in priority for
orders that are implemented by the physicians.
Supplement orders accounted for 165 of the 281
total orders, or %58.72 of the total orders.
%72.7 of the supplement orders were implemented.

93% of the orders were implemented.

Diet Change Order Implementation

Diet change order recommendations were the last in
priority of the three order types to be implemented by
the physician.

This study puts the time for implementing a therapeutic diet order into perspective and highlights
that there is a significant unnecessary time gap.
Allowing RDs the privilege to write therapeutic diet orders can relieve the time lapse, which could
in turn reduce order errors, missed meals and length of stay in the hospital, while increasing the
amount of patients that meet their nutritional needs and doing so in a timely fashion.
Future studies should focus on the time that the RD made the recommendation to the time the
patient received the correct meal, supplement or tube feeding.
Another study could be to compare the length of stay in the hospital to the time in which the
patient was receiving appropriate nutritional intervention.

Diet change orders accounted for 87 of the total 281

total orders, or %30.96.
%59.7 of the diet change order recommendations
were implemented.

CONTACT INFORMATION
For additional information, please contact:

Of the total 281 orders, 82 orders were never implemented by the physician prior to discharge; this accounts for %29.18 of the total order recommendations.

Mary Arnold
Aramark Dietetic Intern
ARAMARK Distance Learning Dietetic Internship Program

The maximum amount of hours from order recommendation to discharge was 196 hours, or 8 days. The minimum amount of time was 2.5 hours.

Arnold-mary@aramark.com

Unacknowledged Orders and Discharge Time

The average amount of time for a patient to be discharged after order recommendation, if an order is not implemented, is 65.05 hours.