Enteral and Parenteral Order Writing Survey-A Collaborative Evaluation Between the Academy of Nutrition and Dietetics' Dietitians in Nutrition Support Dietetics Practice Group and the American Society for Parenteral and Enteral Nutrition (ASPEN) Dietetics Practice Section.

INTRODUCTION: In 2014 and 2017, the Centers for Medicare and Medicaid Services authorized nutrition-related ordering privileges for registered dietitian nutritionists (RDNs) in hospital and long-term care settings, respectively. Despite this practice advancement, information describing current parenteral nutrition (PN) and enteral nutrition (EN) ordering practices is lacking. Dietitians in Nutrition Support, a dietetic practice group of the Academy of Nutrition and Dietetics and the Dietetics Practice Section of the American Society of Parenteral and Enteral Nutrition (ASPEN) utilized a survey to describe PN and EN ordering practices among RDNs in the United States. METHODS: A cross-sectional study design was utilized to describe RDN PN and EN ordering privileges. Respondents were asked to describe PN and EN ordering privileges, primary practice setting, primary patient population served, nutrition specialty certification, highest degree earned, career length, and if applicable, the nature of prior denials for ordering privileges or reasons for not applying for ordering privileges. RESULTS: Seven hundred two RDNs completed the survey (12% response rate), with 664 RDNs providing complete data. The majority of respondents (n = 558) cared for adult/geriatric patients. Among this subset, 47% had no PN ordering privileges; 14% could order and sign PN; 28% could order PN with provider cosignature; 10% could order partial PN with provider cosignature. Nineteen percent of RDNs had no EN ordering privileges; 37% could order and sign EN; 44% could order EN with provider cosignature. RDNs with ordering privileges were more likely to have a nutrition specialty certification and work in an academic or community hospital setting. CONCLUSION: PN and EN ordering privileges are varied because of institution and state requirements. Future research describing the outcomes associated with RDN ordering privileges is needed. This paper has been approved by the Academy's Research, International, and Scientific Affairs team and Council on Research and the ASPEN Board of Directors. This article has been co-published with permission in the Journal of the Academy of Nutrition and Dietetics. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Either citation can be used when citing this article.

Expanded Practice in Midwifery: Designing, Implementing, and Maintaining Programs.

Advances in health care science and delivery, coupled with patient need for access to care, have driven expanded practice in midwifery for decades. The process for development and implementation of expanded practices for midwives and midwifery practices is described. Important components include assessment of need, identifying stakeholders and supporters, development of a program proposal, obtaining privileges, developing training programs, and conducting ongoing quality management and program evaluation. Examples of expanded practice in midwifery are presented.

Ordering of Diagnostic Imaging by Physical Therapists: A 5-Year Retrospective Practice Analysis.

BACKGROUND: Significant progress has been made in implementing direct access. As more therapists transition into direct access roles, it seems prudent to consider how additional resources common to other first-contact providers might impact patient care. OBJECTIVES: Direct referral for diagnostic imaging by physical therapists is relatively rare in the civilian setting and little has been published on the subject. The primary objective of this study was to examine the appropriateness of diagnostic imaging studies referred by civilian physical therapists at an academic medical center. Secondary objectives were to track reimbursement data and overall use rates. DESIGN: This was a single-center, retrospective practice analysis of 10 physical therapists over a period of nearly 5 years. METHODS: The electronic medical record was reviewed for each patient who had an imaging referral placed by a physical therapist. Relevant clinical exam findings and patient history were provided to a radiologist who then applied the American College of Radiology Appropriateness Criteria to determine appropriateness. Reimbursement data and therapist use rates were also evaluated. RESULTS: Of the 108 total imaging studies, 91% were considered appropriate. Overall, use rates per direct access evaluation were 9% for plain film x-rays and 4% for advanced imaging. Reimbursement was 100%. LIMITATIONS: This study was limited to 10 physical therapists at 1 practice location. Appropriateness was evaluated by 1 radiologist. The educational background of referring therapists was not evaluated. CONCLUSIONS: Physical therapists demonstrated appropriate use of diagnostic imaging in the vast majority of cases (91%). They were judicious in their use of imaging, and there were no issues with reimbursement. These findings could be useful for physical therapists interested in acquiring diagnostic imaging referral privileges.

Tools for Discussing Identity and Privilege Among Medical Students, Trainees, and Faculty.

Introduction: Physicians and students of all backgrounds should be prepared to interact with patients of various socioeconomic, racial, ethnic, gender, religious, and sexual orientation identities. The approach described here emphasizes how important it is for physicians and physicians-in-training to develop self-awareness before engaging with patients. Methods: Over the course of 6 months, we conducted workshops on identity awareness for four groups: (1) fourth-year medical students (N = 6), (2) first-year medical students (N = 88), (3) faculty and staff (N = 11), and (4) residents/fellows (N = 4). Exercises in this workshop prompted learners to reflect on the development of social and professional identities through the use of an identity wheel activity, a group reading about professional identity formation, and a hands-on activity modeling social inequity. Results: Our analysis of responses to pre- and postsurveys indicated that learners in the first-year medical student group (N = 88) experienced increased awareness and acknowledgment of social identity, professional identity, professional relationships, and the concepts of privilege and difference following participation in this workshop. Discussion: These exercises guide learners toward critical thinking about privilege and identity to better prepare them for culturally inclusive patient interactions. These materials can be used with physicians at various levels of training. The earlier they are used, the more time learners will have to reflect on social and professional identities before interacting with patients.

US hospital-based direct access with radiology referral: an administrative case report.

BACKGROUND AND PURPOSE: Legislative gains in the US allow physical therapists to function in expanded scopes of practice including direct access and referral to specialists. The combination of direct access with privileges to order imaging studies directly offers a desirable practice status for many physical therapists, especially in musculoskeletal focused settings. Although direct access is legal in all US jurisdictions, institutional-based physical therapy settings have not embraced these practices. Barriers cited to implementing direct access with advanced practice are concerns over medical and administrative opposition, institutional policies, provider qualifications and reimbursement. This administrative case report describes the process taken to allow therapists to see patients without a referral and to order diagnostic imaging studies at an academic medical center. Nine-month implementation results show 66 patients seen via direct access with 15% referred for imaging studies. Claims submitted to 20 different insurance providers were reimbursed at 100%. DISCUSSION: While institutional regulations and reimbursement are reported as barriers to direct access, this report highlights the process one academic medical center used to implement direct access and advanced practice radiology referral by updating policies and procedures, identifying advanced competencies and communicating with necessary stakeholder groups. Favorable reimbursement for services is documented.

2013-2014 National Health Law Moot Court Competition Best Brief.

This document was judged Best Brief submitted to the 2013­2014 National Health Law Moot Court Competition. The brief was submitted by students Jessica Robinson DeShon, Brandon Jackson, and Matthew Ward on behalf of Faulkner University School of Law in Montgomery, Alabama. Address correspondence to Professor Joe Lester at Jlester@Faulkner.edu.

Regulation and oversight of independent health facilities in Canada.

Independent health facilities ("IHFs") are an important part of Canada's health care system existing at the interface of public and private care. They offer benefits to individual patients and the public at large, such as improved access to care, reduced wait times, improved choice in the delivery of care, and more efficient use of health care resources. They can also provide physicians greater autonomy, control of resources, and opportunity for profit compared to other practice settings, particularly because IHFs can deliver services outside of publicly-funded health care plans. IHFs also present challenges, particularly around quality of care and patient safety, and the potential to breach the principles of "Medicare" under the Canada Health Act. Various measures are in place to address these challenges, while still enabling the benefits IHFs can offer. IHFs are primarily regulated and overseen at the provincial level through legislation, regulations and provincial medical regulatory College by-laws. Health Canada is responsible for administering the overarching framework for "Medicare". Oversight and regulatory provisions vary across Canada, and are notably absent in the Maritime provinces and the territories. This article provides an overview of specific provisions related to IHFs across the country and how they can co-exist with the Canada Health Act.