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.

A systematic review of the psychology literature addressing hospital practice.

Hospitals, with their unique practice constraints and opportunities, are one of the most important arenas wherein the field of clinical psychology has developed throughout its history. However, there have been few efforts to comprehensively examine the literature on this topic. This is a literature worth examining, not only out of historical interest but also in the effort to provide direction for the field. Accordingly, systematic, scoping review methods were used to address the question: What does the psychology literature tell us about the nature and evolution of psychology practice in hospitals? The review identified 115 papers on this topic dating from 1916-2017, primarily in the form of practice commentaries and case studies. Analysis of the papers revealed 2 broad themes. One involved the nature of hospital practice, which concentrated on the major domains of assessment, psychotherapy and research activities along with issues related to training. The second involved structural and policy-related considerations such as cost-effectiveness and reimbursement models, leadership, the structure of practice, relationship to physicians, and hospital privileges. Implications of the review include the need for better data on the hospital practices of psychologists and continued work on role definition and the unique value of psychology. Other implications include direction for training models, practice models such as stepped care and a compromise between program and department-based management, privileges, and mental health reform. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Effect of Registered Dietitian Nutritionist Order-Writing Privileges on Enteral Nutrition Administration in Selected Intensive Care Units.

BACKGROUND: Adequate nutrition is linked to improved patient outcomes during critical illness. Nutrition care is further enhanced by registered dietitian nutritionist (RDN) order-writing privileges, which improve the implementation of nutrition interventions. The purpose of this performance improvement project was to evaluate the effect of RDN order-writing privileges on enteral nutrition (EN) order compliance and nutrition delivery in selected intensive care units (ICUs) at a university-affiliated teaching hospital. METHODS: Patients admitted to selected ICUs from January 23, 2018, to January 25, 2018, were screened for eligibility. Demographic and nutrition data were collected retrospectively from the electronic health record. Percent of energy and protein needs met were calculated. Data were compared with historical internal controls identified prior to RDN order-writing privileges. RESULTS: Fifty adult patients (150 EN days) were included in data analysis, with 93 patients (279 EN days) included in historical data. Compared with historical data, cumulative EN order compliance increased by 17% and tube feed infusion rate compliance by 15% post-RDN order-writing privileges. Mean (± SD) protein needs delivered significantly increased from 72.1 ± 28.6% to 89.1 ± 24.8% after RDN order-writing implementation (P < 0.001). CONCLUSIONS: RDN order-writing privileges improved EN order compliance and significantly improved protein delivery in selected ICUs. Future studies are recommended to confirm these results and determine if other variables besides protein delivery are statistically significant with a larger sample size.

Admitting privileges and hospital-based care after presenting for abortion: A retrospective case series.

OBJECTIVE: To examine the pathways of care for abortion patients transferred or referred to emergency departments (EDs) or hospitals before and after abortion-providing physicians obtained hospital admitting privileges. DATA SOURCES: This case series was based on retrospective chart review at three abortion clinics in which physicians had obtained admitting privileges in the previous 5 years. STUDY DESIGN: We identified patients who were transferred or referred to a hospital or ED. Patients were grouped according to the pathway by which their care was transferred or referred to the ED/hospital. PRINCIPAL FINDINGS: Both before and after admitting privileges, the majority of patients were referred to a hospital before the abortion was attempted and most were for suspected ectopic pregnancy or to perform the abortion in a hospital. Direct ambulance transfer from the facility to the ED/hospital was the least common pathway. We observed few changes in practice from before to after admitting privileges. Preexisting mechanisms of coordination and communication facilitated care that was tailored for the specific patient. CONCLUSIONS: We did not find evidence that physician admitting privileges influenced the pathways through which abortion patients obtain hospital-based care, as existing mechanisms of collaboration between hospitals and abortion facilities allowed for management of patients who sought hospital-based care.

Maternity Care Services Provided by Family Physicians in Rural Hospitals.

BACKGROUND: The purpose of this study was to describe how many rural family physicians (FPs) and other types of providers currently provide maternity care services, and the requirements to obtain privileges. METHODS: Chief executive officers of rural hospitals were purposively sampled in 15 geographically diverse states with significant rural areas in 2013 to 2014. Questions were asked about the provision of maternity care services, the physicians who perform them, and qualifications required to obtain maternity care privileges. Analysis used descriptive statistics, with comparisons between the states, community rurality, and hospital size. RESULTS: The overall response rate was 51.2% (437/854). Among all identified hospitals, 44.9% provided maternity care services, which varied considerably by state (range, 17-83%; P < .001). In hospitals providing maternity care, a mean of 271 babies were delivered per year, 27% by cesarean delivery. A mean of 7.0 FPs had privileges in these hospitals, of which 2.8 provided maternity care and 1.8 performed cesarean deliveries. The percentage of FPs who provide maternity care (mean, 48%; range, 10-69%; P < .001), the percentage of FPs who do cesarean deliveries (mean, 66%; range, 0-100%; P < .001), and the percentage of all physicians who provide maternity care who are FPs (mean, 63%; range, 10-88%; P < .001) varied widely by state. Most hospitals (83%) had no firm numbers of procedures required to obtain privileges. CONCLUSIONS: FPs continue to provide the majority of maternity care services in US rural hospitals, including cesarean deliveries. Some family medicine residencies should continue to train their residents to provide these services to keep replenishing this valuable workforce.

Prescribing privileges for psychologists among university students in Islamabad.

Psychologists as part of a team, make important contributions for the treatment of psychiatric disorders. New Mexico and Louisiana in United States have recently granted prescribing privileges to psychologists who have successfully completed additional training. This study determined the opinions of conveniently selected university students in Islamabad on clinical psychologists being granted similar prescribing privileges after additional training and certification by the Pakistan Medical and Dental Council (PMDC). Four hundred and five students completed the questionnaires; with 51 students enrolled in Psychology departments who were excluded from the reported analysis. One hundred and sixty-five respondents were male (46.6%), and 189 (53.4%) were female. Two hundred and seventy-six (78%) students were enrolled in masters, while the rest in higher degree programme. Cumulatively, 272 (76.8%) students believed that after additional training, clinical psychologists may be allowed to prescribe drugs for the treatment of psychiatric disorders by the PMDC. This viewpoint was reinforced by the act that 264 (74.6%) students replied affirmatively to the question that they would feel comfortable in referring a friend or taking a family member to a clinical psychologist who is trained in prescribing drugs. Results of our study demonstrated that university students in our study were overwhelmingly in favour of prescribing privileges for psychologists in Pakistan. Professional bodies like PMDC and Pakistan Psychological Association need to broach this subject for greater access to psychiatric services in the country.

Office surgery safety: the myths and truths behind the Florida moratoria--six years of Florida data.

BACKGROUND: Office-based surgery is an important method of health care delivery, and in 2000, the Florida Board of Medicine restricted office procedures. The objective of this study was to analyze the deaths resulting from office procedures in Florida. METHODS: The authors reviewed all office surgical incidents that resulted in death, injury, or hospital transfer in Florida from January of 2000 to January of 2006. Various methods were used to determine board status, office accreditation, and hospital privileges. RESULTS: In 6 years of Florida data, a total of 46 deaths related to office procedures were reported. Twenty of those were surgical procedures that are within the scope of plastic surgery, although non-board-certified plastic surgeons performed nine. Of those 20 related to plastic surgery, 11 died before discharge. Although all 11 survived long enough to be transferred to a hospital, we classified them as office deaths. The other nine died after appropriate discharge. Of the nine, seven deaths were from thromboembolism and the others from unknown causes. Thirty-five deaths were related to non-board-certified plastic surgeons and specialists in other fields. Board-certified plastic surgeons accounted for less than one-fourth of the deaths. There were no deaths from a board-certified plastic surgeon since April of 2004. CONCLUSIONS: There were over 600,000 operations during the study period. The fact that 11 office deaths were reported would suggest that the location in which these procedures were performed was not as much of a factor as the regulators have suggested. The most frequent cause of death after discharge was thromboembolism.

System failure. Most U.S. hospitals have never filed a report with the databank that records doctor suspensions; critics say it's time for a new method.

The National Practitioner Data Bank was born in 1990, touted as an authoritative way to track doctors whose privileges were suspended. Initial predictions expected up to 10,000 reports yearly, but only about 10,800 reports have been made in 15 years. Many believe hospitals skirt the system by just issuing lesser punishments. "It happens," admits Mark Pincus, right, the databank administrator.

Colonoscopy: why are general surgeons being excluded?

BACKGROUND: The role of surgeons as endoscopists has been extensively debated in the literature, with conflicting studies published regarding the safety and efficacy of surgeons performing colonoscopies. A multitude of medical federations and societies have set various standards for granting endoscopy privileges, many with a bias against general surgeons [1, 3]. We reviewed the colonoscopy experience at our institution to evaluate differences between gastroenterologists (GI) and general (GS) and colorectal surgeons (CRS) in procedure times and complication and cecal intubation rates. METHODS: Between January 2000 and July 2002, 5237 colonoscopies were performed at our institution. The data for procedure times, completion, and complication rates were collected in a prospective database. Complications were defined as perforation, bleeding, and postpolypectomy syndrome. Incomplete colonoscopies due to colitis, poor bowel preparation, or tumor obstruction were excluded. Chi-squared test was used to compare complication and cecal intubation rates between the three groups. Median procedure times were compared using the Kruskall-Wallis and Dunn's pairwise tests. A significant p-value was defined as <0.05. RESULTS: No differences in the complication rate was noted between the three groups: GI (0.12%), CRS (0.15%), and GS (0.11%) ( p = 0.99). There was a trend toward a lower incomplete colonoscopy rate in the GS group compared to CRS and GI: 0.32% vs 0.84% and 0.36%, respectively ( p = 0.07). The median colonoscopy times for GS (29 min), however, were shorter than for GI (34 min, p < 0.001) or CRS (31 min, p < 0.001). CONCLUSION: General surgeons perform colonoscopies expeditiously, with as low a morbidity rate and as high a completion rate as their gastroenterology or colorectal surgery colleagues. As the results of this study confirm, general surgeons should not be excluded from endoscopy suites.

Hospital peer review and the National Practitioner Data Bank: clinical privileges action reports.

CONTEXT: The National Practitioner Data Bank (NPDB) is believed to be an important source of information for peer review activities by the majority of those who use it. However, concern has been raised that hospitals may be underreporting physicians with performance problems to the NPDB. OBJECTIVE: To examine variation in clinical privileges action reporting by hospitals to the NPDB, changes in reporting over time, and the association of hospital characteristics with reporting. DESIGN: Retrospective cohort study of privileges action reports to the NPDB between 1991 and 1995, linked with the 1992 and 1995 databases from the Annual Survey of Hospitals conducted by the American Hospital Association. SETTING AND PARTICIPANTS: A total of 4743 short-term, nonfederal, general medical/surgical hospitals throughout the United States that were continuously open between 1991-1995 and registered with the NPDB. MAIN OUTCOME MEASURES: (1) Reporting of 1 or more privileges actions during the 5-year study period and (2) privileges action reporting rates (numbers of actions reported per 100000 admissions). RESULTS: Study hospitals reported 3328 privileges actions between 1991 and 1995; 34.2% reported 1 or more actions during the period. The range of privileges action reporting rates for these hospitals was 0.40 to 52.27 per 100000 admissions, with an overall rate of 2.36 per 100000 admissions. The proportion of hospitals reporting an action decreased from 11.6% in 1991 to 10.0% in 1995 (P=.008). After adjustment for other factors, urban hospitals had significantly higher reporting than rural hospitals (adjusted odds ratio [OR], 1.21 [95% confidence interval [CI], 1.02-1.43]), while members of the Council of Teaching Hospitals of the Association of American Medical Colleges had significantly lower reporting than nonmembers (adjusted OR, 0.54 [95% CI, 0.40-0.73]). There were notable regional differences in reporting, with the east south Central region having the lowest rate per 100000 admissions (1.49 [95% CI, 1.33-1.65]). CONCLUSIONS: The results of this study indicate a low and declining level of hospital privileges action reporting to the NPDB. Several potential explanations exist, 1 of which is that the information reported to the NPDB is incomplete.

Reimbursement, employment, and hospital privilege data of certified nurse-midwifery services.

This article reports data that pertain to the distribution of reimbursement modalities, other supporting data necessary to apply for provider contracts, and employment benefits. The frequency of hospital privileges, the type of privileges, and the category of privileges are also reported. Participants were also asked several questions that related to provider contracts: number of provider contracts in existence, number of new contracts obtained on average per year, type of data needed to apply for a contract, and whether or not physician co-signature is required for reimbursement. Questionnaires were sent to all certified nurse-midwifery practices in the United States that were listed with the American College of Nurse Midwives in 1994 (n = 1,839), and the response rate was 27%.

Use of National Practitioner Data Bank disclosure information for decision making.

Hospital, state licensing boards, and managed care organizations query the National Practitioner Data Bank to receive malpractice payment and adverse licensure or clinical privileges reports concerning licensed health care practitioners. The results of a national survey of queriers strongly suggest that Data Bank reports impart valuable information that affects licensing and credentialing decisions. Thus, the Data Bank is fulfilling the role lawmakers intended in improving the quality of health care.

The National Practitioner Data Bank: the first 4 years.

The National Practitioner Data Bank became operational September 1, 1990, as a flagging system to identify health care practitioners who may have been involved in incidents of medical incompetence. Query volumes have grown substantially over the Data Bank's first 4 years of operation. The greatest increase has come in the number of voluntary queries. By the end of 1994, the Data Bank had processed more than 4.5 million requests for information on practitioners, more than 1.5 million of which were received in 1994 alone. The proportion of queries for which the Data Bank contains information on the practitioner in question has grown as the Data Bank has come to contain more reports. During 1994, 7.9 percent of queries were matched. The Data Bank contained more than 97,500 reports at the end of 1994. More than 82 percent of the reports concerned malpractice payments. Licensure reports made up the bulk of the rest. Physicians predominate in reports, accounting for slightly more than 76 percent of the total. The remainder are related to dentists (16 percent) and all other types of practitioners (8 percent). Since reporting of adverse actions is mandatory only for physicians and dentists, the proportion of reports attributable to these types of practitioners is higher than it would be if adverse action reporting requirements were uniform for all practitioners. State malpractice payment rates and adverse action rates vary widely, but a State's rate in any given year is highly correlated with its rate in any other year. State malpractice rates are not strongly correlated with adverse action rates, neither are the rates for physicians strongly correlated with those for dentists. There is a weak tendency for States with smaller physician populations to have higher levels of licensure and privileging actions.

National survey on hospital-based privileges in family practice obstetrics.

PURPOSES: To document the content and level of obstetrical hospital-based privileges for members of the American Academy of Family Physicians and to describe variations between regions, rural vs urban practices, and various physician characteristics. METHODS: About 12% of the active members of the American Academy of Family Physicians listed as offering obstetrical care by the Academy as of March 1991 were randomly sampled by mailed questionnaire. Samples were drawn from three national regions. Privileges were grouped by degree of restriction, based on whether consultation or transfer was required. RESULTS: Of 1464 surveys mailed, 1026 physicians (70%) responded. Only 740 (72%) stated that they still practiced obstetrics. Privileges ranged from least restricted (100% provided vaginal vertex delivery, with no consultation required) to most restricted (79% provided amniocentesis, with consultation or transfer required). A surprisingly large proportion of physicians reported having fewer routine and more advanced privileges without consultations being required, such as ultrasonography (53%), vaginal breech delivery (41%), and cesarean section (25%). Physicians having more advanced privileges tended to be located in the West or mountain-plains region; be trained in the Midwest, mountain-plains region, or the West; work in middle-sized, nonteaching hospitals in more rural countries; have completed advanced obstetrical training (> or = 6 months); and deliver more than 40 infants per year. CONCLUSIONS: Overall, a considerable number of hospital-based obstetrical privileges are granted to family physicians. No uniformity in privileges prevails, owing to significant regional and practice variations. Teaching hospitals reportedly restrict obstetrical care by family physicians more than other hospitals. The variations in restrictions could not be explained by degree of training.

Limitation of private attending pediatricians' neonatal intensive care privileges in level III institutions throughout the United States.

OBJECTIVE: To determine the privileges of Private Attending Pediatricians (PAP) in caring for newborns requiring intensive (ITC), intermediate (IMC), or continuing (CC) care in Level III neonatal intensive care units (NICUs) throughout the United States. DESIGN: A two-page mail questionnaire was sent to 429 Level III NICUs to obtain the statement best describing the PAPs' privileges, the number of PAP, and some of the PAPs' functions. Level III NICUs were classified by geographic region as Eastern, Central, or Western United States. RESULTS: Responses were received from 301 NICUs (70%) representing 48 states, the District of Columbia, and > 9000 PAP. Twenty-two institutions had no PAP. In the remaining 279 institutions, 96% (267/279) had restricted the PAPs' privileges partially or completely. In 32% (88/279), the PAP were not allowed to render any type of NICU care. In 18% (51/279) of the institutions, the PAP were allowed to render CC only. In 27% (76/279) of the institutions, the PAP were allowed to render IMC and CC only. Limitation of PAPs' privileges were reported in all geographic areas in the U.S., were more pronounced in the Eastern than the Central or Western sections of the country, and were noted in institutions with small (< or = 10) as well as large (> or = 60) numbers of PAP. Limitation of PAPs' privileges was determined by the PAP him/herself in many institutions. Proficiency in resuscitation was considered to be a needed skill. Communication with parents of an infant under the care of a neonatologist was encouraged. CONCLUSIONS: The PAPs' privileges were limited partially or completely in most Level III NICUs. Knowledge of this restricted role impacts significantly on curriculum design for pediatric house officers, number and type of health care providers required for Level III NICUs and future house officer's career choices.

1992 NAPNAP membership survey: part II. Practice characteristics of pediatric nurse practitioners indicate greater autonomy for PNPs.

The 1992 membership survey, authorized by the Executive Board of NAPNAP as part of an ongoing plan to survey members every 4 years, had three foci: (a) demographic characteristics of NAPNAP members, (b) practice characteristics of NAPNAP members, and (c) opinions of NAPNAP members related to health care issues. Information gathered from this membership survey will be used to assist in planning NAPNAP programs and direction, to advocate for pediatric nurse practitioners and for NAPNAP, and to inform health professionals, policy makers, and the general public about characteristics of a pediatric nurse practitioner and the work pediatric nurse practitioners do. NAPNAP members received the survey during the summer 1992, and 65% of the random sample of 800 were returned, a clear indication of strong interest on the part of NAPNAP members to be heard. This article, the second of two describing survey results, presents data describing characteristics of members' practice and the clients they serve.

Economic credentialing survey of university teaching hospitals.

Economic credentialing, the process of applying economic criteria to the determination of initial appointments or reappointments of physicians to hospital medical staffs, has become a major issue in hospital medical staff relations. Nearly all major academic health center hospitals have the ability to perform economic analyses of faculty/physician clinical practices, and more than one-third of their CEOs see nothing wrong with terminating or denying hospital privileges for excessive use of hospital resources. Sixty-eight percent of surveyed academic health center respondents currently develop and review physician practice profiles, but only 35 percent of these respondents include economic data.

Obstetric care in family practice residencies: a national survey.

BACKGROUND: Supervision of obstetric care by family practice faculty increases the likelihood that family practice residents will choose to practice obstetrics. METHODS: A survey instrument was developed to obtain information about practice faculty and the educational setting in which residents learn family physician obstetric care. Questionnaires were sent to all family medicine residency directors and all full-time family physician faculty. RESULTS: Two hundred eighty-four program directors and 1396 faculty members responded. The mean percentage of recent graduates estimated to be practicing obstetrics was 30 percent. Factors independently associated with an increased likelihood of resident graduates practicing obstetrics included supervision of resident deliveries by family physicians, increasing number of family practice center deliveries, regional differences, and availability of training to perform Cesarean sections. Sixty-four percent of the responding family physician faculty were currently supervising deliveries, but only 5 percent had Cesarean section privileges. Seven percent of the faculty reported denial of obstetric privileges. Eighty-nine percent of all respondents supported the mandatory inclusion of obstetrics in family medicine residencies. CONCLUSIONS: Residency programs in family practice can increase the number of their graduates practicing obstetric care by focusing on the family physician supervision model, faculty development that supports this model, and clinical privileges of faculty.