RESEARCH
Research and Professional Briefs
Implementation of Dietitian Recommendations
for Enteral Nutrition Results in Improved
Outcomes
JENNIFER M. BRAGA, RD; ALICE HUNT, PhD, RD; JANET POPE, PhD, RD; ELAINE MOLAISON, PhD, RD
ABSTRACT
A primary role of the registered dietitian (RD) is to assess
nutritional needs of patients in states of physiological
stress and illness and to recommend changes to diet and
tube feedings when warranted. However, implementation
of changes is dependent upon the physician accepting the
recommendations of the RD. This study evaluated out-
comes of two groups of enterally fed patients in a long-
term acute-care facility in northwest Louisiana: (a) those
for whom the physician accepted RD recommendations;
and (b) those for whom the physician did not accept RD
recommendations. Data showed that physician-pre-
scribed enteral formulas provided 10.0% less kilocalories
and 7.8% less protein than the RD-assessed needs. t tests
showed that when RD recommendations were imple-
mented, patients had a significantly shorter length of stay
(28.5⫾1.8 vs 30.5⫾4.8 days, P⬍0.05), as well as signifi-
cantly improved albumin (0.13⫾0.17 vs ⫺0.44⫾0.21 g/dL
[1.3⫾1.7 vs ⫺4.4⫾2.1 g/L], P⬍0.05) and weight gains
(0.51⫾0.1 vs ⫺0.42⫾0.2%, P⬍0.05) when compared to those
who continued with physician’s orders. These data suggest
that if RDs had the authority to write nutrition orders and
provide early nutrition intervention, patient care would
improve.
J Am Diet Assoc. 2006;106:281-284.
A
high percentage of hospitalized patients are either
malnourished or at risk for malnutrition (1-5). Gal-
lagher-Allred and colleagues (3) reported that of
1,327 hospitalized adult patients studied, 40% to 55%
were found to be either malnourished or at risk for mal-
nutrition, and up to 12% were severely malnourished.
Surgical patients at risk for malnutrition were two to
J. M. Braga is a clinical dietitian, Doctor’s Hospital,
Shreveport, LA. A. Hunt and J. Pope are professors of
Nutrition and Dietetics and E. Molaison is assistant
professor of Nutrition and Dietetics, School of Human
Ecology, Louisiana Tech University, Ruston.
Address correspondence to: Alice Hunt, PhD, RD,
School of Human Ecology, Louisiana Tech University,
PO Box 3167 TS, Ruston, LA 71272. E-mail: hunt@ans.
latech.edu
Copyright © 2006 by the American Dietetic
Association.
0002-8223/06/10602-0007$32.00/0
doi: 10.1016/j.jada.2005.10.039
© 2006 by the American Dietetic Association
three times more likely to have complications and in-
creased mortality, and length of stay was extended by as
much as 90% compared to the length of stay of well-
nourished patients. Implementing early, high-quality
medical nutrition therapy can reduce inpatient length of
stay (6), and aggressive nutrition support can facilitate
recovery of wound healing and decrease infections (7-9).
Enteral tube feedings are used when a patient cannot
consume sufficient kilocalories and protein. Registered
dietitians (RDs) are trained to assess nutritional needs
and determine appropriate enteral formulas. However,
many, if not most, hospitals do not allow RDs to write diet
orders; therefore, the RD and patient must rely on the
physician to implement RD recommendations for nutri-
tion support (10). A key frustration of many RDs is the
lack of acceptance of their clinical expertise (11). The
purpose of this study is to compare outcomes between
enterally fed patients for whom the physician accepted
RD recommendations and patients for whom the physi-
cian did not accept RD recommendations.
METHODS
A retrospective review of medical charts was conducted in
a long-term acute-care facility. Chart review was used to
evaluate outcomes in two groups of enterally fed patients,
those for whom the physician accepted RD recommenda-
tions, and those for whom the physician did not accept RD
recommendations. Approval for the study was obtained
from the Louisiana Tech University Human Subjects
Committee and the Hospital.
All patients received enteral tube feedings and had a
documented diagnosis of malnutrition or fit one of the
following definitions of malnutrition: ⬍90% of ideal body
weight, serum albumin ⬍3.0 g/dL (30.0 g/L), or body mass
index ⬍21 (calculated as kg/m2). Additional criteria for
inclusion in the study were: length of stay between 21 and
38 days, age between 18 and 85 years, an RD visit within
48 hours of a request for nutrition consult or within 72
hours of admission, and initial weight and albumin doc-
umented in the chart and a second weight and albumin
obtained after 21 to 38 days. Exclusion criteria included
patients who had a medical history or current diagnosis
of renal malfunction, blood transfusion, dehydration,
and/or cancer, and those who expired while in the hospi-
tal.
Medical records were retrospectively reviewed. The fol-
lowing information was recorded: age, admission and dis-
charge dates, length of stay, race, sex, height, weight,
diagnosis, past medical history, physician, type of tube
Journal of the AMERICAN DIETETIC ASSOCIATION 281
feeding, calorie and protein prescription, albumin, recom-
mendations of the RD, and number of days until dietary Table 1. Characteristics of enterally fed patients in a long-term
recommendations were taken. A tally was kept of the acute-care facility in northwest Louisiana who had registered die-
number of charts on which RDs made recommendations titian (RD) recommendations taken vs those who continued with
to change the tube-feeding formula. The review continued physician orders
until 50 charts on which recommendations made by the RD Physician
RD were accepted and 50 charts on which the physician’s Recommendations Orders
tube-feeding orders were continued were obtained. Accepted Continued
Number Cruncher Statistical Software (2002, NCSS,
version II, Hintze, Kaysville, UT) was used for statistical Characteristics No. % No. %
analysis of data. Means and percentages were used to
Sex
describe the average number of kilocalories and grams of
Male 25 50 25 50
protein recommended by the RD and those ordered by the
Female 25 50 25 50
physician. Differences in kilocalories and protein ordered
Age (y)
by the physician and recommended by the RD were cal-
18-30 1 2 1 2
culated and expressed as a percentage of estimated re-
31-60 4 8 3 6
quirements. t tests were used to assess differences in
61-85 45 90 46 92
percent change from initial body weight, change from
Type of tube feeding
initial albumin, and length of stay between subjects who
NGa 2 4 1 2
had RD recommendations implemented and those who
PEGb 47 94 49 98
continued with physician orders.
PEJc 1 2 0 0
RESULTS a
NG⫽nasogastric tube.
b
A total of 272 charts documenting care of patients on PEG⫽percutaneous endoscopic gastrostomy.
c
PEJ⫽percutaneous endoscopic jejunostomy.
enteral tube feeding were reviewed. In all cases, the phy-
sician wrote the initial order for tube-feeding formulas
and rate. Based on an assessment of nutrition needs, the
RDs agreed with 21 (8%) of the initial physician orders for DISCUSSION
enteral nutrition. For the remaining 251 (92%) patients, In this study, RDs disagreed with the majority of the
the RDs recommended changes in the physician’s orders. physicians’ orders for enteral feeding. Physicians tended
However, physicians implemented the recommendations to order formulas that provided less energy and protein
made by the RD in only 106 (42%) of the cases. Of the 251 than that calculated by the RD. While RDs did make
patients for whom RDs made recommendations for recommendations to increase the formulas, the physi-
change, 100 met the study criteria. cians, in most cases, did not implement them.
The final analysis included 100 enterally fed patients Skipper and colleagues (12) conducted a study to deter-
with malnutrition for whom RDs made recommendations mine how often RDs’ recommendations were imple-
for changes in formula. Patients were divided into two mented by physicians and found that of 865 recommen-
groups, 50 for whom the RD’s recommendation for change dations, 42% were implemented. Significantly higher
was accepted and 50 for whom the physician did not rates were recorded for recommendations discussed with
implement the RD’s recommendation but continued with the physician (65%). The authors concluded that recom-
the original diet order. There were no significant differ- mendations by RDs are overlooked and that physicians do
ences in age, sex, or type of tube feeding between the two not respond to RD recommendations unless RDs take it
groups. Most patients were between the ages of 61 and 85 upon themselves to contact the physician directly.
years (91%). Mean age was 73.7⫾10 years in the group Results of the current study showed that patients
with RD recommendations implemented and 74.7⫾11 whose RD recommendations were followed had signifi-
years in the group with physicians’ orders continued. cantly higher albumin levels and weight gains, as well as
Percutaneous endoscopic gastrostomy tube feedings were a significantly shorter length of stay, compared to those
used in the majority of cases in both groups (Table 1). who continued with physician’s orders. Previous research
There were no significant differences in the average has shown that malnutrition leads to longer lengths of
composition of tube feedings in patients for whom RDs’ stay and, inevitably, higher hospital costs (4,13), and that
recommendations were followed and patients for whom implementing early, high-quality medical nutrition ther-
physicians’ orders were continued. Physicians’ formula- apy can reduce length of stay (3,6). Marinella and Mark-
tions provided approximately 11.5% less energy and 7.8% ert (14) reported that serum albumin ⬍3.4 g/dL (⬍34.0
less protein than recommended by the RD. RDs recom- g/L) was a reliable predictor of prolonged hospital stay
mended slightly more energy and protein than calculated and death in patients 60 years of age or older. Brugler
during the assessment due to “rounding up.” Length of and colleagues (15) reported that patients with low albu-
stay for patients whose RD recommendations were fol- min levels experienced poorer health outcomes and
lowed was significantly shorter than those for whom phy- higher costs of care. These patients also required signif-
sician orders were continued (28.5⫾1.8 vs 30.5⫾4.8 days, icantly more after-discharge care. Weddle and colleagues
P⬍.05). When RD recommendations were taken, patients (16) reported that patients were four times more likely to
also had significantly higher levels of albumin and weight achieve their recommended energy intake and maintain/
gain compared to patients who continued on the physi- increase visceral protein if an RD’s recommendations
cian’s original orders (Table 2). were taken.

282 February 2006 Volume 106 Number 2

 Table 2. Differences in calorie and protein provided in tube feedings, length of stay, weight, and albumin between enterally fed patients in a
long-term acute-care facility in northwest Louisiana with registered dietitian (RD) recommendations taken vs those with physician orders
continued
RD recommendation accepted
Variable (nⴝ50)
Energy (kcal)a 1,877.0⫾241
Difference from assessed (%) ⫹4.7
Protein (g)a 84.0⫾0.13
Difference from assessed (%) ⫹3.15
Length of stay (days)a 28.5⫾1.8
Weight change (%)a 0.51⫾0.1
Albumin change (g/dL)b 0.13⫾0.17
a
Values are mean⫾standard deviation.
b
To convert g/dL to g/L, multiply by 10.
*P⬍0.05.
RDs have education and training in assessing the nu-
tritional needs of critically ill patients, and they have the
knowledge and skills to provide enteral feedings that
meet the patients’ needs (17). In some institutions, phy-
sicians have granted individual RDs permission to write
diet orders for their patients. These instances are, for the
most part, not official hospital policies and are not a
standard occurrence.
Recently, some health care institutions have advanced
the RD’s role in writing diet orders. At the University of
Massachusetts Medical Center, RDs are allowed to write
orders for diets, oral and parenteral nutrient supplemen-
tation, custom-mix parenteral feedings, tube feedings,
blood glucose monitoring, and home-care orders (paren-
teral and enteral). RDs also order laboratory tests such as
chemistries, indirect calorimetry, and bone densitometry
(18). In 1995, the Toronto Rehabilitation Institute, in
Toronto, Canada, recognizing that RDs are the experts in
nutrition, authorized RDs to write diet and tube-feeding
orders and change existing physician orders without a
physician’s cosignature (19).
The Clinical Privileges for Dietitian Nutrition Order
Writing program has been implemented at a number of
long-term acute-care hospitals. The Clinical Privileges for
Dietitian Nutrition Order Writing program was designed
to identify specific nutrition-care directives that RDs can
order. Moreland and colleagues (10) tested the effective-
ness of this program. They found that 75% of the patients
had improved nutritional status during the course of
hospitalization compared to 55% before the program was
implemented. The Clinical Privileges for Dietitian Nutri-
tion Order Writing program grants RDs a 3-month pro-
bation period in which they are allowed full privileges for
writing diet orders. The medical director monitors and
reviews patient records and determines whether the RD
is allowed full status. Once this status is granted, RDs
are evaluated annually.
The current study has documented an improvement in
outcomes when RDs’ recommendations are followed.
These data suggest that RDs’ recommendations for
changes in formula and prompt nutrition intervention
can improve patient care. There is a need to document RD
effectiveness and establish a more comprehensive role for
RDs in determining tube-feeding formulas.
Physician orders continued
(nⴝ50)
1,586.0⫾329
⫺11.5
65.0⫾15
⫺7.8
30.5⫾4.8*
⫺0.42⫾0.2*
⫺0.44⫾0.21*
CONCLUSIONS
Enteral recommendations by RDs may have resulted in 1.5
fewer days in hospital and improved albumin. In order to
provide optimal nutrition care for enteral-fed patients, RDs
should:
● make sure physicians become aware of inadequacies in
enteral feedings and provide research and other docu-
mentation that support the benefits of appropriate en-
teral feeding;
● work with hospital administration and physicians to
determine why physicians do not accept RD recommen-
dations and establish policies that ensure patients re-
ceive optimal nutrition during enteral feeding; and
● conduct additional outcomes-based research to justify a
change in policy to give RDs more responsibility in
establishing tube-feeding formulas.
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