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Clinical Nutrition Authority to Write Diet and Nourishment Orders - Adult/Pediatric - Inpatient [54]

Clinical Nutrition Authority to Write Diet and Nourishment Orders - Adult/Pediatric - Inpatient [54] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols



Delegation Protocol Number: 54

Delegation Protocol Title:
Clinical Nutrition Authority to Write Diet & Nourishment Orders - Adult/Pediatric - Inpatient

Delegation Protocol Applies To:
UW Health at University Hospital, American Family Children’s Hospital (AFCH) and The American Center (TAC)

Target Patient Population:
American Family Children’s Hospital (AFCH) Inpatients
University Hospital and The American Center (TAC) Inpatients

Delegation Protocol Champions:
Bart Caponi, MD – Department of Medicine - Hospitalist
Daniel Sklansky, MD – Department of Pediatrics – Pediatric Hospitalist

Delegation Protocol Reviewers:
Robin Crist, RDN – Clinical Nutrition
Cassandra Kight, RDN – Clinical Nutrition
Emily Wallace, RDN – Clinical Nutrition

Responsible Department:
Clinical Nutrition

Purpose Statement:
The purpose of this protocol is to delegate authority from the ordering provider to Registered Dietitian
Nutritionists (RDNs) to enter, modify, and clarify diet orders and to order nutritional supplements

Who May Carry Out This Delegation Protocol:
Registered Dietitian Nutritionists (RDNs) who are trained in the use of this delegation protocol.

Guidelines for Implementation:
1. The ordering provider will determine that a patient may have an oral diet.
2. The provider will order “Consult Nutrition (Inpatient)” and choose the “Delegate to Manage
Diet/Supplements” as the delegation privilege.
3. The activated protocol delegates authority to the RDN to
3.1. Clarify contradictory diet orders
3.2. Modify existing diet order to better meet the patient’s macro- and/or micro nutrient needs
3.3. Modify existing diet order to align with evidence-based practice
3.4. Order nourishments or supplements from the approved UW Health formularies and nourishment list.
4. RDN assesses patient and determines the appropriate diet order based on patient’s reason for admission,
prior medical/surgical history, medications, current clinical status including appetite and tolerance of diet,
and weight/nutritional status, as pertinent.
5. For pediatric patients, when possible based on census and time of day, RDN will
5.1. Ask pediatric resident for his/her nutrition plan
5.2. Change that plan based on the RDN’s expertise
5.3. Explain the rationale for those changes
6. Documentation: RDN enters diet order into Health Link. RDN places progress note in Health Link
indicating enactment of protocol, diet order selected, indication(s), patient response, if any,
recommendation for follow-up care, and education provided or needed, if any.
7. If diet is to be held for diagnostic testing or procedure(s), the ordering provider is responsible for
ordering “Hold diet for procedure” and indicating length of hold.
8. At any time during protocol implementation, ordering provider may make the patient NPO or
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


otherwise change the diet order in response to changes in the patient’s condition.
9. Additional Guidance
9.1. Diets – the RDN may:
9.1.1. Change a diet consistency to a more restrictive order when indicated based on patient tolerance
or patient /family request, e.g., from regular to mechanical soft due to poor dentition.
9.1.2. Modify the diet order to reflect appropriate therapeutic diets for nutrient modifications, food
allergies or intolerances, and/or religious and/or animal food exclusion modifications.
9.1.3. Modify or liberalize diet restriction to increase the patient’s oral intake (after discussion with
ordering provider); if the patient or family requests change or patient is not tolerating current diet,
i.e., change from cardiac to regular.
9.1.4. Order a more restrictive diet when warranted for clinical condition, i.e., from general to
diabetes meal plan.
9.1.5. Clarify diet order to reflect evidence based recommendations appropriate to patient’s clinical
status as referenced in the Academy of Nutrition and Dietetics Adult or Pediatric Nutritional Care
Manuals.
9.2. Nourishments/Supplements:
9.2.1. The RDN may order supplements or nourishments at the time of the initial assessment
or reassessment when:
• Oral intake prior to admission is judged to be inadequate based on diet history
• Oral intake during admission is judged to be inadequate based on
documented percent of meals eaten or calorie counts
• Patient or family requests supplementation
• The patient’s clinical condition warrants additional protein and/or calories
9.2.2. The RDN may discontinue provider ordered nutritional supplements upon the request of the
patient or family or if the patient refuses to consume supplements. The RDN will suggest
intake of non-formulary products that may result in better acceptance.
9.2.3. The RDN may change the existing supplement order if:
• The supplement fails to meet the identified nutritional need
• The patient or family request an alternative product
• The patient’s condition changes, and the existing supplement is no longer appropriate, e.g., the
patient needs a lower volume product or a lower potassium product
10. The RDN may place orders for vitamins and minerals as warranted by the patient’s condition, laboratory values, or to
correct any deficiencies inherent in the diet restrictions. The medication form listed is Tables 1 and 2 is tablet, unless
otherwise specified.
11. The RDN may place orders for protein supplementation (e.g. Beneprotein, ProSource) to meet estimated protein
needs of patient.

Order Mode: Protocol/Policy, Without Cosign

References:
Academy of Nutrition and Dietetics. Nutrition Care Manual: https://uconnect.wisc.edu/depts/uwhc/clinical-nutrition-
services/.
Academy of Nutrition and Dietetics: 2016 Nutrition Care Manual https://www.nutritioncaremanual.org/

Collateral Tools: NA

Approved By:
UWHC Nutrition Committee: May 2011, July 2014; *February 2017
UWHC Medical Board: May 2011, August 2014; *March 2017

Effective: March 2017

Scheduled for Review: March 2020
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org



*Expedited Review Process

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


Table 1: Oral Vitamin/Mineral Repletion for Adult Patients on Delegation Protocol

Vitamin Adult Dose, Route, Frequency Clinical Condition
Ascorbic Acid
500 mg twice daily x 10 days • Non-healing wound or
pressure ulcer
Cholecalciferol
Dietary Reference Intake for Vitamin D: Oral
Adults 19 to 70 years: Recommended Daily
Allowance (RDA): 600 units/day (IOM 2011)
Female: Pregnancy/Lactating: RDA: 600
units/day (IOM 2011). Adults >70 years: RDA:
800 units/day (IOM 2011).
Vitamin D deficiency prevention: Oral 1,500 to
2,000 units daily to maintain serum 25(OH)D
levels >30 ng/mL (Holick 2011), or other dose
as patient was on at home.
Vitamin D deficiency treatment: Oral 6,000
units daily (or 50,000 units ergocalciferol once
weekly) for 8 weeks to achieve serum 25(OH)D
level >30 ng/mL, followed by maintenance dose
of 1,500 to 2,000 units daily (Holick 2011).
• To meet Recommended
Dietary Allowances with
inadequate intake or
exposure to sunlight
• Documented Vitamin D
deficiency
• Continuation of Vitamin D
supplementation patient
received at home for
underlying medical
condition (e.g. osteopenia)
Cystic Fibrosis specific
multivitamin ( softgels and
liquids) and Vitamin D
2 capsules of soft-gels
• Cystic Fibrosis (CF)

Folic acid 1 mg once daily
• Low serum folate
• Heavy alcohol use
• Pregnancy
• Pregnancy in CF (in addition
to CF multivitamins)
• Chronic Kidney Disease
(CKD)
• RRT not on Renal
Multivitamin with higher
amount of folic acid
Multivitamin with minerals


1 tablet once daily


• Recommended diet fails to
provide 100% of RDI for one
or more vitamins or
minerals
• Increased needs (e.g. burn,
wound healing)
• Prior inadequate
micronutrient intake
• Heavy alcohol intake
• Medications which interfere
with metabolism of one or
more vitamins (phenytoin,
phenobarbital,
sulfasalazine)
Pyridoxine 25 mg tablet once daily
• CKD
• Acute Kidney Injury (AKI)
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


with Continuous Renal
Replacement Therapy
(CRRT)
• Documented deficiency
Renal Multivitamin 1 tablet once daily
• CKD, AKI
• Patient on RRT
Thiamine 100 mg tablet once daily
• Risk of refeeding syndrome
• Heavy alcohol intake
• Documented deficiency
• AKI with CRRT
Vitamin A 15,000 units tablet once daily x 10 days
Continue usual home regimen dose for CF
patients
• Non-healing wound or
pressure ulcer
• Documented deficiency
• Continuation of home
regimen for CF
Vitamin E 400 – 800 units once daily
• Continuation of home
regimen for CF
Zinc 50 mg tablet once daily x 10 days
• Non-healing wound or
pressure ulcer
• Documented deficiency


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


Table 2: Oral Vitamin/Mineral Repletion for Pediatric Patients on Delegation Protocol

Vitamin Pediatric Dose, Route, Frequency Clinical Condition
Cholecalciferol
Recommended Daily Allowance (RDA): Infant:
400 units/day. Children and Adolescents: 600
units/day (IOM 2011)
Vitamin D deficiency, prevention: (Wagner 2008):
Breast-fed infants (fully or partially): 400 units/day
beginning in the first few days of life. Continue
supplementation until infant is weaned to ≥1,000
mL/day or 1 qt/day of vitamin D-fortified formula
or whole milk (after 12 months of age)
Formula-fed infants ingesting <1,000 mL of
vitamin D-fortified formula: 400 units/day. Infants
ingesting >500 mL formula: 200 units/day.
Children and Adolescents without adequate
intake: 600 units/day to meet the RDA.
Vitamin D deficiency treatment: Note: In addition
to calcium and phosphorus supplementation
(Holick 2011; Golden 2014): Infants: Oral: 1,000
(mild to moderate deficiency) to 2,000 units daily
to achieve a serum 25(OH)D level within normal
limits; followed by a maintenance dose of 400 to
1,000 units daily.
Children and Adolescents: 2,000 units daily to
achieve serum 25(OH)D level within normal range;
followed by a maintenance dose of 600 to 1,000
units daily.
If treating a deficiency, measure 25(OH)D level at
3-month intervals until normal concentrations
have been achieved.
• To meet RDA for infants
receiving human milk or
infant formulas, children
and adolescents with
inadequate intake or
exposure to sun, those
with dark skin
pigmentation, or those
with dietary fat
malabsorption
• Documented Vitamin D
deficiency
• Continuation of Vitamin D
supplementation patient
received at home for
underlying medical
condition (e.g.
osteopenia)

Cystic Fibrosis specific
multivitamin (drops,
chewables, softgels) and
Vitamin D
Consult Pulmonology Service for dosing of
multivitamins for children with CF. The dose is
specific to the age of the patient and the brand of
the vitamin.

Vitamin D supplementation for children with CF.
Consult with Pulmonary Team.
• Cystic Fibrosis (CF)

Iron Infants: Breastfed term infants beginning at 4
months until consuming appropriate iron-
containing complementary foods: 1 mg/kg/day

For infants and children with proven or suspected
iron-deficiency anemia (IDA), Up-to-date®
suggests Oral/Enteral supplementation with 3 to
6 mg/kg/day of elemental iron, depending on the
severity of IDA.

• Premature infants need 2
to 4 mg/kg/day
• Infants born at term have
sufficient stores until 4-6
months of age
• Full-term, formula-fed
infants do not need
additional iron
• Screening recommended
beginning 12 months of
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


age
Multivitamin +/- minerals
(drops, chewables,
gummy)
Infants: Polyvitamin drops +/- iron, 1mL
Toddlers 2-3 yrs: ½ tablet or 1 gummy
Children 4 yrs and older: 1 tablet or 2 gummies

• Recommended EN
regimen fails to provide
100% of Reference Daily
Intake (RDI) for one or
more vitamins
• Increased needs (burns,
wound healing)
• Medications which
interfere with metabolism
of one or more vitamins
(e.g. phenytoin,
phenobarbital,
sulfasalazine).

Renal Multivitamin Need and dosing is patient specific. Consult
Pediatric Nephrology Team.
• Inadequate EN and RRT
Selenium Dosing to be determined individually for each
patient in coordination with primary service
• Long-term parenteral
nutrition without source
of selenium (e.g.
shortages)
• HIV disease progression
• Bariatric surgery or severe
gastrointestinal
dysfunction
Thiamine Severe deficiency should be initially addressed
with IV thiamine.
Children: 10-50 mg/dose every day for 2 weeks,
then 5-10 mg/dose daily for 1 month
• Suspected thiamine
deficiency due to severely
restricted diet (anorexia,
food faddism)
• Alcohol abuse in a child or
adolescent
Zinc Dosing to be determined individually for each
patient in coordination with primary service
• Malnutrition
• Severe or persistent
diarrhea
• Malabsorption syndromes
including celiac disease,
cystic fibrosis, and short
bowel syndrome
• Inflammatory bowel
disease (Crohn’s,
ulcerative colitis)
• Sickle cell anemia



Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org