The activities of a dietitian-led gastroenterology clinic using extended scope of practice

Dietitian-led micronutrient management in a public bariatric surgery outpatient clinic

AIMS

This study aimed to explore the multidisciplinary team attitudes and knowledge of bariatric surgery micronutrient management (pre- and postoperative care) and to evaluate the implementation of an extended-scope of practice dietitian-led model of care for micronutrient monitoring and management.

METHODS

A mixed method study design included quantitative evaluation of micronutrient testing practices and deficiency rates. Qualitative reflexive thematic analysis was used to interpret multidisciplinary experience with micronutrient monitoring in a traditional and dietitian-led model of care. In addition, deductive analysis used normalisation process theory mapping of multidisciplinary experience with the implementation of the dietitian-led model of care.

RESULTS

In the traditional model, a lack of quality evidence to guide micronutrient management, and a tension in trust between surgeons and patients related to adherence to micronutrient prescriptions were described as challenges in current practice. The dietitian-led model was seen to overcome some of these challenges, increasing collaborative, and coordinated, consistent and personalised patient care that led to increased testing for and detection of micronutrient deficiencies. Barriers to sustainability of the dietitian-led model included a lack of workforce succession planning, and no clearly defined delegation for some aspects of care.

CONCLUSION

An extended scope dietitian-led model of care for micronutrient management after bariatric surgery improves clinical care. Challenges such as succession planning must be considered in design of extended scope services.

Management advice for patients with reflux-like symptoms: an evidence-based consensus

Patients with reflux-like symptoms (heartburn and regurgitation) are often not well advised on implementing individualised strategies to help control their symptoms using dietary changes, lifestyle modifications, behavioural changes or fast-acting rescue therapies. One reason for this may be the lack of emphasis in management guidelines owing to 'low-quality' evidence and a paucity of interventional studies. Thus, a panel of 11 gastroenterologists and primary care doctors used the Delphi method to develop consolidated advice for patients based on expert consensus. A steering committee selected topics for literature searches using the PubMed database, and a modified Delphi process including two online meetings and two rounds of voting was conducted to generate consensus statements based on prespecified criteria (67% voting 'strongly agree' or 'agree with minor reservation'). After expert discussion and two rounds of voting, 21 consensus statements were generated, and assigned strength of evidence and Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) rating. Eleven statements achieved the strongest (100%) agreement: five are related to diet and include identification and avoidance of dietary triggers, limiting alcohol, coffee and carbonated beverages, and advising patients troubled by postprandial symptoms not to overeat; the remaining six statements concern advice around smoking cessation, weight loss, raising the head-of-the-bed, avoiding recumbency after meals, stress reduction and alginate use. The aim of developing the consensus statements is that they may serve as a foundation for tools and advice that can routinely help patients with reflux-like symptoms better understand the causes of their symptoms and manage their individual risk factors and triggers.

How to Implement the 3-Phase FODMAP Diet Into Gastroenterological Practice

Background/Aims

The 3-phase fermentable oligo-, di-, mono-saccharides, and polyols (FODMAP) diet has shown a high level of efficacy in irritable bowel syndrome, largely based on dietitian delivered education. However, access to dietitians can be limited, and challenges exist when applying the diet to a wide range of cultures, such as limited FODMAP analysis of local foods. This review aims to discuss ways to optimally use the FODMAP diet in practice in a wide range of cultures, directed at gastroenterologists from a dietitian's perspective.

Methods

Recent literature was analysed via search databases including Medline, CINAHL, PubMed and Scopus.

Results

The dietetic process involves detailed assessment and follow-up through the 3 stages of the FODMAP diet (restriction, re-introduction, and long-term maintenance). Emerging evidence suggests the diet can be delivered by other health professionals such as the gastroenterologist or nurse, but training on how to do so successfully would be needed. Self-guided approaches through use of technology or specialised food delivery services may be an alternative when dietitians are not available, but efficacy data is limited. Regardless of delivery mode, nutritional and psychological risks of the diet must be mitigated. Additionally, culturally appropriate education must be provided, with accommodations necessary when the FODMAP content of local foods are unknown.

Conclusion

While the diet has shown improved irritable bowel syndrome outcomes across studies, it is important to acknowledge the essential role of dietitians in implementing, tailoring, and managing the diet to achieve the best outcome for each individual.

Outcomes from an extended scope of practice speech-language pathology service for low risk ENT outpatients: A 5-year service review

Purpose: Early evidence supports the safety and efficiency of extended scope speech-language pathology (SLP) clinics designed to manage low risk ear nose and throat (ENT) outpatient referrals, however long-term data is lacking. The aim of this study was to complete a 5-year audit of clinical outcomes, including rates of re-referral, for a SLP Allied Health Practitioner (SLP AHP) led dysphagia and dysphonia service within an Integrated Specialist ENT Service.Method: A retrospective audit was undertaken of all patients referred with non-urgent dysphonia and/or dysphagia symptoms over a 5-year period since establishment of the SLP AHP service. Clinical outcomes, rates and reasons for re-referral to the specialist ENT waiting list were investigated.Result: Of 616 patient referrals, 462 patients were seen by the SLP AHP service. Most (72%, n = 333) received all required management through the clinical model, with only 28% (n = 129) requiring additional ENT intervention, consistent with previously published data. Only 36 of the 616 (6%) were re-referred/re-presented within 12 months of first presentation, of which only 12 were referred for same condition as initial referral. No adverse outcomes were recorded on the clinical database during this 5-year period.Conclusion: Results provide further evidence that the SLP AHP service is a safe and efficient method for managing low risk ENT outpatient referrals.

Trends, challenges, opportunities, and future needs of the dietetic workforce: a systematic scoping review

CONTEXT

Issues related to nutrition and health are prominent, yet it is unclear if the dietetics workforce is being used optimally.

OBJECTIVE

Trends, challenges, opportunities, and future needs of the international dietetic workforce are investigated in this review, which was registered with Open Science Framework (10.17605/OSF.IO/DXNWE).

DATA SOURCES

Eight academic and 5 grey-literature databases and the Google search engine were searched from 2010 onward according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Of 2050 articles screened, 184 were eligible for inclusion.

DATA EXTRACTION

To chart data, a directed content analysis and a constant comparison technique were used.

DATA ANALYSIS

The following 13 themes were identified: 1) emerging or expanding areas of practice; 2) skill development; 3) economic considerations; 4) nutrition informatics; 5) diversity within the workforce; 6) specific areas of practice; 7) further education; 8) intrapersonal factors; 9) perceptions of the profession; 10) protecting the scope of practice; 11) support systems; 12) employment outcomes; and 13) registration or credentialing.

CONCLUSIONS

The dietetics profession is aware of the need to expand into diverse areas of employment. Comprehensive workforce data are necessary to facilitate workforce planning.

Behavioral and Diet Therapies in Integrated Care for Patients With Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a common, symptom-based condition that has negative effects on quality of life and costs health care systems billions of dollars each year. Until recently, management of IBS has focused on over-the-counter and prescription medications that reduce symptoms in fewer than one-half of patients. Patients have increasingly sought natural solutions for their IBS symptoms. However, behavioral techniques and dietary modifications can be effective in treatment of IBS. Behavioral interventions include gastrointestinal-focused cognitive behavioral therapy and gut-directed hypnotherapy to modify interactions between the gut and the brain. In this pathway, benign sensations from the gut induce maladaptive cognitive or affective processes that amplify symptom perception. Symptoms occur in response to cognitive and affective factors that trigger fear of symptoms or lack of acceptance of disease, or from stressors in the external environment. Among the many dietary interventions used to treat patients with IBS, a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols is the most commonly recommended by health care providers and has the most evidence for efficacy. Patient with IBS who choose to follow a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols should be aware of its 3 phases: restriction, reintroduction, and personalization. Management of IBS should include an integrated care model in which behavioral interventions, dietary modification, and medications are considered as equal partners. This approach offers the greatest likelihood for success in management of patients with IBS.

Health service usage and re-referral rates: comparison of a dietitian-first clinic with a medical specialist-first model of care in a cohort of gastroenterology patients

BACKGROUND

The dietitian-first gastroenterology clinic (DFGC) is an expanded scope of practice initiative implemented in response to increased gastroenterology specialist demand. This study examined re-referral rates to gastroenterology and overall health service usage up to 24 months post management in DFGC compared with a traditional, gastroenterology specialist-first model.

METHODS

Patients discharged from DFGC in the first year were matched with those seen in the traditional model. Demographic, clinical and process-related service characteristics were compared, and logistic regression analysis was undertaken to model re-presentation and model of care (MoC) as the variable of interest considering covariates in univariate analyses. Analyses were performed at 12, 18 and 24 months post discharge.

RESULTS

The DFGC (122 patients) and traditional-model (62 patients) cohorts had similar baseline demographic characteristics. Wait-times (68.6 vs 272.9 days; p<0.001), treatment-times (89.4 vs 259.9 days; p<0.001) and usage of other services (1.4 vs 2.1 specialities; p=0.01) were lower in DFGC. Re-referral rates were low in both DFGC and traditional models at 12 months (0.82% vs 1.61%), 18 months (2.46% vs 6.45%) and 24 months (4.91% vs 8.06%), respectively, with no significant difference between the models at any time point.

CONCLUSION

Most patients do not re-present for similar conditions within 2 years when managed in the DFGC or traditional medical model. Patients managed in DFGC have lower overall health service usage compared with patients managed in the traditional model. These findings support the safety and effectiveness of a DFGC model as one strategy to manage specialist gastroenterology service demands.

Dietitian first gastroenterology clinic: an initiative to reduce wait lists and wait times for gastroenterology outpatients in a tertiary hospital service

OBJECTIVE

The demand for outpatient gastroenterology medical specialist consultations is above what can be met within budgetary and staffing constraints. This study describes the establishment of a dietitian first gastroenterology clinic to address this issue, the patient journey and its impact on wait lists and wait times in a tertiary gastroenterology service.

DESIGN

A dietitian first gastroenterology clinic model was developed and a mixed-methods approach used to evaluate the impact of the service over a 21-month period.

SETTING

Gold Coast University Hospital, Queensland, Australia (a public tertiary hospital).

PATIENTS

658 patients were triaged to the clinic between June 2016 and March 2018.

INTERVENTION

A dietitian first gastroenterology clinic for low-risk gastroenterology patients.

MAIN OUTCOME MEASURES

We examined demographic, referral, wait list, wait time and service activity data, patient satisfaction and patient journey.

RESULTS

At the time of audit, 399 new (67.9% female) and 307 review patients had been seen. Wait times for eligible patients reduced from 280 to 66 days and the percentage of those in breach of their recommended wait times reduced from 95% to zero. The average time from referral to discharge was 117.8 days with an average of 2.4 occasions of service. 277 patients (69.4%) had been discharged to the care of their general practitioner and 43 patients (10.7%) had an expedited specialist medical review. Patient surveys indicated a high level of satisfaction.

CONCLUSION

A dietitian first gastroenterology model of care helps improve patient flow, reduces wait times and may be useful elsewhere to address outpatient gastroenterology service pressures.

Dietary management of celiac disease: Revisiting the guidelines

OBJECTIVE

Medical nutrition therapy (MNT), by lifelong compliance with a gluten-free diet, is likely the only treatment for celiac disease (CD). Clinical practice guidelines (CPGs) regarding the management of CD emphasize the role of MNT over other treatment options. The aim of the present study was to review and critically appraise CD-specific MNT CPGs and identify areas in need of improvement for better adherence and outcomes.

METHODS

A comprehensive search was performed using PubMed, Guidelines International Network (GIN), Google Scholar, gray literature, and websites of CD scientific organizations for CPGs, consensus and practice papers on the dietary management of CD, published in the English language.

RESULTS

A total of 12 CPGs were retrieved and critically appraised by three independent reviewers using the Appraisal of Guidelines Research & Evaluation (AGREE) II instrument. All CPGs were of low quality based on AGREE II. Among the 12 CPGs, the National Institute for Health and Care Excellence guidelines achieved the highest score and were unanimously recommended without modifications by the three reviewers, whereas the American Gastroenterology Association, Alberta Health Services, British Society of Paediatric Gastroenterology, Hepatology and Nutrition, Clinical Resource Efficiency Support Team, and Federation of International Societies of Pediatric Gastroenterology, Hepatology and Nutrition guidelines received the lowest scores.

CONCLUSIONS

The present study reveals the low quality of guidelines regarding the MNT of CD patients, indicating the need for updated and improved guidelines taking into consideration the proposed items of AGREE II.

Dietitian visits were a safe and cost-effective form of follow-up care for children with celiac disease

AIM

This study compared follow-up protocols for paediatric celiac disease (CD) led by either paediatricians or dietitians at Swedish university hospitals.

METHODS

We followed 363 CD patients under 18 years at the university hospitals in Malmö (n = 140) and Lund (n = 79) between 2011 and 2013 and after they merged to become Skåne (n = 144) between 2014 and 2016. Both Lund and Malmö provided regular paediatrician follow-up visits, whereas Skåne provided mainly dietitian-led visits.

RESULTS

Children at Lund were followed for a mean of 1.0 ± 0.5 visits per year, compared to 0.7 ± 0.6 at Malmö (p < 0.0001) and 0.9 ± 0.6 at Skåne (p = 0.11). The ratio of annual paediatrician to dietitian annual visits was 1.4:1.0 at Lund, which was higher than Malmö (0.9:1.0; p = 0.0017) and Skåne (0.6:1.0; p < 0.0001). There was no difference in the prevalence of non-compliant patients between the clinics (p = 0.26, Malmö 13.6%, Lund 10.1%, Skåne 7.6%). Tissue transglutaminase autoantibody levels reversed equally over time at all three clinics after the subjects started a gluten-free diet (r = -0.55, p < 0.0001). The total mean annual cost per patient was lowest at Malmö and highest at Lund (p < 0.0001).

CONCLUSION

Dietary compliance was similar regardless of whether care was provided by a dietitian or paediatrician. Dietitian-led follow-up visits may provide lower long-term costs.

Introducing novel advanced practice roles into the health workforce: Dietitians leading in gastrostomy management

AIM

The number of advanced practice roles in the Australian health-care system is growing alongside contemporary health-care reforms. The present study aimed to evaluate the impact of introducing novel advanced practice dietitian roles in gastrostomy tube (g-tube) management and develop a competency framework for progressing opportunities in dietetics practice and policy.

METHODS

A questionnaire was distributed to service lead dietitians at six participating health-care networks at the completion of a dedicated advanced practice funding grant, and at 12-month follow up. Service changes (e.g. number of dietitians credentialed, service and adverse events, change in patient waiting times and staff satisfaction), enablers and barriers for the implementation of the novel roles (including pre-, during, and post-implementation), and clinical costing estimates to measure the financial impact on the health system were investigated. Participant feedback was also used to synthesise the development of an advanced scope of practice pathway to competency.

RESULTS

Responses were received from all participating health-care networks. Five out of six sites successfully implemented an advanced practice role in g-tube management, with conservative health system savings estimated at $185 000. Ten dietitians were credentialed, with a further seven trainees in progress. Over 200 service events were recorded, including those diverted from other health professionals. Enabling factors for successful introduction included strong executive and stakeholder support, resources provided by grant funding, and established credentialing governance committees. Barriers included recruitment and governance processes.

CONCLUSIONS

Opportunities exist for further expansion of advanced and extended practice roles for dietitians to meet future health-care demands.

Dietitians' opinions regarding refeeding syndrome, clinical guidelines and extended scope of practice

AIM

Refeeding syndrome (RFS) prevalence rates vary across studies depending on the criteria used for assessment and identification. For registered dietitians, the assessment and management of RFS is highly reliant on daily serum electrolyte values; however, registered dietitians working within Australia do not currently possess laboratory test ordering privileges. We aimed to examine the opinions of registered dietitians regarding RFS identification, management and guidelines and the option of using extended scope of practice to order electrolyte monitoring autonomously.

METHODS

A multi-method action research approach was used, incorporating two projects. The first was a survey examining Australian registered dietitians' (n = 187) opinions regarding RFS identification, management and guidelines, and autonomous electrolyte monitoring. To establish if results were similar internationally, an interview was conducted with 22 registered dietitians working within 10 different countries. Data were analysed using chi-square tests and thematic analysis.

RESULTS

Australian registered dietitians (75%) identify patients at risk of RFS at a high rate of more than once per fortnight, with 74% reporting that they have previously worked with a patient diagnosed with RFS. Results varied internationally, with respondents from eight countries reporting that RFS is a problem within acute care versus respondents from five countries having never treated a patient with RFS. The majority (≥89%) of registered dietitians desire new guidelines and the option to order patient electrolyte monitoring autonomously.

CONCLUSIONS

Our findings suggest that more stringent tools for the identification of RFS are necessary. There was limited uniformity across countries, and updated practice guidelines are needed.