Introduction The Allied Health Professionals prescribing and medicines supply mechanisms scoping project report identified an evidence base for extending prescribing rights to dietitians based on improved patient safety and experience, effectiveness and value and clear clinical responsibility.1Currently at our Trust the dietitian completes the nutritional assessment and calculates requirements for patients requiring parenteral nutrition (PN) and then a doctor signs the prescription. This means that the doctor is taking legal responsibility for another healthcare professional’s assessment which has implications for patient safety. The aim of this audit was to identify who completed the nutritional assessment, calculated requirements and decided on the composition of the PN prescription and formulation and who signed the legal prescription.
Method This was a point prevalence audit at a tertiary referral centre for intestinal failure. All patients receiving PN were included and a questionnaire regarding the healthcare professionals involved in the assessment and the decision regarding the prescription of the PN was completed.
Results Twenty-seven patients were on PN on the day of the audit. Ten patients were on a surgical ward and 17 were on a medical ward. The initial nutritional assessment and calculation of requirements was completed by a dietitian in 100% of cases. Nine patients (33%) were considered at risk of refeeding syndrome but none developed refeeding. In 89% of cases (n = 24) the legal prescription was signed by a junior doctor. Of these 24 patients the doctor was directly involved in the patients nutritional care in only 7 cases (29%). Over the previous 7 days amendments to the PN were made by the dietitian alone (n = 14), the dietitian and doctor (n = 4), the dietitian and pharmacist (n = 2). Nineteen patients were also receiving oral diet, 2 were on trophic enteral nutrition and 6 were nil by mouth.
Conclusion This audit has shown that at this tertiary referral centre the dietitian is responsible for completing the nutritional assessment and calculating requirements for patients requiring PN including the prevention of refeeding syndrome. Ongoing monitoring of the patient occurs in conjunction with other members of the nutrition team. Previous work showed a dietitian and pharmacist working together are safe to prescribe and manage PN.2Supplementary prescribing would enable dietitians to work in conjunction with pharmacists to take clinical and legal responsibility for the PN they are recommending instead of asking junior doctors to take on responsibility for their clinical decisions. This is likely to save doctors time and improve patient safety.
Disclosure of interest None Declared.
Marks D. Allied Health Professionals prescribing and medicines supply mechanisms scoping project report. Department of Health, 2009
Farrer K et al. Pharm J 2008;280:626