An Independent Chapter of the

American Society for Parenteral

and Enteral Nutrition

Volume 21, Issue 4

December 2014

Presidents Column Christie Moulder MS, RDN, CNSC

We had a successful fall conference in Richmond, VA on November 7 th and 8th.
A variety of speakers traveled from near and far to deliver excellent presentations. Many of the talks were dynamic and interactive and I would like to
thank the attendees for their thought provoking questions and comments. I
also want to thank all the exhibitors and sponsors for their support. The board
was delighted to honor, Gisela Barnadas, RD, MS, CNSC with a lifetime achievement award for her contributions to the nutrition support field over the past
30 years.
Planning for the 2015 conference started immediately after the 2014 conference. Based on results from evaluations and taking into consideration ease of
travel for speakers and attendees, the 2015 conference will likely take place in
or near Charlottesville, VA. The board would love to hear from you if you have
ideas for speakers or topics. For those of you traveling to Long Beach, CA for
Clinical Nutrition Week, please keep future VASPEN presentations in mind and
take note of any impressive speakers or hot nutrition support topics.
The results of this years ballot are in and we have filled all vacant board positions as follows:
President-Elect Stacy McCray, RD, University of Virginia Health System
Director of Dietitians Katie Reese, RD, CNSC, University of Virginia Health System
Director of Physicians Bryan Collier, DO, FACS, CNSC, Carilion Roanoke Memorial Hospital
Director of Industry Megan Tingler, RD, Home Solutions
Newsletter Editor Austin Shinall, RD, CNSC, University of Virginia Health System
Watch for additional updates about the 2015 conference in future newsletters.
It has been an honor to serve as President of the VASPEN board. I wish you all
a joyous holiday season.
Christie L Moulder, MS, RD, CNSC

Inside this issue:

Presidents Column

Treasurers Report and

Board Members

Continuing Education
Column

3-5

Update to RDNs Order 6

Writing Privileges
Announcements

Volume 21, Issue 4

Page 2

2014 VASPEN Board of Directors

President

Christie Moulder, MS, RDN, CNSC

President-Elect

Carol Rees Parrish, MS, RD

Past President

Joe Krenitsky, MS, RDN

Secretary

Ellen Sviland, MS, RD, LD, CNSC

Treasurer

Ed Pickett, PharmD, BCNSP

Director of Nurses

Felicia Schaps, RN, CRNI, OCN, CNSC, CQA

Director of Physicians

Bryan Collier, DO, FASC, CNSC

Director of Dietitians

Amy Berry, MS, RD, CNSC

Director of Industry

Megan Tingler, RD, LDN, CNSC

Director of Pharmacy

Bill Peard, RPh, BCNSP

Newsletter Editor

Katie Reese, RD, CNSC

Send us your ideas

and updates!
We welcome new ideas for
newsletter content, job
openings, or current events
for inclusions in the newsletter.

Please send to:

Katie Reese, RD, CNSC
kr8gm@virginia.edu

Trusted Advisor

Laura Johnson, PhD, RD, CNSC

Treasurers Corner
Checking: $4,777.21
Patillo Donald CD: $10,364.07
Total funds: $15,141.28
The Patillo Donald Fund provides funding for the annual
Patillo Donald Memorial Lecture. This fund is held in
perpetuity in memory of Patillo Donald, a UVA researcher and clinician who provided VASPEN with invaluable leadership and support before her untimely
death.
Donations to the fund may be made at:
VASPEN
c/o Ed Pickett, Treasurer
PO Box 1386
Staunton, VA 24402

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CONTINUING EDUCATION SERIES:

Presentation Summaries from Nutrition Support Update 2014

Richmond, Virginia
The following are summaries from three of the sessions presented at VASPEN conference in November

Social Media Savvy: Strategies for the Nutrition Expert

Presented by Beth Wallace Smith, RD, CNSC, LDN
Clinical Dietitian IV, Childrens Hospital of Philadelphia
With her personable demeanor and fascinating subject matter, Beth Smith, RD, LDN, CNSC from
Childrens Hospital of Philadelphia aroused the audience by delivering a memorable presentation about
strategies for using social media for the nutrition expert. Beth first explained the importance of social media as related to nutrition and shared shocking statistics. A survey conducted by the Academy of Nutrition
and Dietetics in 2010 revealed that >99% of participants said they felt as though the food and nutrition
information found on the web is reliable and trustworthy. Beth also made the point that Registered Dietitians need to be the most trusted source of information, thus need training in using social media.
Beth provided a wealth of social media options for RDs to use for disseminating nutrition information. Blogging, microblogging (Twitter), social networking (Facebook), online organizing (Pinterest),
online video channels (YouTube) and photo sharing (Instagram) can all be used as outlets for nutrition information. Methods for creating and establishing a presence on social media was shared and included establishing oneself as a RD, boosting credibility by using a topical name (such as BSmithNutrition, Beths
social media name) and by letting others know where to find ones social media sites. From here, Beth revealed specific strategies to be used for each individual social media outlet.
The importance of using social media was stressed throughout the presentation as well as the support for doing so. Four reasons for RDs to create a blog included the sharing of the RDs wealth of
knowledge, distributing and explaining new research, and the distance that information can be shared
along with potential for income. Support for video blogging was also emphasized as this form of social media can give life to ideas and help readers understand material, create a personal connection by providing
a face to a name and add variety to content within the blog.
Other forms of social media such as Twitter, Facebook and Pinterest were not only explained but
also highlighted as another method for dispersing nutrition information. Beth discussed the benefits to the
audience for using these outlets. By using Twitter, RDs can share information in a succinct and successful
manner, Facebook provides true networking and the opportunity to share more detailed information to
fans and Pinterest enables images of nutrition information to be viewed and shared in an organized fashion.
Beth wrapped up by mentioning simple and easy ways in which all social media information can be
distributed to followers. HootSuite.com allows users to organize the delivery of content for social media
sites by serving as an all-inclusive calendar for integrating social media blasts. Beths delivery of dynamic
information for ways in which RDs can keep up and compete with the explosion of social media usage was
a presentation all guests were glad they woke up for.
Amanda Crane, Dietetic Intern
University of Virginia Health System

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CONTINUING EDUCATION SERIES:

Presentation Summaries from Nutrition Support Update

2014
Short Bowel Syndrome: Overview and Therapeutic Strategies
Presented by Clarivet Torres, MD
Medical Director, Intestinal Rehabilitation Program, Childrens National Medical Center, Washington DC
On the second day of the 2014 Nutrition Support Update conference in Richmond, Virginia, Dr.
Clarivet Torres gave an informative presentation on short bowel syndrome and the Intestinal Rehabilitation
Program (IRP) at Childrens National Medical Center in Washington, DC.
The mission of the IRP is The use of multiple therapies by a comprehensive medical/surgical approach and close follow-up by trained medical staff to promote intestinal adaptation and eventually weaning of patients from parenteral nutrition. The IRP program has a 99% survivability rate for short bowel syndrome (SBS) patients through medical and non-transplant surgical treatment with the goal to avoid bowel
transplantation and decrease mortality if awaiting a transplant.
The primary goals of SBS treatment includes growth and development within the gut, maintenance
of fluid and electrolytes, advancement of enteral feeds with discontinuation of parenteral nutrition, and
prevention of infections. These combined goals aim to provide SBS patients with an optimal quality of life.
Complications of parenteral nutrition including infection, intestinal failure associated liver disease
(IFALD), metabolic complications, anemia and bone disorders were also discussed. The associated link between intravenous fat emulsions contributing to intestinal failure associated liver disease (IFALD) were also
highlighted. Improvement and prevention of IFALD can been seen with timely initiation of enteral feeds,
cycling of parenteral nutrition and decreasing delivered lipid amounts.
The IRP at Childrens National Medical Center works towards their goals by providing baseline parenteral nutrition immediately post-operatively. Once deemed medically feasible, enteral nutrition is started
as a 20 hour per day cycle providing constant stimulation to the gut mucosal, and eventually introducing
oral intake.
Next Dr. Torres discussed research conducted at Childrens National Medical Center that included 80
pediatric patients dependent on parenteral nutrition. Of the 80 participants, 61% presented with hyperbilirubinemia and 22 patients had fibrosis or cirrhosis of the liver. Through adherence to the IRP treatment,
86% were weaned off parenteral nutrition and 10 are in the process of weaning. Dr. Torress research displayed faster reversal of cholestasis for patients using traditional soybean intralipid emulsion than using
Omegaven, an omega-3 lipid solution. Bilirubin was also decreased in these patients, showing those with
advanced liver disease can display improved liver functions with appropriate weaning of parenteral nutrition and avoiding bowel transplantation.
Dr. Torres concluded her presentation with images of patients before enrollment in IRP and after
significant time off of parenteral nutrition. The transformations of her patients were remarkable and are a
testament of the hard work and dedication of Dr. Torres and her colleagues at Childrens National Medical
Centers Intestinal Rehabilitation Program.
Sarah Novelly, Dietetic Intern
University of Virginia Health System

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CONTINUING EDUCATION SERIES:

Presentation Summaries from Nutrition Support Update 2014

Richmond, Virginia
Glucose Control for the Nutrition Support Clinician
Presented by Joseph Krenitsky, MS, RDN
Nutrition Support Specialist, University of Virginia Health System, Charlottesville, Virginia
Those attending the VASPEN conference this fall were very eager to hear from Joe Krenitsky, MS,
RDN, who serves as one of the lead dietitians for the Nutrition Support Medicine Team at UVA Health System. He heads the teams research developments, and has authored and co-authored multiple articles on
an array of topics including the GI section of the ASPEN Core-Curriculum.
In Joes discussion, he focused on the question of proper glucose control and the effect on nutritional status in critically ill patients. Hyperglycemia, defined as blood glucose greater than 126 mg/dl, is reportedly seen in 57-98% hospitalized critically ill patients. Insulin resistant and gluconeogenesis continues despite being in the fed state during critical illness. Stress hormones such as cortisol, epinephrine and glucagon also contribute to elevated blood sugar levels. The effects of hyperglycemia in such cases include catabolism, delayed gastric emptying, an increased inflammatory response, and increased oxidative stress.
Joe discussed several studies that investigated the effects of insulin drips in ICU populations. Results
of these studies showed increased mortality rates in patients with tight blood glucose control, 80 to 110
mg/dl. The data suggests that attempting to enforce normal blood glucose with insulin drips in critically ill
patients presents to be more dangerous than mild hyperglycemia. The risks of wide fluctuations in glucose
levels are apoptosis, endothelial cell activation, and oxidative stress. A level state of hyperglycemia showed
lower mortality rates.
A balance of carbohydrate, protein, and fat for critically ill patients is another key factor to blood
sugar regulation. Hypocaloric nutrition support better protects against hypoglycemia than hypocaloric IV
dextrose. The mix of macronutrients in enteral nutrition formulas allow for consistent delivery of carbohydrates, providing predictable blood glucose patterns.
Specialty EN formulas have been developed specifically for blood glucose control. These formulas
are comprised of reduced carbohydrate content or carbohydrates that metabolize at a slower rate. However, the data regarding these specialty use EN formulas is insufficient for ICU patients with hyperglycemia.
Patients at risk for hypoglycemia, or who have non-insulin dependent diabetes are more likely better candidates for trial use of these formulas during bolus feeds.
In conclusion, blood glucose management in the adult ICU population should range between 140180 mg/dl. The ideal range for patients may need to be individualized depending on medical history and the
condition of their present illness or injury. Interruptions in feeding schedules can cause untimely insulin administration resulting in hypoglycemia. When changes are made to the nutrition support regimen, collaboration between the nutrition professional and the patients primary and multi-disciplinary care teams are
imperative in order to obtain adequate blood glucose control.
Lauren Lett, Dietetic Intern
University of Virginia Health System

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Order Writing Privileges for RDNs in Virginia

Wendy Phillips, MS, RD, CNSC, CLE, FAND
VAND President and CMS Advisor to VANDs Public Policy

The Centers for Medicare and Medicaid Services (CMS) issued a final rule enabling registered dietitian nutritionists (RDNs) in the hospital setting to become privileged to independently order therapeutic diets effective July
11, 2014. For now, this rule change ONLY applies to hospitals and critical access hospitals, not long term care
facilities or other care settings. The Academy is working diligently to get this privilege expanded to these care
settings.
Individual dietitians need to be granted privileges at their hospital before writing orders independently. CMS
outlined the processes that they will accept for privileging qualified dietitians in hospitals. Hospitals will have
the flexibility to either
1) Appoint RDs to the medical staff and grant them specific nutritional ordering privileges -- or -2) Authorize ordering privileges without appointment to the medical staff, all through the hospitals appropriate medical staff rules, regulations, and bylaws.
The required and essential medical staff oversight of RDs and their ordering privileges will be ensured if one of
these processes is followed.
Laws in Virginia affecting order writing privileges for RDNs
There is a Virginia law that affects order writing privileges for RDNs, titled Rules and Regulations for the Licensure of Hospitals in Virginia. Section 12 VAC 5-410-260: Dietary service states that All patient diets shall be
ordered in writing by a member of the medical staff. Therefore, until this regulation is changed, RDNs in Virginia may only write independent nutrition orders in hospitals who appoint the RDs to the medical staff (option
1 above). Many hospitals will choose not to do this. Therefore, VAND is working to amend Virginia hospital
licensing regulations to align them with the new federal regulations allowing qualified RDNs to become privileged to order therapeutic diets and nutrition-related therapies such as enteral and parenteral nutrition without becoming members of the medical staff.
Proposed language to update the hospital licensing laws has been shared with our partners at the Medical Society of Virginia and the Virginia Hospital and Healthcare Association to garner interdisciplinary support for our
efforts. We have spoken with officials from the Virginia Department of Healths Office of Licensure and Certification, who have agreed to submit the proposed change via the fast track process for regulations. The estimated timeline is about 6 months, which is much faster than it would have been if they did not agree to the fast
track process. The steps of this process in Virginia are explained here.
What can nutrition support professionals do in the meantime?
Legislators want to know that their constituents are receiving quality and safe healthcare in a cost-effective
manner. Dietitians should track patient outcomes and improvements in patient safety when the RDNs are
managing the nutrition care plan. Other healthcare providers, such as pharmacists and physicians, can help
track these improvements and/or document the time spent implementing dietitian recommendations as a result of the RDN not having order writing privileges. This helps establish the need for reducing burdensome regulations impeding healthcare professionals from practicing to the full extent of their scope of practice. Legislators also love to hear stories about their constituents having an improved quality of life, so if you have stories
to share about patient care being enhanced by RDN involvement, then please share these with Wendy Phillips
at wp4b@virginia.edu (omitting patient specific identifiers).
For updates to the regulatory process, please check the monthly eBlasts through the Virginia Academy of Nutrition and Dietetics, and/or the website at www.eatrightvirginia.org. Additional questions or comments may be
addressed to the VAND President at wp4b@virginia.edu.

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Announcements
Continuing Education and Events
Weekend Warrior Nutrition Support Program at University of Virginia Health System
Saturday and Sunday, March 21 - 22, 2015

Nutrition Support Traineeship at University of Virginia Health System

Monday through Friday, April 13 - 17, 2015
Monday through Friday, May 4 - 8, 2015
Find more information at www.GInutrition.virginia.edu or email Stacey McCray at sf8n@virginia.edu.