By Mary Ellen Posthauer RDN, CD, LD, FAND

In response to Dr. Michael Miller's February blog, I would like to educate readers on the role and responsibility of the registered dietitian (RD) on the wound care team. The RD's educational and professional requirements include completing a bachelor's degree in nutrition from an accredited university, completing an accredited supervised practice program (usually 12 months) and passing the national examination to become a registered dietitian with the Commission on Dietetic Registration. All registered dietitians must maintain continuing professional educational requirements. Many RDs have a master's degree and/or have completed additional certifications in specialized areas of practice, such as certification for nutrition support (CNSD). The alphabet soup of letters for RDs is no different than the multiple initials behind many other professionals' names, including Dr. Miller's. Sorry, there is no secret handshake. Certification and licensure are state dependent just as in other health care professions. Dietetic registration and state licensure requirements also define scope of practice and define continuing education requirements. My own practice includes both the state of Indiana where I am certified to practice, and the state of Illinois, where I am licensed to practice.

Just as the recommendations for wound care treatment, dressings and support surfaces are modified with evolving evidence-based research, the nutrition interventions recommended by the RD are based on evidence. The Academy of Nutrition and Dietetics (Academy) has an extensive evidence-based library that helps guide dietetic practice. In addition to the wealth of information on the Academy's Evidence Analysis Library, the Dietary Reference Intakes (DRIs) are from the Institute of Medicine, Food and Nutrition Board. The DRIs are estimated average requirements for groups across the life span and are based on "scientific evidence." For example, the DRI for adult females for vitamin C is 60 mg/d and 90 mg/d for males. The DRI for this water-soluble vitamin can easily be achieved by consuming a good source of fruit/vegetables, such as citrus juices or fruits. The DRI for zinc can be met by consuming daily sources of protein, meat, fish, poultry etc. Based on the evidence available, mega doses of either zinc or vitamin C are not recommended unless a deficiency can be confirmed. Mega doses of zinc above the Tolerable Upper Limit (as defined by IOM) of 40 mg of zinc may interfere with healing and cause a copper deficiency. Many of my RD colleagues agree that the mega doses of vitamin C and zinc are ordered by the wound clinics (because it is their standard protocol) and are not the recommendation of the RD.

Monitoring lab values is only one aspect of evaluating overall health status and as my previous blogs have noted, care must be taken when interpreting them as a nutritional marker. Frequent monitoring of pre-albumin, albumin etc. are good markers of morbidity, but not accurate markers of nutritional status. Frequent monitoring can be counter-productive when the focus should be on whether or not the individual is accepting the nutrition interventions chosen for their treatment. This includes monitoring whether the person is eating or not eating, whether they enjoy the food, what medications they may be taking that may adversely affect their appetite, whether they are able to feed themselves, and/or what other diseases or conditions impact their ability to heal. Perhaps the RDs that Dr. Miller thinks are hiding behind the mashed potatoes and macaroni and cheese are really observing how residents are eating and enjoying their meals in order to determine if the nutrition interventions are effective.

For the record, I am one of those dietitians who does attend weekly wound rounds with the wound care nurse, DON, and Dining Services Director. Hiding behind anyone (eg. administrator) has personally never been my style. My goal is simple: complete a thorough nutrition assessment, provide individualized nutrition care interventions, and monitor and evaluate the effectiveness of these interventions on healing. And yes, this may include determining how well a person is eating. Dr. Miller's offensive and patient derisive description, "See the hole, feed the hole" is totally opposite of how RDs care for patients. Our approach is patient-centered and caring. In addition, as an integral member of the interdisciplinary team, the RD's weekly review and recommendations are written, signed by the team and placed in the medical record.

I would argue that the majority of wound care patients do not require TPN or parenteral feedings. The fact is that TPN is for individuals without a functional GI tract, those who are severely malnourished or those whose conditions require the bowel to rest, such as severe pancreatitis. Yes, TPN is more expensive then enteral or oral nutrition and would require approval by the payer source for the individual and/or facility. The individual with a wound is the center of the interdisciplinary circle of care that includes all of the disciplines involved in treating the person. The individual and/or their health care representative must understand the risks and benefits associated with parenteral feedings (or enteral feedings) and consent to the treatment. What we as health care professionals consider as in the best interest of the individual doesn't always match their preference. There is data that notes there are complications from both enteral and parenteral nutrition, so monitoring for tolerance and signs/symptoms of complications is important. I challenge Dr. Miller to publish his data on the success of parenteral nutrition for wound healing and to join his RD partners and become an Associate of the Academy of Nutrition and Dietetics. In the meantime, I will continue to share successful nutrition interventions for wound healing on my blog.

Sources
American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Available at: http://www.nutritioncare.org

Nutrition and Dietetics. Evidence Analysis Library®. Enteral vs. parenteral nutrition. Available to subscribers at: http://www.adaevidencelibrary.com

Jeejeebhoy KN. Total parenteral nutrition: potion or poison? Am J Clin Nutr [serial online]. 2001;74:160-163. Available at: http://www.ajcn.org/cgi/reprint/74/2/160.

About The Author
Mary Ellen Posthauer RDN, CD, LD, FAND is an award winning dietitian, consultant for MEP Healthcare Dietary Services, published author, and member of the Purdue University Hall of Fame, Department of Foods and Nutrition, having held positions on numerous boards and panels including the National Pressure Ulcer Panel and the Academy of Nutrition and Dietetics’s Unintentional Weight Loss work group.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.