July 2013 Issue

Dynamic Duos — Teaming Up to Achieve Success
By Lindsey Getz
Today’s Dietitian
Vol. 15 No. 7 P. 38

Today’s Dietitian profiled five RD/DTR teams in various specialties to demonstrate how these nutrition professionals can work together in harmony and make a more profound difference in the lives of patients.

Registered dietetic technicians (DTRs) undergo many hours of training—at least 450 hours of supervised practice in addition to required coursework—and there are many positions in hospitals, clinics, long term care facilities, and other institutions in which they can play a vital role in patient care.

Yet despite their extensive training and ability to provide support in these institutions, many believe they’re often overlooked as critical members of a patient’s health care team. While their role may not always get the credit it deserves, the truth is that DTRs can be a tremendous team asset and help facilitate optimal nutrition care.

“Unfortunately, most RDs in the United States haven’t had the opportunity to work with a DTR and are unaware of the knowledge and value they bring to the field of dietetics,” says Alberta Scruggs, RD, LD. “Many times I hear RDs say they’re overwhelmed with so much work, but RDs should pass some of that work to a DTR. They may be surprised how the DTR will lighten their load.”

In a successful working partnership, RDs and DTRs share the workload. This allows RDs to accomplish much more than they ever could on their own. In busy health care settings, DTRs also are more likely to have time for patient interaction—something RDs may not have time to do. Scruggs says that when she was a DTR in long term care, face time with the patient was one of her responsibilities. “Oftentimes, when a new resident entered the facility, the RD wasn’t available, but I was,” Scruggs recalls. “If the resident had conditions beyond my scope of practice or experience, I contacted the RD to see what care could be provided.”

Grace Burney, DTR, who works at a long term care facility, says DTRs are great at “breaking the ice” with patients. “We’re there to help,” she says. “We do all those things that the RD wouldn’t have time to do. We also assist with prep and getting the patient ready to see the RD. That takes a lot of the workload off of the RD. We have the expertise to handle a lot of tasks.”

DTRs also have the expertise to fill several roles. Burney herself has worked in many different areas of dietetics—everything from acute care to long term care, where she is now.

Today’s Dietitian interviewed members of five different RD/DTR teams (including Burney’s) mostly in the Cleveland area to show the various skill sets DTRs possess and how they work to support RDs in diverse roles.

Team 1
Field area: Long-term care
Location: Eliza Bryant Village in Cleveland
At Eliza Bryant, the oldest black skilled nursing facility in the United States, Burney says the day-to-day operations are her responsibility while the facility’s dietitian, Deborah Kemokai-Wright, RD, LD, oversees and reviews what’s done. “I do assessments, feeding calculations, and weight monitoring under Deborah’s license and her review,” Burney says. “If anyone is high risk or I’m not 100% sure of what to recommend, the first thing I do is call Deborah. We have phone access 24/7 to one another, and we talk at least once a day. She doesn’t need to be here for me to ask for her recommendation.” It’s a Batman and Robin kind of relationship, she adds.

Burney believes she can serve as the support that enables the RD to do her best, but she always aims to do her best as well. “As a DTR in Ohio, you’re working under your RD’s license,” Burney explains. “A good DTR is a team player who’s always acutely aware of that fact—that you’re operating under someone else’s license, and you need to act accordingly. My ethics are always in place.”

Burney says she feels lucky that she and Kemokai-Wright are friends. But she says that even if RDs and DTRs aren’t friends outside of work, a successful team will be able to connect on the job. “You have to understand each other and be able to form a true partnership,” Burney says. “You don’t have to want to go to dinner together, but when you’re on the job, you have to understand each other’s flow. That’s the best kind of working relationship you can get: when you truly connect and can offer that support.”

Team 2
Field area: Clinical research, bionutrition division
Location: University Hospitals Case Medical Center in Cleveland
Alicia Thomas, MS, RD, LD, calls her team a “party of three,” as it’s comprised of herself, a nutrition assistant (Wanda Rhymes), and a DTR (Jacquelyn Leach). Together, the women accomplish a tremendous number of tasks in the clinical research field, but it all comes down to working as a team. With various research studies to manage, Thomas says she could never do it without their support.

One of the larger-scale projects Thomas is involved with is a three-year research study that requires a high enrollment quota of randomized patients. That quota must be met in a certain amount of time. “The only way this can ever be done is with a team effort,” Thomas says. “Wanda and Jackie have to find the patients in the community and track them down, document it, and enter the data. If that piece wasn’t done in a timely manner, we wouldn’t meet the recruitment criteria.”

“To make this work, I put an extensive spreadsheet in place where we track everything, such as our attempted calls and when they were made,” Leach says. “We’re required to obtain so many recruits on weekdays and weekends, so we keep close track of that and divvy up the work. It’s important that we get things done in the right time and the right order.”

Thomas says the team works well together because they’ve been able to identify each other’s strengths and play off them. “We just know who’s good at doing what and who’s able to share the work in a certain way,” Thomas says. “For instance, we have a sophisticated software program that Jackie is adept at, so she’s been very hands-on in taking on that responsibility. Wanda, on the other hand, has tremendous experience in the metabolic kitchen, so she does a lot in that area.”

In working together, Thomas says it’s become a true partnership. “I’ve always valued the DTR role,” she says. “They allow for me—or any dietitian for that matter—to pursue bigger and bolder opportunities because that support is in place. I simply cannot imagine not having that added support and nutrition expertise available. Technically, I’m the supervisor, but I view Wanda and Jackie as my colleagues. I go to them for advice and cannot imagine not having that relationship.”

Team 3
Field area: Acute/chronic clinical inpatient nutrition
Location: Hospital in northern California
When patients come to the facility where Katrelia Robinson, DTR, works, she screens each one and identifies those with basic needs, whom she can work with, and those with more complicated cases. While those patients may be passed on to team dietitian Julianne Kanzaki, MPH, RD, Robinson can manage many needs of the low-risk patients. “It’s really helpful to me because Katrelia handles a lot of the initial diet education and also helps identify those that may need some extra support,” Kanzaki says. “She also manages the menus, which is really important because we have a lot of renal patients and diabetes patients, and menus can be complicated. I can trust that Katrelia is handling that, which takes a lot of the burden off my shoulders so I’m able to see more patients.”

Robinson says she regularly reports back to Kanzaki to keep her in the loop, but she can handle much of the basic workload herself. “Julianne doesn’t have to worry about the nitty-gritty details because I handle those for her,” Robinson says. “I can even help with higher-risk patients by gathering all the data and placing that information in the chart to simplify the process for Julianne. Nurses also know they can grab me [to address] immediate needs or if they have a patient that needs to be seen immediately. I can handle it right away and then communicate the information to Julianne.”

Kanzaki says patients can fall through the cracks if it weren’t for the added help she receives from a DTR. She doesn’t have the time to get to know patients as well as Robinson or to put in the amount of face time Robinson can. “With the amount of patients I have on my list, it’s simply impossible to see everyone on a daily basis,” Kanzaki says. “That’s why DTR support is so critical to me. It’s incredibly important on a clinical level.”

Both Robinson and Kanzaki recognize that by working together, they’re providing the most optimal support possible. “Just by my visiting everyone daily, it helps with ‘customer service’ for the hospital,” Robinson says. “Patients know we’re paying attention to them. We’re able to offer more of a personal touch because we’re there for them. With all the work RDs have, they can’t meet with patients as regularly, but that’s why we’re there to help.”

Team 4
Field area: Specialty nutrition
Location: Center for Gut Rehabilitation and Transplantation at the Cleveland Clinic
At the Cleveland Clinic, Tom Pemberton, DTR, provides support to six dietitians, working with patients with a diagnosis of intestinal failure characterized by short-bowel syndrome and intestinal malabsorption. Pemberton spends the majority of his time with hospitalized patients, whose diets are individualized, and says that each morning he circulates a list of inpatients to communicate the day’s priorities for patient care.

Throughout the day he sees patients as a follow-up to the plan of care created by the patient’s RD, provides education on diet, and accepts primary responsibility for maintaining inpatients’ prescriptive diet. He also acts as a liaison with patient foodservice. “When working as a team, it’s important to define the roles and responsibilities of each team member while still being flexible,” Pemberton says.

Working as a team involves a genuine collaborative effort among Pemberton; Lisa Moccia, RD, LD, CNSD; and five other dietitians. For example, Moccia will diagnose a nutritional problem and provide an assessment of the patient’s needs, while Pemberton will help the patient interpret that plan to better meet his or her needs. Both are responsible for patient education and updating patient information, but Pemberton takes the lead with communicating the meal plan to both unit nursing staff and patient foodservice.

Each day provides new challenges and successes with patients, but one particular case stands out in Pemberton’s mind. For years he and the RDs on the team had followed a patient with intestinal failure who depended on parenteral nutrition because she couldn’t tolerate oral food intake. After an intestinal transplant, the patient discontinued the alternative nutrition support and resumed eating solid foods. Pemberton recalls the patient was stunned by her almost-immediate weight gain and confessed that she needed to learn to eat properly all over again. “I was surprised I needed to teach fundamental nutrition again,” Pemberton says.

Team 5
Field area: Inpatient and outpatient pediatric nutrition
Location: MetroHealth Medical System in Cleveland
MetroHealth is a county hospital that serves more than 70,000 infants, children, and adolescents each year in an urban environment. More than 40% of the children and adolescents aged 5 to 19 who come to MetroHealth meet the criteria for overweight and obesity, which is higher than the national average.

This crisis has required critical support from the clinical health care teams and has led to the development of a wellness center that offers various nutrition and fitness classes. In working together, the clinical teams can support these patients and get them on the road to better health.

Susie Akers, RD, LD, LWMC, handles clinical responsibilities and also directs and manages the Aamoth Family Pediatric Wellness Center. Dawn Kritz, DTR, facilitates classes on nutrition and cooking topics at the wellness center, reinforcing the clinical team’s recommendations. “Dawn teaches patients and their families about portion control, reading food labels, and cooking quick and easy nutrient-dense snacks and meals,” Akers says. “She also monitors quarterly fitness and nutrition parameters to help participants and the clinical team see that progress is being made.”

Akers says working as a team reinforces each patient’s wellness goals. She says all team members, including pediatricians, nurse practitioners, and nurses, communicate with one another. Their ability to work together is what helps make a difference in the lives of patients and has led to numerous success stories. Akers shares a particularly memorable moment: “One of our teen boys living in a group home came to a clinical visit in spring 2012 for obesity, acanthosis nigricans, and high blood pressure. He drank sweet beverages excessively and never ate fruits or vegetables. Portions were large, and he really didn’t want to make any changes. The medical staff introduced the boy to the wellness center, our diet technician, and personal trainers. He participated in a few classes. Soon he became interested in running a 5K with the staff and completed the race with us. Six months later, he returned for a clinical visit. He had lost more than 40 lbs, was on the wrestling team at school, and admitted he was eating fruits and vegetables on a daily basis. His goal was to lose 40 more pounds. As a staff, we were thrilled.”

— Lindsey Getz is a freelance writer based in Royersford, Pennsylvania.