Q1: Are Dietitians able to practice Insulin Dose Adjustment (IDA)?
Yes, it is within dietitians’ scope of practice to provide and/or teach insulin dose adjustment (IDA). Dietitians must practice IDA within limits of their knowledge, skills, abilities and judgment, in compliance with CDBC Standards of Practice and Code of Ethics, and current evidence-informed clinical practice guidelines as well as any policies and guidelines that may be required by their employer. A Health Authority, hospital or health care facility may restrict the scope of practice for health care professionals. Dietitians must comply with employer policies related to IDA.
Q2: Can I initiate an insulin order?
No, dietitians cannot initiate an insulin order. Initiation of an insulin order is equivalent to “prescribing” insulin. In the current Dietitians Regulation, dietitians are not authorized to prescribe.
Q3: Can I teach how to use an insulin pump?
In a setting where a patient needs insulin pump or pen training where the organizational scope allows it, you can teach insulin pump/pen settings. It is important to consider personal dietetic scope as well. In a small community setting, where a physician may refer to you for diabetes care and management, it is pertinent that you be comfortable and capable of performing these activities. Seek training for tasks that are outside your personal scope. It is equally important to ensure that you are equipped and comfortable to voice your personal scope boundaries. A significant source of risk is identified when a sole practicing dietitian is expected to take on practice that is not supported by, or in collaboration with, a physician, and other members of an interdisciplinary team, and doesn’t feel able to speak up when patient load or difficulty becomes an issue.
Teaching the priming of an insulin pen, or the setting of an insulin pump, as well as use of an orange with which to practice, is within scope for a dietitian (personal scope needs to be assessed by you personally and you can use the Decision Tool for New Aspects of Dietetic Practice, available on the Quality Assurance Page), as long as doing so doesn’t include administration of dose of insulin into the patient (as per Q6). A patient must self-administer insulin, and this can be in your presence. Following the Standards of Record Keeping is key, so as to document thoroughly the teaching and the complete patient encounter, including risks, adverse reactions, and referral back to the physician.
Q4: I work in a very small rural setting, and we are quite short-staffed. If a patient comes to me with an insulin dose starting prescription, but hasn’t started using the insulin yet, am I able to make an insulin dose adjustment?
The following considerations need to be in place when encountering a patient who is in possession of an insulin prescription that differs from the required insulin dose (by your assessment), whereby the insulin regimen has not yet been started. In this situation, a dose adjustment by you is not permitted, as the insulin has not yet been administered. Considering the difficulty in healthcare short staffing, physician availability, and timely access to a correct dose of insulin, your best course is to contact the physician directly, recommending a change in initial dose, and requesting a new physician prescription to be communicated directly to the patient’s pharmacy. In this manner, the patient will receive an appropriate first dose. Once insulin has been initiated, you (within personal scope), can perform insulin dose adjustment. Again, this is with the understanding that you are not working in silo, and have access to refer the patient to an interdisciplinary team.
Q5: Can I administer insulin to my patients?
No, dietitians cannot administer insulin in any setting. In the current Dietitians Regulation, Dietitians are not authorized to “administer” drugs.
Q6: Am I able to aid a patient by physically manipulating buttons on an in-situ insulin pump? Does this qualify as administration of insulin?
The term “administer” isn’t defined in the Health Professions Act and the Health Professions General Regulation. The Dietitians Regulation does not include “administration of a drug” as one of the restricted activities that Dietitians can perform. So how does this pertain to physically changing insulin dose on a patient’s in-situ insulin pump? You may find yourself in this situation if you are working in diabetes management with insulin dose adjustment with a patient who has a visual or other disability.
A manual adjustment to insulin dose is not likely to trigger an immediate insulin bolus to be delivered, and the actual dose delivery could be decided upon by the patient, or by a blood sugar level, after the change has been made. Effectively, this means that you would not be directly administering the insulin dose.
It is important to consider workplace and personal scope in the context of this answer. As with all dietetic practice, it is important to consider adequate and timely documentation (per the Standards for Record Keeping) as well as any collaboration with regulated healthcare professionals whose scope includes administration of scheduled drugs.
Q7: Am I allowed to provide my patients with free, pre-dosed insulin samples to my patients?
No, dietitians cannot hand out or “dispense” free, pre-dosed insulin samples to patients in any setting as insulin is a Schedule II drug in the BC Drugs Schedule Regulation. In the current Dietitians Regulation, Dietitians are not authorized to “dispense” drugs. Note: Vitamin/mineral supplements that can be purchased from non-pharmacy outlets are classified as “Unscheduled” in the BC Drugs Schedules Regulation. These Unscheduled vitamin/mineral Supplements can be dispensed by dietitians. Who else may dispense insulin? Registered Nurses and Pharmacists may dispense Schedule II drugs such as insulin.
Q8: Am I able to insert a soft flexible cannula for insulin injection to a client with diabetes?
Q9: I do not have my Certified Diabetes Educator (CDE). What is my scope regarding insulin adjustments?
Although an employer may require CDE designation or another type of training (for example, on-the-job training at a Health Authority) to adjust insulin, the CDBC does not. However, if you do not feel confident and safe discussing insulin adjustments with your inter-professional team and your patients, please inform them and refer them to a health professional who is able to help them. The answer to your situation is supported in Principle 3 of the CDBC Code of Ethics. It relates to your individual level of competence and practice readiness.
Q10: Is testing a client’s blood glucose using finger prick test within my scope?
Performing blood glucose monitoring using a finger prick test is considered a public domain activity. Being in the public domain means that the activity is not restricted to any specific health professional. Anyone can prick another person’s finger and draw blood, assuming consent is provided. RDs may perform public domain activities. However, as health professionals, RDs must have a dietetic-based reason to carry out these activities. Additionally, RDs must understand the implications of results obtained from performing these public domain activities and refer clients to the suitable health professionals when the results obtained relate to another health professional’s scope of practice (for example, a dietitian may not “diagnose” diabetes following a high blood glucose reading and should refer the client to their physician).
Testing and/or knowing a diabetic patient’s blood glucose concentration may be an important component of a dietetic assessment and may directly impact an RD’s therapeutic nutrition plan and counselling to the diabetic patient.
Q11: In the context of my work with out-patients with diabetes, can I perform a retinal exam (once properly trained)?
Retinal Examinations are not part of the dietetic scope of practice. In the Optometrists Regulation, optometry is defined as: “the health profession in which a person provides the services of
- assessment of the eye or vision system through the use of instruments, devices, diagnostic drugs or other means,
- treatment, management or prevention of
- disorders of refraction,
- sensory or ocular motor disorders, or
- diseases or disorders of the eye or anatomical structure directly related to the vision system, and
- dispensing vision appliances.”
Part of the diabetic nutrition plan and counselling may include the prevention of adverse complications of poor blood glucose control to patients’ capillaries. You are unlikely to be the best professional to perform this task. The eye health of a patient should ultimately be overseen by an Optometrist or Ophthalmologist.