Q1: I am planning on taking a job that requires me to work with patients who are receiving Enteral Nutrition. Please advise me on how to register with Restricted Activities.
Visit the Restricted Activities section of the CDBC website for information on how to register and to determine which Restricted Activities you may need.
Q2: Can I recommend a client’s use of an enteral formula that is not approved or available in Canada? Under what circumstances can I make an exception?
Commercially prepared enteral nutrition (EN) formulations that do not meet the regulatory requirements for federal food regulation are not appropriate for use and should not be recommended in Canada. To do so would be considered unsafe dietetic practice. If a client chooses to use an EN formulation that has not been approved by Health Canada, which includes the Canada Food Inspection Agency (CFIA) and the Health Products and Food Branch (HPFB), you should advise the client that the product is inappropriate and recommend a suitable EN formulation. If you have questions about a food or natural health product, you can contact Health Canada.
An exception exists when you have recommended a formula that meets the required regulations, but the client has chosen to use an unregulated product. If it is within your individual scope of practice, you may work with the client to determine the amount and rate of feed of the unregulated EN product. This complies with Principle 5 of the CDBC Code of Ethics where “A Registered Dietitian demonstrates respect, dignity and privacy at all times when interacting with clients at by… including the client or substitute decision maker in discussions of service provision and by… inviting the client to make choices .”
You must be aware of the legal implications in the event of an adverse event occurring related to the use of an unregulated commercial product while under your care. You must document all encounters thoroughly and continue to recommend appropriate EN formulations. Additionally, you should consult with your employer and your insurance provider for liability coverage to make sure these interventions are supported.
Q3: Where can I find out information about how EN products are regulated in Canada?
EN formulations are classified as “Foods for Special Dietary Use” under the Canada Food and Drugs Act. The composition and labelling of Foods for Special Dietary Use are regulated under Division 24 of the Food and Drug Regulations and include: formulated liquid diets, meal replacements, carbohydrate-reduced foods, sodium reduced foods, etc. Regulations for Foods for Special Dietary Use are enforced by the Canadian Food Inspection Agency (CFIA). Depending on the composition of a product, Health Canada may also be involved in the regulation of Foods for Special Dietary Use. Enteral and parenteral feeding are Restricted Activities under the Dietitians Regulation and present significant risk of harm to the public.
Q4: Can I physically check the fluid volume and/or replace the volume in the balloon retention device? Can I use a Stoma Length measuring device to aid in selecting an appropriate low-profile button tube?
No, changing the fluid volume/replacing fluid in a balloon retention tube and using a stoma length measuring device are not clearly defined in as scope per the Dietitians Regulation. In other words, the Dietitians Regulation does not state that a dietitian is permitted to perform a procedure “below the dermis” though a gastrostomy. Therefore, procedures below the dermis are not permitted.
Although there is room in the regulation around the word “administer” to interpret changing fluid volume/replacing fluid in a balloon gastrostomy as being within scope, the legislation does not support this at present. Additionally, the CDBC has also developed standards and guidelines for feeding tubes insertions, which are limited to naso/oro gastric or post-pyloric tubes. The practice guidelines (scroll to the bottom of the page) for tube feeding insertions are clear in excluding enterostomy tubes.
Q5: How can I aid in ensuring that the balloon retention tube remains appropriate to use if I cannot check the volume?
You may teach family and patients how to check and/or replace balloon volume by description/demonstration (on a tube that is not connected to the patient). Similarly, you may teach the use of a stoma length measuring device as long as it is not directly applied to a patient’s stoma. Please consider whether these activities are within your personal scope before performing such tasks. You may choose to consult the Decision Tool for New Aspects of Dietetic Practice, specifically regarding your personal competencies.
Q6: What role do I play in troubleshooting enterostomy tube issues? (As a dietitian, I am often the first healthcare professional contacted by patients)
It is important to consider the risks involved should the procedure go unexpectedly. To assess risks, you may want to ask yourself the following questions:
- Is it within your scope professionally and personally to safely resolve any issues related to a pierced balloon?
- a balloon that is difficult or from which it is impossible to remove the fluid?
- a tube that may need replacement after an attempt to refill the balloon?
- complications arising from using a stoma length measuring device?
- Could this procedure be best handled by another health professional whose scope includes intervention and removal/re-insertion of the balloon gastrostomy if needed?
It is important to consider a working partnership in your practice in order to align yourself with someone (i.e. likely RNs) whose scope includes working with enterostomy tubes when procedures below the dermis are required. This partnership will be particularly useful when certain aspects of tube troubleshooting need to be addressed.
Per the Restricted Activities Interpretive Guide, dietitians registered with Restricted Activity C are allowed to “physically manipulate or adjust the enteral device or system”, as well as teaching enteral nutrition administration and tube maintenance (i.e. unblocking, maintaining patency). However, dietitians are not permitted to perform tasks (instillation/infusion) below the dermis, unless it involves enteral nutrition as defined by the Interpretive Guide.
Q7: Can I adjust an enterostomy tube into or out of the stoma? Can I rotate the tube?
You may not pull the tube out of, nor may you push it into the stoma. The CDBC has consulted with the College of Physicians and Surgeons of BC to clarify that the rotation of an enterostomy tube (of a ¼ turn or more) does not constitute a restricted activity limited to physician practice. It is therefore considered to be within a dietitian’s scope of practice, when competent and safe to practicing Restricted Activity C. As a dietitian, you must ensure that this specific activity is within your personal scope and that you are registered with Restricted Activity C to you perform it.
Q8: Am I liable if the patient misunderstands my advice for maintaining their home tube feeding and becomes compromised?
As with any other activity, providing clear, plain language instruction is important (Standard of Practice 9), along with clear documentation of the intervention in the medical record (Standard of Practice 15 and CDBC Standards for Record Keeping).
Once education and emergency contact information has been provided, it is the responsibility of the capable patient or caregiver, who consented to undertake an activity independently, to complete the task correctly. As in all other areas of dietetics, you are not responsible for a patient’s non-compliance to recommendations, guidelines and education provided.
Q9: If I perform or teach others to perform an activity that is considered within scope, such as the administration of enteral nutrition (EN), what can I do to ensure that I am performing or teaching it correctly?
Aside from establishing and enforcing entry-to-practice requirements for the practice of Restricted Activities, the CDBC Continuing Competence Program (CCP) ensures reflection of performance by the dietitian. Through this process, dietitians demonstrate ongoing growth and development of their professional knowledge and skills, while having a systematic way to document how their learning activities impact their practice. Employers may play a key role in offering continuing education opportunities in the form of courses, webinars and on-the-job training which ensures provision of a supportive environment where dietitians can work effectively. While the CCP doesn’t guarantee competence, self-reporting continuing education is an indicator of competence (1). Literature shows that self-reflection on practice, access to a variety of learning activities and development and maintenance of a learning portfolio are among the most important aspects of a continuing competence program (1,2,3,4).
Q10: Are dietitians able to ensure the enterostomy tube is optimized for administration of tube feeding? For example, measuring the external length of a feeding tube? Or adjusting the external bumper of the tube? What about cutting the excess from the end of a tube to aid in replacing an adaptor?
Yes, a dietitian registered with Restricted Activity C can perform these activities, per the wording of Restricted Activity C as defined in the Restricted Activity Interpretive Guide:
“If a substance is being administered by instillation through enteral means, the RD: … physically manipulates or adjusts the enteral delivery device or system.”
The external bumper may be adjusted by the dietitian to support the maintenance of the correct position of the enterostomy tube within the stoma. The purpose of measuring the external length of the tube is to ensure that the tube has not migrated into or out of the stoma. If the position is not optimized (i.e. the tube appears to have moved), dietitians are not permitted to adjust the tube by moving it into or out of the stoma, since that would be deemed a procedure “below the dermis”. If the tube has migrated or there is another indication that it is not appropriate to use for feeding, a dietitian must recognize that any action taken will be outside of a dietitian’s scope and refer to another health professional (Standard of Practice 2.3).
Q11: Is a dietitian able to instruct a person to clean the skin around the feeding tube (basic stoma care)?
Yes. This activity is directly related to the provision of nutrition by enterostomy tube, and so it falls within a dietitian’s scope of practice. Generally, nursing professionals are responsible for stoma care, but in some practice situations, you may be asked to provide instruction or care. You must be registered with Restricted Activity C, otherwise refer to another health professional who is competent to provide this type of care.
Stoma care may include instructing patients/caregivers how to
- clean the stoma with warm soapy water and how to air dry the stoma,
- apply over-the-counter agents (such as barrier creams) that were recommended by the healthcare team,
- replace the dressings and any adhesive required for the dressings.
Administration of scheduled medications is not part of a dietitian’s legal scope. Any troubleshooting required (leaking, irritated, swollen, infected stoma) must be referred to an appropriate healthcare team member and documented in the patient’s medical record.
Q12: Can I recommend home blenderized tube feeding to clients?
A: Yes. It is within a dietitian’s scope of practice to design and/or administer home blenderized tube feeding (HBTF), as any other product available for enteral nutrition. If you do so, you must be mindful of your own personal skill and competence to practice HBTF and take the necessary steps to ensure safe, ethical, and competent practice. You must also have the appropriate Restricted Activities (RAs) in order to practice HBTF:
- RA “A” – design, compound or dispense therapeutic diets if nutrition is administered through enteral means, and
- RA “C” administer a substance to a person by instillation through enteral means.
When providing care in HBTF, you should also consider the CDBC Code of Ethics and Standards of Practice in terms of:
- Providing a client-centered care approach and informed consent,
- Conducting evidence informed practice,
- Adhering to legislation or organizational requirements, and
- Communicating and collaborating with clients, their families, and the health care team.
Refer to Decision Tool for New Aspects of Dietetic Practice to navigate any unfamiliar new dietetic situations, including HBTF.
For more information on HBTF, you may want to consult information provided by the College of Dietitians of Ontario or check out Dietitians of Canada’s learning resource on Home Blenderized tube feeds, available at a cost .
Q13: Is providing education to care aides, RNs, or LPNs in the management of tube feeds for clients considered to be a delegated function?
No. When an RD provides instruction of enteral feeding to non-regulated staff (i.e. a care aide), this is not deemed as “delegation” and the RD’s responsibility ends with the completion of teaching. “Delegation” implies ongoing monitoring of the care provider’s ability to perform the task and accepting accountability for the care giver’s actions.
Further, an RD cannot delegate a Restricted Activity to another registered professional (i.e. RN, LPN) when the activity lies within the other professional’s scope of practice. RNs and LPNs are governed by the BC College of Nursing Professionals. As registered health professionals, RNs and LPNs are legally responsible for their practice, including the administration of enteral feeds on a doctor’s order.