During this pandemic outbreak, the Health Professions Act and the Dietitians Regulation and other laws governing health care delivery continue to be in place. The College expects dietitians to fulfill their commitment to their patients and the profession during the COVID-19 pandemic by providing quality nutrition care that is within their individual competence. For more information about this, refer to the communication sent to registrants about expectations of CDBC registrants during the pandemic.
Many of you are reaching out for support from the College since your practices may have become virtual when they are normally in-person. dietitians practicing virtual dietetics are encouraged to review the Virtual Dietetic Practice Policy and Guideline in order to ensure they are meet the College requirements. Some of your questions though, are not as straightforward as simply interpreting the Virtual Practice Policy and Guideline and the following provide additional information to help guide dietitians in their practice.
The CDBC acknowledges and thanks the College of Dietitians of Ontario in sharing its resource, College of Dietitians of Ontario Pandemic Planning Guide, which was consulted during the creation of this blog post.
Q1: My work site is short-staffed and does not have the means to provide us with access to a virtual appointment system. I can communicate with staff via phone, but the difficulty lies with connecting with patients and their families for nutrition assessments. What should I do?
As a regulated health professional, you are responsible to determine situations where virtual dietetic care is not appropriate and when in-person care is needed. Virtual care should be equivalent to in-person care and provide the same quality and safety of dietetic services.
For example, if a dietitian is asked to determine a therapeutic diet for a dysphagic client where a swallowing assessment is necessary, the College would expect that the dietitian would have to do this in-person and follow the proper infection prevention protocol in place at their facility.
Another example is where enteral nutrition needs assessment may be needed. In some work settings, part of the enteral nutrition assessment, delivery and monitoring may be completed virtually and with interprofessional collaboration. In other settings, staff shortages or lack of expertise may require the dietitian to perform the nutrition assessment and coordinate enteral feeding delivery and monitoring in-person.
Q2: Before the pandemic, I serviced different long-term care sites. In order to prevent spread of COVID-19 (Novel Coronavirus disease) to vulnerable elderly patients, working at multiple sites is no longer allowed. However, I’m worried that nutrition services are not covered adequately without a dietitian at these sites. How can I ensure that patient nutrition needs are still met while I’m working at only one site?
If you think that additional dietitians need to be deployed in long-term care facilities where you would normally work, please contact your health authority. Each health authority has the ability to redeploy current staff to other locations or contact to the Ministry of Health and the BC Emergency Health Provider Registry to add emergency staff. Contact information to each Health Authority for health professionals is available on the BCCDC website:
- Fraser Health: 1-866-990-9941
- Interior Health: 1-866-778-7736
- Island Health:
- South Island: 1-866-665-6626
- North Island: 1-866-770-7798
- Northern Health: 250-565-2990
- Vancouver Coastal Health: 604-675-3900
It is important that dietitians raise issues with continuity of care for their clients/patients and document nutritional need in their record keeping if they are no longer able to provide dietetic services at certain sites.
Q3: Can the College provide me with a consent form that I can use with virtual clients?
The CDBC’s role is to establish standards of practice to enhance the quality of dietetic services to the public. Generally, the College doesn’t provide template forms as it constitutes the practice of the profession and falls outside of its mandate. The College defers to the various Health Authorities and facilities to develop forms that best meet their needs based on the workplace policies, specific clients and different legislation applicable. The PHSA Virtual Practice Tool Kit provides detailed guidelines about discussing risks of virtual consultations, which may a good starting point to plan how you will obtain and record informed patient consent.
Q4: What virtual platform does the College recommend?
The College cannot make recommendations about virtual practice platforms to use and defers to the Privacy office/committee at your workplace to recommend/mandate appropriate platforms. You may also find relevant information on acceptable platforms in the PHSA Virtual Practice Toolkit. Various platforms are compared and recommended for different areas of virtual practice. When choosing a platform, you need to be mindful of your obligations and standard of practice with respect to privacy, informed consent and client-centered care. We encourage you to carefully consider risk and limitations of each platform and discuss them with clients before adopting it.
Q5: The PHSA Virtual Practice Toolkit doesn’t mention Facebook. Can I use Facebook if I make it a Private Group?
Facebook is not considered a secure virtual platform. There are key matters to review when inviting clients to join the Facebook group. Do all clients use Facebook? Do you provide an alternative for clients who don’t? Are clients clear that even in a Facebook private group, private data isn’t secure and should not be shared? Are you able to enforce professional boundaries and avoid crossing over into sharing personal details about your life or eliciting extraneous personal information about your client? The College encourages you to review Professional Boundaries in a Therapeutic Relationship.
You should avoid using platforms such as Facebook to provide any counseling and instead, select a more secure and more accessible platform on which to conduct your practice. You may use the PHSA Virtual Practice Toolkit to guide your platform selection. This document lists the platforms that have usability in single user to group settings (i.e. teacher to multiple learner style settings).
Q6: I foresee an opportunity to expand my practice during the pandemic now that it is virtual. Can I cross provincial boundaries to offer my services? What are some considerations?
A CDBC registrant can provide dietetic services to clients in BC. Each regulatory body within Canada has its own requirements for registration and dietetic practice. This means that, in some cases, you may not practice dietetics in other provinces (virtually or otherwise) unless you are registered in that province. Please review the Virtual Dietetic Practice Policy for details within Canada. Outside of Canada, CDBC has no jurisdiction and it is up to you to contact the appropriate regulatory body within the province or country where you are looking to practice.
Here are a few considerations for you to reflect upon when undertaking virtual dietetic practice:
- Do you have access to a high quality and secure virtual connection?
- Are you accessible? Is it easy and convenient for clients to make appointments with you, given a likely time zone difference?
- How are you keeping client records confidential and secure? Per CDBC Standards for Record Keeping section 5: “Dietitians ensure reasonable measures are in place to maintain the security of client health records.”
- What is the liability to you if (1) client records are stolen, or (2) you are unable to respond to an emergency, such as calling 911? It is recommended that you discuss these questions with your liability insurance provider.
- Is there an option for alternative RD care if you are unavailable for a virtual appointment?
- Does your liability insurance cover your practice in other jurisdictions?
Q7: My entire practice has become virtual. My clients with extended benefits were able to claim my services when I offered in-person counseling, but now that I am only able to offer virtual counseling, many of them are being told by their extended benefits companies that they are not eligible for reimbursements. Can the College help to advocate?
The role of the College is to hold registrants to practice standards with a focus on protection of the public. The College recognizes virtual practice as being a valid means to deliver dietetic services and has established a policy and guidelines to support this kind of practice. However, supporting registrants in obtaining service coverage with Extended Benefits providers is not within the College’s mandate. Dietitians of Canada, as a professional association, is in a position to advocate for dietitians. It is recommended that you reach out to them for help. Please email Lisa McKellar, Dietitians of Canada Regional Executive Director for BC at Lisa.McKellar@dietitians.ca if you need support and advocacy.
Q8: I am a dietitian in another province who is looking to provide virtual dietetic services in BC. Do I have to be registered with the CDBC if I am providing:
- Purely educational groups where I may or may not know where the client lives?
- More interactive educational groups where I am more familiar with the clients (not 1:1)?
- Static or custom meal plans?
BC requires Dietitians from outside of BC to register with the CDBC to practice dietetics in BC. Please review the CDBC Virtual Dietetic Practice Policy and Guideline for clarity on expectations of the CDBC registrants when they practice virtually in BC.
Dietitians who practice virtually must inform themselves of the province in which their clients reside, since health is a provincial jurisdiction and the laws are specific to each province. For example, BC has Restricted Activities that may be different than those in Alberta.
Dietitians must consult with their Liability Insurance providers to ensure that they are covered appropriately for practice in another province. Additionally, dietitians are required to have a health emergency plan, should it be required for implementation during virtual service provision (for example, dialing 9-1-1 outside of the province of residence of your client is not functional nor is it appropriate in response to a medical emergency).
Each province has its own legislation and wording regarding the definition of dietetics. In BC, it is the BC Dietitians Regulation. Dietetics is defined as:
“the assessment of nutritional needs, design, implementation and evaluation of nutritional care plans and therapeutic diets, the science of food and human nutrition, and dissemination of information about food and human nutrition to attain, maintain and promote the health of individuals, groups and the community”
Your proposed nutrition-related activities constitute practicing dietetics in BC and therefore, in order for you to provide services, as well as use your title as Registered Dietitian (RD), you must be registered with the CDBC.
If you wish to become registered with CDBC, please contact Sabrina Lauser, Manager of Registration and Communication at firstname.lastname@example.org.
Q9: The ICU COVID unit at my hospital restricts many healthcare workers from entering. I am doing virtual consultations and assessments by speaking with nursing and physicians that have access to the chart and patient. I’m unable to document my nutrition care plan in the paper medical record as it is held in the restricted unit. How do I ensure that my nutrition care plan is documented correctly and completely?
While there may be only a handful of dietitians in the province who are in this situation where they are remotely providing nutrition support plans and follow-ups for COVID-isolated patients, appropriate documentation while practicing virtually is important for all dietitians who have moved away from practicing in-person dietetics. Indeed, as supported by ASPEN – Nutrition Therapy in Patients with COVID-19 Requiring ICU Care, documentation is very important during this pandemic. Refer to the CDBC Standards for Record Keeping for details on CDBC registrant documentation obligations.
Where it is not possible to document into a medical record, you may find that you are relying on email communication. Your workplace may outline the standards and limitations of the use of email communications relating to patients. It is possible that a section or entire email is of clinical significance, in which case, it could be permitted by the recipient to be transcribed into the electronic medical record or printed and placed into a paper medical record. You are encouraged to review relevant resources available in your workplace and discuss the best approach with your team.
The manner with which your workplace uses email for documentation falls outside of the CDBC jurisdiction, however, in supporting you as a registrant, there are some factors to consider:
- Will your email be used in its entirety? Or just the clinically significant pieces? If the email requires altering, is it clear that you are the sender? If the email is altered or pieces omitted, with or without the use of the electronic signature, it may no longer reflect your intent or be missing context.
- Is the email being used in a timely fashion? If the medical situation has changed for your patient since sending/receiving an email, is the email content still relevant? Is the time stamp included in charting?
- Is there a process to ensure that the receiver understands your email and will apply its content in an appropriate context?
- Consider adding your name and title to the email as it may not be automatically included in the signature log of the chart.
All emails communicating patient care (including nutrition care plans, progress note, etc.) must be consistent with workplace guidelines.
Email may not be the preferred method of communicating with the team. Perhaps you are involved in daily virtual rounds, where you are able to provide verbal follow-up and recommendations to the team. For example, in the context where charts are being held in isolation for nurses and physicians who work with COVID-19 patients, d
Dietitians find themselves holding onto assessment and/or follow-up notes that would otherwise be part of the medical record. It would be expected that these notes are also consistent with workplace guidelines and be placed into the medical record at the earliest available time (e.g., if a nurse/physician colleague needs the information for the care plan, when the medical record becomes available, or when the patient is moved from the isolated unit to another unit).
If you have questions about your role in documentation for virtual dietetic practice, please reach out to your resource clinician, clinical educator or practice leader to determine if there are documentation management systems in place for allied health use at your workplace (for example, use of Health Information Management Systems).
Q10: Does the College have any guidance for private practice dietitians having requests for conducting home visits for more “urgent” referrals during the pandemic? It is difficult to maintain distancing measures and there is fear of virus spread among home care support workers who are required to access multiple personal residences.
As a regulated health professional, you are responsible to determine situations where virtual dietetic care is not appropriate and when in-person care is needed. Virtual care should be equivalent to in-person care and provide the same quality and safety of dietetic services. There should always be appropriate coverage for home care to ensure that vulnerable patients receive the care they require. Refer to CDBC policy QA-06: Right to Refuse Treatment for more information about balancing refusal of care with the need for refer to ensure continuity of care.
For example, you may have a home tube feed client or a client with dysphagia who requires in-person support. The College expects that you would provide an in-person visit, while following the proper infection prevention protocol as per the BCCDC and PHSA resources for infection prevention protocols and proper Personal Protective Equipment. However, if a virtual appointment can be considered to provide equivalent care as in-person, you may find that your assessment, delivery and monitoring can be completed virtually and with interprofessional collaboration.
When in-person clinical care is required, use your clinical judgement to determine the shortest appointment length possible and focus on physical assessments only. The remainder of each visit (education, informed choice discussion, prescriptions, counselling, information sharing, support) should be delivered virtually wherever possible. Refer to the PHSA Covid-19 Virtual Health Toolkit for more information.
In order to conduct in-person visits in the safest way possible, consider:
- Maintaining a distance of two metres from your client, their support staff and family wherever possible,
- Wear PPE and practice hand hygiene as available to you and as per your health authority guidelines,
- Where appropriate, ask extra support people and family members in the home to refrain from entering the room where you are conducting your appointment
- Schedule time between visits to reduce client overlap and to ensure time to doff PPE appropriately and to disinfect surfaces
The College acknowledges and thanks the College of Midwives of BC for the use and adaptation of their pandemic planning and patient care materials.