Consults for Dummies

I discontinued a consult today without assessing the patient.

This wasn’t the first time I did that and it won’t be the last. The consult was for tube feeds. The patient did not have any enteral nutrition at this or any time in his history. The error was likely due to a simply mistake made by the nurse while screening the patient. The same mistake happens on a daily basis on every floor in our hospital.

Hospitals complete a screening process for their inpatients. Every person admitted

to a hospital will have a nursing assessment completed. Part of the assessment is nutrition status where a few basic questions may lead to a nutrition consult.

Overall, this is a great process. When this screening process works, it correctly identifies patients who are malnourished or who are at risk of becoming malnourished and catches other nutrition-related problems. The dietitian will assess the patient within 48 hours (according to our policy), and the goal is that this will lead to improved patient outcomes.

Do We Help?

On an anecdotal level, I think we do to a certain extent. If I have a person who comes into the hospital and has a specific need or condition that may be missed by the nurse or doctor, then I can address the problem promptly. Certainly, anyone on nutrition support will need to be seen by a dietitian. I see the greatest benefit in patients who have multiple medical complications, digestive problems/disorders, and underweight.

The evidence may not be as positive though. I’ve not extensively researched nutrition screening, but a 2013 Cochrane review found that current evidence did not support the effectiveness of nutrition screening. On the flip side, the authors also found that there wasn’t evidence of no effect. Nutrition screening happens to be in a gray area and, as always, “more high qualities studies should be conducted” was the take-away message.

To delve a little deeper into this study, only three studies were included in the review. One study found that patient’s weight increased due to intervention. Another study found weight gain and a reduction in hospital-inquired infections. There wasn’t any significant difference in the length of stay, pressure sores, malnutrition, and treatment costs.

Do We Hurt?

I hesitate to discuss this but I do think it’s important to consider the potential of harm. My conclusion is a firm no. I’ve seen and assessed many patients who had no nutrition-related problems. I wasted some of their time but, as I’m a fairly pleasant person, I think they appreciated talking to me for a few minutes. If a dietitian assesses someone who isn’t at nutritional risk, the greatest potential harm is that the hospital isn’t using their resources wisely.

Think about a dietitian who has to see 15 patients. Based on an 8-hour workday, she’ll have to see about one patient every 30 minutes which is pretty tight. Sure, the dietitian may end up staying late, but if this is her daily work load, she’s going to try to make everyone fit into that day. She’ll try to get in and out of her patients rooms as quickly as possible. This workload has the potential to harm the legitimate consults. If all 15 of those consults are valid, then the hospital may want to hire more dietitians. However, if even three of them are error consults, then that dietitian is wasting 90 minutes of her day.

Conclusion

I do occasionally cancel consults but, more often than not, I end up seeing them even if they aren’t appropriate. There is a concern that, if you don’t see a consult, you’ll be reprimanded by your manager even if there is a legitimate reason. Our managers also strongly discourage discontinuing consults which further leads to inefficiency.

We have to follow our clinical policies but we also need to prioritize our high risk patients over incorrect screens. I do err on the side of caution, but it’s incredibly important that we don’t waste our time. As dietitians, I would encourage each of us, including myself, to discontinue inappropriate consults and instead spend our valuable time on areas where we are most needed.