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PubMedDate not supplied

Consultant nurse: an appropriate title for the advanced nurse practitioner?

The term 'consultant nurse' has been offered as an appropriate title for the 'advanced nurse practitioner'. Although both share similar roles and functions the way that each will perform within these roles will differ. Many of the principles and processes involved in consultancy may be viewed by nurses as incongruent with nursing practice, including the relationship between the consultant and the consultee and the view that the consultant nurse should not have a direct care role. The title itself has medical connotations and therefore is viewed negatively by many nurses as it conjures up a view of an aloof, elitist practitioner. Nursing is unique, and although many of the processes involved in consultancy are appropriate to nursing they should only be used in a way that keeps the patient at the centre of care. The title is therefore seen as inappropriate for the advanced nurse practitioner.

Clinical Competence↗
PubMedDate not supplied

Differentiating between a consultant nurse and a clinical nurse specialist.

With the introduction of nurse consultants, and regulation of the use of the designation 'specialist nurse', experienced practitioners such as clinical nurse specialists have seen their position eroded. Nurse consultants are a new NHS-employment category, and are expected to be at the top rank of the profession both in status and in salary. However, this article argues that nurses at various levels have the same core functions, and that these do not differ for nurse consultants. Distinguishing between practitioners that might have the same job description could be better done by measuring outcomes. More care needs to be taken over the use of words such as 'expert', which is used differently in different contexts, and it is suggested that competencies be developed by which to measure the effects of expertise. Although nurse consultant appointments are often driven by various political directives and they are employed to meet local and national priorities, difficult issues need to be faced. First, if nurse consultant jobs are the top of the clinical career ladder, will clinical nurse specialists (CNSs) need to accept a lower rung on it? Further, perhaps the title CNS should become obsolete or be regulated? Can CNSs claim parity of pay using the 'Agenda for Change' framework?

Attitude of Health Personnel↗
PubMed2003

Intraoperative consultation for renal lesions. Implications and diagnostic pitfalls in 324 cases.

Intraoperative consultation rarely is requested for lesions in the kidney. Of 324 renal lesions submitted for gross or frozen section intraoperative consultation, 199 specimens were submitted for gross consultation only; no diagnostic pitfalls were noted. The clinical implications and diagnostic pitfalls in 125 specimens submitted for frozen section were the focus of our study. Frozen section intraoperative consultation was requested to evaluate surgical margins in partial nephrectomy specimens, solid renal mass in an unusual clinical or radiologic setting, synchronous renal and extrarenal masses, cystic renal lesion, ureteral surgical margins for transitional cell carcinoma, multiple renal masses, solid mass in a diffusely cystic kidney, and renal injury. Among the 125 cases, the diagnoses were deferred in 17 (6 renal cell carcinomas with granular cytoplasm, 7 cystic lesions, 3 metastatic tumors, 1 leiomyoma). The frozen section diagnoses were incorrect owing to limited sampling in 5 and misinterpretation in 4 (melanoma vs angiomyolipoma, lymphoma vs angiomyolipoma, benign cyst vs cystic renal cell carcinoma, metastatic renal cell carcinoma vs pheochromocytoma). Awareness of distinctive indications for frozen section intraoperative consultation and diagnostic pitfalls should improve diagnostic accuracy and facilitate proper management of these lesions.

Diagnosis, Differential↗
PubMed2002

Quantifying the value of in-house consultation in surgical pathology.

In-house consultation is a well-known method to improve diagnostic accuracy and agreement, but the technique has not been well studied. We reviewed the results of in-house consultation in a large private hospital practice setting for a 1-month period and determined its effect on diagnostic accuracy using the final sign-out as the "gold standard." During this 1-month period, 352 cases were reviewed as in-house consultations. Initial complete agreement was found in 315 (89.5%) cases. Using the initial diagnosis as the test case and the final sign-out as the gold standard, of the 37 discrepant cases, 4 (1.1%) were thought to represent false-negative results, (0.3%) a false-positive result, 3 (0.9%) differences in type, and 29 (8.2%) differences in diagnostic threshold. Disagreements in 10 cases were thought to be potentially clinically significant. Internal consultation was obtained on approximately 20% of all cases seen in the laboratory and disagreements were found in 2% of all cases. Internal consultation has a significant and measurable impact on the practice of surgical pathology.

False Negative Reactions↗
PubMed1981

The effectiveness of cardiology consultation. Concordance with diagnostic and drug recommendations.

In an effort to characterize the effectiveness of cardiology consultation, the outcomes of consultants' recommendations for diagnostic actions and cardiac drugs were quantitatively examined in 394 cases. Drug recommendations were made more frequently (49 percent) than diagnostic recommendations (38 percent) and were associated with a higher rate of concordance (82 percent to 64 percent). Recommendations to start therapy with a drug, especially an antihypertensive or an antianginal, were associated with a lower concordance rate than recommendations to continue or discontinue drug therapy. Consultees' responses to recommendations for diagnostic action did not vary significantly according to the type of action suggested. Nonconcordance with diagnostic suggestions was particularly high when a service made a large number of consult requests. Concordance was increased if the consultant left a follow-up note. Consultees' responses to drug and diagnostic recommendations were independent of one another. The study represents the first systematic assessment of cardiology consultation activities and provides a methodology for subsequent studies.

Adult↗
PubMed2006

The profession of ferryman: considerations on the analyst's internal attitude in consultation and in referral.

Psychoanalytic consultation is an interview with a patient who will not be taken in treatment by the consultant analyst, but who will be sent to another, perhaps specifically chosen, colleague after one or more assessment sessions. This practice is becoming increasingly important since, besides traditional private relationships between consultant and patient, it is now common in many specialized centres affiliated to official psychoanalytical institutions. The author explores some fundamental aspects of the analyst's internal attitude in consultation: motivation to know; a 'concave' attitude to listening; responsibility in proposing suitable technical choices and referral to a further specialist; empathy and partial identification; the balance between authentic experience in the consultation and risks of seduction; internal links within the community of colleagues; the technique for sending patients on. He presents a clinical example, specifically aimed at reproducing the internal attitude of the analyst, together with the necessary work that allows a difficult patient to initiate psychoanalytic treatment.

Adult↗
PubMed2005

Prenatal consultation practices at the border of viability: a regional survey.

OBJECTIVE: We undertook a survey of all practicing neonatologists in New England to determine their attitudes and practices regarding prenatal consultations for infants at the border of viability. METHODS: A self-administered anonymous survey, mailed to every practicing neonatologist in the 6 Northeast states of Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont, explored respondent attitudes and practices with respect to a hypothetical clinical scenario of a prenatal consultation for an infant at the border of viability. RESULTS: Our final sample included 149 surveys from 175 eligible neonatologists, giving a response rate of 85%. Seventy-seven percent of respondents indicated that they thought neonatologists and parents should make the decision jointly to withhold resuscitation. Only 40% indicated that the decision actually is made by both parties. A majority of neonatologists (58%) saw their primary role during the prenatal consultation as providing factual information to the parents. Far fewer (27%) thought that their main role was to assist the parents in weighing the risks and benefits of various management options. A majority of respondents indicated that parental understanding of the mother's current medical situation (96%), desired parental role (77%), and parental prior experience with premature or handicapped children (64%) were frequently or always discussed. However, far fewer respondents reported frequently or always asking about parental interpretations of a "good quality of life" (42%), parental prior experiences with death or dying (30%), and parental religious or spiritual beliefs (25%). Short-term outcomes and complications such as the need for surfactant/respiratory distress syndrome (89%) and the risk of intraventricular hemorrhage (81%) were discussed more extensively than long-term outcomes such as motor delays or cerebral palsy (68%), cognitive delays or learning disabilities (63%), and chronic lung disease (61%). Multivariate logistic regression analysis revealed 2 characteristics that were significant predictors of shared decision-making for the final decision regarding resuscitation in the delivery room for extremely premature infants, ie, believing that the main role of the neonatologist during prenatal consultations is to help parents weigh the risks and benefits of each resuscitation option (odds ratio: 4.1; 95% confidence interval: 1.6-10.9) and having >10 years of clinical experience (odds ratio: 3.6; 95% confidence interval: 1.5-8.8). CONCLUSIONS: Overall, our results showed that neonatologists are quite consistent in discussing clinical issues but quite varied in discussing social and ethical issues. If neonatologists are to perform complete prenatal consultations for infants at the border of viability as described by the latest American Academy of Pediatrics guidelines, then they will be expected to address quality-of-life values more robustly, to explain long-term outcomes, and to incorporate parental preferences during their conversations. Potential barriers to shared decision-making have yet to be outlined.

Attitude of Health Personnel↗
PubMed2003

Outcomes of dual-protease inhibitor salvage therapy in human immunodeficiency virus-infected patients referred to a telephone consultation service.

OBJECTIVE: To determine the clinical outcomes of dual-protease inhibitor salvage therapy in heavily experienced patients after their providers consulted the National HIV Telephone Consultation Service (Warmline, 800-933-3413). DESIGN: Observational survey study. SETTING: Consultation service for United States health care providers. PATIENTS: Thirty-one human immunodeficiency virus (HIV)-infected patients who had received previous treatment with at least two protease inhibitor--or nonnucleoside reverse transcriptase inhibitor--based regimens and had a viral load of at least 1000 copies/ml. INTERVENTION: Patients whose providers consulted Warmline regarding antiretroviral salvage regimens were identified through a review of telephone calls from January-July 2001. Virologic and immunologic outcomes were determined for patients who had received a regimen containing either ritonavir and indinavir or ritonavir and amprenavir. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were percentages of patients with a viral load less than 500 copies/ml at 3 and 6 months and changes in log10 viral load and CD4+ cell count at 3 and 6 months compared with baseline values. By using intent-to-treat analysis, a viral load less than 500 copies/ml was achieved in 35% of the 31 patients at 3 months and in 32% of them at 6 months. By using as-treated analysis, this outcome was achieved in 48% of 23 patients who continued therapy at 3 months and in 59% of 17 patients who continued therapy at 6 months. At 3 months (23 patients) and 6 months (17 patients), respectively, changes in viral load were -1.7 log10 copies/ml (p<0.001) and -1.4 log10 copies/ml (p<0.001), and changes in CD4+ cell count were +99 cells/mm3 (p<0.001) and +95 mm3 (p=0.012), compared with baseline. CONCLUSION: Significant improvements in virologic and immunologic markers occurred in patients heavily experienced with antiretroviral therapy after starting dual-protease inhibitor treatment regimens. Salvage therapy guided by Warmline consultation appears to be beneficial for this patient population with limited treatment options.

Acquired Immunodeficiency Syndrome↗
PubMed1992

Ongoing consultation as a method of improving performance of staff members in a group home.

A model of ongoing consultation was implemented in a community group home for 8 adults with severe and profound mental retardation. Two consultants, highly experienced in working with people with mental retardation and in the procedures used in group homes, taught staff members to use a token reinforcement system, to engage the adults in a variety of activities, and to improve the content and style of the staff members' interactions with the adults. The consultants taught skills to 9 staff members through brief mini-workshops, direct observation of the staff members' use of the skills during regular activities in the group home, and individual verbal feedback regarding a staff member's performance of the skills. Evaluation of the ongoing consultation process by the 2 consultants showed it to be effective in improving the performance of the staff members and in changing the behaviors of the adults who lived in the home. Continued implementation of the process, however, appeared to be necessary for the behavior changes of staff members to be maintained at high levels.

Adolescent↗
PubMed1980

Anti-rabies treatments in New Mexico: impact of a comprehensive consultation-biologics system.

Fewer than 20% of the 30,000 anti-rabies treatments administered in the United States each year are necessary. New Mexico established a comprehensive consultation-biologics program to assist physicians in making appropriate and systematic rabies treatment decisions. In 1978, 32 individuals received anti-rabies treatments as the result of 144 physician consultation requests. Dog and cat exposures accounted for 70 per cent of consultations and 63 per cent of the treatments. A seasonal peak of both consultations and treatments was observed in the summer and early autumn. The cost of biologics was $212 per treatment. Coordinated use of laboratory diagnostic services and animal control resources obviated the need for treatment in over 60 per cent of the 112 consultations not resulting in treatment. Experience in 1978 suggested that the system was probably responsible for a greater than five-fold reduction in the annual rate of anti-rabies treatments in New Mexico. Efficient physician utilization and high acceptability of the program may be attributed to maximization of private sector input into design and implementation of this public health program.

Adult↗
PubMed1989

Length of hospital stay of medical and surgical inpatients referred for psychiatric consultation: a retrospective study.

Retrospective analysis of 406 consecutive psychiatric consultations with general hospital inpatients revealed that their mean length of stay (LOS) was 26.1 days, while the mean LOS of the other hospital patients was only 11.1 days. In 36.5 percent of the consultation patients the LOS in hospital was longer than that exceeded by 10 percent of the hospital patients. The factor most strongly related to a very long LOS of psychiatric consultation patients appeared to be the referring ward. Particularly on cancer wards very long LOS patients were referred to the psychiatrist. The psychiatric consultant often supported the ward staff by making recommendations for the management of such patients. Patients with a long LOS might be a suitable group for carrying out a controlled cost-effectiveness study of psychiatric consultations in a natural setting.

Adolescent↗
PubMed1989

Psychiatric consults on medical and surgical wards: a six year study.

Using a psychiatric consultation database 1,463 consults were completed over a six-year period (1980 to 1986). Many variables were studied, including demographics, who requested the consults, the reasons for consultation, DSM-III diagnoses, and treatment recommendations. Most variables were unstable from year to year despite thorough and consistent supervision. This study demonstrates the vulnerability of traditionally reported consultation data in establishing norms for defining psychiatric morbidity in the hospital. Future recommendations are discussed.

Adult↗
PubMed1985

Radiologist as consultant: direct contact between referring clinician and radiologist before CT examination.

The need for better direct communication between referring clinicians and radiologists has recently been emphasized. Responding to this need, a system was designed and implemented that used a radiologist as a consultant for scheduling body computed tomographic (CT) examinations. Under this system (in the "experimental" period), the referring clinician was required to consult with a body CT radiologist to schedule an examination in addition to completing a standard written radiology requisition. Before implementing this system (in the "control" period), only the written requisition was required. Ninety-five percent of referring clinicians were willing to cooperate with the new system. Benefits of the verbal consultation system included obtaining more clinical information (p less than 0.001) than was on the requisition alone (2.05 +/- 1.72 extra clinical data items), formulation of improved scanning protocols, a reduction in the number of post-CT diagnostic tests, and improved clinician-radiologist rapport. The costs of the system were mainly the nearly 5 min it took to schedule each case. It was concluded that a system that uses the radiologist as consultant and requires oral consultation between clinicians and radiologists can be implemented and has measurable benefits for patient care.

Economics, Medical↗
PubMed1990

Job-stress and medical consultation rates for physical illness among blue collar workers of an electrical factory in Japan: a four-year prospective follow-up study.

To investigate the relationship between job-stress and medical consultation rates for physical illness, a prospective study was conducted for male blue workers of an electrical factory in Japan. 8 job-stress variables and 8 possible confounders were assessed by means of mailed questionnaires in the initial study; 375 workers without medical history of illness were followed for four years; they were interviewed once a year and medical consultations for physical illness were recorded. Age-adjusted rates of medical consultation during the four-year period were significantly higher in the subjects with higher job-dissatisfaction scores than in those with lower job-dissatisfaction scores (p less than 0.05). The results of the multiple logistic regression analysis indicated that job-dissatisfaction together with age and education was significantly correlated with medical consultation (p less than 0.05). The results suggest that job-dissatisfaction is a potential factor for medical consultation in Japanese blue collar workers.

Adult↗
PubMed1996

Progress and evaluation of a consultation-liaison psychiatry service to an obstetric-gynaecology hospital.

OBJECTIVE: Recently we described the establishment and first 6 months of a psychiatric consultation-liaison service to a Melbourne obstetric-gynaecology teaching hospital. The follow-up report evaluates the service in two ways: first, it compares referral data for the 12 months of 1992 with that of the first 6 months of operation in 1990; and second, it reports on results of a survey of referrer and patient satisfaction with the service. METHOD: Referral data were collected for the data comparison from the consultation-liaison referral book and patients' files. Referrer and patient satisfaction was evaluated by questionnaires sent to 45 medical staff, 7 charge nurses, and 100 consecutive patients. RESULT: A fairly constant referral rate for inpatients has emerged at 0.8%, this very low referral rate being some cause for concern. An internal shift in the type of referrals over time has developed, with an increase in obstetric and a decrease in gynaecology referrals. High referrer satisfaction, with 86% of the doctors finding the consultation(s) "very" or "quite" helpful, and high patient satisfaction, with 83% of respondents having found the consultation(s) "very" or "quite" helpful, was found. CONCLUSIONS: Despite high referrer and consumer satisfaction, and objective evidence of need, this pioneering consultation-liaison service in obstetric-gynaecology continues to be grossly under-utilised. Increasing the referral rate will be one of the greatest challenges in the future of this service.

Adaptation, Psychological↗
PubMed1993

Ethnicity as a risk factor for consultations in primary health care and out-patient care.

OBJECTIVE: To determine the influence of ethnicity, defined as foreign-born people, on consultation rates, admissions and prescriptions in out-patient care and primary health care. DESIGN: Prospective study of attenders at four different caregivers during seven consecutive weeks in 1988. Age-and sex-standardized relative risks and odds ratios with 95% confidence interval were calculated. SETTING: A suburban area in Lund, a city located in the south of Sweden, with 28% foreign-born people. SUBJECTS: This population (N = 5085) made 1,348 consultations. MAIN OUTCOME MEASURES: Ethnic group and consultation rates of the local primary health care centre, the emergency department, hospital out-patient department, and private care, admissions to specialist care, prescriptions, and certified sick leave. RESULTS: Swedes made fewer age-and sex-standardized visits to the emergency department (RR = 0.69(0.48-0.99)) while the foreign-born people showed an opposite non-significant trend (RR = 1.37(0.95-1.99)). Latin Americans (RR = 1.60(1.02-2.51)) visited the local Primary Health Care centre in the residential area more than expected, while people born in Asia and Africa consulted the Primary Health Care centre less than expected (RR = 0.44(0.28-0.69)). There were no differences between Swedes and foreign-born people in being put on the sick-list, but foreign-born people were given significantly fewer prescriptions (RR = 0.07(0.03-0.19)) than Swedes. Foreign-born people, Latin Americans, and non-Swedish Scandinavians were referred significantly more often to hospital than other groups. CONCLUSIONS: There were important differences in consultations between Swedes and foreign-born people. It seems important to study these differences further to find out if they were due to morbidity or cultural differences in order to be able to meet the demands and needs of different ethnic groups.

Africa↗
PubMed1996

The third party in general practice consultations.

OBJECTIVE: To describe the impact of outside agents in doctor-patient consultations. DESIGN: In-depth group discussions with psychoanalytically oriented leadership. SETTING: A Balint group which met weekly for two years. SUBJECTS: 15 senior general practitioners with an interest in teaching. FINDINGS: Outside agents are almost invariably present in general practice consultations. The "third party" in the consultation fitted four separate categories according to its helpful or disturbing, real or projected characteristics. CONCLUSION: The dyadic nature of general practice consultations is illusory. The third party is an inherent component of the consultation and may be used consciously to gain extra insight into the needs of patients and their doctors.

Consultants↗
PubMed1981

Noninteractive emergency consultation for acute intoxication.

The delivery of consultation for treatment of acute intoxication encounters several obstacles. The physician must recognize the case with which he needs assistance; he must be aware that assistance is available; the help must be technically correct; the delivery system must maintain responsible professional continuity while providing consultation at the time and place where it is required. The consultation must be appropriate to the clinical problem at hand in that immediate life-threatening aspects are covered quickly while continuing care and principles are deferred. Availability of specialized equipment and drugs must be assured by some method of precrisis communication. A system for delivery of telephone consultation for the treatment of acute intoxication is described. The system is based on a collection of prepared tapes, providing consultation of 3 to 6 min duration, oriented toward specific topics such as etiologic substances, common clinical syndromes, and commonly encountered complications. The advantages and disadvantages of the program are discussed.

Acute Disease↗