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PubMed1989

Do you need an external consultant? A model for decision making.

Consultation is an integral part of the clinical nurse specialist (CNS) role. Some problems, however, are best resolved by a consultant from outside of the organization. This paper presents a decision-making model for use by CNSs in determining the need for an external consultant. The decision-making model involves two general steps. Each step introduces a series of incumbent questions. In the first step, the nature of the problem is assessed, and questions about the philosophical foundation, theoretical framework, and problem substruction are introduced. In the second step, the requirements for solution of the problem are described, precipitating questions about the consultant role requirements, role functions, and introspection and evaluation. Through systematic questioning about the nature of the problem and the solution requirements, the CNS may make an informed decision regarding the recommendation to employ an external consultant. An overall blueprint for the systematic questioning in this decision-making process is presented.

Attitude↗
PubMedDate not supplied

[Objectives of consultation in anesthesia].

Recently developed in France (1970), pre-anaesthetic consultation continues to gain in importance because of a number of considerations. Psychological considerations: Consultation provides information about the patient to be operated, wins the patient's co-operation for his/her preparation for operation, and takes some of the drama out of surgery and anaesthetic. Medical considerations: More complete pre-operative examination (discovery of hereditary defects, and current medication) carried out by means of a long and very methodical interrogation, difficult to do at the patient's bedside. The best and most accurate possible assessment of the anaesthetic risk will reduce per- and post-operative complications or at least reduce their effects by better prevention and preparation of the patient, notably in the case of patients with respiratory problems, following possible complementary examinations or other specialized consultations. Anaesthetic considerations: By means of the choice and discussion of an anaesthetic technique according to the patient's own wishes, the anaesthetic risk, the type of hospitalization, especially in ambulatory anaesthetic, when pre-anaesthetic consultation is indispensable. Care coordination: The anaesthetist doctor assumes a double role of clinician and coordinator with the surgical team, the other specialists, and especially the general practitioner whose work he will continue when the patient is hospitalized, and who will have a leading role in the pre-operative preparation of the patient, and the realization of complementary examinations often carried out at home. The consultation makes for a per-operative approach which is carried out earlier, is more complete and more humane.

Anesthesia↗
PubMed1988

Data omitted from psychiatric consultation notes.

To assess how often psychiatric consultants omit written data from their consultation notes, the authors reviewed 78 initial consultation notes written by second-year psychiatric residents. Data considered essential for an adequate psychiatric evaluation were typically omitted. Categories that were observed to have the highest frequencies of missing data included family history of psychiatric illness (60.3%), history of substance abuse (44.9%), marital status (37.2%), previous psychotropic drug use (35.9%), previous psychiatric treatment (26.9%), and patient history of psychiatric illness (24.4%). The frequencies of omissions were significantly (p less than .001, except for the last item, p less than .01) higher than those from the consultation notes written by a second cohort of psychiatric residents who used a worksheet that listed data categories. The authors' findings argue for the use of worksheets delineating data categories to ensure that clinicians write adequate consultation notes.

Data Collection↗
PubMed1986

Minor psychiatric morbidity and general practice consultation: the West London Survey.

Data from a large-scale (N greater than 3000) community survey (the 'West London Survey') were used to examine the effect of minor psychiatric morbidity on the probability of contact with primary medical care, and factors which influenced this effect. The presence of such morbidity was found to double the probability of consulting, and about one-fifth of consultations could be attributed to it. Logistic analysis was used to investigate the joint effect on general practice consultation of minor psychiatric morbidity, three other health-related variables and five sociodemographic variables. It was found, as expected, that the health variables exerted much more influence on consulting than the sociodemographic variables, but that the relationship was characterized by complex interactions between health and sociodemographic variables. In particular, sex, socioeconomic status and minor psychiatric morbidity interacted in their effect on the probability of general practitioner consultation. The findings are interpreted in the context of previous theoretical and empirical work.

Adolescent↗
PubMedDate not supplied

The corporate nurse consultant.

With the increase in for-profit, multi-hospital, corporate systems, a new nursing role has evolved: that of corporate nurse consultant. This article discusses how the role and functions of this consultant differ from those of an independent consultant. It also describes the corporate nurse consultant's responses to integrating corporate imperatives with the needs of individual institutions. Suggestions are offered for enhancing the relationship between the corporate nurse consultant and an institution's nurse executive.

Administrative Personnel↗
PubMed1987

A nurse practitioner in general practice: working style and pattern of consultations.

The work of a specially trained nurse practitioner, to whom patients had open access, was studied in an inner city general practice over a period of six months in 1983. A total of 858 patients of all ages and ethnic origins sought consultations for 979 problems. Morbidity from every diagnostic group was presented but the majority of the problems (60.4%) fell into the 'Supplementary' group: preventive medicine; health instruction and education; social, marital and family problems; administrative procedures. The consultation room setting and the long appointment times available (20 minutes) may partly account for this. Additional problems, mostly concerning health education, were raised in 46.0% of consultations. Most patients chose a consultation with the nurse practitioner appropriately and in more than one-third of all consultations the nurse managed the presenting problem without further referral for investigation, prescription or other medical advice. It is concluded that nurses have a much larger and more autonomous part to play in the care of patients than hitherto.

England↗
PubMed1985

Obstetric consultations during labor and delivery in a university-based family practice.

This study retrospectively examined the use of obstetrical consultants by family medicine residents and faculty at the University of Washington Hospital from July 1, 1980, to June 30, 1981. Of 125 deliveries, 104 (83 percent) were vaginal deliveries, 99 percent of which were performed by the family physician involved. There were 21 (17 percent) cesarean sections. Before the audit began, 13 complications of labor and delivery were established as criteria suggesting the need for consultation. Medical records were retrospectively examined for complications meeting these criteria. Formal consultations occurred in 32 percent of all deliveries. Of the patients with at least one of the 13 complications, 75 percent had consultations obtained. Patients with these complications had intrapartum risk scores that were significantly higher than patients without the listed complications. Apgar scores at 1 and 5 minutes were significantly lower in the group of patients meeting the consultation criteria (7.0 vs 8.0 at 1 minute; 8.3 vs 9.0 at 5 minutes). The criteria successfully identified a group of high-risk patients and could be an appropriate guide for decision making in the specific setting studied. Patients without one of the predetermined complications had a low rate of surgical intervention (cesarean section or midforceps deliveries); the negative predictive value was 98 percent.

Adult↗
PubMed1979

The consultant dietitian in nursing homes. I. Methodology and general information.

The functions of the consultant dietitian and the foodservice supervisor were studied by surveying dietitians consulting in nursing homes and the administrators of each dietitian's nursing home accounts. Data were available from consultants and administrators in 297 nursing homes in a twelve-state, midwestern region. Almost 60% of the homes had employed a consultant for three to eight years, and nearly half had employed the present consultant for the same length of time. Generally, the dietitians made one to three visits to the homes a month, for a total of 3 to 12 hr. The administrators listed personnel, cost of department operation, and facilities as problem areas in foodservice. Dietitians reported greater concern than did administrators in all of the rated problem areas except cost. Problem ratings of the two groups reflected differences in interest and expertise.

Consultants↗
PubMed1979

The consultant dietitian in nursing homes. II. Functions and change effectiveness.

Data are reported on functions and effectiveness of consultant dietitians in nursing homes. Key responsibilities of the consultants included: Planning and writing menus, in-service training, nutritional assessment, and discussing diets with physicians. Activities performed on each visit to the nursing home were resident visitation and dietary consultation, nutritional assessment, communication with other departments, and checking foodservice and sanitation procedures. Most important activities of the consultant, as perceived by the administrators, were in three functional areas: Menu planning, modified diets, and education and training. Administrators indicated that the most significant change brought about by consultants involved modified diets, menus, sanitation, and communication between the foodservice department and other departments and with the administration.

Consultants↗
PubMed1982

[Empirical results on the consultation behavior of neurotic, psychosomatic and somatically ill patients II].

Three groups of out-patients classified by means of clinical diagnostics and testpsylogic characteristics as neurotic, psychosomatically and somatically ill, showed significant differences with regard to the variables 'duration of complaint', 'latency in seeking counseling', and 'number of consultants'. The data revealed a polarization concerning the positions of the neurotic and the psychosomatically ill patients. Neurotic patients exhibited an active participation in consultation characterized by critical evaluation of the physician's manner both in the professional and in the personal sector which must be classified as adequate to the complaint in question. The ulcer patients, in our investigation standing for psychosomatic patients, were passive in their participation in consultation and uncritical in regard to professional and personal aspects of the medical advice. Their significantly lower rate of changing consultants, compared to both the other groups, is interpreted as the expression of a specific object relation toward the physician they originally chose. Because of the somatically oriented qualification of the physicians consulted it can be stated that the behaviour of the psychosomatically afflicted patients is per definition inadequate to their illness since the psychic dimension of their suffering is not taken into account. The illness-dependent behaviour of the patients in the three groups under investigation may be interpreted as immanent to their afflictions.

Humans↗
PubMed1981

Liability of the pharmacist as a therapeutic consultant.

The legal implications of pharmacists serving as therapeutic consultants to other health professionals are discussed. The legal view of the consultant relationship and the relative liability exposure of the primary practitioner and the consultant are reviewed. The pharmacist's liability when serving as a therapeutic consultant is considered in light of the high standard of care that would probably be used in evaluating the pharmacist's performance. Other legal issues considered include potential criminal liability of the pharmacist, whether responses should be in writing, impact of charging for therapeutic consultation services, and coverage for such activities under professional liability insurance policies. By being aware of the legal implications in these areas, pharmacists may limit their liability exposure to an acceptable level.

Pharmaceutical Services↗
PubMed1980

Drug regimen review in skilled nursing facilities by consulting clinical pharmacists.

The organization and operational methods of clinical pharmacists providing contractual pharmaceutical services in skilled nursing facilities (SNFs) are described, and the use of a model toidentify drug therapy problems is analysed. A group of clinical pharmacists incorporated as Clinical Pharmacy Consultants (CPC) provided consultative services through contractual agreements with pharmacy vendors or SNF administrators. Using a drug regimen review model designed by CPC, the consulting pharmacists reviewed 13,081 medical charts at 10 SNFs. Of the reviews, 928 (7.1%) indicated potential or real drug therapy problems; on an annual basis this corresponds to approximately eight drug therapy problems per 10 beds per year in an SNF. About 60% of the problems could be attributed either to prescribing of medication with no documented indication (23.9%) or to lack of objective data for monitoring drug therapy effectiveness (34.6%). Because these problems are related to disease state management, it was concluded that consulting clinical pharmacists could help to improve patient care in SNFs, primarily through drug therapy review and staff consultation.

Consultants↗
PubMed1995

Paediatric consultation patterns in general practice and the accident and emergency department.

The age, sex, source of referral and diagnosis of children brought to a paediatric accident and emergency department by their parents were compared to those consulting their general practitioner. A simultaneous, prospective review of these consultations was carried out over a six-week period in an inner-city paediatric teaching hospital and a group practice in a socially deprived urban area. 730 children less than 13 years of age who presented for a new consultation were seen. 629 (86%) presented initially to the general practitioner, who dealt with all but 25 (4.0%) without onward referral to the accident and emergency department. 127 consultations took place at the accident and emergency department, of which 104 (82%) were parental referrals. There was no sex difference in children seen by the general practitioner. There was a decreasing trend with increasing age in the proportion of children who consulted the general practitioner, perhaps due to the higher frequency of injury in the older children. Over three quarters (77%) of injured children were brought directly to the accident and emergency department, compared with only 4% of children without injuries (p < 0.001). Of 22 children with injuries who presented to the general practitioner, only 4 (18%) required onward referral. General practitioners met the great majority of the paediatric workload generated by the practice. Audit between primary and secondary care gives a more reliable picture than data from only one source. Injured children are more likely to be taken to the accident and emergency department. Further study of the severity of injury in children is required to determine if there is potential to reduce parental referrals to accident and emergency departments.

Child↗
PubMed1995

[Pediatric consultations at the second-opinion level].

OBJECTIVE: To study the inter-consultations made with the second level by two out-patient paediatrics clinics, with regard to the reliability of the information system and the characteristics of the people referred in relation to the requested specialties. DESIGN: Descriptive. SETTING: Urban health centre. PATIENTS AND OTHER PARTICIPANTS: All children for whom a second level opinion was sought during 1993. MEASUREMENTS AND MAIN RESULTS: An inter-consultation was requested for 493 children, with an average age of 7.5. 65% were in the 6 to 14 age group, 33.3% in the 10-14 group. 45.4 of each 100 consultations were for ophthalmology, which, together with infant traumatology, dermatology, ENT and allergy, made up 87.8% of all the inter-consultations. Broken down by specialty, the most common reasons were: defects of refraction in ophthalmology; hip disorders in nursing children and feet problems, both in traumatology; changes in nevi, resistant eczemas and skin infections, all in dermatology; relapse cases of otitis and adenoiditis in ENT; and seasonal rhinoconjunctivitis (RCJ) in allergy. The result of the referral was known in writing in 31.6% of cases. The reason for the referral was recorded in the clinical notes in 92.7% of cases. CONCLUSIONS: The total number of referrals depends on the limit of paediatric age. By children's ages, the referrals most requested were: less than one month to cardiology, from 1 to 12 months to traumatology, from 2 to 3 years to ENT, over 9 to allergy and over 12 to ophthalmology, traumatology and endocrinology. Almost half the consultations are for ophthalmology, the main reasons being problems in refraction and the check-ups engendered by this problem. An internal channel to return information needs to be established.

Adolescent↗
PubMed1995

Consultation in family practice obstetrics.

PURPOSE: To examine the types of non-low-risk obstetric patients managed by family physicians in urban teaching hospitals, and to determine indications for consultation for women at low risk when labour began. METHOD: Retrospective chart review for all patients delivered by family physicians in three downtown Toronto teaching hospitals during 1 year. RESULTS: Of 1710 cases, 595 (34.8%) were classified as non-low risk, with the main indications being postdates (> 42 weeks) (19.9%); pregnancy-induced hypertension (19.3%); and premature labour (< 37 weeks) (14.8%). Of the 1115 low-risk patients, 363 (32.6%) had an intrapartum consultation, usually for failure to progress (50.1%) or fetal distress (12.7%). More than 80% of intrapartum consultations were associated with induction and augmentation of labour. CONCLUSION: Family physicians can continue to care for many non-low-risk women, usually with the help of obstetricians. Consultations were obtained for many women at low risk. We need to reevaluate whether some mandatory consultations are necessary in family practice obstetrics.

Family Practice↗
PubMed1993

Preoperative intensive care unit consultations: accurate and effective.

OBJECTIVES: To determine if a structured preoperative ICU consultation would correctly assign patients to preoperative invasive monitoring, postoperative ICU care, or recovery room care, and to compare morbidity, mortality, and resource utilization among all groups. DESIGN: Prospective, observational study. SETTING: A university hospital. PATIENTS: A total of 475 patients who were referred preoperatively by surgeons for ICU consultation and were evaluated by ICU physicians. INTERVENTIONS: Patients assessed to have clinical evidence of cardiovascular compromise were admitted preoperatively to the ICU for invasive hemodynamic monitoring and optimization. Patients without such evidence, but who were to undergo major operations or had anticipated major fluid replacement were independently selected for invasive monitoring by anesthesiologists. Patients who developed physiologic instability or became unstable due to hemorrhage also underwent invasive monitoring. Nonmonitored patients who remained stable were given postoperative ICU care or went to the recovery room based on an assessment by the surgeon and anesthesiologist at the end of the operation. MEASUREMENTS AND MAIN RESULTS: Of 8,916 elective surgical cases, ICU physicians were consulted in 475 (5.3%) patients preoperatively. Sixty-seven patients were admitted preoperatively to the ICU for invasive hemodynamic monitoring and optimization; 60 patients had surgery (0.7% of elective cases, 12.6% of ICU consultations). Patients selected for ICU preoperative monitoring were older than non-monitored patients and had higher numbers of cardiovascular and total risk factors than any other group. They had higher Acute Physiology and Chronic Health Evaluation (APACHE II) scores, higher Therapeutic Intervention Scoring System (TISS) points, a higher number of complications, and longer ICU stays than non-monitored postoperative ICU patients. In addition, they had a higher number of complications than nonmonitored recovery room patients. APACHE II scores, TISS points, number of complications, and ICU days in the preoperative ICU admission group were not increased when compared with all other monitored patients. Neither hospital days nor total hospital charges were increased when compared with the other elective ICU patients. Patients selected for ICU preoperative monitoring who underwent surgery had an 11.7% mortality rate and accounted for four of five cardiovascular-related deaths. CONCLUSIONS: A small number of high-risk patients can be selected for preoperative monitoring on the basis of clinical assessment without increasing ICU stay or hospital bills. A structured preoperative consultation correctly identifies those patients who need monitoring and ICU care, but does not overutilize scarce and expensive ICU beds.

Aged↗
PubMedDate not supplied

[The blood bank as a consultation service].

This is a 6-month prospective clinical trial which evaluates the importance that blood bank may have as a consultation service for in-patient care. From January 31-July 31 1994, the blood bank physicians gave 108 consults which helped the consulting physician in an adequate diagnostic and therapeutic management of transfusion-related problems. The main reasons for consultation were coagulopathies, suspicion of refractoriness to platelet concentrates, and presence of antibodies against red cell antigens. The main underlying disorders were hematological, surgical, hepatic, renal and rheumatic diseases. We conclude that our blood bank as a consultation service was helpful in improving the transfusional management of our patients.

Blood Banks↗
PubMed1996

[Repeat consultations in pediatric hospital emergencies].

The objectives of this study were to analyze the social and clinical aspects of the infant and child population who excessively utilize the hospital emergency services. To this end, the clinical histories of 130 children admitted to a pediatric hospital have been analyzed. These children were between the ages of 2 months and 10 years and had 10 or more visits to the emergency room or had more than 4 visits during the same year. The control group was arbitrarily composed of 270 children admitted to the same service during the same period of time. We found that in the study group the sociocultural level was low in 71% and 17% had serious social deprivation (significant differences with the control population, p < 0.05). Twenty percent had at least one previous febrile convulsion (p < 0.001) and 33% had more than four hospital admissions. No significant differences in the number of urgent consultations were found between the different days of the week no between the different months. The most frequent diagnosis was upper respiratory tract infections. The number of consultations was higher (p < 0.05) in children with serious social deprivation, chronic pathology, multiple hospital admissions and whose home was near the hospital. We conclude that children with reiterative consultations to the hospital emergency services usually have a social level lower than the control group. Most of these consultations are caused by banal problems and the children are subjected to an excessive number of analytical and radiological tests. Therefore, adequate health education is necessary among these sociocultural level groups in order to avoid using the emergency services as primary attendance consultations.

Child↗