Discharge from the hospital is a vulnerable time for patients. Nearly 1 in 5 patients experiences an adverse event during this transition, with a third of these being likely preventable.1, 2 Comprehensive discharge instructions are necessary to ensure a smooth transition from hospital to home, as the responsibility for care shifts from providers to the patient and caregivers. Unfortunately, patients often go home without understanding critical information about their hospital stay, such as their discharge diagnosis or medication changes,3, 4 leaving them both dissatisfied with their discharge instructions5 and at risk for hospital readmission.

Efforts to improve discharge education have focused on increasing communication between care provider and patient. The use of designated discharge coordinators,6, 7 implementation of teach‐back techniques to assess and confirm understanding,8 and adoption of patient‐centered educational materials all offer tools to improve communication with patients. However, guidelines for communication between providers and their shared role in patient discharge education, particularly between nurses and physicians, are scarce. Daily interdisciplinary rounds9 and shared electronic health records are potential ways to foster such communication, but the methods and frequency with which providers communicate about discharge instructions with each other is poorly understood. Furthermore, despite a common set of goals for discharge instructions,10, 11 it is unclear where the responsibility to provide these elements lies: with nurses, physicians, neither, or both.

Understanding perceptions and communication practices of providers in their delivery of discharge instructions is an important first step in defining responsibilities and improving accountability for discharge education. In this study, we surveyed nurses and physicians about their discharge education practices to better understand how each group sees their own role in discharge teaching, and how these findings may generate recommendations to improve future practices.

METHODS

RESULTS

One hundred twenty‐nine providers responded to the survey with an overall survey response rate of 129/184 (70%). Forty‐five (64%) nurses, 56 (71%) interns, and 28 (78%) hospitalists participated. We organized the results into 4 sections based on the survey's question domains. First, we analyzed providers' (defined as nurses, interns, and hospitalists) perceived responsibility for the elements of patient discharge education (see Supporting Information, Text Box, in the online version of this article). Second, we examined how providers' responsibility compared to their reported practice. Third, we looked at the communication between nurses and physicians on the care team around these shared elements of discharge education. Lastly, we looked at providers' willingness to adopt tools to improve nursephysician communication around the time of discharge.

Discharge Education by Providers on the Care Team

Despite nurses' reluctance to claim sole responsibility for elements of discharge education, nurses on the whole reported providing discharge education more often than either interns or hospitalists (P < 0.05). Figure 1 illustrates each group's reported practice of communicating specific discharge education on a Likert scale. For the 9 elements viewed as a shared responsibility and the 2 elements where there was disagreement, nurses reported communicating most items significantly more often than both interns and hospitalists (P < 0.001 for all elements except reason for follow‐up appointments, explanation of diagnosis in lay terms, and changes to medication regimen made during hospitalization). Items that were reported to be a physician responsibility were communicated more often by interns and hospitalists than nurses (P < 0.005), but were the items least often communicated by any care provider. Hospitalists did not report communicating any items significantly more than interns.

Figure 1

DISCUSSION

Our study demonstrated that nurses, interns, and hospitalists all feel that they play a pivotal role in discharge education. Compared to both interns and hospitalists, nurses were more likely to view discharge education as a shared responsibility, but nurses also reported providing more discharge education to patients. The elements of discharge education deemed a physician responsibility were reported as the least often provided to patients. Despite the majority of responses indicating that discharge education is a shared nursephysician responsibility, reported provider communication about discharge education was infrequent. Arguing for more communication, elements for which nurses and physicians perceived communicating more frequently were also more often reportedly conveyed to patients. The summative findings suggest that inconsistent discharge education and communication between providers may be leading to patients who are not regularly receiving complete discharge information. Nurses, interns, and hospitalists, however, were all very engaged in potential solutions to improve discharge communication, providing opportunities for immediate impact.

The question becomes where to start. Poor discharge instructions are associated with increased hospital readmission,10 and comprehensive discharge education is a suggested strategy to reduce preventable readmissions.12 Academic hospitalists, despite likely having witnessed the negative impact of poor discharge education, were not more likely than interns to report educating patients, nor did they report communicating more often with nurses. In teaching institutions, specifically, discharge education is being provided by multiple physicians: interns, residents, and hospitalists who may not have clearly defined roles in providing discharge education.13 Thus, providing comprehensive discharge instructions may require a hardwired system to ensure all elements of discharge education are addressed.

Further, our increasing dependence on technology may paradoxically necessitate more formal structures for in‐person communication, as the ability to enter discharge orders remotely leads to less frequent direct communication. Fortunately, as institutions move to computerized systems for discharge orders and instructions, there are increasing opportunities for a standardized approach to the elements of discharge education. While these results may suggest that one individual should be solely responsible for discharge education, trials using teams of nurse practitioners to facilitate transitions of care found no difference in patient length of stay or 30‐day readmission rates.14, 15

Formal systems that increase communication in high‐risk circumstances remain a focus in patient safety, and have been implemented successfully in procedural settings and with handoffs in patient care.1618 A prominent example is operating room time‐outs, which implemented a structured tool and shared process to increase nursephysician communication and reduce mortality.19 Since elements of discharge education with more frequent communication between nurses and physicians were more often conveyed to patients, our results suggest that a discharge time‐out might offer similar benefit. Fortunately, nurses and physicians rated verbal communication as the most desirable solution to share discharge education information. While not formally evaluated, one solution may be adoption of the previously described critical conversation, a structured format and a consistent time for communication that ensures both nurses and physicians understand what education needs to be provided to patients and by whom.20 The 13 discharge elements outlined in our study now provide a starting point for defining specific discussion points at discharge, delineation of who should communicate each element, and the basis for developing an operational discharge time‐out.

There are several limitations to our study. First, the survey instrument was not previously used or validated. However, we did seek formal and structured input while developing our survey, and conducted pilot testing to ensure clarity and comprehension with representatives of all study groups. Second, the 13 discharge education elements we included do not represent a comprehensive list, and were chosen based on our literature review and best practices at our institution. Third, our cross‐sectional study only captures perceptions and practices during a single time point, and may not adequately capture the greater continuum of true practice. Finally, our results may not be generalizable outside UCSFMC or other academic medical centers, particularly if other institutions have employed specific structures for discharge, such as a dedicated discharge coordinator.

CONCLUSION

Discharging patients is a complex process and one in which multiple providers and poor systems contribute to the redesign challenges. Providing high‐quality discharge education instructions to patients is an important step in making a complex process safer. Poor communication between nurses and physicians, complicated by ambiguous perceptions of responsibility for specific information, offers an opportunity for improvement efforts. We should not let well thought out treatment plans fail due to poor patient education on discharge. Our findings argue for a more systematic approach to the discharge education provided by nurses, interns, and hospitalists.

Discharge from the hospital is a vulnerable time for patients. Nearly 1 in 5 patients experiences an adverse event during this transition, with a third of these being likely preventable.1, 2 Comprehensive discharge instructions are necessary to ensure a smooth transition from hospital to home, as the responsibility for care shifts from providers to the patient and caregivers. Unfortunately, patients often go home without understanding critical information about their hospital stay, such as their discharge diagnosis or medication changes,3, 4 leaving them both dissatisfied with their discharge instructions5 and at risk for hospital readmission.

Efforts to improve discharge education have focused on increasing communication between care provider and patient. The use of designated discharge coordinators,6, 7 implementation of teach‐back techniques to assess and confirm understanding,8 and adoption of patient‐centered educational materials all offer tools to improve communication with patients. However, guidelines for communication between providers and their shared role in patient discharge education, particularly between nurses and physicians, are scarce. Daily interdisciplinary rounds9 and shared electronic health records are potential ways to foster such communication, but the methods and frequency with which providers communicate about discharge instructions with each other is poorly understood. Furthermore, despite a common set of goals for discharge instructions,10, 11 it is unclear where the responsibility to provide these elements lies: with nurses, physicians, neither, or both.

Understanding perceptions and communication practices of providers in their delivery of discharge instructions is an important first step in defining responsibilities and improving accountability for discharge education. In this study, we surveyed nurses and physicians about their discharge education practices to better understand how each group sees their own role in discharge teaching, and how these findings may generate recommendations to improve future practices.

METHODS

RESULTS

One hundred twenty‐nine providers responded to the survey with an overall survey response rate of 129/184 (70%). Forty‐five (64%) nurses, 56 (71%) interns, and 28 (78%) hospitalists participated. We organized the results into 4 sections based on the survey's question domains. First, we analyzed providers' (defined as nurses, interns, and hospitalists) perceived responsibility for the elements of patient discharge education (see Supporting Information, Text Box, in the online version of this article). Second, we examined how providers' responsibility compared to their reported practice. Third, we looked at the communication between nurses and physicians on the care team around these shared elements of discharge education. Lastly, we looked at providers' willingness to adopt tools to improve nursephysician communication around the time of discharge.

Discharge Education by Providers on the Care Team

Despite nurses' reluctance to claim sole responsibility for elements of discharge education, nurses on the whole reported providing discharge education more often than either interns or hospitalists (P < 0.05). Figure 1 illustrates each group's reported practice of communicating specific discharge education on a Likert scale. For the 9 elements viewed as a shared responsibility and the 2 elements where there was disagreement, nurses reported communicating most items significantly more often than both interns and hospitalists (P < 0.001 for all elements except reason for follow‐up appointments, explanation of diagnosis in lay terms, and changes to medication regimen made during hospitalization). Items that were reported to be a physician responsibility were communicated more often by interns and hospitalists than nurses (P < 0.005), but were the items least often communicated by any care provider. Hospitalists did not report communicating any items significantly more than interns.

Figure 1

DISCUSSION

Our study demonstrated that nurses, interns, and hospitalists all feel that they play a pivotal role in discharge education. Compared to both interns and hospitalists, nurses were more likely to view discharge education as a shared responsibility, but nurses also reported providing more discharge education to patients. The elements of discharge education deemed a physician responsibility were reported as the least often provided to patients. Despite the majority of responses indicating that discharge education is a shared nursephysician responsibility, reported provider communication about discharge education was infrequent. Arguing for more communication, elements for which nurses and physicians perceived communicating more frequently were also more often reportedly conveyed to patients. The summative findings suggest that inconsistent discharge education and communication between providers may be leading to patients who are not regularly receiving complete discharge information. Nurses, interns, and hospitalists, however, were all very engaged in potential solutions to improve discharge communication, providing opportunities for immediate impact.

The question becomes where to start. Poor discharge instructions are associated with increased hospital readmission,10 and comprehensive discharge education is a suggested strategy to reduce preventable readmissions.12 Academic hospitalists, despite likely having witnessed the negative impact of poor discharge education, were not more likely than interns to report educating patients, nor did they report communicating more often with nurses. In teaching institutions, specifically, discharge education is being provided by multiple physicians: interns, residents, and hospitalists who may not have clearly defined roles in providing discharge education.13 Thus, providing comprehensive discharge instructions may require a hardwired system to ensure all elements of discharge education are addressed.

Further, our increasing dependence on technology may paradoxically necessitate more formal structures for in‐person communication, as the ability to enter discharge orders remotely leads to less frequent direct communication. Fortunately, as institutions move to computerized systems for discharge orders and instructions, there are increasing opportunities for a standardized approach to the elements of discharge education. While these results may suggest that one individual should be solely responsible for discharge education, trials using teams of nurse practitioners to facilitate transitions of care found no difference in patient length of stay or 30‐day readmission rates.14, 15

Formal systems that increase communication in high‐risk circumstances remain a focus in patient safety, and have been implemented successfully in procedural settings and with handoffs in patient care.1618 A prominent example is operating room time‐outs, which implemented a structured tool and shared process to increase nursephysician communication and reduce mortality.19 Since elements of discharge education with more frequent communication between nurses and physicians were more often conveyed to patients, our results suggest that a discharge time‐out might offer similar benefit. Fortunately, nurses and physicians rated verbal communication as the most desirable solution to share discharge education information. While not formally evaluated, one solution may be adoption of the previously described critical conversation, a structured format and a consistent time for communication that ensures both nurses and physicians understand what education needs to be provided to patients and by whom.20 The 13 discharge elements outlined in our study now provide a starting point for defining specific discussion points at discharge, delineation of who should communicate each element, and the basis for developing an operational discharge time‐out.

There are several limitations to our study. First, the survey instrument was not previously used or validated. However, we did seek formal and structured input while developing our survey, and conducted pilot testing to ensure clarity and comprehension with representatives of all study groups. Second, the 13 discharge education elements we included do not represent a comprehensive list, and were chosen based on our literature review and best practices at our institution. Third, our cross‐sectional study only captures perceptions and practices during a single time point, and may not adequately capture the greater continuum of true practice. Finally, our results may not be generalizable outside UCSFMC or other academic medical centers, particularly if other institutions have employed specific structures for discharge, such as a dedicated discharge coordinator.

CONCLUSION

Discharging patients is a complex process and one in which multiple providers and poor systems contribute to the redesign challenges. Providing high‐quality discharge education instructions to patients is an important step in making a complex process safer. Poor communication between nurses and physicians, complicated by ambiguous perceptions of responsibility for specific information, offers an opportunity for improvement efforts. We should not let well thought out treatment plans fail due to poor patient education on discharge. Our findings argue for a more systematic approach to the discharge education provided by nurses, interns, and hospitalists.

Discharge from the hospital is a vulnerable time for patients. Nearly 1 in 5 patients experiences an adverse event during this transition, with a third of these being likely preventable.1, 2 Comprehensive discharge instructions are necessary to ensure a smooth transition from hospital to home, as the responsibility for care shifts from providers to the patient and caregivers. Unfortunately, patients often go home without understanding critical information about their hospital stay, such as their discharge diagnosis or medication changes,3, 4 leaving them both dissatisfied with their discharge instructions5 and at risk for hospital readmission.

Efforts to improve discharge education have focused on increasing communication between care provider and patient. The use of designated discharge coordinators,6, 7 implementation of teach‐back techniques to assess and confirm understanding,8 and adoption of patient‐centered educational materials all offer tools to improve communication with patients. However, guidelines for communication between providers and their shared role in patient discharge education, particularly between nurses and physicians, are scarce. Daily interdisciplinary rounds9 and shared electronic health records are potential ways to foster such communication, but the methods and frequency with which providers communicate about discharge instructions with each other is poorly understood. Furthermore, despite a common set of goals for discharge instructions,10, 11 it is unclear where the responsibility to provide these elements lies: with nurses, physicians, neither, or both.

Understanding perceptions and communication practices of providers in their delivery of discharge instructions is an important first step in defining responsibilities and improving accountability for discharge education. In this study, we surveyed nurses and physicians about their discharge education practices to better understand how each group sees their own role in discharge teaching, and how these findings may generate recommendations to improve future practices.

METHODS

RESULTS

One hundred twenty‐nine providers responded to the survey with an overall survey response rate of 129/184 (70%). Forty‐five (64%) nurses, 56 (71%) interns, and 28 (78%) hospitalists participated. We organized the results into 4 sections based on the survey's question domains. First, we analyzed providers' (defined as nurses, interns, and hospitalists) perceived responsibility for the elements of patient discharge education (see Supporting Information, Text Box, in the online version of this article). Second, we examined how providers' responsibility compared to their reported practice. Third, we looked at the communication between nurses and physicians on the care team around these shared elements of discharge education. Lastly, we looked at providers' willingness to adopt tools to improve nursephysician communication around the time of discharge.

Discharge Education by Providers on the Care Team

Despite nurses' reluctance to claim sole responsibility for elements of discharge education, nurses on the whole reported providing discharge education more often than either interns or hospitalists (P < 0.05). Figure 1 illustrates each group's reported practice of communicating specific discharge education on a Likert scale. For the 9 elements viewed as a shared responsibility and the 2 elements where there was disagreement, nurses reported communicating most items significantly more often than both interns and hospitalists (P < 0.001 for all elements except reason for follow‐up appointments, explanation of diagnosis in lay terms, and changes to medication regimen made during hospitalization). Items that were reported to be a physician responsibility were communicated more often by interns and hospitalists than nurses (P < 0.005), but were the items least often communicated by any care provider. Hospitalists did not report communicating any items significantly more than interns.

Figure 1

DISCUSSION

Our study demonstrated that nurses, interns, and hospitalists all feel that they play a pivotal role in discharge education. Compared to both interns and hospitalists, nurses were more likely to view discharge education as a shared responsibility, but nurses also reported providing more discharge education to patients. The elements of discharge education deemed a physician responsibility were reported as the least often provided to patients. Despite the majority of responses indicating that discharge education is a shared nursephysician responsibility, reported provider communication about discharge education was infrequent. Arguing for more communication, elements for which nurses and physicians perceived communicating more frequently were also more often reportedly conveyed to patients. The summative findings suggest that inconsistent discharge education and communication between providers may be leading to patients who are not regularly receiving complete discharge information. Nurses, interns, and hospitalists, however, were all very engaged in potential solutions to improve discharge communication, providing opportunities for immediate impact.

The question becomes where to start. Poor discharge instructions are associated with increased hospital readmission,10 and comprehensive discharge education is a suggested strategy to reduce preventable readmissions.12 Academic hospitalists, despite likely having witnessed the negative impact of poor discharge education, were not more likely than interns to report educating patients, nor did they report communicating more often with nurses. In teaching institutions, specifically, discharge education is being provided by multiple physicians: interns, residents, and hospitalists who may not have clearly defined roles in providing discharge education.13 Thus, providing comprehensive discharge instructions may require a hardwired system to ensure all elements of discharge education are addressed.

Further, our increasing dependence on technology may paradoxically necessitate more formal structures for in‐person communication, as the ability to enter discharge orders remotely leads to less frequent direct communication. Fortunately, as institutions move to computerized systems for discharge orders and instructions, there are increasing opportunities for a standardized approach to the elements of discharge education. While these results may suggest that one individual should be solely responsible for discharge education, trials using teams of nurse practitioners to facilitate transitions of care found no difference in patient length of stay or 30‐day readmission rates.14, 15

Formal systems that increase communication in high‐risk circumstances remain a focus in patient safety, and have been implemented successfully in procedural settings and with handoffs in patient care.1618 A prominent example is operating room time‐outs, which implemented a structured tool and shared process to increase nursephysician communication and reduce mortality.19 Since elements of discharge education with more frequent communication between nurses and physicians were more often conveyed to patients, our results suggest that a discharge time‐out might offer similar benefit. Fortunately, nurses and physicians rated verbal communication as the most desirable solution to share discharge education information. While not formally evaluated, one solution may be adoption of the previously described critical conversation, a structured format and a consistent time for communication that ensures both nurses and physicians understand what education needs to be provided to patients and by whom.20 The 13 discharge elements outlined in our study now provide a starting point for defining specific discussion points at discharge, delineation of who should communicate each element, and the basis for developing an operational discharge time‐out.

There are several limitations to our study. First, the survey instrument was not previously used or validated. However, we did seek formal and structured input while developing our survey, and conducted pilot testing to ensure clarity and comprehension with representatives of all study groups. Second, the 13 discharge education elements we included do not represent a comprehensive list, and were chosen based on our literature review and best practices at our institution. Third, our cross‐sectional study only captures perceptions and practices during a single time point, and may not adequately capture the greater continuum of true practice. Finally, our results may not be generalizable outside UCSFMC or other academic medical centers, particularly if other institutions have employed specific structures for discharge, such as a dedicated discharge coordinator.

CONCLUSION

Discharging patients is a complex process and one in which multiple providers and poor systems contribute to the redesign challenges. Providing high‐quality discharge education instructions to patients is an important step in making a complex process safer. Poor communication between nurses and physicians, complicated by ambiguous perceptions of responsibility for specific information, offers an opportunity for improvement efforts. We should not let well thought out treatment plans fail due to poor patient education on discharge. Our findings argue for a more systematic approach to the discharge education provided by nurses, interns, and hospitalists.

Malnutrition is present in 20% to 50% of hospitalized patients.1, 2 Despite simple, validated screening tools, malnutrition tends to be underdiagnosed.3, 4 Over 90% of elderly patients transitioning from an acute care hospital to a subacute care facility are either malnourished or at risk of malnutrition.5 Malnutrition has been associated with increased risk of nosocomial infections,6 worsened discharge functional status,7 and higher mortality,8 as well as longer lengths of stay7, 8 and higher hospital costs.2

Malnutrition describes either overnutrition or undernutrition that causes a change in body composition and decreased function.9 Malnutrition in hospitalized patients is typically related to undernutrition due to either reduced intake or increased metabolic rate. Reasons for reduced intake include poor appetite, reduced ability to chew or swallow, and nil per os (NPO) status. Patients with acute or chronic illnesses may either be malnourished on admission, or develop malnutrition within a few days of hospital admission, due to the effects of the inflammatory state on metabolism. Given that malnutrition is potentially modifiable, it is important to screen for malnutrition and, when present, develop, implement, and monitor a nutrition care plan10 (Figure 1).

Figure 1

The purpose of this review is to provide the hospitalist with an overview of screening, assessment, and development and implementation of a nutrition care plan in the acutely ill hospitalized patient.

PATIENT SCREENING

Nutrition screening identifies patients with nutritional deficits who may benefit from further detailed nutrition assessment and intervention.11 The Joint Commission requires that all patients admitted to acute care hospitals be screened for risk of malnutrition within 24 hours.12 Those considered at risk for malnutrition have significant weight changes, chronic disease or an acute inflammatory process, or have been unable to ingest adequate calories for 7 days.13

Those not at risk should be regularly rescreened throughout their hospital stay. The American Society of Parenteral and Enteral Nutrition (ASPEN) recommends that institutions create and approve a screening process according to the patient population served.10 There are several tools validated for use in the acute care setting.14 Many institutions trigger an automatic nutrition consult when certain screening criteria are met.

PATIENT ASSESSMENT

Nutrition assessment should be performed by a dietitian or nutrition consult provider in patients who screen at risk for malnutrition to characterize and determine the cause of nutritional deficits.10 The nutrition assessment identifies history and physical examination elements to diagnose malnutrition. An ASPEN consensus statement recommends the diagnosis of malnutrition if 2 or more of the following are present: insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation, and decreased functional status measured by hand‐grip strength.9 The nutrition assessment should also consider how long the patient has been without adequate nutrition, document baseline nutrition parameters,15 and estimate caloric requirements to determine nutrition support therapy needs.10 Nutrition assessment typically includes the following components.

DEVELOPMENT OF A NUTRITION CARE PLAN

The formal nutrition assessment of the at‐risk patient derives the information needed for the development of a nutrition care plan. This plan guides the provision of nutrition therapy, the intervention, the monitoring protocols, evaluation, and reassessment of nutrition goals or termination of specialized nutrition support.10 Assessments for adequacy of nutritional repletion are best done by repeated screening and physical examinations.18

IMPLEMENTATION OF NUTRITION CARE PLAN

Nutritional interventions include dietary modifications, enteral nutrition, and parenteral nutrition.

PATIENT MONITORING

Laboratory monitoring with nutrition support should include baseline electrolytes, glucose, renal function, coagulation studies, triglycerides, magnesium, phosphorus, cholesterol, platelet count, and hepatobiliary enzymes. Electrolytes, calcium, magnesium, and phosphorus should be checked daily for 3 days and, if normal, should then be checked biweekly. Capillary glucose should be monitored several times a day until stable. Weekly triglycerides, albumin, cholesterol, coagulation studies, and liver enzymes should also be checked in patients while on parenteral nutrition.25 Patients at risk for refeeding syndrome should have potassium, phosphate, calcium, and magnesium measured daily for 7 days, with repletion as necessary. These electrolytes should be monitored 3 times the following week if stable.49

Patients should be monitored clinically for gastrointestinal tolerance of enteral nutrition. All 3 North American guidelines recommend monitoring gastric residual volumes (GRV); however, there is no consensus on the volume considered to require intervention. Motility agents are recommended as first line treatment of high GRV.36, 37, 42 If high GRV continues, tube feeding should be held, and tube placement, medications, and metabolic assessment should be reviewed. Placement of a transpyloric feeding tube may be indicated.50

TERMINATION OF THERAPY

Termination of nutrition support often involves transitioning from one mode of support to another. PN can be discontinued when oral or enteral intake reaches 60% of total calories; enteral intake can be discontinued when oral intake reaches the same level. However, the patient should be observed maintaining their intake; if they cannot, nutrition support should be resumed.12

TRANSITION OF CARE PLAN

Patients discharged from the hospital on enteral or parenteral nutrition require the support of a coordinated multidisciplinary team including dietitians, home nutrition delivery companies, primary care physicians trained in specialized nutrition support, community pharmacists, and other healthcare professionals, if indicated. These relationships should be established prior to discharge, with education about the patient's individualized nutrition plan, and training with the equipment and supplies.10, 56

CONCLUSION

This review provides an overview of managing the at‐risk or malnourished patient by describing the processes of screening, assessment, and development and implementation of a nutrition care plan in the acutely ill hospitalized patient. Malnutrition is a relatively common, yet underdiagnosed entity that impacts patient outcomes, length of stay, hospital costs, and readmissions. Acute illness in a patient already nutritionally debilitated by chronic disease may cause rapid depletion in nutritional stores. Hospitals are required to screen patients for malnutrition on admission and at regular intervals, and to develop and implement a nutrition care plan for those at risk. The plan guides how nutrition therapy is provided, monitored for adequacy and adverse effects, and assessed for achievement of nutritional goals. It encompasses the use of dietary modifications, and enteral and parenteral nutrition. Clinicians must be aware of serious but avoidable adverse effects, particularly refeeding syndrome in malnourished patients. Prior to discharge, the patient should have already been transitioned from EN or PN to taking adequate amounts of calories by mouth; otherwise, careful discharge planning to educate the patients and/or caregivers, and coordinate the necessary multidisciplinary community services is necessary.

Malnutrition is present in 20% to 50% of hospitalized patients.1, 2 Despite simple, validated screening tools, malnutrition tends to be underdiagnosed.3, 4 Over 90% of elderly patients transitioning from an acute care hospital to a subacute care facility are either malnourished or at risk of malnutrition.5 Malnutrition has been associated with increased risk of nosocomial infections,6 worsened discharge functional status,7 and higher mortality,8 as well as longer lengths of stay7, 8 and higher hospital costs.2

Malnutrition describes either overnutrition or undernutrition that causes a change in body composition and decreased function.9 Malnutrition in hospitalized patients is typically related to undernutrition due to either reduced intake or increased metabolic rate. Reasons for reduced intake include poor appetite, reduced ability to chew or swallow, and nil per os (NPO) status. Patients with acute or chronic illnesses may either be malnourished on admission, or develop malnutrition within a few days of hospital admission, due to the effects of the inflammatory state on metabolism. Given that malnutrition is potentially modifiable, it is important to screen for malnutrition and, when present, develop, implement, and monitor a nutrition care plan10 (Figure 1).

Figure 1

The purpose of this review is to provide the hospitalist with an overview of screening, assessment, and development and implementation of a nutrition care plan in the acutely ill hospitalized patient.

PATIENT SCREENING

Nutrition screening identifies patients with nutritional deficits who may benefit from further detailed nutrition assessment and intervention.11 The Joint Commission requires that all patients admitted to acute care hospitals be screened for risk of malnutrition within 24 hours.12 Those considered at risk for malnutrition have significant weight changes, chronic disease or an acute inflammatory process, or have been unable to ingest adequate calories for 7 days.13

Those not at risk should be regularly rescreened throughout their hospital stay. The American Society of Parenteral and Enteral Nutrition (ASPEN) recommends that institutions create and approve a screening process according to the patient population served.10 There are several tools validated for use in the acute care setting.14 Many institutions trigger an automatic nutrition consult when certain screening criteria are met.

PATIENT ASSESSMENT

Nutrition assessment should be performed by a dietitian or nutrition consult provider in patients who screen at risk for malnutrition to characterize and determine the cause of nutritional deficits.10 The nutrition assessment identifies history and physical examination elements to diagnose malnutrition. An ASPEN consensus statement recommends the diagnosis of malnutrition if 2 or more of the following are present: insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation, and decreased functional status measured by hand‐grip strength.9 The nutrition assessment should also consider how long the patient has been without adequate nutrition, document baseline nutrition parameters,15 and estimate caloric requirements to determine nutrition support therapy needs.10 Nutrition assessment typically includes the following components.

DEVELOPMENT OF A NUTRITION CARE PLAN

The formal nutrition assessment of the at‐risk patient derives the information needed for the development of a nutrition care plan. This plan guides the provision of nutrition therapy, the intervention, the monitoring protocols, evaluation, and reassessment of nutrition goals or termination of specialized nutrition support.10 Assessments for adequacy of nutritional repletion are best done by repeated screening and physical examinations.18

IMPLEMENTATION OF NUTRITION CARE PLAN

Nutritional interventions include dietary modifications, enteral nutrition, and parenteral nutrition.

PATIENT MONITORING

Laboratory monitoring with nutrition support should include baseline electrolytes, glucose, renal function, coagulation studies, triglycerides, magnesium, phosphorus, cholesterol, platelet count, and hepatobiliary enzymes. Electrolytes, calcium, magnesium, and phosphorus should be checked daily for 3 days and, if normal, should then be checked biweekly. Capillary glucose should be monitored several times a day until stable. Weekly triglycerides, albumin, cholesterol, coagulation studies, and liver enzymes should also be checked in patients while on parenteral nutrition.25 Patients at risk for refeeding syndrome should have potassium, phosphate, calcium, and magnesium measured daily for 7 days, with repletion as necessary. These electrolytes should be monitored 3 times the following week if stable.49

Patients should be monitored clinically for gastrointestinal tolerance of enteral nutrition. All 3 North American guidelines recommend monitoring gastric residual volumes (GRV); however, there is no consensus on the volume considered to require intervention. Motility agents are recommended as first line treatment of high GRV.36, 37, 42 If high GRV continues, tube feeding should be held, and tube placement, medications, and metabolic assessment should be reviewed. Placement of a transpyloric feeding tube may be indicated.50

TERMINATION OF THERAPY

Termination of nutrition support often involves transitioning from one mode of support to another. PN can be discontinued when oral or enteral intake reaches 60% of total calories; enteral intake can be discontinued when oral intake reaches the same level. However, the patient should be observed maintaining their intake; if they cannot, nutrition support should be resumed.12

TRANSITION OF CARE PLAN

Patients discharged from the hospital on enteral or parenteral nutrition require the support of a coordinated multidisciplinary team including dietitians, home nutrition delivery companies, primary care physicians trained in specialized nutrition support, community pharmacists, and other healthcare professionals, if indicated. These relationships should be established prior to discharge, with education about the patient's individualized nutrition plan, and training with the equipment and supplies.10, 56

CONCLUSION

This review provides an overview of managing the at‐risk or malnourished patient by describing the processes of screening, assessment, and development and implementation of a nutrition care plan in the acutely ill hospitalized patient. Malnutrition is a relatively common, yet underdiagnosed entity that impacts patient outcomes, length of stay, hospital costs, and readmissions. Acute illness in a patient already nutritionally debilitated by chronic disease may cause rapid depletion in nutritional stores. Hospitals are required to screen patients for malnutrition on admission and at regular intervals, and to develop and implement a nutrition care plan for those at risk. The plan guides how nutrition therapy is provided, monitored for adequacy and adverse effects, and assessed for achievement of nutritional goals. It encompasses the use of dietary modifications, and enteral and parenteral nutrition. Clinicians must be aware of serious but avoidable adverse effects, particularly refeeding syndrome in malnourished patients. Prior to discharge, the patient should have already been transitioned from EN or PN to taking adequate amounts of calories by mouth; otherwise, careful discharge planning to educate the patients and/or caregivers, and coordinate the necessary multidisciplinary community services is necessary.

Malnutrition is present in 20% to 50% of hospitalized patients.1, 2 Despite simple, validated screening tools, malnutrition tends to be underdiagnosed.3, 4 Over 90% of elderly patients transitioning from an acute care hospital to a subacute care facility are either malnourished or at risk of malnutrition.5 Malnutrition has been associated with increased risk of nosocomial infections,6 worsened discharge functional status,7 and higher mortality,8 as well as longer lengths of stay7, 8 and higher hospital costs.2

Malnutrition describes either overnutrition or undernutrition that causes a change in body composition and decreased function.9 Malnutrition in hospitalized patients is typically related to undernutrition due to either reduced intake or increased metabolic rate. Reasons for reduced intake include poor appetite, reduced ability to chew or swallow, and nil per os (NPO) status. Patients with acute or chronic illnesses may either be malnourished on admission, or develop malnutrition within a few days of hospital admission, due to the effects of the inflammatory state on metabolism. Given that malnutrition is potentially modifiable, it is important to screen for malnutrition and, when present, develop, implement, and monitor a nutrition care plan10 (Figure 1).

Figure 1

The purpose of this review is to provide the hospitalist with an overview of screening, assessment, and development and implementation of a nutrition care plan in the acutely ill hospitalized patient.

PATIENT SCREENING

Nutrition screening identifies patients with nutritional deficits who may benefit from further detailed nutrition assessment and intervention.11 The Joint Commission requires that all patients admitted to acute care hospitals be screened for risk of malnutrition within 24 hours.12 Those considered at risk for malnutrition have significant weight changes, chronic disease or an acute inflammatory process, or have been unable to ingest adequate calories for 7 days.13

Those not at risk should be regularly rescreened throughout their hospital stay. The American Society of Parenteral and Enteral Nutrition (ASPEN) recommends that institutions create and approve a screening process according to the patient population served.10 There are several tools validated for use in the acute care setting.14 Many institutions trigger an automatic nutrition consult when certain screening criteria are met.

PATIENT ASSESSMENT

Nutrition assessment should be performed by a dietitian or nutrition consult provider in patients who screen at risk for malnutrition to characterize and determine the cause of nutritional deficits.10 The nutrition assessment identifies history and physical examination elements to diagnose malnutrition. An ASPEN consensus statement recommends the diagnosis of malnutrition if 2 or more of the following are present: insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation, and decreased functional status measured by hand‐grip strength.9 The nutrition assessment should also consider how long the patient has been without adequate nutrition, document baseline nutrition parameters,15 and estimate caloric requirements to determine nutrition support therapy needs.10 Nutrition assessment typically includes the following components.

DEVELOPMENT OF A NUTRITION CARE PLAN

The formal nutrition assessment of the at‐risk patient derives the information needed for the development of a nutrition care plan. This plan guides the provision of nutrition therapy, the intervention, the monitoring protocols, evaluation, and reassessment of nutrition goals or termination of specialized nutrition support.10 Assessments for adequacy of nutritional repletion are best done by repeated screening and physical examinations.18

IMPLEMENTATION OF NUTRITION CARE PLAN

Nutritional interventions include dietary modifications, enteral nutrition, and parenteral nutrition.

PATIENT MONITORING

Laboratory monitoring with nutrition support should include baseline electrolytes, glucose, renal function, coagulation studies, triglycerides, magnesium, phosphorus, cholesterol, platelet count, and hepatobiliary enzymes. Electrolytes, calcium, magnesium, and phosphorus should be checked daily for 3 days and, if normal, should then be checked biweekly. Capillary glucose should be monitored several times a day until stable. Weekly triglycerides, albumin, cholesterol, coagulation studies, and liver enzymes should also be checked in patients while on parenteral nutrition.25 Patients at risk for refeeding syndrome should have potassium, phosphate, calcium, and magnesium measured daily for 7 days, with repletion as necessary. These electrolytes should be monitored 3 times the following week if stable.49

Patients should be monitored clinically for gastrointestinal tolerance of enteral nutrition. All 3 North American guidelines recommend monitoring gastric residual volumes (GRV); however, there is no consensus on the volume considered to require intervention. Motility agents are recommended as first line treatment of high GRV.36, 37, 42 If high GRV continues, tube feeding should be held, and tube placement, medications, and metabolic assessment should be reviewed. Placement of a transpyloric feeding tube may be indicated.50

TERMINATION OF THERAPY

Termination of nutrition support often involves transitioning from one mode of support to another. PN can be discontinued when oral or enteral intake reaches 60% of total calories; enteral intake can be discontinued when oral intake reaches the same level. However, the patient should be observed maintaining their intake; if they cannot, nutrition support should be resumed.12

TRANSITION OF CARE PLAN

Patients discharged from the hospital on enteral or parenteral nutrition require the support of a coordinated multidisciplinary team including dietitians, home nutrition delivery companies, primary care physicians trained in specialized nutrition support, community pharmacists, and other healthcare professionals, if indicated. These relationships should be established prior to discharge, with education about the patient's individualized nutrition plan, and training with the equipment and supplies.10, 56

CONCLUSION

This review provides an overview of managing the at‐risk or malnourished patient by describing the processes of screening, assessment, and development and implementation of a nutrition care plan in the acutely ill hospitalized patient. Malnutrition is a relatively common, yet underdiagnosed entity that impacts patient outcomes, length of stay, hospital costs, and readmissions. Acute illness in a patient already nutritionally debilitated by chronic disease may cause rapid depletion in nutritional stores. Hospitals are required to screen patients for malnutrition on admission and at regular intervals, and to develop and implement a nutrition care plan for those at risk. The plan guides how nutrition therapy is provided, monitored for adequacy and adverse effects, and assessed for achievement of nutritional goals. It encompasses the use of dietary modifications, and enteral and parenteral nutrition. Clinicians must be aware of serious but avoidable adverse effects, particularly refeeding syndrome in malnourished patients. Prior to discharge, the patient should have already been transitioned from EN or PN to taking adequate amounts of calories by mouth; otherwise, careful discharge planning to educate the patients and/or caregivers, and coordinate the necessary multidisciplinary community services is necessary.

A curbside consultation is an informal process whereby a consultant is asked to provide information or advice about a patient's care without doing a formal assessment of the patient.14 Curbside consultations are common in the practice of medicine2, 3, 5 and are frequently requested by physicians caring for hospitalized patients. Several surveys have documented the quantity of curbside consultations requested of various subspecialties, the types of questions asked, the time it takes to respond, and physicians' perceptions about the quality of the information exchanged.111 While curbside consultations have a number of advantages, physicians' perceptions are that the information conveyed may be inaccurate or incomplete and that the advice offered may be erroneous.13, 5, 10, 12, 13

Cartmill and White14 performed a random audit of 10% of the telephone referrals they received for neurosurgical consultation over a 1‐year period and noted discrepancies between the Glascow Coma Scores reported during the telephone referrals and those noted in the medical records, but the frequency of these discrepancies was not reported. To our knowledge, no studies have compared the quality of the information provided in curbside consultations with that obtained in formal consultations that included direct face‐to‐face patient evaluations and primary data collection, and whether the advice provided in curbside and formal consultations on the same patient differed.

We performed a prospective cohort study to compare the information received by hospitalists during curbside consultations on hospitalized patients, with that obtained from formal consultations done the same day on the same patients, by different hospitalists who were unaware of any details regarding the curbside consultation. We also compared the advice provided by the 2 hospitalists following their curbside and formal consultations. Our hypotheses were that the information received during curbside consultations was frequently inaccurate or incomplete, that the recommendations made after the formal consultation would frequently differ from those made in the curbside consultation, and that these differences would have important implications on patient care.

METHODS

This was a quality improvement study conducted at Denver Health, a 500‐bed university‐affiliated urban safety net hospital from January 10, 2011 to January 9, 2012. The study design was a prospective cohort that included all curbside consultations on hospitalized patients received between 7 _AM and 3 _PM, on intermittently selected weekdays, by the Internal Medicine Consultation Service that was staffed by 18 hospitalists. Data were collected intermittently based upon hospitalist availability and was done to limit potential alterations in the consulting practices of the providers requesting consultations.

Consultations were defined as being curbside when the consulting provider asked for advice, suggestions, or opinions about a patient's care but did not ask the hospitalist to see the patient.15, 15 Consultations pertaining to administrative issues (eg, whether a patient should be admitted to an intensive care bed as opposed to an acute care floor bed) or on patients who were already being followed by a hospitalist were excluded.

The hospitalist receiving the curbside consultation was allowed to ask questions as they normally would, but could not verify the accuracy of the information received (eg, could not review any portion of the patient's medical record, such as notes or lab data). A standardized data collection sheet was used to record the service and level of training of the requesting provider, the medical issue(s) of concern, all clinical data offered by the provider, the number of questions asked by the hospitalist of the provider, and whether, on the basis of the information provided, the hospitalist felt that the question(s) being asked was (were) of sufficient complexity that a formal consultation should occur. The hospitalist then offered advice based upon the information given during the curbside consultation.

After completing the curbside consultation, the hospitalist requested verbal permission from the requesting provider to perform a formal consultation. If the request was approved, the hospitalist performing the curbside consultation contacted a different hospitalist who performed the formal consultation within the next few hours. The only information given to the second hospitalist was the patient's identifiers and the clinical question(s) being asked. The formal consultation included a complete face‐to‐face history and physical examination, a review of the patient's medical record, documentation of the provider's findings, and recommendations for care.

Upon completion of the formal consultation, the hospitalists who performed the curbside and the formal consultations met to review the advice each gave to the requesting provider and the information on which this advice was based. The 2 hospitalists jointly determined the following: (a) whether the information received during the curbside consultation was correct and complete, (b) whether the advice provided in the formal consultation differed from that provided in the curbside consultation, (c) whether the advice provided in the formal consultation dealt with issues other than one(s) leading to the curbside consultation, (d) whether differences in the recommendations given in the curbside versus the formal consultation changed patient management in a meaningful way, and (e) whether the curbside consultation alone was felt to be sufficient.

Information obtained by the hospitalist performing the formal consultation that was different from, or not included in, the information recorded during the curbside consultation was considered to be incorrect or incomplete, respectively. A change in management was defined as an alteration in the direction or type of care that the patient would have received as a result of the advice being given. A pulmonary and critical care physician, with >35 years of experience in inpatient medicine, reviewed the information provided in the curbside and formal consultations, and independently assessed whether the curbside consultation alone would have been sufficient and whether the formal consultation changed management.

Curbside consultations were neither solicited nor discouraged during the course of the study. The provider requesting the curbside consultation was not informed or debriefed about the study in an attempt to avoid affecting future consultation practices from that provider or service.

Associations were sought between the frequency of inaccurate or incomplete data and the requesting service and provider, the consultative category and medical issue, the number of questions asked by the hospitalist during the curbside consultation, and whether the hospitalist doing the curbside consultation thought that formal consultation was needed. A chi‐square test was used to analyze all associations. A P value of <0.05 was considered significant. All analyses were performed using SAS Enterprise Guide 4.3 (SAS Institute, Inc, Cary, NC) software. The study was approved by the Colorado Multiple Institutional Review Board.

RESULTS

Fifty curbside consultations were requested on a total of 215 study days. The requesting service declined formal consultation in 3 instances, leaving 47 curbside consultations that had a formal consultation. Curbside consultations came from a variety of services and providers, and addressed a variety of issues and concerns (Table 1).

The hospitalists asked 0 to 2 questions during 8/47 (17%) of the curbside consultations, 3 to 5 questions during 26/47 (55%) consultations, and more than 5 questions during 13/47 (28%). Based on the information received during the curbside consultations, the hospitalists thought that the curbside consultations were insufficient for 18/47 (38%) of patients. In all instances, the opinions of the 2 hospitalists concurred with respect to this conclusion, and the independent reviewer agreed with this assessment in 17 of these 18 (94%).

The advice rendered in the formal consultations differed from that provided in 26/47 (55%) of the curbside consultations, and the formal consultation was thought to have changed management for 28/47 (60%) of patients (Table 2). The independent reviewer thought that the advice provided in the formal consultations changed management in 29/47 (62%) of the cases, and in 24/28 cases (86%) where the hospitalist felt that the formal consult changed management.

Information was felt to be inaccurate or incomplete in 24/47 (51%) of the curbside consultations (13/47 inaccurate, 16/47 incomplete, 5/47 both inaccurate and incomplete), and when inaccurate or incomplete information was obtained, the advice given in the formal consultations more commonly differed from that provided in the curbside consultation (19/24, 79% vs 7/23, 30%; P < 0.001), and was more commonly felt to change management (22/24, 92% vs 6/23, 26%; P < 0.0001) (Table 2). No association was found between whether the curbside consultation contained complete or accurate information and the consulting service from which the curbside originated, the consulting provider, the consultative aspect(s) or medical issue(s) addressed, the number of questions asked by the hospitalist during the curbside consultation, nor whether the hospitalists felt that a formal consultation was needed.

DISCUSSION

The important findings of this study are that (a) the recommendations made by hospitalists in curbside versus formal consultations on the same patient frequently differ, (b) these differences frequently result in changes in clinical management, (c) the information presented in curbside consultations by providers is frequently inaccurate or incomplete, regardless of the providers specialty or seniority, (d) when inaccurate or incomplete information is received, the recommendations made in curbside and formal consultations differ more frequently, and (e) we found no way to predict whether the information provided in a curbside consultation was likely to be inaccurate or incomplete.

Our hospitalists thought that 38% of the curbside consultations they received should have had formal consultations. Manian and McKinsey7 reported that as many as 53% of questions asked of infectious disease consultants were thought to be too complex to be addressed in an informal consultation. Others, however, report that only 11%33% of curbside consultations were thought to require formal consultation.1, 9, 10, 16 Our hospitalists asked 3 or more questions of the consulting providers in more than 80% of the curbside consultations, suggesting that the curbside consultations we received might have had a higher complexity than those seen by others.

Our finding that information provided in curbside consultation was frequently inaccurate or incomplete is consistent with a number of previous studies reporting physicians' perceptions of the accuracy of curbside consultations.2, 3 Hospital medicine is not likely to be the only discipline affected by inaccurate curbside consultation practices, as surveys of specialists in infectious disease, gynecology, and neurosurgery report that practitioners in these disciplines have similar concerns.1, 10, 14 In a survey returned by 34 physicians, Myers1 found that 50% thought the information exchanged during curbside consultations was inaccurate, leading him to conclude that inaccuracies presented during curbside consultations required further study.

We found no way of predicting whether curbside consultations were likely to include inaccurate or incomplete information. This observation is consistent with the results of Bergus et al16 who found that the frequency of curbside consultations being converted to formal consultations was independent of the training status of the consulting physician, and with the data of Myers1 who found no way of predicting the likelihood that a curbside consultation should be converted to a formal consultation.

We found that formal consultations resulted in management changes more often than differences in recommendations (ie, 60% vs 55%, respectively). This small difference occurred because, on occasion, the formal consultations found issues to address other than the one(s) for which the curbside consultation was requested. In the majority of these instances, the management changes were minor and the curbside consultation was still felt to be sufficient.

In some instances, the advice given after the curbside and the formal consultations differed to only a minor extent (eg, varying recommendations for oral diabetes management). In other instances, however, the advice differed substantially (eg, change in antibiotic management in a septic patient with a multidrug resistant organism, when the original curbside question was for when to order a follow‐up chest roentgenogram for hypoxia; see Supporting Information, Appendix, in the online version of this article). In 26 patients (55%), formal consultation resulted in different medications being started or stopped, additional tests being performed, or different decisions being made about admission versus discharge.

Our study has a number of strengths. First, while a number of reports document that physicians' perceptions are that curbside consultations frequently contain errors,2, 3, 5, 12 to our knowledge this is the first study that prospectively compared the information collected and advice given in curbside versus formal consultation. Second, while this study was conducted as a quality improvement project, thereby requiring us to conclude that the results are not generalizable, the data presented were collected by 18 different hospitalists, reducing the potential of bias from an individual provider's knowledge base or practice. Third, there was excellent agreement between the independent reviewer and the 2 hospitalists who performed the curbside and formal consultations regarding whether a curbside consultation would have been sufficient, and whether the formal consultation changed patient management. Fourth, the study was conducted over a 1‐year period, which should have reduced potential bias arising from the increasing experience of residents requesting consultations as their training progressed.

Our study has several limitations. First, the number of curbside consultations we received during the study period (50 over 215 days) was lower than anticipated, and lower than the rates of consultation reported by others.1, 7, 9 This likely relates to the fact that, prior to beginning the study, Denver Health hospitalists already provided mandatory consultations for several surgical services (thereby reducing the number of curbside consultations received from these services), because curbside consultations received during evenings, nights, and weekends were not included in the study for reasons of convenience, and because we excluded all administrative curbside consultations. Our hospitalist service also provides consultative services 24 hours a day, thereby reducing the number of consultations received during daytime hours. Second, the frequency with which curbside consultations included inaccurate or incomplete information might be higher than what occurs in other hospitals, as Denver Health is an urban, university‐affiliated public hospital and the patients encountered may be more complex and trainees may be less adept at recognizing the information that would facilitate accurate curbside consultations (although we found no difference in the frequency with which inaccurate or incomplete information was provided as a function of the seniority of the requesting physician). Third, the disparity between curbside and formal consultations that we observed could have been biased by the Hawthorne effect. We attempted to address this by not providing the hospitalists who did the formal consultation with any information collected by the hospitalist involved with the curbside consultation, and by comparing the conclusions reached by the hospitalists performing the curbside and formal consultations with those of a third party reviewer. Fourth, while we found no association between the frequency of curbside consultations in which information was inaccurate or incomplete and the consulting service, there could be a selection bias of the consulting service requesting the curbside consultations as a result of the mandatory consultations already provided by our hospitalists. Finally, our study was not designed or adequately powered to determine why curbside consultations frequently have inaccurate or incomplete information.

In summary, we found that the information provided to hospitalists during a curbside consultation was often inaccurate and incomplete, and that these problems with information exchange adversely affected the accuracy of the resulting recommendations. While there are a number of advantages to curbside consultations,1, 3, 7, 10, 12, 13 our findings indicate that the risk associated with this practice is substantial.

A curbside consultation is an informal process whereby a consultant is asked to provide information or advice about a patient's care without doing a formal assessment of the patient.14 Curbside consultations are common in the practice of medicine2, 3, 5 and are frequently requested by physicians caring for hospitalized patients. Several surveys have documented the quantity of curbside consultations requested of various subspecialties, the types of questions asked, the time it takes to respond, and physicians' perceptions about the quality of the information exchanged.111 While curbside consultations have a number of advantages, physicians' perceptions are that the information conveyed may be inaccurate or incomplete and that the advice offered may be erroneous.13, 5, 10, 12, 13

Cartmill and White14 performed a random audit of 10% of the telephone referrals they received for neurosurgical consultation over a 1‐year period and noted discrepancies between the Glascow Coma Scores reported during the telephone referrals and those noted in the medical records, but the frequency of these discrepancies was not reported. To our knowledge, no studies have compared the quality of the information provided in curbside consultations with that obtained in formal consultations that included direct face‐to‐face patient evaluations and primary data collection, and whether the advice provided in curbside and formal consultations on the same patient differed.

We performed a prospective cohort study to compare the information received by hospitalists during curbside consultations on hospitalized patients, with that obtained from formal consultations done the same day on the same patients, by different hospitalists who were unaware of any details regarding the curbside consultation. We also compared the advice provided by the 2 hospitalists following their curbside and formal consultations. Our hypotheses were that the information received during curbside consultations was frequently inaccurate or incomplete, that the recommendations made after the formal consultation would frequently differ from those made in the curbside consultation, and that these differences would have important implications on patient care.

METHODS

This was a quality improvement study conducted at Denver Health, a 500‐bed university‐affiliated urban safety net hospital from January 10, 2011 to January 9, 2012. The study design was a prospective cohort that included all curbside consultations on hospitalized patients received between 7 _AM and 3 _PM, on intermittently selected weekdays, by the Internal Medicine Consultation Service that was staffed by 18 hospitalists. Data were collected intermittently based upon hospitalist availability and was done to limit potential alterations in the consulting practices of the providers requesting consultations.

Consultations were defined as being curbside when the consulting provider asked for advice, suggestions, or opinions about a patient's care but did not ask the hospitalist to see the patient.15, 15 Consultations pertaining to administrative issues (eg, whether a patient should be admitted to an intensive care bed as opposed to an acute care floor bed) or on patients who were already being followed by a hospitalist were excluded.

The hospitalist receiving the curbside consultation was allowed to ask questions as they normally would, but could not verify the accuracy of the information received (eg, could not review any portion of the patient's medical record, such as notes or lab data). A standardized data collection sheet was used to record the service and level of training of the requesting provider, the medical issue(s) of concern, all clinical data offered by the provider, the number of questions asked by the hospitalist of the provider, and whether, on the basis of the information provided, the hospitalist felt that the question(s) being asked was (were) of sufficient complexity that a formal consultation should occur. The hospitalist then offered advice based upon the information given during the curbside consultation.

After completing the curbside consultation, the hospitalist requested verbal permission from the requesting provider to perform a formal consultation. If the request was approved, the hospitalist performing the curbside consultation contacted a different hospitalist who performed the formal consultation within the next few hours. The only information given to the second hospitalist was the patient's identifiers and the clinical question(s) being asked. The formal consultation included a complete face‐to‐face history and physical examination, a review of the patient's medical record, documentation of the provider's findings, and recommendations for care.

Upon completion of the formal consultation, the hospitalists who performed the curbside and the formal consultations met to review the advice each gave to the requesting provider and the information on which this advice was based. The 2 hospitalists jointly determined the following: (a) whether the information received during the curbside consultation was correct and complete, (b) whether the advice provided in the formal consultation differed from that provided in the curbside consultation, (c) whether the advice provided in the formal consultation dealt with issues other than one(s) leading to the curbside consultation, (d) whether differences in the recommendations given in the curbside versus the formal consultation changed patient management in a meaningful way, and (e) whether the curbside consultation alone was felt to be sufficient.

Information obtained by the hospitalist performing the formal consultation that was different from, or not included in, the information recorded during the curbside consultation was considered to be incorrect or incomplete, respectively. A change in management was defined as an alteration in the direction or type of care that the patient would have received as a result of the advice being given. A pulmonary and critical care physician, with >35 years of experience in inpatient medicine, reviewed the information provided in the curbside and formal consultations, and independently assessed whether the curbside consultation alone would have been sufficient and whether the formal consultation changed management.

Curbside consultations were neither solicited nor discouraged during the course of the study. The provider requesting the curbside consultation was not informed or debriefed about the study in an attempt to avoid affecting future consultation practices from that provider or service.

Associations were sought between the frequency of inaccurate or incomplete data and the requesting service and provider, the consultative category and medical issue, the number of questions asked by the hospitalist during the curbside consultation, and whether the hospitalist doing the curbside consultation thought that formal consultation was needed. A chi‐square test was used to analyze all associations. A P value of <0.05 was considered significant. All analyses were performed using SAS Enterprise Guide 4.3 (SAS Institute, Inc, Cary, NC) software. The study was approved by the Colorado Multiple Institutional Review Board.

RESULTS

Fifty curbside consultations were requested on a total of 215 study days. The requesting service declined formal consultation in 3 instances, leaving 47 curbside consultations that had a formal consultation. Curbside consultations came from a variety of services and providers, and addressed a variety of issues and concerns (Table 1).

The hospitalists asked 0 to 2 questions during 8/47 (17%) of the curbside consultations, 3 to 5 questions during 26/47 (55%) consultations, and more than 5 questions during 13/47 (28%). Based on the information received during the curbside consultations, the hospitalists thought that the curbside consultations were insufficient for 18/47 (38%) of patients. In all instances, the opinions of the 2 hospitalists concurred with respect to this conclusion, and the independent reviewer agreed with this assessment in 17 of these 18 (94%).

The advice rendered in the formal consultations differed from that provided in 26/47 (55%) of the curbside consultations, and the formal consultation was thought to have changed management for 28/47 (60%) of patients (Table 2). The independent reviewer thought that the advice provided in the formal consultations changed management in 29/47 (62%) of the cases, and in 24/28 cases (86%) where the hospitalist felt that the formal consult changed management.

Information was felt to be inaccurate or incomplete in 24/47 (51%) of the curbside consultations (13/47 inaccurate, 16/47 incomplete, 5/47 both inaccurate and incomplete), and when inaccurate or incomplete information was obtained, the advice given in the formal consultations more commonly differed from that provided in the curbside consultation (19/24, 79% vs 7/23, 30%; P < 0.001), and was more commonly felt to change management (22/24, 92% vs 6/23, 26%; P < 0.0001) (Table 2). No association was found between whether the curbside consultation contained complete or accurate information and the consulting service from which the curbside originated, the consulting provider, the consultative aspect(s) or medical issue(s) addressed, the number of questions asked by the hospitalist during the curbside consultation, nor whether the hospitalists felt that a formal consultation was needed.

DISCUSSION

The important findings of this study are that (a) the recommendations made by hospitalists in curbside versus formal consultations on the same patient frequently differ, (b) these differences frequently result in changes in clinical management, (c) the information presented in curbside consultations by providers is frequently inaccurate or incomplete, regardless of the providers specialty or seniority, (d) when inaccurate or incomplete information is received, the recommendations made in curbside and formal consultations differ more frequently, and (e) we found no way to predict whether the information provided in a curbside consultation was likely to be inaccurate or incomplete.

Our hospitalists thought that 38% of the curbside consultations they received should have had formal consultations. Manian and McKinsey7 reported that as many as 53% of questions asked of infectious disease consultants were thought to be too complex to be addressed in an informal consultation. Others, however, report that only 11%33% of curbside consultations were thought to require formal consultation.1, 9, 10, 16 Our hospitalists asked 3 or more questions of the consulting providers in more than 80% of the curbside consultations, suggesting that the curbside consultations we received might have had a higher complexity than those seen by others.

Our finding that information provided in curbside consultation was frequently inaccurate or incomplete is consistent with a number of previous studies reporting physicians' perceptions of the accuracy of curbside consultations.2, 3 Hospital medicine is not likely to be the only discipline affected by inaccurate curbside consultation practices, as surveys of specialists in infectious disease, gynecology, and neurosurgery report that practitioners in these disciplines have similar concerns.1, 10, 14 In a survey returned by 34 physicians, Myers1 found that 50% thought the information exchanged during curbside consultations was inaccurate, leading him to conclude that inaccuracies presented during curbside consultations required further study.

We found no way of predicting whether curbside consultations were likely to include inaccurate or incomplete information. This observation is consistent with the results of Bergus et al16 who found that the frequency of curbside consultations being converted to formal consultations was independent of the training status of the consulting physician, and with the data of Myers1 who found no way of predicting the likelihood that a curbside consultation should be converted to a formal consultation.

We found that formal consultations resulted in management changes more often than differences in recommendations (ie, 60% vs 55%, respectively). This small difference occurred because, on occasion, the formal consultations found issues to address other than the one(s) for which the curbside consultation was requested. In the majority of these instances, the management changes were minor and the curbside consultation was still felt to be sufficient.

In some instances, the advice given after the curbside and the formal consultations differed to only a minor extent (eg, varying recommendations for oral diabetes management). In other instances, however, the advice differed substantially (eg, change in antibiotic management in a septic patient with a multidrug resistant organism, when the original curbside question was for when to order a follow‐up chest roentgenogram for hypoxia; see Supporting Information, Appendix, in the online version of this article). In 26 patients (55%), formal consultation resulted in different medications being started or stopped, additional tests being performed, or different decisions being made about admission versus discharge.

Our study has a number of strengths. First, while a number of reports document that physicians' perceptions are that curbside consultations frequently contain errors,2, 3, 5, 12 to our knowledge this is the first study that prospectively compared the information collected and advice given in curbside versus formal consultation. Second, while this study was conducted as a quality improvement project, thereby requiring us to conclude that the results are not generalizable, the data presented were collected by 18 different hospitalists, reducing the potential of bias from an individual provider's knowledge base or practice. Third, there was excellent agreement between the independent reviewer and the 2 hospitalists who performed the curbside and formal consultations regarding whether a curbside consultation would have been sufficient, and whether the formal consultation changed patient management. Fourth, the study was conducted over a 1‐year period, which should have reduced potential bias arising from the increasing experience of residents requesting consultations as their training progressed.

Our study has several limitations. First, the number of curbside consultations we received during the study period (50 over 215 days) was lower than anticipated, and lower than the rates of consultation reported by others.1, 7, 9 This likely relates to the fact that, prior to beginning the study, Denver Health hospitalists already provided mandatory consultations for several surgical services (thereby reducing the number of curbside consultations received from these services), because curbside consultations received during evenings, nights, and weekends were not included in the study for reasons of convenience, and because we excluded all administrative curbside consultations. Our hospitalist service also provides consultative services 24 hours a day, thereby reducing the number of consultations received during daytime hours. Second, the frequency with which curbside consultations included inaccurate or incomplete information might be higher than what occurs in other hospitals, as Denver Health is an urban, university‐affiliated public hospital and the patients encountered may be more complex and trainees may be less adept at recognizing the information that would facilitate accurate curbside consultations (although we found no difference in the frequency with which inaccurate or incomplete information was provided as a function of the seniority of the requesting physician). Third, the disparity between curbside and formal consultations that we observed could have been biased by the Hawthorne effect. We attempted to address this by not providing the hospitalists who did the formal consultation with any information collected by the hospitalist involved with the curbside consultation, and by comparing the conclusions reached by the hospitalists performing the curbside and formal consultations with those of a third party reviewer. Fourth, while we found no association between the frequency of curbside consultations in which information was inaccurate or incomplete and the consulting service, there could be a selection bias of the consulting service requesting the curbside consultations as a result of the mandatory consultations already provided by our hospitalists. Finally, our study was not designed or adequately powered to determine why curbside consultations frequently have inaccurate or incomplete information.

In summary, we found that the information provided to hospitalists during a curbside consultation was often inaccurate and incomplete, and that these problems with information exchange adversely affected the accuracy of the resulting recommendations. While there are a number of advantages to curbside consultations,1, 3, 7, 10, 12, 13 our findings indicate that the risk associated with this practice is substantial.

A curbside consultation is an informal process whereby a consultant is asked to provide information or advice about a patient's care without doing a formal assessment of the patient.14 Curbside consultations are common in the practice of medicine2, 3, 5 and are frequently requested by physicians caring for hospitalized patients. Several surveys have documented the quantity of curbside consultations requested of various subspecialties, the types of questions asked, the time it takes to respond, and physicians' perceptions about the quality of the information exchanged.111 While curbside consultations have a number of advantages, physicians' perceptions are that the information conveyed may be inaccurate or incomplete and that the advice offered may be erroneous.13, 5, 10, 12, 13

Cartmill and White14 performed a random audit of 10% of the telephone referrals they received for neurosurgical consultation over a 1‐year period and noted discrepancies between the Glascow Coma Scores reported during the telephone referrals and those noted in the medical records, but the frequency of these discrepancies was not reported. To our knowledge, no studies have compared the quality of the information provided in curbside consultations with that obtained in formal consultations that included direct face‐to‐face patient evaluations and primary data collection, and whether the advice provided in curbside and formal consultations on the same patient differed.

We performed a prospective cohort study to compare the information received by hospitalists during curbside consultations on hospitalized patients, with that obtained from formal consultations done the same day on the same patients, by different hospitalists who were unaware of any details regarding the curbside consultation. We also compared the advice provided by the 2 hospitalists following their curbside and formal consultations. Our hypotheses were that the information received during curbside consultations was frequently inaccurate or incomplete, that the recommendations made after the formal consultation would frequently differ from those made in the curbside consultation, and that these differences would have important implications on patient care.

METHODS

This was a quality improvement study conducted at Denver Health, a 500‐bed university‐affiliated urban safety net hospital from January 10, 2011 to January 9, 2012. The study design was a prospective cohort that included all curbside consultations on hospitalized patients received between 7 _AM and 3 _PM, on intermittently selected weekdays, by the Internal Medicine Consultation Service that was staffed by 18 hospitalists. Data were collected intermittently based upon hospitalist availability and was done to limit potential alterations in the consulting practices of the providers requesting consultations.

Consultations were defined as being curbside when the consulting provider asked for advice, suggestions, or opinions about a patient's care but did not ask the hospitalist to see the patient.15, 15 Consultations pertaining to administrative issues (eg, whether a patient should be admitted to an intensive care bed as opposed to an acute care floor bed) or on patients who were already being followed by a hospitalist were excluded.

The hospitalist receiving the curbside consultation was allowed to ask questions as they normally would, but could not verify the accuracy of the information received (eg, could not review any portion of the patient's medical record, such as notes or lab data). A standardized data collection sheet was used to record the service and level of training of the requesting provider, the medical issue(s) of concern, all clinical data offered by the provider, the number of questions asked by the hospitalist of the provider, and whether, on the basis of the information provided, the hospitalist felt that the question(s) being asked was (were) of sufficient complexity that a formal consultation should occur. The hospitalist then offered advice based upon the information given during the curbside consultation.

After completing the curbside consultation, the hospitalist requested verbal permission from the requesting provider to perform a formal consultation. If the request was approved, the hospitalist performing the curbside consultation contacted a different hospitalist who performed the formal consultation within the next few hours. The only information given to the second hospitalist was the patient's identifiers and the clinical question(s) being asked. The formal consultation included a complete face‐to‐face history and physical examination, a review of the patient's medical record, documentation of the provider's findings, and recommendations for care.

Upon completion of the formal consultation, the hospitalists who performed the curbside and the formal consultations met to review the advice each gave to the requesting provider and the information on which this advice was based. The 2 hospitalists jointly determined the following: (a) whether the information received during the curbside consultation was correct and complete, (b) whether the advice provided in the formal consultation differed from that provided in the curbside consultation, (c) whether the advice provided in the formal consultation dealt with issues other than one(s) leading to the curbside consultation, (d) whether differences in the recommendations given in the curbside versus the formal consultation changed patient management in a meaningful way, and (e) whether the curbside consultation alone was felt to be sufficient.

Information obtained by the hospitalist performing the formal consultation that was different from, or not included in, the information recorded during the curbside consultation was considered to be incorrect or incomplete, respectively. A change in management was defined as an alteration in the direction or type of care that the patient would have received as a result of the advice being given. A pulmonary and critical care physician, with >35 years of experience in inpatient medicine, reviewed the information provided in the curbside and formal consultations, and independently assessed whether the curbside consultation alone would have been sufficient and whether the formal consultation changed management.

Curbside consultations were neither solicited nor discouraged during the course of the study. The provider requesting the curbside consultation was not informed or debriefed about the study in an attempt to avoid affecting future consultation practices from that provider or service.

Associations were sought between the frequency of inaccurate or incomplete data and the requesting service and provider, the consultative category and medical issue, the number of questions asked by the hospitalist during the curbside consultation, and whether the hospitalist doing the curbside consultation thought that formal consultation was needed. A chi‐square test was used to analyze all associations. A P value of <0.05 was considered significant. All analyses were performed using SAS Enterprise Guide 4.3 (SAS Institute, Inc, Cary, NC) software. The study was approved by the Colorado Multiple Institutional Review Board.

RESULTS

Fifty curbside consultations were requested on a total of 215 study days. The requesting service declined formal consultation in 3 instances, leaving 47 curbside consultations that had a formal consultation. Curbside consultations came from a variety of services and providers, and addressed a variety of issues and concerns (Table 1).

The hospitalists asked 0 to 2 questions during 8/47 (17%) of the curbside consultations, 3 to 5 questions during 26/47 (55%) consultations, and more than 5 questions during 13/47 (28%). Based on the information received during the curbside consultations, the hospitalists thought that the curbside consultations were insufficient for 18/47 (38%) of patients. In all instances, the opinions of the 2 hospitalists concurred with respect to this conclusion, and the independent reviewer agreed with this assessment in 17 of these 18 (94%).

The advice rendered in the formal consultations differed from that provided in 26/47 (55%) of the curbside consultations, and the formal consultation was thought to have changed management for 28/47 (60%) of patients (Table 2). The independent reviewer thought that the advice provided in the formal consultations changed management in 29/47 (62%) of the cases, and in 24/28 cases (86%) where the hospitalist felt that the formal consult changed management.

Information was felt to be inaccurate or incomplete in 24/47 (51%) of the curbside consultations (13/47 inaccurate, 16/47 incomplete, 5/47 both inaccurate and incomplete), and when inaccurate or incomplete information was obtained, the advice given in the formal consultations more commonly differed from that provided in the curbside consultation (19/24, 79% vs 7/23, 30%; P < 0.001), and was more commonly felt to change management (22/24, 92% vs 6/23, 26%; P < 0.0001) (Table 2). No association was found between whether the curbside consultation contained complete or accurate information and the consulting service from which the curbside originated, the consulting provider, the consultative aspect(s) or medical issue(s) addressed, the number of questions asked by the hospitalist during the curbside consultation, nor whether the hospitalists felt that a formal consultation was needed.

DISCUSSION

The important findings of this study are that (a) the recommendations made by hospitalists in curbside versus formal consultations on the same patient frequently differ, (b) these differences frequently result in changes in clinical management, (c) the information presented in curbside consultations by providers is frequently inaccurate or incomplete, regardless of the providers specialty or seniority, (d) when inaccurate or incomplete information is received, the recommendations made in curbside and formal consultations differ more frequently, and (e) we found no way to predict whether the information provided in a curbside consultation was likely to be inaccurate or incomplete.

Our hospitalists thought that 38% of the curbside consultations they received should have had formal consultations. Manian and McKinsey7 reported that as many as 53% of questions asked of infectious disease consultants were thought to be too complex to be addressed in an informal consultation. Others, however, report that only 11%33% of curbside consultations were thought to require formal consultation.1, 9, 10, 16 Our hospitalists asked 3 or more questions of the consulting providers in more than 80% of the curbside consultations, suggesting that the curbside consultations we received might have had a higher complexity than those seen by others.

Our finding that information provided in curbside consultation was frequently inaccurate or incomplete is consistent with a number of previous studies reporting physicians' perceptions of the accuracy of curbside consultations.2, 3 Hospital medicine is not likely to be the only discipline affected by inaccurate curbside consultation practices, as surveys of specialists in infectious disease, gynecology, and neurosurgery report that practitioners in these disciplines have similar concerns.1, 10, 14 In a survey returned by 34 physicians, Myers1 found that 50% thought the information exchanged during curbside consultations was inaccurate, leading him to conclude that inaccuracies presented during curbside consultations required further study.

We found no way of predicting whether curbside consultations were likely to include inaccurate or incomplete information. This observation is consistent with the results of Bergus et al16 who found that the frequency of curbside consultations being converted to formal consultations was independent of the training status of the consulting physician, and with the data of Myers1 who found no way of predicting the likelihood that a curbside consultation should be converted to a formal consultation.

We found that formal consultations resulted in management changes more often than differences in recommendations (ie, 60% vs 55%, respectively). This small difference occurred because, on occasion, the formal consultations found issues to address other than the one(s) for which the curbside consultation was requested. In the majority of these instances, the management changes were minor and the curbside consultation was still felt to be sufficient.

In some instances, the advice given after the curbside and the formal consultations differed to only a minor extent (eg, varying recommendations for oral diabetes management). In other instances, however, the advice differed substantially (eg, change in antibiotic management in a septic patient with a multidrug resistant organism, when the original curbside question was for when to order a follow‐up chest roentgenogram for hypoxia; see Supporting Information, Appendix, in the online version of this article). In 26 patients (55%), formal consultation resulted in different medications being started or stopped, additional tests being performed, or different decisions being made about admission versus discharge.

Our study has a number of strengths. First, while a number of reports document that physicians' perceptions are that curbside consultations frequently contain errors,2, 3, 5, 12 to our knowledge this is the first study that prospectively compared the information collected and advice given in curbside versus formal consultation. Second, while this study was conducted as a quality improvement project, thereby requiring us to conclude that the results are not generalizable, the data presented were collected by 18 different hospitalists, reducing the potential of bias from an individual provider's knowledge base or practice. Third, there was excellent agreement between the independent reviewer and the 2 hospitalists who performed the curbside and formal consultations regarding whether a curbside consultation would have been sufficient, and whether the formal consultation changed patient management. Fourth, the study was conducted over a 1‐year period, which should have reduced potential bias arising from the increasing experience of residents requesting consultations as their training progressed.

Our study has several limitations. First, the number of curbside consultations we received during the study period (50 over 215 days) was lower than anticipated, and lower than the rates of consultation reported by others.1, 7, 9 This likely relates to the fact that, prior to beginning the study, Denver Health hospitalists already provided mandatory consultations for several surgical services (thereby reducing the number of curbside consultations received from these services), because curbside consultations received during evenings, nights, and weekends were not included in the study for reasons of convenience, and because we excluded all administrative curbside consultations. Our hospitalist service also provides consultative services 24 hours a day, thereby reducing the number of consultations received during daytime hours. Second, the frequency with which curbside consultations included inaccurate or incomplete information might be higher than what occurs in other hospitals, as Denver Health is an urban, university‐affiliated public hospital and the patients encountered may be more complex and trainees may be less adept at recognizing the information that would facilitate accurate curbside consultations (although we found no difference in the frequency with which inaccurate or incomplete information was provided as a function of the seniority of the requesting physician). Third, the disparity between curbside and formal consultations that we observed could have been biased by the Hawthorne effect. We attempted to address this by not providing the hospitalists who did the formal consultation with any information collected by the hospitalist involved with the curbside consultation, and by comparing the conclusions reached by the hospitalists performing the curbside and formal consultations with those of a third party reviewer. Fourth, while we found no association between the frequency of curbside consultations in which information was inaccurate or incomplete and the consulting service, there could be a selection bias of the consulting service requesting the curbside consultations as a result of the mandatory consultations already provided by our hospitalists. Finally, our study was not designed or adequately powered to determine why curbside consultations frequently have inaccurate or incomplete information.

In summary, we found that the information provided to hospitalists during a curbside consultation was often inaccurate and incomplete, and that these problems with information exchange adversely affected the accuracy of the resulting recommendations. While there are a number of advantages to curbside consultations,1, 3, 7, 10, 12, 13 our findings indicate that the risk associated with this practice is substantial.