Dietetics:Clinical Practice

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Introduction

Screening and prioritizing a patient caseload is an important skill to have as a clinical dietitian, as it determines which patients are at nutritional risk and where to allocate clinical and staffing resources. Some dietetic interns may struggle with this during their internship as it requires synthesizing, integrating and applying information from numerous sources. This wiki offers some guidelines and examples of how to screen and prioritize a patient caseload in an acute care setting. As noted throughout this page, there are no universal guidelines and each health authority, hospital or clinical area will differ with its protocol and procedures.

What Should You Consider When Prioritizing a Patient Caseload in Acute Care?

Depending on the health authority/hospital this information can be obtained from the patient census, diet records, chart, Kardex, computer database, patient or meal rounds or through discussion with other members of the interdisciplinary healthcare team. The following is a general list of questions to consider when prioritizing a patient caseload in acute care.


Nutrition Support: Enteral Nutrition (EN)/Parenteral Nutrition (PN)

  • Is the patient starting EN or PN?
  • Is the patient showing signs of intolerance to nutrition support?
  • Is the patient transitioning from EN/PN to an oral diet/EN?


Restrictive or Modified Texture Diets

  • Is the patient on one or more specialized diets that restrict dietary intake?
  • Is the patient on a modified texture diet, such as a dysphagia diet?
  • Does the patient have any food allergies, intolerances or preferences that restrict dietary intake?


Inadequate Intake

  • Has the patient been NPO for several consecutive days?
  • Has the patient not been eating due to a decreased level of consciousness or decreased appetite?
  • Has the patient been on a clear fluid or full fluid diet for several consecutive days?
  • Has the patient been having any GI symptoms (e.g. nausea, vomiting, diarrhea, abdominal pain)?


Malnutrition

  • Has the patient lost a significant amount of weight?
  • Is the patient at risk of refeeding syndrome?
  • Is the patient hypermetabolic/hypercatabolic (increased protein and energy needs)?


Interventions

  • Has the patient recently undergone major surgery/procedures, illness or trauma that may affect intake, digestion or absorption?
  • Is the patient mechanically ventilated (e.g. tracheostomy)?


Bloodwork

  • Does the patient have abnormal laboratory values that may be of nutritional concern?

Sample Screening and Prioritization Tools

File:Possible Screening and Prioritization Procedure for Dietitian Workload.pdf

File:Nutrition Care Indicator Categories.pdf

Practice Case Study

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If you would just like to practice a screening and prioritization scenario, view the PowToon.

Below is a link to a worksheet for the case study in the PowToon.

Patient Screening and Prioritizing Case Study Worksheet

Further Reading

  1. Chima CS, Dietz-Seher C, Kushner-Benson S. Nutrition risk screening in acute care: A survey of practice. Nutrition in clinical practice: official publication of the American Society for Parenteral and Enteral Nutrition. 2008;23:417-423.
  2. Porter J, Jamieson R. Triaging in dietetics: Do we prioritise the right patients? Nutrition & Dietetics. 2013;70:21-26.
  3. Skipper A, Ferguson M, Thompson K, Castellanos VH, Porcari J. Nutrition screening tools: An analysis of the evidence. Journal of Parenteral and Enteral Nutrition. 2012;36:292-298.