Prioritizing a Caseload


Screening and prioritizing a patient caseload is an important skill to have as a clinical dietitian. It involves deciding which patients are at nutritional risk and where to allocate clinical and staffing resources. Some dietetic interns find this to be a steep learning curve, as it requires synthesizing and integrating information from numerous sources.

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This page offers some guidelines and examples of how to screen and prioritize a patient caseload in an acute care setting. There are no universal guidelines and each health authority, hospital or clinical area will differ with its protocol and procedures. Thank you to Mignon Radakrishnan, MEd, RD, for providing the content for this page in consultation with dietetics students. She developed this material in January 2014 during her work with Vancouver Coastal Health.

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

A patient census is a list of all the current patients in the ward and a brief description of their condition. Dietitians will review their census and prioritize which patient should be seen first. More information about the patient can be obtained from the diet records, medical chart, Kardex (nursing notes), 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)?


Biochemistry

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

(May, 2014)

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

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

Patient Screening and Prioritizing Case Study Worksheet

1. Dietitians of Canada Nutrition Screening Course: http://www.dietitians.ca/Learn/Learning-On-Demand/lodstoreproduct?guid=36aa6d2d-ebd3-4fc5-acd5-d16b76e6218c

  • A self-paced course offered by Dietitians of Canada to learn more about validated screening tools.


2. Porter J, Jamieson R. Triaging in dietetics: Do we prioritise the right patients? Nutrition & Dietetics. 2013;70:21-26. DOI: 10.1111/j.1747-0080.2012.01637.x

  • A study comparing the dietetic traige guidelines in several Australian hospitals. Results found a limited evidence base in this area and lack of consistency in guidelines.


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. DOI: 10.1177/0148607111414023

  • A review of many common malnutrition screening tools and the benefits of each.
source: http://wiki.ubc.ca/Dietetics:Prioritizing_a_Caseload