Clinical Decision Making

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Clinical Decision Making

  1. 1. Clinical Decision Making in Intensive Care Graham Nimmo Intensive Care Unit Western General Hospital
  2. 2. Overview  Background  Clinical decisions in intensive care: inventory  Factors affecting CDM  Clinical observation  Can we do better ?
  3. 3. CDM: a cognitive taxonomy  Problem solving  Pattern recognition  Decision analysis theory  Hypothetico-deductive reasoning  Dual process theory: System 1 intuitive and System 2 analytical Croskerry Can J Anesth 2005; Gladwell, Blink 2005
  4. 4. CDM: big business !  CVC Haematology: where? Who ? When ?  ODM figures  Vanc infusion dose and rate  Death certificate: diagnosis  Fluids and norad  GCS ?extubate
  5. 5. CDM: early one evening….  What to say to family ?  Vent settings x 2  Fluids  Norad  B-blocker  NIV settings  Fluids: urine output
  6. 6. CDM 2  Food trolley  Remove CVC  Admission: handover, story, diagnosis, problems, NG (varices)  Feeding  SAH reduced GCS intubate and scan  Colleague unwell: cover  CXR CVC
  7. 7. CDM 2  CXR Quinton, HF anticoagulant  New password Apex  Transfuse ?  Intubate ?  Access, monitors, drugs, who does what, tube,, ventilation  CT head: Neurosurgeon discussion
  8. 8. CDM 3  A referral ? admit  Ward SHO crying  Antibiotic choice
  9. 9. CDM: a clinical inventory  Reflex: hypoxaemia so increase O2, agitated so more sedation  Why ? Sort the underlying problem  Diagnosis: syndromes and diseases  Investigations, support, therapy  Monitoring  Referral: speciality
  10. 10. CDM: a clinical taxonomy Prognosis  Admission or not ?  Relatives  End of life care: limitation, withdrawal  ‘On behalf’ CDM
  11. 11. CDM: a clinical taxonomy  Team working and SA  Distributed decision making  Prioritisation Professional  Regarding colleagues  Joint decision making
  12. 12. What affects clinical decision making ?  Context  Values  Affect  Critical thinking  Interruptions  Clinical reasoning  Words  NTS  Physical factors  Stress and Fatigue  Ergonomics  Experience  What we hear  What we think  Cognitive biases  Heuristics
  13. 13. Interruptions: Critical Incidents  ‘Distractions’ Buckley 1997 Anaesthesia 52:403- 409  ‘Failure to carry out planned treatment’; lapses and slips’ Rothschild 2005 Crit Care Med 33:1694-1700
  14. 14. Interruptions: Clinical Practice  Intra-thecal vancomycin  Tom Reader  ‘Good interruptions’: redirection, prioritising  Interruptions helping in detection of problems Wright 1991 Lancet 338:676-678
  15. 15. Interruptions: Clinical Practice  Is it a problem ?  Audit to identify frequency and type of interruptions in the ICU setting  Implications for patient care ?  Nimmo GR, Mitchell CM. JICS October 2008
  16. 16. Aims of the audit  To document the incidence of interruptions in the Intensive Care Unit.  To document what form the interruptions were taking.  To identify when the majority of the interruptions occurred.
  17. 17. Methods  Study design  an observational study  over a 4 week period  in the 16 bedded general and neuro- intensive care unit.  Study protocol  A single investigator collected directly observed data.  Interruptions were documented and categorised.
  18. 18. Results Morning handover ward round Daily main ward round Evening handover ward round Weekly grand round Total observation time (hours) 5.5 16.07 2.23 5.35 Total number of interruptions 186 516 38 103 Simple interruptions 78 (42%) 269 (52%) 21 (52%) 36 (35%) Breaks in task 40 (22%) 161 (31%) 17 (45%) 33 (32%) Turn taking interruptions 68 (37%) 86 (17%) - 34 (33%) Essential interruptions 20 (11%) 139 (27%) 16 (42%) 17 (17%)
  19. 19. Modes of Interruption Verbal in person  Between staff : 128 social; 49 clinical within ward round; clinical from around ICU 143  Patient: verbal 15  Students verbal: 22  Domestic staff: 15  Referring clinicians on ward: 19
  20. 20. Modes of Interruption 2 Equipment  Phone: landline 43; mobile 5  Text: 4  Bleep: 28  Alarms: 130
  21. 21. Conclusions  Interruptions are very prevalent in the intensive care setting, with a mix of essential vs unnecessary disruptions.  Future research is necessary to document more precisely when and what interruptions are happening and in relation to critical incidents. “Interruptions can be viewed as sources of irritation or opportunities for service, as moments lost or experience gained, as time wasted or horizons widened. They can annoy us or enrich us, get under our skin or give us a shot in the arm. Monopolize our minutes or spice our schedules, depending on our attitude toward them.” William Arthur Ward, scholar, author
  22. 22. Evidence Based Medicine Clinical Judgment Patient Factors
  23. 23. CDM: Miller’s Triangle
  24. 24. CDM: the pyramid ?  What affects clinical decision making ?  Knowledge and skills  Behaviours: attitude (multiple selves), emotions (affect: self, family, patients, relatives, colleagues), values.
  25. 25. 30 Cognitive Errors after Croskerry Aggregate bias Gender bias Psych-Out Errors Anchoring Hindsight bias Representativeness Ascertainment bias Multip.Alternatives Search satisficing Availability Omission bias Sutton’s Slip Base rate neglect Order effects Triage-Cueing Commission bias Outcome bias Unpacking principle Confirmation bias Overconfidence Vertical line failure Diagnostic creep Playing the odds Visceral bias Attribution error Posterior prob. Ying-Yang Out Gambler’s Fallacy Premature closure Zebra retreat
  26. 26. Quiz  What is Cushing’s triad ?  Is ‘coning’ fatal ?  How far back should we read the Medical literature ?
  27. 27. Quiz  What is Cushing’s triad ?  Hypertension, bradycardia, abnormal breathing  Is ‘coning’ fatal ?  Yes.  How far back should we read the Medical literature ?  Cushing Am J Sci 1903:125
  28. 28. Cushing: blood-pressure reaction  Rapid encroachment on intra-cranial space by a foreign body…extravasated blood….a high tension pulse  A regulatory mechanism controls the rise and a fatal bulbar anaemia is warded off.  In the majority…the vagus centre is likewise stimulated …with the familiar slowing of the pulse rate Am J Sci 1903:125:1017-1044
  29. 29. Kocher: stages of medullary compression  Stage I : compensationsstadium. No major symptoms or signs(loss of CSF/venous blood)  Stage II: angfangstadium. Headache, disturbed sensorium  Stage III: Hohesstadium. Raised BP, impaired breathing, pupils changes, pulse 50, 40 or less  Stage IV: the terminal stage Lahmunngsstadium: falling BP, coma, pupil dilation, breathing inadequacy, rapid pulse
  30. 30. Cushing’s Triad  Brain Trauma Foundation  Principles of Surgical Practice, Majul and Kingsnorth Eds.  Davidsons  Oxford Textbook of Intensive Care Medicine  ATLS  Wikipedia
  31. 31. Suspension of Disbelief (belief)
  32. 32. Haemodynamics 0 20 40 60 80 100 120 140 160 1 2 3 TIMESCALE HR 0 50 100 150 200 250 HR SBP DBP M AP T 0 BP T-1 T+1
  33. 33. Enhancing CDM  Disciplined noticing: clinical observation  Critical thinking  Clinical reasoning
  34. 34. Solutions  Training in critical thinking  Training in real decision theory  Training in major cognitive and affective biases  Training in logical thought  Awareness of self and metacognition  Timely feedback  Training in cognitive forcing strategies
  35. 35. Doing a Paddington
  36. 36. 1. RAM with immediate investigations and support and targeted examination 2. Monitoring & frequent re- assessment 3. Definitive diagnosis & treatment: secondary exam 4. Decision Making THE FOUR KEY ELEMENTS OF EMERGENCY MANAGEMENT
  37. 37. SICS Education and Training group cdm section http://www.scottishintensivecare.org.uk/education/decisions/index.htm Scottish Clinical Skills Network special interest group on cdm http://www.scsn.scot.nhs.uk/resources/SpecialInterestGroups.htm http://dieoff.org/page163.htm http://www.bmj.com/cgi/content/full/bmj.39371.524271.55v1 http://journal.sjdm.org/ http://www.fammed.ouhsc.edu/robhamm/index.htm Related Links

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