Clinical decision making in Emergency Medicine

Jutamas Saoraya Department of Emergency Medicine

King Chulalongkorn Memorial Hospital

Outline• Nature of clinical decision making

• decision making process

• pattern recognition

• rule using algorithm

• hypothetico-deductive

• naturalistic or event-driven

• How to make optimal decision

• Errors in clinical decision making and how to avoid it

Nature of clinical decision making in the ED

• vast amount of information

• uncertainties

• rapid decision making

Rosen’s

Patient management decisions

• Triage: What patients need to be seen first?

• Stabilization: What management interventions are needed to stabilize the patient?

• Diagnostic: What clinical findings are needed to make the diagnosis?

• Therapeutic: What ongoing therapy is needed?

• Disposition: Will the patient need to be admitted? Where?

Medical inquiries

Clinical decision making

Clinical reasoning

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Emergency physician’s decision making processes

• pattern recognition

• rule using algorithm

• hypothetico-deductive

• naturalistic or event-driven

Clinical decision rules

• tools designed to help clinicians make bedside diagnostic and therapeutic decisions

Clinical decision rules example

• CHA2DS2-VASc

• HEART Score

• Centor Score

• CURB-65

• qSOFA

• PSI/PORT score

• PECARN pediatric head injury

• Ottawa ankle rule

• Ottawa Knee rule

• Glasgow-Blatchford Bleeding score

• PERC

• Wells for DVT

hypothetico-deductiveinitial medical inquiries

hypothesis generation

hypothesis evaluation

hypothesis refinement

hypothesis verification

naturalistic or event-driven

• more likely to be utilized in emergency medicine than any other specialty

• Treat signs and symptoms before definitive diagnosis

• presumptive diagnosis instead of definitive diagnosis

• ruling out worst case scenario

Case: ชาย 30 ป เหนอยฉบพลน

• BT 36 C PR 120/min RR 30/min BP 80/60 mmHg SpO2 88%

Optimal Decision Making

• Medical inquiries

• Thorough history

• uninterrupted physical examination

Optimal Decision Making• generate life-threatening and most likely diagnostic hypothesis

• Collect data to confirm or exclude life threats first, then most likely diagnosis

• use information databases and expert systems to broaden diagnostic hypotheses

• Avoid diagnostic testing whenever possible by using readily available decision making algorithm

• Order only those tests that will affect disposition or that will confirm or exclude diagnostic hypotheses

• Use guidelines and protocols for specific therapeutic decisions to conserve mental energies while on duty

Optimal Decision Making• Bottom line: Life threat? hospitalization? patient’s safety?

• close the disposition and follow-up loop

• Understand fully why the patient is in the emergency department

• chief complaint

• acuity

• expectation

เกณฑมาตรฐาน ศรว

• โรค/กลมอาการ/ภาวะฉกเฉนทตองรกลไกการเกดโรค สามารถใหการวนจฉยเบองตนและ ใหการบำบดโรคฯ การรกษาผปวย ไดอยางทนทวงทตามความเหมาะสมของสถานการณ รขอจากดของ ตนเองและปรกษาผเชยวชาญหรอผมประสบการณมากกวา ไดอยางเหมาะสม

Emergency condition• Cardiac arrest • Pulmonary edema • Malignant hypertension • Shock• Ruptured and threatening

ruptured dissecting aneurysm • Acute coronary syndrome • Cardiac tamponade • Anoxic spell • Respiratory failure• Respiratory obstruction,

suffocation • Acute exacerbation of asthma• Pneumothorax• Superior vena cava obstruction • Hyperglycemic crisis

• Hypoglycemia• Disseminated intravascular

clotting• Acute hemolytic crisis• Incompatible blood transfusion• Acute psychosis, delirium,

aggression (violence)• Hyperventilation syndrome• Severe depression• Suicide attempt• Panic attack• Reaction to severe stress• Acute corneal abrasion and ulcer• Acute glaucoma• Anuria/oliguria• Acute urinary retention

Emergency condition•Hyperkalemia•Obstructed labor•Threatened uterine rupture•Severe pre-eclampsia, eclampsia •Prolapsed umbilical cord•Rape •Coma•Syncope•Convulsion•Acute increased intracranial pressure•Asphyxia of the newborn•Fetal distress •Acute abdomen

•Serious bleeding; massive bleeding; gastrointestinal, intracranial bleeding, hyphema, •antepartum and postpartum hemorrhage•Acute poisoning; drugs, food, chemicals, substances•Bites & stings•Injury /accident; head & neck injury, fracture, dislocation, body and limb injuries, •compartment syndrome, falls, serious injury, electrical injury, burns, inhalation injuries, near-drowning & submersion

Errors in clinical reasonings

• Affective domain

• fear, anger

• cultural stereotyping

• attribution error: blaming patients for their illness

Errors in clinical reasonings

• Cognitive domain

• medical inquiry

• confirmation bias: only see what you want to see

• unfocused diagnostic testing

Errors in clinical reasonings • Cognitive domain

• diagnostic decision making

• biased memory

• context or situational bias

• psych out

• anchoring bias

• premature closure

• analysis paralysis

The consequences model

“analysis paralysis”

“Retrospective bias”

Patient modifying factors

• Pregnancy

• Children

• Adults

• Elderly

• Immunocompromised

• Psychiatric

How to avoid errors• avoid cling to a previous diagnosis

• avoid inheriting someone else’s thinking

• pay attention to vital signs and nurses’ and EMS note

• if the diagnosis is not certain

• enlist the patient as a partner in that uncertainty

• arrange for appropriate follow up

• give specific precautions in written form

How to avoid errors• beware of high risk times: sign out time, personal fatigue,

high volume or high acuity time

• beware of high risk patients : hostile, violent, abusive, psychiatric , patients who elicit a negative visceral response

• beware of return visit

• beware of high risk diagnosis : MI, PE, SAH, tendon and nerve injuries, retained foreign bodies, ICH, appendicitis, meningitis, ectopic pregnancy , testicular torsion

Summary• Nature of clinical decision making

• decision making process

• pattern recognition

• rule using algorithm

• hypothetico-deductive

• naturalistic or event-driven

• How to make optimal decision

• Errors in clinical decision making and how to avoid it