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Clinical decision making(1)

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DR RML DELHI
DR RML DELHI

This document provides an overview of clinical decision making (CDM) and discusses several related topics: - It outlines the five domains of emergency care that involve CDM: assessment and stabilization; monitoring; assessing illness severity; making a differential diagnosis; and determining treatment. - CDM can be influenced by many factors including knowledge, biases, context, and non-technical skills. Both intuitive and analytical thinking styles impact CDM. - Improving CDM involves training to enhance critical thinking skills and address common cognitive errors and biases. Receiving timely feedback is also important to make better clinical judgments.

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An Introduction to Clinical Decision Making Dr Graham R. Nimmo Chair, Scottish Clinical Decision Making Special Interest Group Clinical Skills Managed Educational Network and Scottish Clinical Skills Network
Overview • Intro to clinical decision making (CDM) • The five second rule: a case based CDM challenge • How do we think and make decisions? • What affects our CDM? • How can we improve CDM and enhance patient safety? • Next?
CDM and non-technical skills • Team working • Decision making • Situation awareness • Task management • Diagnosis • Prognosis
CDM exercise 1 • Think about your choice of speciality, profession, job • What influenced you in that decision making?
CDM exercise 2 Look at the next slide and ask yourself: • “Which beach would I rather be on?”
A or B ?
CDM in the acutely ill • 21 year old with known asthma • In respiratory ward • Phone call • Decisions • Recognition
The five second rule
CDM in the acutely ill • In the ward • Assessment and management • Looks…. • Obs…. • Actions System 1 thinking: (intuitive) Cognitive style Heuristic Cognitive awareness Low Cost Low Automaticity High Rate Fast Reliability Low Errors Usually Effort Low Predictive power Low Emotional component High Scientific rigour Low
Importance of CDM in managing sick patients • Patients still die from ‘simple’ things either missed, delayed or done sub-optimally • Decisions including diagnosis • Approx 80% of clinical time spent in the cognitive domain
1. Acute assessment + stabilisation with immediate investigations and support. Targeted secondary exam 2. Monitors: reassess Surface Invasive Real time or Delayed Illness severity 4. Differential diagnosis/ definitive diagnosis Immediate, medium term and long term treatment 3. CDM Team work Task Mx Situation Awareness Critical Thinking THE FOUR KEY DOMAINS OF EMERGENCY CARE
1. Advanced First Aid ASSESSMENT • Hello, how are you ? • Response • Airway: patent ? • Breathing ACTION • Look: obstruction • Listen: ? noise • Clear or secure: headtilt/chin lift or jaw thrust? Airway: oral or nasal? • High concn oxygen: mask type? Flow?
1. Advanced First Aid ASSESSMENT • Sounds ? • Common 3 are ? • Causes are ? ACTION • Clear and keep open • Get help 2222? • Advanced airway management required? Tracheal tube? Size? Cut to what length? Are drugs needed for anaesthesia and intubation? If yes, which?
1. Advanced First Aid ASSESSMENT Sounds • Nil: complete obstruction or not breathing • Snoring/gurgling: reduced GCS, foreign material • Stridor: anaphylaxis, burns/thermal; tumour; abscess/infection For each ask ‘what is the diagnosis?’ ACTION • Clear and keep open • Get help 2222 • Positioning • Advanced airway management required
1. Advanced First Aid plus 2. OBSERVE • Rate • Volume • Symmetry • Character • Work of breathing • Compromise Ix & MONITOR • CXR, PEFR, ABGs • Repeat observations • Pulse oximetry • TREAT • Oxygen • Nebulisers
1. Advanced First Aid ASSESS • Pulse: which pulse? • Skin: cap refill time, temperature • BP: where? Which method? PHYSIOLOGY • MAP = CO x SVR • CO = HR x SV • Low BP = decompensation
1. Advanced First Aid iv access • Site • Size • Blood sampling iv access • Upper limb Femoral • High flow: short and thick • Fluids • Drugs
Wide bore peripheral cannulae
1. Advanced First Aid • Disability ? • Conscious level, focal neurology • DEFG • Difficult bit
IMMEDIATE INVESTIGATIONS • Arterial blood gases: O2 , CO2 , acid-base • Potassium • Glucose can all be done on a • Haemoglobin blood gas sample • 12 lead ECG • CXR • Targeted investigations • What should we do having analysed this information?
1. Advanced First Aid • Evidence • Environment: context • Targeted secondary Examination • Explanation • Everything else…
Advanced First Aid=Phase 1:abcde • abcde, treating as you go • Repeated assessment and continuous monitoring: patient better or worse ? • Do we need enhanced abcde ? • Targeted secondary examination
1. Acute assessment + stabilisation & immediate investigations and support. Targeted secondary exam 2. Monitors: reassess Surface Invasive Real time or Delayed Illness severity 4. Differential diagnosis/ definitive diagnosis Immediate, medium term and long term treatment 3. CDM Team work Task Mx Situation Awareness Critical Thinking THE FOUR KEY DOMAINS OF EMERGENCY CARE
Illness Severity Assessment • Speed of action needed • Level & type of expertise: resuscitation; diagnostic; therapeutic • Where should the patient be ? Nursing intensity, monitoring, medical input? • Definitive treatment: speed ?
SEVERITY SCORING 1:CLINICAL ABNORMAL PHYSIOLOGY • Airway compromised • Resp rate • Pulse rate • SBP • GCS OBSERVATIONS • Bad • <10 or >30 • <45 or >120 • <100 (110) or >200 • Fall of 2 points, <15
SEVERITY SCORING 2: INVESTIGATIONS ABNORMAL INVESTIGATIONS • Hypoxaemia • Hypercarbia • Potassium • Glucose • H+ • Base excess • Lactate RESULTS • <3 or >6 (ECG) • <3 or >20 • >50 or <30 • < -5 or > +10 • Diagnosis ?
ICM 2001;27:74-83 Base Excess and Mortality Red = Dead Green = survivor Relationship between base excess and mortality in ICU
SEVERITY SCORING 3: organ failures • Clinical: cardiovascular (shock) • CNS reduced conscious level • Urea and creatinine: renal • ABGs: respiratory (oxygenation+/or CO2 clearance) • Clotting: coagulation • WBC: bone marrow • Gut/liver: glucose; lactate; clinical
4. Differential Diagnosis, ultimate diagnosis and definitive treatment • Get more history • Trachea • Chest • JVP and heart • Abdomen • Skin, CNS • GP, family, SAS • Deviation • Lateralising signs, wheeze, crackles • HS III or IV, murmurs • Swelling, pulsation • Rashes, neck stiffness, lateralising signs
ASSESSMENT • A clinical + • B investigations + • C organ failures + • D diagnosis
Decision making • Diagnosis (and treatment) • Is the diagnosis correct (complete) ? • Prognosis • Admit ? • Discharge ? • Stop ? • Distributed
Diagnostic Error • Ranked 2nd cause of adverse events (Harvard study, 1991) • Diagnostic failure highest in EM, GP, Gen Med • Passing on to specialists in wards, ICU • 2/3 of claims against UK GPs are for diagnostic failure
Type 2 thinking (analytical) Cognitive style Systematic Cognitive awareness High Cost High Automaticity Low Rate Low Reliability High Errors Few Effort High Predictive power High Emotional component Low Scientific rigour High Diagnosis • History: full • Examination: complete • Investigations • Differential Dx • Treatment • Refine diagnosis
Categorising Clinical Decision Making • Cognitive theory: traditional • Technical • Professional • Distributed
Traditional cognitive taxonomy or “how you think it” • Problem solving • Pattern recognition • Decision analysis theory • Hypothetico-deductive reasoning
CDM: a universal model of diagnostic reasoning Intuitive • Experiential-inductive • Bounded rationality • Heuristic • Pattern recognition • Hard wired response • Thin slicing • Unconscious thinking theory Analytical • Hypothetico-deductive • Unbounded rationality • Normative reasoning • Robust CDM • Acquired, critical, logical thought • Multiple branching/arborisation • Deliberate, purposeful thinking
A or B ?
CDM What affects clinical decision making ? • Knowledge and skills • Behaviours: attitude (multiple selves), emotions (affect: self, family, patients, relatives, colleagues), values.
What affects clinical decision making ? • Context • Values • Affect • Knowledge • Critical thinking • Interruptions • Clinical reasoning • Words • Non-technical Skills • Physical factors • Stress and Fatigue • Ergonomics • Experience • What we hear • What we think • Cognitive biases • Heuristics • Epiphanies • Geography
30 Cognitive Errors after Croskerry Zebra retreatPremature closureGambler’s Fallacy Ying-Yang OutPosterior prob.Attribution error Visceral biasPlaying the oddsDiagnostic creep Vertical line failureOverconfidenceConfirmation bias Unpacking principleOutcome biasCommission bias Triage-CueingOrder effectsBase rate neglect Sutton’s SlipOmission biasAvailability Search satisficingMultip.AlternativesAscertainment bias RepresentativenessHindsight biasAnchoring Psych-Out ErrorsGender biasAggregate bias
Hard wiring Heuristics and Biases Ambient conditions/Context Task characteristics Age and Experience Affective state Gender Personality Intellectual ability Education Training Critical thinking Logical competence Rationality Feedback Pattern Recognition Repetition Rational override Dysrationalia override Calibration Diagnosis Patient Presentation Pattern Processor RECOGNIZED TYPE 1 processes TYPE 2 processes NOT RECOGNIZED
1. Acute assessment + stabilisation & immediate investigations and support. Targetted secondary exam 2. Mons: reassess Surface Invasive Real time or Delayed Tissue hypoxia 4. Differential diagnosis/ definitive diagnosis Immediate, medium term and long term treatment 3. CDM Team work Task Mx Situation Awareness Critical Thinking THE FOUR KEY DOMAINS OF EMERGENCY CARE
Evidence Based Medicine Clinician factors: judgment, affect, experience Patient Factors
Solutions • Training in critical thinking • Training in major cognitive and affective biases • Training in logical thought • Awareness of self and metacognition • Timely feedback • Training in cognitive forcing strategies
Clinical decision making(1)
Clinical decision making(1)

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Clinical decision making(1)

  • 1. An Introduction to Clinical Decision Making Dr Graham R. Nimmo Chair, Scottish Clinical Decision Making Special Interest Group Clinical Skills Managed Educational Network and Scottish Clinical Skills Network
  • 2. Overview • Intro to clinical decision making (CDM) • The five second rule: a case based CDM challenge • How do we think and make decisions? • What affects our CDM? • How can we improve CDM and enhance patient safety? • Next?
  • 3. CDM and non-technical skills • Team working • Decision making • Situation awareness • Task management • Diagnosis • Prognosis
  • 4. CDM exercise 1 • Think about your choice of speciality, profession, job • What influenced you in that decision making?
  • 5. CDM exercise 2 Look at the next slide and ask yourself: • “Which beach would I rather be on?”
  • 6. A or B ?
  • 7. CDM in the acutely ill • 21 year old with known asthma • In respiratory ward • Phone call • Decisions • Recognition
  • 9. CDM in the acutely ill • In the ward • Assessment and management • Looks…. • Obs…. • Actions System 1 thinking: (intuitive) Cognitive style Heuristic Cognitive awareness Low Cost Low Automaticity High Rate Fast Reliability Low Errors Usually Effort Low Predictive power Low Emotional component High Scientific rigour Low
  • 10. Importance of CDM in managing sick patients • Patients still die from ‘simple’ things either missed, delayed or done sub-optimally • Decisions including diagnosis • Approx 80% of clinical time spent in the cognitive domain
  • 11. 1. Acute assessment + stabilisation with immediate investigations and support. Targeted secondary exam 2. Monitors: reassess Surface Invasive Real time or Delayed Illness severity 4. Differential diagnosis/ definitive diagnosis Immediate, medium term and long term treatment 3. CDM Team work Task Mx Situation Awareness Critical Thinking THE FOUR KEY DOMAINS OF EMERGENCY CARE
  • 12. 1. Advanced First Aid ASSESSMENT • Hello, how are you ? • Response • Airway: patent ? • Breathing ACTION • Look: obstruction • Listen: ? noise • Clear or secure: headtilt/chin lift or jaw thrust? Airway: oral or nasal? • High concn oxygen: mask type? Flow?
  • 13. 1. Advanced First Aid ASSESSMENT • Sounds ? • Common 3 are ? • Causes are ? ACTION • Clear and keep open • Get help 2222? • Advanced airway management required? Tracheal tube? Size? Cut to what length? Are drugs needed for anaesthesia and intubation? If yes, which?
  • 14. 1. Advanced First Aid ASSESSMENT Sounds • Nil: complete obstruction or not breathing • Snoring/gurgling: reduced GCS, foreign material • Stridor: anaphylaxis, burns/thermal; tumour; abscess/infection For each ask ‘what is the diagnosis?’ ACTION • Clear and keep open • Get help 2222 • Positioning • Advanced airway management required
  • 15. 1. Advanced First Aid plus 2. OBSERVE • Rate • Volume • Symmetry • Character • Work of breathing • Compromise Ix & MONITOR • CXR, PEFR, ABGs • Repeat observations • Pulse oximetry • TREAT • Oxygen • Nebulisers
  • 16. 1. Advanced First Aid ASSESS • Pulse: which pulse? • Skin: cap refill time, temperature • BP: where? Which method? PHYSIOLOGY • MAP = CO x SVR • CO = HR x SV • Low BP = decompensation
  • 17. 1. Advanced First Aid iv access • Site • Size • Blood sampling iv access • Upper limb Femoral • High flow: short and thick • Fluids • Drugs
  • 19. 1. Advanced First Aid • Disability ? • Conscious level, focal neurology • DEFG • Difficult bit
  • 20. IMMEDIATE INVESTIGATIONS • Arterial blood gases: O2 , CO2 , acid-base • Potassium • Glucose can all be done on a • Haemoglobin blood gas sample • 12 lead ECG • CXR • Targeted investigations • What should we do having analysed this information?
  • 21. 1. Advanced First Aid • Evidence • Environment: context • Targeted secondary Examination • Explanation • Everything else…
  • 22. Advanced First Aid=Phase 1:abcde • abcde, treating as you go • Repeated assessment and continuous monitoring: patient better or worse ? • Do we need enhanced abcde ? • Targeted secondary examination
  • 23. 1. Acute assessment + stabilisation & immediate investigations and support. Targeted secondary exam 2. Monitors: reassess Surface Invasive Real time or Delayed Illness severity 4. Differential diagnosis/ definitive diagnosis Immediate, medium term and long term treatment 3. CDM Team work Task Mx Situation Awareness Critical Thinking THE FOUR KEY DOMAINS OF EMERGENCY CARE
  • 24. Illness Severity Assessment • Speed of action needed • Level & type of expertise: resuscitation; diagnostic; therapeutic • Where should the patient be ? Nursing intensity, monitoring, medical input? • Definitive treatment: speed ?
  • 25. SEVERITY SCORING 1:CLINICAL ABNORMAL PHYSIOLOGY • Airway compromised • Resp rate • Pulse rate • SBP • GCS OBSERVATIONS • Bad • <10 or >30 • <45 or >120 • <100 (110) or >200 • Fall of 2 points, <15
  • 26. SEVERITY SCORING 2: INVESTIGATIONS ABNORMAL INVESTIGATIONS • Hypoxaemia • Hypercarbia • Potassium • Glucose • H+ • Base excess • Lactate RESULTS • <3 or >6 (ECG) • <3 or >20 • >50 or <30 • < -5 or > +10 • Diagnosis ?
  • 27. ICM 2001;27:74-83 Base Excess and Mortality Red = Dead Green = survivor Relationship between base excess and mortality in ICU
  • 28. SEVERITY SCORING 3: organ failures • Clinical: cardiovascular (shock) • CNS reduced conscious level • Urea and creatinine: renal • ABGs: respiratory (oxygenation+/or CO2 clearance) • Clotting: coagulation • WBC: bone marrow • Gut/liver: glucose; lactate; clinical
  • 29. 4. Differential Diagnosis, ultimate diagnosis and definitive treatment • Get more history • Trachea • Chest • JVP and heart • Abdomen • Skin, CNS • GP, family, SAS • Deviation • Lateralising signs, wheeze, crackles • HS III or IV, murmurs • Swelling, pulsation • Rashes, neck stiffness, lateralising signs
  • 30. ASSESSMENT • A clinical + • B investigations + • C organ failures + • D diagnosis
  • 31. Decision making • Diagnosis (and treatment) • Is the diagnosis correct (complete) ? • Prognosis • Admit ? • Discharge ? • Stop ? • Distributed
  • 32. Diagnostic Error • Ranked 2nd cause of adverse events (Harvard study, 1991) • Diagnostic failure highest in EM, GP, Gen Med • Passing on to specialists in wards, ICU • 2/3 of claims against UK GPs are for diagnostic failure
  • 33. Type 2 thinking (analytical) Cognitive style Systematic Cognitive awareness High Cost High Automaticity Low Rate Low Reliability High Errors Few Effort High Predictive power High Emotional component Low Scientific rigour High Diagnosis • History: full • Examination: complete • Investigations • Differential Dx • Treatment • Refine diagnosis
  • 34. Categorising Clinical Decision Making • Cognitive theory: traditional • Technical • Professional • Distributed
  • 35. Traditional cognitive taxonomy or “how you think it” • Problem solving • Pattern recognition • Decision analysis theory • Hypothetico-deductive reasoning
  • 36. CDM: a universal model of diagnostic reasoning Intuitive • Experiential-inductive • Bounded rationality • Heuristic • Pattern recognition • Hard wired response • Thin slicing • Unconscious thinking theory Analytical • Hypothetico-deductive • Unbounded rationality • Normative reasoning • Robust CDM • Acquired, critical, logical thought • Multiple branching/arborisation • Deliberate, purposeful thinking
  • 37. A or B ?
  • 38. CDM What affects clinical decision making ? • Knowledge and skills • Behaviours: attitude (multiple selves), emotions (affect: self, family, patients, relatives, colleagues), values.
  • 39. What affects clinical decision making ? • Context • Values • Affect • Knowledge • Critical thinking • Interruptions • Clinical reasoning • Words • Non-technical Skills • Physical factors • Stress and Fatigue • Ergonomics • Experience • What we hear • What we think • Cognitive biases • Heuristics • Epiphanies • Geography
  • 40. 30 Cognitive Errors after Croskerry Zebra retreatPremature closureGambler’s Fallacy Ying-Yang OutPosterior prob.Attribution error Visceral biasPlaying the oddsDiagnostic creep Vertical line failureOverconfidenceConfirmation bias Unpacking principleOutcome biasCommission bias Triage-CueingOrder effectsBase rate neglect Sutton’s SlipOmission biasAvailability Search satisficingMultip.AlternativesAscertainment bias RepresentativenessHindsight biasAnchoring Psych-Out ErrorsGender biasAggregate bias
  • 41. Hard wiring Heuristics and Biases Ambient conditions/Context Task characteristics Age and Experience Affective state Gender Personality Intellectual ability Education Training Critical thinking Logical competence Rationality Feedback Pattern Recognition Repetition Rational override Dysrationalia override Calibration Diagnosis Patient Presentation Pattern Processor RECOGNIZED TYPE 1 processes TYPE 2 processes NOT RECOGNIZED
  • 42. 1. Acute assessment + stabilisation & immediate investigations and support. Targetted secondary exam 2. Mons: reassess Surface Invasive Real time or Delayed Tissue hypoxia 4. Differential diagnosis/ definitive diagnosis Immediate, medium term and long term treatment 3. CDM Team work Task Mx Situation Awareness Critical Thinking THE FOUR KEY DOMAINS OF EMERGENCY CARE
  • 44. Solutions • Training in critical thinking • Training in major cognitive and affective biases • Training in logical thought • Awareness of self and metacognition • Timely feedback • Training in cognitive forcing strategies