Intuition, Rapid Response Teams and Mentoring

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Intuition, Rapid Response Teams and Mentoring

• Thomas A. Iannucci, M.D., FACOG Department of
  Maternal-Fetal Medicine
• Advocate Lutheran General Hospital

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Making Decisions

• Decision-making is commonly described as a
  multistage process
• Define a problem
• Generate alternatives
• Evaluate options (possible formal analytical
  methods)
• Choice
• Implement decision

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Making Decisions

• How does intuition work when making decisions?
• Assess situation come to a solution
• No comparison of alternatives
• Referring to Critical, Complex decisions, not
  simple
• What are we using in these cases?
• Sixth sense
• Intuition
• Gut

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Making Decisions

• What is intuition?
• Is it just there?
• Can we improve our intuition?
• To improve it we need to better understand how
  intuition works
• Can we actually harness and enhance our intuition
  to become better decision makers?
• Can we share our intuition?

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Making Decisions

• Gary Klein, PhD-psychologist researching
  decision-making
• Asked fire commanders about making life and death
  decisions
• When questioning how they made difficult
  decisions, he concluded they frequently resorted
  to intuition.

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Intuition in Decisions

• He asked fire commanders about their most
  challenging situations
• One commander stated that E.S.P. played a role in
  a particular situation
• He firmly believed that he had experienced extra
  sensory perception

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Intuition in Decisions

• Situation
• The commanders crew had arrived at a fire that
  appeared to be a simple contained, kitchen fire.
• The fire however was not responding to the direct
  water spray from the living room
• He also noted that the fire was much hotter than
  expected
• His sixth sense then kicked in
• He pulled his crew completely out of the house

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Intuition in Decisions

• Soon after they left the house the living room
  floor collapsed

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Intuition in Decisions

• Klein then asked him why he made the decision to
  pull the crew out
• He was surprised that the water had no effect on
  a seemingly small fire
• He was puzzled at how hot the fire was
• He thought it seemed odd at how quiet the fire
  was from the living room

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Intuition in Decisions

• His explanation was summarized by Klein
• He pattern he saw did not fit
• The situation violated his expectations
• Frankly, he wasnt sure what was going on

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Intuition in Decisions

• Overall, our experiences provide us with an
  expected set of patterns.
• Intuition is fundamentally a pattern recognition
  process
• We use our expectations of these patterns to
  match with a given situation
• At times we cannot always verbalize what is wrong
  when these patterns dont match, but we innately
  know that the pattern doesnt match.

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Intuition in Decisions

• In follow-up studies Klein studied other
  professions including
• Military commanders
• Pilots
• Nurses
• He found that intuition played a powerful role in
  how experts in all fields sized up" a situation
  and made decisions.

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Intuition in Decisions

• Intuition is fundamentally a pattern recognition
  process
• The patterns are formed from past experience
• The process occurs very quickly
• Unlike other decision-making processes we dont
  think through a series of alternatives

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Intuition in Decisions

• Intuition gradually develops as someone gains a
  deep expertise in a specific field
• More situations lead to an increased ability to
  recognize and match patterns
• The thought is that while we are not always aware
  of it our mind is always searching for patterns
  for all situations that we encounter
• We use pattern recognition to spot problems and
  quickly guide us to solutions

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Intuition and RRTs

• Klein interviewed many nurses and physicians in
  his study of intuition
• He realized that these professionals frequently
  use intuition to make decisions
• The patterns we look for are those assembled
  from
• Vital signs, laboratory data, symptoms, physical
  findings, and in obstetrics electronic fetal
  monitoring

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Intuition and RRTs

• There was a clear distinction between novices and
  experts and their ability to match patterns
• He often found that with experience nurses and
  physicians often sensed something wasnt right
  before the data became clear
• How can we use this to improve patient care?

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Intuition and RRTs

• Studies in England in the late 90s showed that
  in the hours before a patient had a cardiac
  arrest or other serious problems there were
  subtle signs of deterioration
• Efforts were made to find ways of detecting these
  changes more proactively
• Their interviews of many nurses after critical
  events occurred

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Intuition and RRTs

• Discussions with nurses often lead to the
  realization that these nurses knew something
  wasnt right and they had a feeling that things
  were turning for the worse
• This led to the development of rapid response
  teams

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Intuition and RRTs

• Rapid response teams are mean to lead to an
  evaluation of the patient prior to them reaching
  a critical situation
• This is distinctly different than code teams
  which are called after a critical situation is
  reached
• This distinction is critical!!

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Intuition and RRTs

• The 100,000 Lives Campaign is a nationwide
  initiative launched by the Institute for
  Healthcare Improvement (IHI) to significantly
  reduce morbidity and mortality in American health
  care.
• Deploy Rapid Response Teamsat the first sign of
  patient decline

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Intuition and RRTs

• Based on research showing that patients often
  exhibit signs and symptoms of increasing
  instability for several hours prior to a cardiac
  arrest changes in breathing, heart rate, or
  mental status, for example the idea is to
  rescue patients early in their decline before a
  crisis occurs.

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Intuition and RRTs

• The Rapid Response Team intervenes upstream from
  a potential code situation, relying on bedside
  nurses who are highly sensitive to signs that a
  patients condition is deteriorating, and
  empowered to call others into action.

• Intuition is fundamentally a pattern recognition
  process
• The patterns are formed from past experience
• The process occurs very quickly
• Unlike other decision-making processes we dont
  think through a series of alternatives

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Intuition and RRTs

• Technical skills
• Adult advanced cardiac life support
  certification
• Pediatric advanced life support certification
• Critical care experience
• Critical thinking
• Assessment and diagnostic abilities
• Ability to communicate concisely
• Ability to recognize when they are unable to
  meet the patient's needs

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Intuition and RRTs

• The attitude of the team members toward the
  bedside staff, patient and families has a direct
  link to the overall success of the rapid response
  team program.
• It is imperative for the responders to keep in
  mind that "all rapid response team calls are
  warranted."
• If the bedside staff member does not feel
  respected and appreciated, or is intimidated by
  the responding staff, he/she may be reluctant to
  call the rapid response team in the future.
• Rapid Response Team. Third Edition/May 2009

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RRTs- other benefits

• Experts and novices at bedside together
• People tend take the opportunity to share their
  intuition with others
• Through discussion of the case, experts can help
  develop the intuition of novices

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RRTs- other benefits

• Bedside patient discussions with the entire team
  present allows a level of teaching that cannot be
  accomplished in a classroom

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Passing on of Wisdom

• The definition of apprenticeship
• Socrates-the Socratic method
• a form of inquiry and debate between individuals
  with opposing viewpoints based on asking and
  answering questions to stimulate critical
  thinking and to illuminate ideas
• It is a dialectical method, often involving an
  oppositional discussion in which the defense of
  one point of view is pitted against the defense
  of another

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Passing on of Wisdom

• Thinking out loud
• A key practice to use at bedside
• Literally, talking through a thought process
• Not to be confused with second guessing yourself
• Explanations must be reassuring

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Passing on of Wisdom

• Thinking out loud
• Im doing this for the patient because
• Im looking at this data because
• Im concerned about this patient because
• Why does this change in vital signs concern me

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Passing on of Wisdom

• Thinking out loud
• Using this process experts can share how they
  develop intuition
• Thought processes going on in the mind of an
  expert
• An optimal form of mentoring

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Passing on of Wisdom

• Mentoring
• Mentoring is ultimately how intuition is
  optimally shared and developed
• It requires
• Astute observation by the mentor and the student
• Astute listening by the inexperienced
• Empathy by the mentor
• Excellent communication skills by the mentor

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Passing on of Wisdom

• Pitfalls of using intuition
• Misuse of analogy
• He picked the wrong analogy
• Can make the wrong match to the situation
• Picked the wrong pattern
• Overly complex situation
• Complexity of the situation can obscure pattern
  recognition
• Too much noise Too many patterns or cant see
  the most important pattern
• Outdated mental models- New data causes out
  dating of information. Keeping up with new
  information

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Passing on of Wisdom

• Pitfalls of Mentoring
• People need to understand your rationale and your
  intent in order to apply knowledge themselves
• Communicate your intuition, get feedback
• Ensure alignment-
• Make sure what you want them to do and what they
  think you want them to do are the same

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Passing on of Wisdom

• Five steps
• Here is what I think is going on
• Here is what I think we should do
• This is why/my rationale
• Here is what we need to watch for
• Tell me what you think
• Tell what you understand of what I said
• Are there any issues with my thinking?

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Conclusion

• There is a link between intuitive thinking, the
  theory behind rapid response teams and how we can
  mentor less experienced members of our team
• Optimal thought processes and teaching are best
  done using a combination of intuition and
  analytical thinking

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Bibliography

• Roberto, MA. The Art of Critical Decision Making.
  Chantilly, VA The Teaching Company, 2009.
• Client, G. Sources of power How People Make
  Decisions. Cambridge MA MIT Press, 1999.
• Gladwell, M. Blink The Power of Thinking Without
  Thinking. 2005.
• Healthcare Protocol Rapid Response Team.
  Institute for Healthcare Clinical Improvement.
  Third ed., May 2009
• Institute for Healthcare Improvement. Rapid
  response information. Online