Clinical Decision Making in Intensive Care

1
Clinical Decision Making in Intensive Care

• Graham Nimmo
• Intensive Care Unit
• Western General Hospital

2
Overview

• Background
• Clinical decisions in intensive care inventory
• Factors affecting CDM
• Clinical observation
• Can we do better ?

3
(No Transcript)
4
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

5
(No Transcript)
6
(No Transcript)
7
CDM big business !

• CVC Haematology where? Who ? When ?
• ODM figures
• Vanc infusion dose and rate
• Death certificate diagnosis
• Fluids and norad
• GCS ?extubate

8
CDM early one evening.

• What to say to family ?
• Vent settings x 2
• Fluids
• Norad
• B-blocker
• NIV settings
• Fluids urine output

9
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

10
CDM 2

• CXR Quinton, HF anticoagulant
• New password Apex
• Transfuse ?
• Intubate ?
• Access, monitors, drugs, who does what, tube,,
  ventilation
• CT head Neurosurgeon discussion

11
CDM 3

• A referral ? admit
• Ward SHO crying
• Antibiotic choice

12
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

13
CDM a clinical taxonomy

• Prognosis
• Admission or not ?
• Relatives
• End of life care limitation, withdrawal
• On behalf CDM

14
CDM a clinical taxonomy

• Team working and SA
• Distributed decision making
• Prioritisation
• Professional
• Regarding colleagues
• Joint decision making

15
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

16
Interruptions Critical Incidents

• Distractions Buckley 1997 Anaesthesia
  52403-409
• Failure to carry out planned treatment lapses
  and slips Rothschild 2005 Crit Care Med
  331694-1700

17
Interruptions Clinical Practice

• Intra-thecal vancomycin
• Tom Reader
• Good interruptions redirection, prioritising
• Interruptions helping in detection of problems
• Wright 1991 Lancet 338676-678

18
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

19
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.

20
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.

21
Results
22
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

23
Modes of Interruption 2

• Equipment
• Phone landline 43 mobile 5
• Text 4
• Bleep 28
• Alarms 130

24
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

25
Evidence Based Medicine
Clinical Judgment
Patient Factors
26
CDM Millers Triangle
27
CDM the pyramid ?

• What affects clinical decision making ?
• Knowledge and skills
• Behaviours attitude (multiple selves), emotions
  (affect self, family, patients, relatives,
  colleagues), values.

28
30 Cognitive Errors after Croskerry
29
Quiz

• What is Cushings triad ?
• Is coning fatal ?
• How far back should we read the Medical
  literature ?

30
Quiz

• What is Cushings triad ?
• Hypertension, bradycardia, abnormal breathing
• Is coning fatal ?
• Yes.
• How far back should we read the Medical
  literature ?
• Cushing Am J Sci 1903125

31
Cushing blood-pressure reaction

• Rapid encroachment on intra-cranial space by a
  foreign bodyextravasated blood.a high tension
  pulse
• A regulatory mechanism controls the rise and a
  fatal bulbar anaemia is warded off.
• In the majoritythe vagus centre is likewise
  stimulated with the familiar slowing of the
  pulse rate
• Am J Sci 19031251017-1044

32
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

33
Cushings Triad

• Brain Trauma Foundation
• Principles of Surgical Practice, Majul and
  Kingsnorth Eds.
• Davidsons
• Oxford Textbook of Intensive Care Medicine
• ATLS
• Wikipedia

34
Suspension of Disbelief (belief)
35
(No Transcript)
36
Enhancing CDM

• Disciplined noticing clinical observation
• Critical thinking
• Clinical reasoning

37
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

38
Doing a Paddington
39
THE FOUR KEY ELEMENTS OF EMERGENCY MANAGEMENT
40
(No Transcript)
41
Related Links
SICS Education and Training group cdm
sectionhttp//www.scottishintensivecare.org.uk/ed
ucation/decisions/index.htmScottish Clinical
Skills Network special interest group on
cdmhttp//www.scsn.scot.nhs.uk/resources/SpecialI
nterestGroups.htmhttp//dieoff.org/page163.htm
http//www.bmj.com/cgi/content/full/bmj.39371.5242
71.55v1http//journal.sjdm.org/http//www.famm
ed.ouhsc.edu/robhamm/index.htm