Clinical decision-making by the emergency department resident physicians for critically ill patients

Abstract

The application of main methodologies for clinical decision-making by residents in emergency medical practice was assessed, and issues in this area were investigated. The treatments provided to 2 611 critical patients by the Peking Union Medical College Hospital of were analyzed by independent investigators who evaluated the main clinical decision-making processes applied by the hospital residents. The application of decision-making strategies by PG1 and PG3 groups, which means the residents in first year and the third year, were compared. The patients were treated according to pattern recognition (43.0%), hypothetico-deductive reasoning (23.4%), event-driven models (19.3%), and rule-using algorithms (5.9%). A significant difference was found between PG1 and PG3 groups (χ²=498.01, P<0.001). Pattern recognition and hypothetic-deductive methods were the most common techniques applied by emergency physicians in evaluating critically ill patients. The decision-making processes applied by junior and senior residents were significantly different, although neither group adequately applied rule-using algorithms. Inclusion of clinical decision-making in medical curricula is needed to improve decision-making in critical care.

Keywords

clinical decision-making / emergency medicine / critically ill patient / resident / methodology

References

[1] Chapman DM, Char DM, Aubin CD. Clinical Decision Making. In: Marx JA. Rosen's Emergency Medicine: Concepts and Clinical Practice. 6th ed. Mosby, 2005: 125-133

[2] Sandhu H, Carpenter C, Freeman K, Nabors SG, Olson A. Clinical decisionmaking: opening the black box of cognitive reasoning. Ann Emerg Med 2006; 48(6): 713-719

[3] Agency for Healthcare Research and Quality. U.S. Department of Health and Human Services. Emergency Severity Index, Version 4: Implementation handbook. 2005

[4] Wears RL. Comments on “Clinical decision-making: an emergency medicine perspective”. Acad Emerg Med 2000; 7(4): 411-412, author reply 412-414

[5] Kovacs G, Croskerry P. Clinical decision-making: an emergency medicine perspective. Acad Emerg Med 1999; 6(9): 947-952

[6] Croskerry P. Achieving quality in clinical decision-making: cognitive strategies and detection of bias. Acad Emerg Med 2002; 9(11): 1184-1204

[7] Atzema C, Bandiera G, Schull MJ, Coon TP, Milling TJ Jr. Emergency department crowding: the effect on resident education. Ann Emerg Med 2005; 45(3): 276-281

[8] Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency department workplace interruptions: are emergency physicians “interrupt-driven” and “multitasking”? Acad Emerg Med 2000; 7(11): 1239-1243

[9] Xu TD, Pei V,Yu XZ, Smith J, Ma S, Wang Z. Developing a standardized curriculum for emergency medicine residency training:an international comparison and resources guide. Chin J Emerg Med 2006; (12): 1147-1148 (in Chinese)

[10] Ghafouri HB, Shokraneh F, Saidi H, Jokar A. How do Iranian emergency doctors decide? Clinical decision-making processes in practice. Emerg Med J. 2011<month>Apr</month><day>21</day>. [Epub ahead of print]

[11] Hall KK, Schenkel SM, Hirshon JM, Xiao Y, Noskin GA. Incidence and types of non-ideal care events in an emergency department. Qual Saf Health Care 2010; 19(Suppl 3): i20-i25

[12] Rudkin SE, Langdorf MI, Macias D, Oman JA, Kazzi AA. Personal digital assistants change management more often than paper texts and foster patient confidence. Eur J Emerg Med 2006; 13(2): 92-96

[13] Croskerry P. The importance of cognitive errors in diagnosis and strategies to prevent them. Acad Emerg Med 2003; 78: 1-6

[14] Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med 2005; 142(2): 115-120

[15] Croskerry P, Nimmo GR. Better clinical decision-making and reducing diagnostic error. J R Coll Physicians Edinb 2011; 41(2): 155-162

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