Decision making in asthma exacerbation: a clinical judgement analysis.
BACKGROUND
Clinical decisions which impact directly on patient safety and quality of care are made during acute asthma attacks by individual doctors based on their knowledge and experience. Decisions include administration of systemic corticosteroids (CS) and oral antibiotics, and admission to hospital. Clinical judgement analysis provides a methodology for comparing decisions between practitioners with different training and experience, and improving decision making.


METHODS
Stepwise linear regression was used to select clinical cues based on visual analogue scale assessments of the propensity of 62 clinicians to prescribe a short course of oral CS (decision 1), a course of antibiotics (decision 2), and/or admit to hospital (decision 3) for 60 "paper" patients.


RESULTS
When compared by specialty, paediatricians' models for decision 1 were more likely to include level of alertness as a cue (54% vs 16%); for decision 2 they were more likely to include presence of crepitations (49% vs 16%) and less likely to include inhaled CS (8% vs 40%), respiratory rate (0% vs 24%) and air entry (70% vs 100%). When compared to other grades, the models derived for decision 3 by consultants/general practitioners were more likely to include wheeze severity as a cue (39% vs 6%).


CONCLUSIONS
Clinicians differed in their use of individual cues and the number included in their models. Patient safety and quality of care will benefit from clarification of decision-making strategies as general learning points during medical training, in the development of guidelines and care pathways, and by clinicians developing self-awareness of their own preferences.
Jenkins
John
J
Queen's University Belfast, Paediatric Department, Antrim Hospital, Antrim, Belfast, UK. j.jenkins@qub.ac.uk
Shields
Mike
M
Patterson
Chris
C
Kee
Frank
F
D000293:Adolescent; D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001249:Asthma / Q000175:diagnosis / Q000628:therapy*; D001291:Attitude of Health Personnel; D002648:Child; D002675:Child, Preschool; D003463:Cues; D003657:Decision Making; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D007600:Judgment; D016014:Linear Models; D009660:Northern Ireland; D010372:Pediatrics / Q000706:statistics & numerical data
D000305:Adrenal Cortex Hormones; D000900:Anti-Bacterial Agents