Decision making in asthma exacerbation - a clinical judgement analysis

John Jenkins ^1*, Michael Shields ², Chris Patterson ¹ and Frank Kee ¹

¹ Queen's University Belfast, United Kingdom
² Royal Belfast Hospital for Sick Children, United Kingdom

^* To whom correspondence should be addressed. E-mail: j.jenkins{at}qub.ac.uk.

Accepted 2 April 2007

Abstract

Background: Clinical decisions which impact directly on patient safety and quality of care are made during acute asthma attacks by individual doctors on the basis of their knowledge and experience. These include administration of systemic corticosteroids (CS), 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 as a cue level of alertness (54% v. 16%); for decision 2 presence of crepitations (49% v. 16%), and less likely to include inhaled CS (8% v. 40%), respiratory rate (0% v. 24%), and air entry (70% v. 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% v. 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.

Keywords: asthma, clinical judgement analysis, decision making, hospital admission, systemic corticosteroids

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