La intervención inmune en la esclerosis múltiple primaria progresiva

Clinical decision-making is the most frequently used term to describe decisions made by clinicians which relate to selecting a particular course of action, diagnosis or plan of care over another (Thompson, 1999). It is a distinct process whereby clinical knowledge, patient information, nursing knowledge and experience interact (Thompson & Dowding, 2001; Banning, 2008).

2.13.1 Theories of clinical decision-making

There are two main theoretical positions with regard to clinical decision-making in nursing and medicine, one analytical (Elstein, Shulman , & Sprafka, 1978) the other intuitive (Benner & Tanner, 1987). One of the most influential analytical clinical decision-making theories is the information processing model (Newell & Simon, 1972). From this the more commonly known hypothetico-deductive model was derived, initially in medical decision making (Elstein et al., 1978) and subsequently applied to nursing (Carnevali, Mitchell, Woods , & Tanner, 1984; Tanner, Padrick, Westfall , & Putzer, 1987). Four stages of medical decision- making were identified by Elstein et al., (1978) and are:

1. Cue acquisition

2. Hypothesis generation 3. Cue interpretation 4. Hypothesis evaluation

A key feature of models based on the information processing theory is that they are limited to some extent by a person’s capacity to store and remember information (Newell & Simon, 1972). The mental processing that is required relies on triggers/cues that unlock knowledge from a persons long term memory (Thompson & Dowding, 2001).

Benner (1984) is often credited with offering an opposing theory regarding decision-making in nursing. In her research on the role of expertise in clinical nursing she identified that expert nurses used intuition. They no longer relied on critical analysis to make a clinical decision and were often not able to describe how they arrived at one particular decision over another (Benner & Tanner, 1987). Intuition was defined as

“understanding  without  a  rationale”   Benner & Tanner (1987) p 23 Intuition is what separates the expert from the learner and is not a conscious process (Banning, 2008).

More recently the concept of a cognitive continuum has been suggested as providing an alternative theoretical framework for clinical decision-making (Standing, 2008). It offers an alternative to the one-dimensional analytical or intuitive models and suggests that decisions are made along a continuum, with analysis at one end and intuition at the other (Thompson, 1999; Banning, 2008; Standing, 2008). It is the structure of the decision-making task, the number of cues and the availability of time that determines the approach used (Thompson & Dowding, 2001; Standing, 2008). Standing (2008) has revised the original cognitive continuum by Hamm (1988) and suggests that if task structure is low e.g. direct patient care and the time available is limited then decision-making is rooted in: intuition, reflective judgement, peer and patient aided judgement and system aided judgement (Standing, 2008; Noon, 2014). In reviewing clinical decision-making theories their applicability to triage practice can be considered. 2.13.2 Decision-making within the context of triage

The clinical decision-making process during a triage encounter is the method by which the nurse arrives at the clinical priority for the patient. Identifying the correct clinical priority for the patient is the primary objective of triage. As time is limited and cues may be minimal, these features suggest a more intuitive approach (Standing, 2008) The use of triage tools (MTS, ATS, CTAS) provides an example of system-aided decision making (Smith, A, 2013a). They provide a significant function in guiding and supporting decisions when the pre-requisites for analytical decision-making, time and structure, are absent. The impact of CCDSS on decision-making processes within the emergency care setting are poorly understood (Hine, Farion, Michalowski , & Wilk, 2009). It is important to note that this research does not seek to explain any influences on decision- making per se but to highlight if a triage CCDSS alters the accuracy of triage decisions. The final section within this chapter describes eTriage and illustrates how a triage assessment takes place via the use of screenshots from the CCDSS.

2.14 eTriage

eTriage was developed by clinical and IT staff within the hospital and upon which this research was conducted. Initial discussions began in 2008 about the possibility of a system and what functionality it might have. A specification was agreed  and  it  was  incorporated  into  the  hospital’s  IT  infrastructure  plan  for  2009.   The researcher led the development of eTriage ensuring all the clinical and operational needs of the users within ED were met. CCDSSs developed with the users are strongly associated with high levels of user acceptance (Garg et al., 2005). eTriage is a module that is fully integrated within the hospital’s Clinical Document Management System (CDMS). It inherited its user and document security, web housing and interface functionality from the CDMS. When the eTriage patient episode is complete the record is written to the existing document store in the CDMS. This ensures that the eTriage record is immediately available to all authorised users. eTriage was developed in Asp.net with AJAX and JavaScript extensions, storing data in a clustered SQL Server 2008 database. The completed system comprised of approximately 22000 lines of code in 91 files. During its three years of operation from 12/04/2010 to 17/06/2013 the system handled the ED attendances of 293,206 patients (Mansfield personal correspondence 2014). The following screen shots will guide the reader through the main areas of eTriage and follow the assessment of hypothetical patients, David with a limb injury and Jayne with potential neutropenic sepsis.

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Once the patient has been registered  on  the  hospital’s  patient administration system the  data  is  pulled  through  into  the  initial  “Patients   Waiting”  screen every 45 seconds (Figure 2.4). This screen is visible from any computer in the ED. Within the main body of this screen is information on:

 Arrival time

 Time waiting for the triage assessment, this turns red after 15 minutes  Name, age and presenting compliant as describe to the ED receptionist  Mode of arrival

Figure 2.4 The triage queue

The options menu enables the users to filter the view to so that only the following appear

 Chest pain  Children

 Ambulance arrivals  Non-ambulance arrivals

All patients <16 years of age are highlighted in pink, patients who present with chest pain are highlighted in orange.

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Figure 2.5 Patient demographic screen

One a patient has been selected (by clicking on them) all their demographic information appears on the main body of the screen.

On the top right hand side of the screen the triage nurse can enter information if the patient has a disability, if their arrival was pre- altered by the ambulance service (Courtesy call or Standby).

There is also accessible information from this screen on previous attendances

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Once the triage nurse has logged on the triage process can begin

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The  first  step  in  the  patient’s  assessment  is  to  decide  if  they  have  sustained  a minor injury (Figure 2.7). These two options for triage will take the user through an abbreviated triage process for patients with minor injuries, which has no free text options. Alternatively if the patient has not sustained a minor injury the triage process enables a brief history to be documented.

This patient, David  has  sustained  a  minor  injury  and  the  “Yes  – Choose  Presentation”  option  is  selected.  

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There now 15 presenting complaints to choose from, each represents one of the MTS presentational flowcharts that is applicable to patient who are injured (Figure 2.8)

David has an ankle injury, therefore Limb Problems is selected

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The MTS presentational flow chart Limb Problems is shown (Figure 2.9). Through a reductive approach the triage nurse works their way down  the  flowchart  until  the  first  relevant  discriminator  is  identified.  There  is  a  “hover”  function  with  the computer mouse to enable the triage nurse to review any discriminator definition, see recent problem example shown below. The discriminators are ordered in priority and with their associated priority colour (red, orange, yellow, green, and blue) (see Table 2.4)

David’s  ankle  injury  happened  that  morning  on  his  way  to  work.  There  are  no  other  discriminators  relevant  in  a  higher  priority category – Recent problem is selected

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The next screen shows the options for pain assessment and management (Figure 2.10). As the patient has not been identified as having moderate or severe pain the options to give a score above 3 are not available. If for example David had been triaged on the previous screen as having a gross deformity (yellow priority) the options for moderate pain (scores 4-6) would be displayed.

David’s  pain  is  mild  and  he  scores  it  at  a  3.  

Figure 2.10 Pain assessment and pain management

By selecting a discriminator the clinical priority/triage category is automatically allocated by eTriage. In this example the selection of the discriminator  “recent  problem”  has   allocated a standard (green) triage priority

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Figure 2.11 Prompt to ensure analgesia is administered

If analgesia is not administered or if the options

declined or already taken are not selected, the triage cannot progress.

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Whilst   not   relevant  to   David’s  presentation  this  screen  demonstrates   the   Early   Warning   Score   function   of   eTriage (Figure 2.12). It would appear as a mandatory screen if appropriate to the presenting problem e.g. chest pain, abdominal pain.

Figure 2.12 Early warning scoring

The stream in which David has been assigned is now allocated. This has happened automatically as David was triaged as a minor injury.

For patients who do not have a minor injury the option to select either the minors or majors stream is at the end of the eTriage process

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The summary on the right hand side of the screen identifies the assessment so far and the analgesia David has been given (Figure 2.13). The triage nurse  now  has  the  option  of  selecting  any  of  the  departmental  pathways  or  guidelines  that  are  relevant  to  the  patient’s  problem. The documentation that is available on this screen has been mapped to all the MTS flow charts so that only the ones relevant for that problem are displayed.

For  David’s  ankle  injury  the  Ankle/Foot  Inversion  Injury  Proforma  would  be  selected.  

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This is the final screen before the end of the triage episode (Figure 2.14). There are options to request bloods. There is also the option to document if at this stage the patient decided not to wait. Some patients might be seen and treated at triage e.g. a patient with a stubbed toes who only requires advice and simple strapping. This could be documented in this screen

No  further  actions  are  required  for  David  and  the  “Finish  &  Print”  button  is  pressed.  The  eTriage  record  and  any  associated  documentation is stored electronically in the CDMS and also printed in ED reception to form the beginning of the full ED clinical record.

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There are several features built into eTriage to prompt the early focussed management of patients who present with possible neutropenic sepsis.

1) A patient on  chemotherapy  would  initially  be  “flagged”  in  eTriage  if  they  were  on  the  hospitals  cancer database. See Figure 2.15 2) There would be an eAlert in eTriage to prompt the triage nurse to consider if neutropenic sepsis could be a feature of the patient

presentation. See Figure 2.15

3) If the triage nurse suspected a (non-cancer database) patient had symptoms of neutropenic sepsis they would select the neutropenic sepsis care pathway. See Figure 2.16. The neutropenic sepsis pathway would print at the end of the Triage episode. See Appendix 4 4) A final prompt would instruct the nurse to inform the shift leader immediately of the patient.

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2.15 Summary

This chapter has considered all the influences that underpinned the rationale for the development of a CDSS to support triage practice. The demand for emergency services has risen exponentially in the last decade. An inexperienced workforce often supplemented with locum doctors because of recruitment problems means that ensuring EDs achieve the mandated performance targets is seen by some as an impossible task. Healthcare professionals are striving to deliver high quality care in often unmanageable circumstances. The current issues that are facing emergency care services have never been so challenging. There are no   “quick   fixes”  as  economic  restrictions  continue  and  demands  for  health  services  continue   to grow. Novel approaches are required to ensure the workforce can deliver high quality care. The development of eTriage was one such idea, conceived by the researcher as a means of addressing the quality and safety challenges in the clinical environment.

Emergency triage is a complex process unique to the speciality of emergency nursing. It requires rapid decision making to ensure patients are prioritised correctly and receive care and treatment promptly. Triage is essentially a risk management tool to ensure that waiting to see a clinician does not compromise a patient’s  clinical  condition.  MTS  is  the  most  frequently  used  system  in  the  UK  and   many European countries yet its accurate use can be challenging. Triage nurses are required to remember a significant number of criteria to use the system correctly. Long queues for triage assessment and the management of multiple clinical demands can make triage work stressful. The CCDSS eTriage was developed to improve the quality and safety of triage decisions and overall safety in the ED for example by providing a direct accessible link to relevant departmental clinical guidelines. It has many other functions, for example it ensures that clinical observations are always recorded when indicated. A literature review of the role of CCDSSs in acute care is presented in the next chapter.