Editorial Volume 18 Issue 4 – Decision-making in acute medicine

Abstract

Acute physicians make patient-centred decisions at the start of the patient’s hospital journey. Dozens more decisions are made by the individual members of the MDT (and, of course, by the patient) during the in-patient period. Decisions are made at every level of seniority and experience and range widely in scope and impact. The original articles in this issue are connected by a common thread: phenomena that inform and influence the decisions made by acute physicians. How do you obtain adequate data to make sound decisions about individual patient care? It is often necessary to collate data around previous admissions and investigations at other healthcare institutions; a process fraught with complications. In this issue Ghelani et al1 undertook the onerous task of calling the main switchboard of all 175 acute hospitals in England on six occasions. Their aim was to identify how long it takes for an outside caller to finally contact a human operative who could put them through to the the correct person or extension. Most healthcare professionals will have some insight into the communication barriers that lie between practitioners in different hospitals, and the inordinate amount of time spent on the phone trying to gain patient information from another institution. The authors’ findings that automated messages and call steering systems impact significantly upon the time required for straightforward datagathering tasks should resonate with many for us. Hopefully, this study will provide substrate for future quality improvement efforts in the UK. How do you decide if your patient is well enough for transfer? The National Early Warning Score (NEWS) is now common currency in acute hospitals. This simple aggregate scoring system uses physiological parameters measures at the bedside and is used to inform assessments about patient acuity. There is currently significant research attention focused on the NEWS’ powers of prognostication. In a previous issues of this journal, we reported how vital sign abnormalities in the Emergency Department are predictors of poor outcomes (although not mortality) 2; monitoring of post-discharge vital signs in the community may predict readmission;3 and minor fluctuations in respiratory rate (in combination with other vital signs) may predicted clinical outcomes several days in advance.4 In this issue Subbe et all5 explore whether patients with low or unchanging NEWS scores are unlikely to deteriorate in future and could therefore be considered for transfer. How do you decide whether your patient requires intravenous fluids? In their qualitative study, Lloyd et al 6thematically analysed data from interviews with clinicians to better delineate the decision-making processes surrounding fluid therapy. They describe how doctors use vital signs, clinical presentation and their own gestalt, and – curiously – these approaches may be affected by the clinical environment and workload, and are not informed by local or national guidelines.