‘What the hell is water?’ How to use deliberate clinical inertia in common emergency department situations

Abstract

Appropriate deliberate clinical inertia refers to the art of doing nothing as a positive clinical response. It includes shared decision-making to improve patient care with the use of clinical judgement. We discuss common clinical scenarios where the use of deliberate clinical inertia can occur. The insertion of peripheral intravenous cannulae, investigating patients with suspected renal colic and the investigation of low risk chest pain are all opportunities for the thoughtful clinician to 'stand there' and use effective patient communication to avoid low value tests and procedures. Awareness is key to identifying these opportunities to practice deliberate clinical inertia, as many of the situations may be so much a part of our environment that they are hidden in plain view.

Human factor‐designed multimodal intervention reduces the rate of unused peripheral intravenous cannula insertion

“…Clearly, the clinician's awareness of these issues should be raised. The opportunity to practice deliberate clinical inertia (the art of not intervening) has been suggested in the insertion of PIVC …”

Why do clinicians overtest? A narrative review and workshop group discussion exploring influences on clinician overtesting as possible causes of overdiagnosis

“…and "just to be safe" (78%). [34] Egerton-Warburton et al [35] found that over half of 1029 emergency physicians in the study reduced their implicit "test threshold" well below the explicit threshold set using empirical data on test accuracy and risk of harm from the disease, due to their discomfort with diagnostic uncertainty. [35] Coon et al [16] also highlighted the "shotgun approach" [16] of ordering a broad range of tests and hoping for a positive result somewhere, which is often used in situations of diagnostic uncertainty.…”

“…[34] Egerton-Warburton et al [35] found that over half of 1029 emergency physicians in the study reduced their implicit "test threshold" well below the explicit threshold set using empirical data on test accuracy and risk of harm from the disease, due to their discomfort with diagnostic uncertainty. [35] Coon et al [16] also highlighted the "shotgun approach" [16] of ordering a broad range of tests and hoping for a positive result somewhere, which is often used in situations of diagnostic uncertainty. However, in assessing factors in uencing tendency to order imaging using hypothetical scenarios, Kini et al's [25] survey of cardiologists and general practitioners did not nd a signi cant association between risk aversion and tendency to order cardiac stress tests and echocardiography (likely due to their small sample size).…”

Implementation of interventions to reduce preventable hospital admissions for cardiovascular or respiratory conditions: an evidence map and realist synthesis

“…In the context of emergency department-based interventions, the concept of 'appropriate deliberate clinical inertia' has been framed in recognition of the need to resist inappropriate or unnecessary interventions. 290 It appears that this concept may be appropriated in primary care to recognise situations in people with chronic conditions that do not result, for example, in any change in the dose or nature of medications. Clear agreement between patients and HCPs that emergency admission will not resolve or in any way modify their symptoms or treatment can act as a sound basis for 'shared decision-making to improve patient care with the use of clinical judgement'.…”

“…Clear agreement between patients and HCPs that emergency admission will not resolve or in any way modify their symptoms or treatment can act as a sound basis for 'shared decision-making to improve patient care with the use of clinical judgement'. 290 Candidacy and 'deservedness'…”