Deliberate Clinical Inertia

In this podcast James Edwards chats to Gerben Keijzers about Deliberate Clinical Inertia.  Deliberate Clinical Inertia involves using clinical judgement to avoid unnecessary investigations.

 

Summary Writer:  Peter Hoppett

Script Writer:  James Edwards

Editor:  Gerben Keijzers

Interviewee:  Gerben Keijzers

Interviewer:  James Edwards

About Professor Gerben Keijzers

Gerben Keijzers is Professor of Emergency Medicine at Gold Coast University Hospital. His research revolves around topics relevant to clinical practice in critical care, with special interest in sepsis, appropriateness of antibiotic use and respiratory medicine. He encourages curiosity and critical thinking.

Gerben’s research related roles include Emergency Department Collaborative Research Group Chair, Research Council member, clinical trials steering committee member and Human Research Ethics Committee member.

Deliberate Clinical Inertia

With Dr Gerben Keijzers, Emergency Staff Specialist at Gold Coast University Hospital, Queensland, Australia

 

Introduction

There can be a tendency for junior doctors to over investigate when given clinical uncertainty. This can result in extended waiting times, creation of delays, extending department stay time as well as side effects from unnecessary investigation or treatment. The concept of deliberate clinical inertia involves using clinical judgement to avoid unnecessary investigations that will not change management.

 

Case

A middle aged male presents to the Emergency Department at 6pm with likely cellulitis on his lower limb on a busy day. The nursing staff note that he may not be seen for a few hours as he is clinically well, so they decide insert a cannula and take some blood tests including a full blood count and a C-reactive protein to assist with his review before a doctor is able to see him. The C-reactive protein is elevated to 50 and as the cannula is in situ the decision is made to treat with intravenous Flucloxacillin which requires him to be moved to the short stay ward in Emergency. He spends the night and receives further Flucloxacillin in the morning as well as a review from the Hospital in the home (HITH) team and at this point he has spent over 14 hours in the department.

  • Cellulitis is a clinical diagnosis, with blood tests unlikely to change management
  • The exception to this may include red flags such as someone with immunocompromise or serious sepsis, in which case the patient may have required admission
  • Clinically if the patient was not septic, systemically well and still able to tolerate oral intake, oral antibiotics would have been safe to use after clinical assessment
  • ‘Baseline bloods to be safe,’ are commonly done for many reasons, including: habit, a (perceived) bid to be more efficient (bloods before seeing the patient) as well as a desire to have all the information to make an informed decision in order to avoid uncertainty
  • Junior doctors should be encouraged to think about the scenarios in which the investigation would change management of the patient (if the management is the same whether the test is positive as well as negative, then do not do the test)
  • Purposeful decision to not do order tests or treatments as a positive response
  • It refers to more deliberation about clinical decisions rather than relying frequently on knee-jerk decisions based on pattern recognition
  • May involve liaising with the patient in shared decision making if there is clinical uncertainty – could involve waiting to see if a condition declares itself with appropriate safety netting
  • Still a role for recognition of patterns (type I decisions) to drive decisions, especially in unwell patients or if everything is textbook
  • Type I (intuitive) based decision making can come from a more senior member of the team – due to the hierarchy that is present in clinical medicine this may take the power out of the junior doctor’s hands
  • Pattern recognition is ingrained in medical school education, can be difficult to break
  • Take a five second pause to deliberate before deciding about investigations to understand if they will change your management of the patient
  • Ask for help from a senior – may be able to avoid further investigations with a senior clinical review (it is their job to supervise, your job to ask for supervision)

Don’t just do something, stand there! The value and art of deliberate clinical inertia available at https://pubmed.ncbi.nlm.nih.gov/29327445/

Emergency Medicine Australasia (2018) 30, 273–278

doi: 10.1111/1742-6723.12922

 

Deliberate clinical inertia: Using meta-cognition to improve decision-making available at https://onlinelibrary.wiley.com/doi/abs/10.1111/1742-6723.13126

Emergency Medicine Australasia (2018)

doi: 10.1111/1742-6723.13126

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Tags: #Choosing Wisely,#clinical judgement,#clinical reasoning,#clinical research,#cultural change,#deliberate clinical inertia,#emergency department,#Emergency Medicine,#human factors,#medical education,#over-diagnosis,#shared decision making

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