Developing critical thinking skills for delivering optimal care.

Healthcare systems across the world are challenged with problems of misdiagnosis, non-beneficial care, unwarranted practice variation and inefficient or unsafe practice. In countering these shortcomings, clinicians must be able to think critically, interpret and assimilate new knowledge, deal with uncertainty and change behaviour in response to compelling new evidence. Three critical thinking skills underpin effective care: clinical reasoning, evidence-informed decision-making and systems thinking. It is important to define these skills explicitly, explain their rationales, describe methods of instruction and provide examples of optimal application. Educational methods for developing and refining these skills must be embedded within all levels of clinician training and continuing professional development.

Underuse of risk assessment and overuse of computed tomography pulmonary angiography in patients with suspected pulmonary thromboembolism.

BACKGROUND: Evidence suggests the potential overuse of computed tomography pulmonary angiography (CTPA) in patients with suspected pulmonary thromboembolism (PTE) in the absence of consistent use of pre-test clinical prediction rules and D-dimer assays. AIM: To evaluate use and diagnostic utility of clinical prediction rules and D-dimer assay in patients with suspected PTE and quantify potentially avoidable overuse of CTPA in low risk patients. METHODS: A total of 344 consecutive patients undergoing CTPA at a tertiary hospital was studied with regards to the use of D-dimer assays and clinical prediction rules for PTE. For each patient, a modified Wells score (mWS), revised Geneva score and PISA model were calculated retrospectively; performance characteristics for each rule for PTE were determined with reference to results of CTPA. Results for the mWS and D-dimer assays (when performed) were used to estimate the overuse of CTPA according to risk category. RESULTS: Use of a clinical prediction rule was documented in only 5.0% of cases. Of 269 low-risk patients who had a calculated mWS ≤4, only 64 (23.8%) had a D-dimer assay performed, with 30 (11.1%) having a PTE on CTPA. Among 75 patients with an mWS >4, 23 (30.7%) had a PTE on CTPA (P < 0.001). Compared to other prediction rules, an mWS>4 had the highest positive predictive value (31.0%) for PTE; all rules demonstrated similar negative predictive values for low-risk scores (87-89%). After adjusting for an 11% false negative rate for PTE in patients with low-risk mWS, overuse of CTPA was reported in up to 190 (55.2%) patients. CONCLUSION: More than 50% of patients with suspected PTE may be subject to unwarranted use of CTPA in the absence of pre-test clinical prediction rules coupled with D-dimer assays.

Received care compared to ADP-guided care of patients admitted to hospital with chest pain of possible cardiac origin.

PURPOSE: To assess the extent to which accelerated diagnostic protocols (ADPs), compared to traditional care, identify patients presenting to emergency departments (EDs) with chest pain who are at low cardiac risk and eligible for early ED discharge. PATIENTS AND METHODS: Retrospective study of 290 patients admitted to hospital for further evaluation of chest pain following negative ED workup (no acute ischemic electrocardiogram [ECG] changes or elevation of initial serum troponin assay). Demographic data, serial ECG and troponin results, Thrombolysis in Myocardial Infarction (TIMI) score, cardiac investigations, and outcomes (confirmed acute coronary syndrome [ACS] at discharge and major adverse cardiac events [MACEs]) over 6 months of follow-up were analyzed. A validated ADP (ADAPT-ADP) was retrospectively applied to the cohort, and processes and outcomes of ADP-guided care were compared with those of care actually received. RESULTS: Patients had mean (±SD) TIMI score of 1.8 (±1.7); six (2.0%) patients were diagnosed with ACS at discharge. At 6 months, one patient (0.3%) re-presented with ACS and two (0.6%) died of non-coronary causes. The ADAPT-ADP defined 97 (33.4%) patients as being at low risk and eligible for early ED discharge, but who instead incurred mean hospital stay of 1.5 days, with 40.2% in telemetry beds, and 21.6% subject to non-invasive testing with only one positive result for coronary artery disease. None had a discharge diagnosis of ACS or developed MACE at 6 months. CONCLUSION: Compared to traditional care, application of the ADAPT-ADP would have allowed one-third of chest pain patients with initially negative investigations in ED to have been safely discharged from ED.

Improving wait time from referral to opiate replacement therapy in a drug recovery service.

While the reported incidence of heroin use in the UK has reduced, related hospital admissions and associated mortality have continued to increase. Prompt access to treatment (opiate replacement therapy (ORT) and counselling support) have been shown to reduce risk and offer clients the optimal route to recovery. The Specialist Drug and Alcohol Recovery Service (Osprey House) within National Health Service Highland had lengthy delays from referral to commencing ORT (median wait 56 days), which this project aimed to reduce. A rapid process improvement workshop (RPIW) was undertaken to redesign the patient pathway from referral to recovery. The RPIW consisted of three phases: phase I, planning and preparation (12 weeks before the workshop week); phase II, the workshop week; and phase III, the follow-up. Metrics included the lead time from referral to initiating ORT and other process measures at baseline, and then repeated at 30, 60, 90 and 180 days, respectively. Additionally, data were routinely collected on the percentage of clients treated within 3 weeks, as was weekly data on the new process of screening clients within 1 day of referral. Multiple lean tools and techniques, including Plan, Do, Study, Act cycles, were used to test and implement new ways of working. Results at 180 days found the median time from referral to initiating ORT improved from a baseline of 56 to 21 days (63% improvement), room usage improved from 49% to 65% (32% increase) and standard work improved from level 1 to level 3. Increases in the number of clients treated within 3 weeks were demonstrated. Other metrics remained static or reported fluctuations too inconsistent to claim improvement at this point. By applying the Lean principles of removing waste and increasing value, we have redesigned our service, reducing the length of time clients with drug problems wait from referral to commencing ORT.