A critical review: a combined conceptual framework of severity of illness and clinical judgement for analysing diagnostic judgements in critical illness.

AIMS AND OBJECTIVES: To analyse theoretical literature on severity of illness and clinical judgement and propose a combined conceptual framework for judgements taken to identify patients' clinical states in critical illness and also to critically review and synthesise general severity of illness prognostic models to identify dimensions and attributes of severity of illness in critical illness. BACKGROUND: The effective treatment of the critically ill requires the early identification of severe illness, and in acute wards, this is predominantly addressed by applying early warning scores focusing on indicators of physiological severity. Clinical judgement complements the application of early warning scores, but is generally not the focus of research and so requires further investigation. DESIGN: A critical review of the literature. METHODS: Severity of illness and clinical judgement literature was reviewed to identify themes for a combined conceptual framework for patient assessment in critical illness. MEDLINE and CINAHL (January 1981-December 2011) were searched for general severity of illness prognostic models in critical illness. Eleven research and five systematic review papers meeting review inclusion criteria were selected. RESULTS: Severity of illness is found to be a crucial theoretical construct in critical illness. It can enhance descriptive models of clinical judgement (such as social judgment theory and an inference/correspondence model in diagnostic judgment) when used to analyse and reflect on judgements made to diagnose the clinical state of the patient. CONCLUSIONS: A combined conceptual framework of severity of illness and a descriptive clinical judgement model further informs patient assessments about the identification of clinical states in critical illness, alongside early warning scores. RELEVANCE TO CLINICAL PRACTICE: This article contributes to an understanding of the complexity of patient assessment and diagnostic judgement in critical illness.

A qualitative study of information about available options for childbirth venue and pregnant women's preference for a place of delivery.

AIM: To explore the level of information about possible venues for childbirth among pregnant women, and to establish the midwives' involvement in giving information and helping women to make choices about where they want to give birth. DESIGN: Qualitative study using tape-recorded unstructured interviews. SETTING: The South East of England. PARTICIPANTS: 33 pregnant women; 20 planning a hospital birth and 13 planning a home birth recruited between 32 and 42 weeks of pregnancy. FINDINGS: Women planning a home birth were well informed about the options available to them, while the majority of those planning a hospital birth were less informed about the availability of home birth and assumed that the hospital was the only option. Midwives did not initiate the discussion of availability of home birth but supported those who already knew and asked for it. CONCLUSIONS: Almost a decade after the adoption of Changing Childbirth (DoH 1993) recommendations as policy in England there is still evidence of lack of information among pregnant women regarding services available to them. In this study the midwives' reluctance to inform women about home birth as a possible venue for childbirth, has been demonstrated.

Developing benchmark inventories to assess the content of telephone consultations in accident and emergency departments: use of the Delphi technique.

The provision of telephone advice to members of the general public from staff based in accident and emergency departments is common practice. However, it is largely conducted on an ad hoc basis without the use of formal guidelines or decision support. The evidence base from which to derive guidelines for the telephone assessment and advice of many common conditions is lacking. This study, using the Delphi technique, was undertaken to develop a number of benchmarks for use as objective measures against which the comprehensiveness of telephone assessments could be tested. Consensus views on the essential and desirable items to be considered for each of 10 presenting complaints was achieved. It is argued that establishing consensus views on clinical topics provides an effective means of developing an evidence base where other sources of evidence are lacking.