ED Rounds – May 2015

It was a good turnout for this month’s more than usually interactive ED Rounds. Thanks to Dr Adams, Dr French and Dr Xidos.

May 12, 2015

Clinical Decision Making

Dr Cherie-Lee Adams

Adverse Events (AEs) Study NEJM (see talk for ref)
30,000 pts
Adverse event rate 3.5% (27.6% due to negligence)
These are events that cause bad things
Most AE occur in Surgical specialties in this study
Older pts suffer more AEs
Study 2
(Leape, Brennan et al 1991)

In Canada
Similar rate
Drug related and diagnostic events are most common

Diagnostic Error
System Error – Technical, Organizational
Cognitive – knowledge, Info gathering
No Fault – Pt related
In Dutch study 83% were preventable
96% were assoc. with Cognitive error

Causes of AE’s
Knowledge failure – 3%
Information processing – 50%
Verification error – 30%
Therefore how do we improve Information processing



System 1 – be quick and accurate
System 2 – careful, thorough and reflective
Loads of BIAS – see Crosskerry
It is proposed that there is more bias in system 1

Factors that promote Bias
Individual -Tired, lots of inputs, multitasking, interactions
Acute Care Environment – Volume, overcrowding, noise, resource limitation
It was agreed that these factors are experienced frequently by the audience
System 1 and 2 Performance Studies (Norman et al Acad Med – 89(2):277-84))
System 1 process – more accurate if take less time to solve problem
But when comparing System 1 and 2 – there was no difference

AEs are common
System 1 is pretty good but potential issues
Slowing down may or may not be helpful

Strategies for Limiting Bias
Crosskerry (2003 Acad Med – 78(8):775-80)
Cognitive Hygiene and Debiasing
Feedback and Education

Physicians in general are not good at receiving feedback
We are emotionally attached to our decisions
We therefore suffer when get it wrong
But we learn from our mistakes
However we can’t actually make mistakes in practice
Could more simulation be a way of learning from mistakes?

Cognitive Hygiene
Optimize you environment
Lots we can do here – think about interruptions, consultations interactions with RNs etc
Optimize yourself
Limit fatigue, exercise, think about bias

Think about Thinking!

Cognitive Unloading
limit reliance on memory
e.g POC Resources, Guidelines etc

Helpful in surgery
e.g ‘diagnostic pasue’
  • Have I been Complete
  • Are there any biases to consider
  • Is this the best time to make a dx
  • Have I considered the worst case scenario

Why Rounds Need To Change

Dr James French

His survey found that “rounds need to change”
1. How do experts make decisions?
2. How were you taught

What are presentations useful for ?
We know that people don’t recall what they are taught in lectures
A lecture is an opportunity to understand things

Effortful thinking produces memory and integration
Learning shouldn’t be passive
Residents call this ‘Pimping’

Problem Based Learning
Dr Adams says that she remembers the cases from med school like she did them yesterday
Dr Lewis remembers the details of all the cases that he has supervised at DMNB

Learning Pyramid
Retention – 5%
Teaching Others – 90%

Discussion on Teaching for the ‘Pain Program’
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A consensus leaning towards some kind of pre-reading /test
Concern that this might put some people off attending

What do We Teach?
Needs assessment has been done.

Millers Prism of Clinical Competence
Knowledge, Skills, Attitudes, Systems
The only time we get to practice skills – Are skills based course, simulation etc
Behaviour – simulation, QUEST feedback
System – simulation

CPD Summit – Dr Jo-Ann Talbott
Reps from all Colleges
Separated learning into 3 cats
1. Group Learning
2. Self Learning (some reflection required)
3. a.Practice Assessment
     b. Knowledge Assessment
Regulatory authorities will be demanding this.

What should we learn?
What knowledge do we need to learn / refresh?
What skills should we practice?

Eradicating the Insulin Sliding Scale

George Xidos

Dr Stephen Hull thinks that they should be eradicated!
We need to be aware that our orders may stay with the patient throughout their stay.
Many diabetics are admitted with other problems
Therefore there is a disconnect
Glycemic control not an issue

But It is important because it impacts on morbidity, hospital stay and mortality, economics

Original Sliding Scale
– referred to as “chasing the rainbow” – Fehlings solution
But of 52 studies – not a single study showed benefit compared to other methods

The reason it doesn’t work is
– It is a reactive system
– responds to hyperglycaemia after it has occurred
Type 1 diabetics failed especially as they get No insulin if Glucose normal
Residents have noticed that inpatients on the basal bolus (Physiologic) infusion get much less hypos than those on sliding scale.

4 groups – see slide
  • Critically ill
  • Non critically ill – poor controlled
  • Non critically ill – well controlled
  • Non diabetic with hyperglycaemia   –  this is the only pt that SSI is useful (as they are already secreting own insulin)

Basal/Bolus Insulin Regimen
See slide
Don’t aim low – Keep between 10-5

Step 1
Calculate total Daily Dosage
If Pt well controlled – use home dose but, Consider decreasing by 20-25% – because they eat less in hospital
Otherwise see dose on slide

Step 2
Basal Insulin
Half total daily dose as long acting basal

Step 3
Nutritional Insulin
Divide remaining dose by 3
Give short acting just before meals
Skip this if they miss meals

Step 4
Correctional insulin
looks a bit like a sliding scale
But this is really just the fine tuning.

Oral Hypoglycemics
If not eating – Hold all OHGs
Metformin – Generally best to HOLD
Sulfonylureas (Gliburide)- associated with severed and prolonged hypoglycaemia and should be HELD
See this update from UToronto
Update – See this Post – Admitting-patients-with-diabetes
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