Decision Making in Pediatric Decision Making in Pediatric Emergency MedicineEmergency Medicine

Ivan Steiner MD, MCFP-EM, FCFP

University of Alberta,

Edmonton, Canada

Goal for todayGoal for today

To review a simple, personal, time tested tool for decision making in the ED.

Game plan Game plan

Look at the difference between ED, wards and clinics.

Review the components of decision making process in the ED.

Outline my template for decision making. Answer questions. Provide a summary.

Warm upWarm up15 patients waiting in the waiting room when a 7

month old baby boy is brought by his parents into the E.D. of

A peripheral hospital. He is unresponsive and is visibly

covered by a rash. His BP = 60/?, P = 160, RR = 50, to = 40o,

O2% = 96% on R.A.

What is the problem?

What are your priorities in this case?

The ED a distinct environmentThe ED a distinct environment

Question:

In what way is the ED different than the wards and clinics?

The ED a distinct environmentThe ED a distinct environment

Lack of control over volume of patients. Variable acuity and availability of resources. Triage. Unknown patients. Short intervention time. Limited information. “One shot” approach. Uncertainty of dealing with unknown, or previously not

encountered problems.So what does this mean to the clinician?

The ED a distinct environmentThe ED a distinct environment

Functioning in an environment with limited , variable resources AND dealing withfrightened,

possibly hostile patients and families .

Key skills and attitude/behaviours required to be successful in the ED:

Prioritized, organized approach to each situation. Empathy, respect, tact. On going, two - way communication.

Take home message for Part 1.Take home message for Part 1.

Decision making may have to start with the little or no information.

The “traditional” approach to patient management does not work in the ED.

A PEP is a “people person”. Rapport!

Decision making:Decision making: key questions to ask oneself key questions to ask oneself

The three “Stop” signs:

1st “Stop” sign

What are the first four key questions to ask oneself ?

Back to our caseBack to our caseA 7 month old baby boy is brought into the

E.D. of a peripheral hospital by his parents.

He is unresponsive and is visibly covered by a

rash. His BP = 60/?, P = 160, RR = 50, to =

40o, O2% = 96% on R.A.

What are the first 4 key questions to ask ?

Decision Making:Decision Making: Key Questions to Ask Oneself Key Questions to Ask Oneself

1. Is the patient in the right institution ? 2. Is the patient in the right part of the ED?3. Is there a need for immediate resuscitation, or

potential for resuscitation of LIFE, limb or salvage of function?

4. What immediate information/resources are required to start management of the patient?

These questions lead to good triage and care!

How do we make decisionsHow do we make decisions

Presumption for PEP: the worst case scenario.

How do we make decisionsHow do we make decisions

First step: trust your eyes, smell, hearing, touch.

Second step: check vital signs. Third step: asses chief complaint.

How do we make decisionsHow do we make decisions

Start with patient presentation and NOT diagnosis.

Anatomy and physiology are great guides!!!!

Back to our caseBack to our case

Where do we start here based on the

4 key questions?

Take home message Part 2.Take home message Part 2.

A good PEP anticipates problems. In the ED, the clinician is first and

foremost a clinical physiologist. He/she is an expert at managing

multiple, often limited resources.

Template to decision makingTemplate to decision making

The 7 step approach.

How to get “Steinerized”

Template: the first 7 stepsTemplate: the first 7 steps

Resuscitation. Monitoring. Symptomatic treatment. Investigations. Diagnosis/definitive treatment. Disposition. Social.

TemplateTemplate: step 1: step 1

Does the patient need resuscitation or stabilization of physiological parameters ?

The 1st “Stop” sign

Life = resuscitate.

Limb = reestablish circulation.

Function = prevent further injury. (P.R.I.C.E.)

Back to our case.Back to our case.

Does he need resuscitation?

Template: step 2Template: step 2

Does the patient need monitoring?

Life = VS=BP, P, RR, to, O2%, weight, sugar, (Co2).

Limb = pulses, colour, sensation.

Function = as above or specific (Visual Acuity)

Back to our case.Back to our case.

Does he need monitoring?

Template: step 3Template: step 3

Is there a need for symptomatic treatment?

Provide symptomatic treatment based on

need and using the most effective route!

Offer it to the patient even though he/she

may choose not to accept it.

Back to our case.Back to our case.

Does he need symptomatic treatment?

Template: step 4Template: step 4

Does the patient need prioritized investigations?

The 2nd “Stop” sign

Body fluids = blood & all other.

Diagnostic imaging = simple & complex.

Other = things that start with “E”.

Back to our case.Back to our case.

Does he need prioritized investigations?

Template: step 5Template: step 5

Do we know what is definitively wrong with the patient and what the definitive treatment options may be?

Usually the answer is NO.

Back to our case.Back to our case.

Do we know what is wrong and what the definitive treatment options are?

Template: step 6Template: step 6

Do we know where this patient will end up?

Too sick to go home = ward vs intensive care.

Will go home = only obvious cases.

Not sure = most patients fit in to this category.

Remember: Starting presumption is that you aredealing with the worst case scenario.

Back to our case.Back to our case.

Do we know where he will end up?

Template: step 7Template: step 7

Are there any immediate social issues ?

Consider these issues early and use the

appropriate resources: social worker, etc.

Back to our case.Back to our case.

Did you consider the parents here ?

Template: the first 7 stepsTemplate: the first 7 steps

Resuscitation. Monitoring. Symptomatic treatment. Investigations. Diagnosis/definitive treatment. Disposition. Social.

Template: the first 7 stepsTemplate: the first 7 steps

How do I make it work? A = Asses.

I = Intervene.

R = Reassess.

The sicker the patient, the more often one repeats A.I.R. and charts each intervention.

Template: the final 7 stepsTemplate: the final 7 stepsThe 3rd “Stop” sign

Resuscitation. Monitoring. Symptomatic treatment. Investigations. Diagnosis/definitive treatment. Disposition. Social.

Template: the 3 “Stop” signsTemplate: the 3 “Stop” signs

1. Before triage & resuscitation

2. Before ordering all investigations

3. Before disposition of the patient

Take home message Part 3.Take home message Part 3.

The 7 point template provides a simple and safe starting point.

The 7 point template provides a safe exit strategy.

The number of A.I.R. are dictated by the clinical status of the patient.

The 3 “STOP” signs help PEP slow down and make good decisions!

QuestionsQuestions

Distilled summaryDistilled summary

Good PEP use a patient/family centered approach in decision making.

Early decisions are based on patient presentation and NOT diagnosis.

Physiology and anatomy never lie! The 7 point template used on entry and exit +

A.I.R. + the 3 STOP signs have been proven, useful and simple to use tools over time.

Teaching Pediatric EM to all medical students and residents who are treating children is essential.

The EndThe End