Jenkins John, Shields Mike, Patterson Chris, Kee Frank
Queen's University Belfast, Paediatric Department, Antrim Hospital, Antrim, Belfast, UK.
Arch Dis Child. 2007 Aug;92(8):672-7. doi: 10.1136/adc.2007.117424. Epub 2007 Apr 11.
Clinical decisions which impact directly on patient safety and quality of care are made during acute asthma attacks by individual doctors based on their knowledge and experience. Decisions include administration of systemic corticosteroids (CS) and oral antibiotics, and admission to hospital. Clinical judgement analysis provides a methodology for comparing decisions between practitioners with different training and experience, and improving decision making.
Stepwise linear regression was used to select clinical cues based on visual analogue scale assessments of the propensity of 62 clinicians to prescribe a short course of oral CS (decision 1), a course of antibiotics (decision 2), and/or admit to hospital (decision 3) for 60 "paper" patients.
When compared by specialty, paediatricians' models for decision 1 were more likely to include level of alertness as a cue (54% vs 16%); for decision 2 they were more likely to include presence of crepitations (49% vs 16%) and less likely to include inhaled CS (8% vs 40%), respiratory rate (0% vs 24%) and air entry (70% vs 100%). When compared to other grades, the models derived for decision 3 by consultants/general practitioners were more likely to include wheeze severity as a cue (39% vs 6%).
Clinicians differed in their use of individual cues and the number included in their models. Patient safety and quality of care will benefit from clarification of decision-making strategies as general learning points during medical training, in the development of guidelines and care pathways, and by clinicians developing self-awareness of their own preferences.
在急性哮喘发作期间，个体医生会根据自身知识和经验做出直接影响患者安全和护理质量的临床决策。这些决策包括全身性皮质类固醇（CS）和口服抗生素的使用，以及住院治疗。临床判断分析提供了一种方法，用于比较不同培训和经验的从业者之间的决策，并改善决策制定。
采用逐步线性回归，根据62名临床医生对60名“虚拟”患者开具短期口服CS（决策1）、抗生素疗程（决策2）和/或住院（决策3）倾向的视觉模拟量表评估来选择临床线索。
按专业比较时，儿科医生决策1的模型更有可能将警觉程度作为线索（54%对16%）；对于决策2，他们更有可能将啰音的存在作为线索（49%对16%），而将吸入性CS（8%对40%）、呼吸频率（0%对24%）和呼吸音（70%对100%）作为线索的可能性较小。与其他级别相比，顾问/全科医生为决策3得出的模型更有可能将喘息严重程度作为线索（39%对6%）。
临床医生在使用个体线索及其模型中包含的线索数量方面存在差异。患者安全和护理质量将受益于在医学培训期间将决策策略的澄清作为一般学习要点、在制定指南和护理路径时以及临床医生培养对自身偏好的自我意识。
