Location based decision making

8 Jan

This is something that I’ve noticed happening to me for as long as I’ve been doing emergency medicine (coming up on 10 years now) – that the physical part of the department that you see the patient in has a significant impact on my decision making process. 

A patient with chest pain arrives in resus, the staffing ratio is much higher here. The expected rate of pathology for all staff working in the area is much higher. Before the doctor sees the patient it is likely that the patient will be on a trolley, on a monitor, often an IV cannula is inserted and lab tests are flying through the chute to the lab before anyone has even further assessed the patient. Often the patient is changed to a gown and an ECG will be done.

A second patient with chest pain arrives and is brought to the minors area. There are no cubicles so they sit in a chair awaiting a doctor’s assessment. No further testing or assessment is done. As there are still no cubicles available to assess the patient the doctor apologetically walks the patient to the psychiatry interview room as it is the only free space in the ED with a door that can close to give the patient even the slightest bit of dignity.

I find when I am the doctor in both those situations I make rather different decisions, or at the very least, I feel inclined to make different decisions even if I ultimately don’t do so. The assumption of course is that if the patient is in the minors area then it’s not possible for the patient to have serious pathology and indeed vice versa – if they’re in resus then it’s not possible for them to have minor pathology.

I suspect everyone working in emergency medicine as noticed this to some degree. Hopefully those who are thorough enough will be able to make appropriate and safe decisions (sometimes involving waiting until a cubicle is free and properly exposing and monitoring the patient) no matter what the environment.

However it is a useful reminder, once again, on how overcrowding in the ED is a threat to safe and effective medical care. Ireland has had its own crisis this week – which of course only means that we got in the papers; the ongoing major incident that is the result of the decision to locate all crowding in the ED has been going on for much longer… While people often view ED attendances as simply punters seen by nurses and doctors, there is rarely reflection on the on the fact that working in an overcrowded environment with the compromises it requires exposes patients to the harm of cognitive biases and poor decision making.

[featured image via wikimedia commons]

UPDATE: the good people at Emergency Medicine News have written an article about this for which I did a short email interview along with a few other actual smart people.

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