Type of cognitive bias
What it means
A predisposition towards a certain decision as a result of a judgement made by caregivers early in the patient care process
Care home patient with intermittent drowsiness and SBP 112 mm Hg triaged as low priority when actually in established shock from pneumonia
The tendency for a particular diagnosis to become embedded in spite of other evidence
A delirious 85-year-old lady labelled as ‘UTI’ despite no urinary symptoms and no markers of infection
A decision being influenced by the way in which the scenario is presented or ‘framed’
‘This 85-year-old lady with dementia, bilateral consolidation and a 90% chance of death in the ITU’
When thinking is preshaped by expectations
Not expecting to be able to obtain a useful history from a patient with dementia, so not attempting to take one
An awareness of these risks of cognitive bias, coupled with the use of objective, non-judgemental language, and a conscious avoidance of offering early diagnosis in the face of medical uncertainty are ways to try to reduce harm to your patients by keeping an open mind regarding the clinical situation until more information is available.
Regular review of frail older patients and clear documentation of changing clinical status, including checking vital signs, reassessing in the event of deterioration and keeping a close track of the diagnostic tests that have been requested and returned, are important aspects of maintaining their safety in the emergency department.
Mrs. Smith was initially reviewed in the rapid assessment area by a consultant who took the handover detailed above from the paramedics. The documentation in the initial assessment notes was as follows:Presenting complaint: Collapse? Cause?No history available from patient.On examination: Confused and drowsy. Incontinent of urine. Off legs. Poor air entry on chest examination and reduced skin turgor. Soft abdomen. Moving all four limbs.Impression: UTI.Plan: Bloods, IV fluids, chest X-ray and reassess in the main assessment areaMrs. Smith was reassessed by a junior doctor later on in the main assessment area of the department. By this point, blood results returned showing acute kidney injury and a raised white cell count. CXR (Chest X-Ray) was a poor-quality film but showed clear right basal consolidation. He reviewed her BP again and noted it had fallen from 112 to 105 mm Hg. He commenced IV antibiotics and increased the rate of her IV fluids.On reviewing Mrs. Smith’s grab sheet, he telephoned her daughter who was able to attend the ED immediately and take part in conversations about her mother’s usual level of function and participate in discussions regarding her goals of care. It was decided that since Mrs. Smith normally functioned quite well within the home and there was a clearly reversible cause for her relatively sudden decline in function, an acute hospital admission for IV treatment was appropriate; however in the event of further deterioration, escalation to intensive care unit or CPR would not be appropriate.Mrs. Smith’s daughter was very upset that the home had not contacted her directly and angrily stated that they were ‘on thin ice’ and that ‘mum’s losing weight, and her skin is so dry today, I don’t think they’re feeding her properly—they just don’t know what they’re doing’.
23.9 Disposition from the Emergency Department
When discharging a patient from the ED, there are a variety of possible destinations—they could be admitted to a medical or surgical ward, transferred to a community hospital, returned to their care home or returned to their own home.
23.9.1 Transferring to an Inpatient Ward (an Acute Admission)
Handover to the admitting team is an important step—the aim should be an accurate account of the patient’s clinical status and events so far, with relevant but concise information relating to their background, function and potential to deteriorate. It is good practice to commence discharge planning at the point of admission, and so any thoughts or information that are available from the ED assessment should be offered as well.
A suggested structure is as follows:
Based on the case progress detailed above, here is a suggested outline for handover, encompassing some of the things you should specifically consider when handing over a frail older patient.
Clinical narrative including communication needs and key informants
‘This is Mrs. Smith; she is an 85-year-old nursing home resident. She was transferred by ambulance with reduced oral intake and drowsiness. On assessment we have found her to have a right lower lobe pneumonia with blood results suggesting acute kidney injury; she also has a hypoactive delirium. Mrs. Smith has a background of vascular dementia, and hypertension. She can normally converse but has no insight into her medical issues and lacks capacity relating to decisions about medical treatment. She usually walks with a Zimmer frame but is currently hoisted, and she is unable to communicate verbally. She is accompanied by her daughter who has Lasting Power of Attorney for welfare decisions’
Physiological parameters with individualised clinical interpretations
‘Mrs. Smith’s oxygen saturations are stable at 95%, and her pulse is currently 90 bpm. Her BP is 105 systolic which suggests shock in view of her background hypertension’
Medication and any changes
‘We have commenced Mrs. Smith on IV antibiotics and IV fluids and withheld her ACE inhibitor and calcium channel blocker. There are no allergies’
Thoughts about discharge planning and the home environment
‘Mrs. Smith’s daughter has raised concerns about standards of care in the home due to some recent weight loss. We do not know whether these concerns are justified; however, this will need to be highlighted to the social worker for investigation whilst Mrs. Smith is an inpatient. We have completed a safeguarding form’
Escalation status including advance care plans
‘Mrs. Smith has come with a DNACPR form which is in her notes. This can travel with her. There is no documentation from the care home about a ceiling of care or any advanced care plan; however following discussion with her daughter in the ED, we have placed a limit of ward-level treatment on Mrs. Smith’s care due to her background frailty and poor functional reserve. This has been documented in her case notes, and her power of attorney is in full agreement’
23.10 Discharging a Patient
23.10.1 Back to Their Care Home or to a Cared-for Environment
Let’s now consider a different scenario. For the purposes of continuity, we have moved forward in time. Mrs. Smith returned to her care home after a 4-day hospital admission where she was successfully treated for an aspiration pneumonia. It is now 6 months later; during this time period, Mrs. Smith’s mobility has deteriorated to the extent that she is now in bed for long periods and requires a hoist to transfer. She has lost a further 2.5 kilos and is no longer able to converse—only opening her eyes to the sound of a familiar voice or during personal care. She now requires feeding, although her oral intake is poor. She has returned to the ED with drowsiness, reduced oral intake and another aspiration pneumonia.