Blood Transfusion Prescribing in the ACT: An Insight into Clinical Decision Making

Article excerpt

Abstract

Medical practitioners with varying levels of experience may make medical decisions in hospitals. Little is known about who is responsible for these decisions. We determined transfusion appropriateness during an audit of blood transfusion, before developing practice improvement strategies, by concurrent medical record review. The prescriber could be determined in 78% of transfusion episodes: most were specialist staff. Registrars and after-hours staff prescribed significantly fewer inappropriate transfusions. The findings have significant implications in understanding clinical decision making in the hospital setting and for the targeting of quality improvement strategies in particular.

Aust Health Rev 2005: 29(2): 240-245

Background

Medical decision-making in hospitals

In hospitals, each clinical team member, in conjunction with the patient, makes management decisions according to their professional discipline. Decisions about medications, infusions, investigations and invasive procedures are generally the domain of medical staff, with the specialist in charge assuming overall responsibility for the direction of patient management. However, there are several tiers in the medical staff hierarchy and decisions may be made at any level. Common decisions having to be made daily or more frequently, decisions with few adverse reactions or cost implications, decisions with well defined clinical guidelines and decisions having to be made urgently would appear suited to the role of junior staff. Decisions signifying major changes in patient management, involving invasive procedures, with a high risk of adverse outcome or with significant cost implications would appear more suited to specialist involvement in the decision making process. Decision making beyond the level of training or experience of medical staff may put the patient at risk, whereas consultant involvement in every decision would require significant resources and may hinder junior staff training.

Although protocols and guidelines assist in the standardisation of clinical decision-making, it remains true in the era of evidence-based medicine that the majority of decisions are based on an integration of knowledge from clinical studies and the experience and interpretation of the practitioner that is a part of the "art" of medicine. Surprisingly, despite the importance of clinical experience in decision making, little is known about which practitioners participate in various clinical decisions.

The decision-making process has been studied from the viewpoint of the patient-doctor interaction. Research is largely based on outpatient settings, with a clear one-on-one doctor-patient relationship. Frosch and Kaplan2 indicated that patients focus on the major treatment approaches, based on expectations of the likely outcomes, with less interest in the daily technical decisions required to implement the strategy. Many of the decisions in hospitals fall into this latter category, functioning to enable the larger treatment plan. It therefore may be that the routine daily decisions, seemingly more amenable to delegation to junior medical staff, are those in which the patient is least involved, and least vigilant.

Why do we need to know who decides?

Planning decisions in health care systems can be improved by a better understanding of the operalions within them. In quality improvement, understanding who the decision makers are may help to target interventions. This information will also enable targeting of appropriate personnel when information is disseminated, or dialogue is initiated. An understanding of the bedside process is important to better management.

What work has been done on clinical decision making in transfusion?

There is very little information on the process of clinical decision making in transfusion. SalemSchatz and colleagues3 showed that at the request of their consultant junior medical staff often prescribe transfusions that they consider inappropriate. …