Clinical care algorithms the good the bad and the ugly
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Clinical Care Algorithms: The Good, The Bad, and The Ugly. R. Matthew Sailors, PhD UTH Medical School Department of Surgery. Overview. Modern World / Why Use Algorithms Types of / Uses for Algorithms Clinical Care Algorithms Types, Use, Automation Good, Bad, and Ugly Algorithms

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Clinical Care Algorithms: The Good, The Bad, and The Ugly

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Clinical care algorithms the good the bad and the ugly

Clinical Care Algorithms:The Good, The Bad, and The Ugly

R. Matthew Sailors, PhD

UTH Medical SchoolDepartment of Surgery


Overview

Overview

  • Modern World / Why Use Algorithms

  • Types of / Uses for Algorithms

  • Clinical Care Algorithms

    • Types, Use, Automation

  • Good, Bad, and Ugly Algorithms

  • Algorithm Classification & Examples

  • Evaluating Algorithms

  • Writing Good Algorithms


Modern world

Modern World

  • Society is making ever greater demands on our healthcare delivery system and, in turn, on the healthcare providers.

  • It is imperative that the workflow of healthcare delivery be altered if quality of care and access to healthcare are to be maintained or improved.

  • One of the many ways of accomplishing this alteration is the automation of clinical algorithms


Why do we use algorithms

Why Do We Use Algorithms?

  • Share or extend expertise

    • Training

    • Disseminate processes / procedures

  • Reduce variability

  • Standardize care

    • Improve overall quality of service

    • Serve as baseline for new strategies

  • Medico-Legal reasons


Types of algorithms

Clinical

Administrative

Financial

Time-based

Data-based

State-based

Evidence-based

Heuristics

Model-based

WAG

Types of Algorithms


Clinical care algorithm

Clinical Care Algorithm

  • Specifically clinical (patient care)

  • NOT

    • Financial

    • Administrative

    • Resource allocation

  • Neutral, high-level term

    • No biases or preconceptions


Clinical care algorithm1

Clinical Care Algorithm

  • Description of a process intended to guide sequential clinical (therapeutic or palliative) interventions.

  • Usually single patient-centric

  • Time or data-driven

  • Evidence-based, models, heuristic, WAG


Clinical care algorithm2

Clinical Care Algorithm

Care Path(way)

Protocol (I)

Protocol (II)

Knowledge Base

Practice

Guideline

Care Plan

Procedure

This is not a hierarchy diagram, just a terminology


Use of clinical algorithms

Serve only as guides

Only good inside the design envelope

Professional clinical judgment override

Handle “routine” situations

Allows experts to concentrate on difficult cases

Use of Clinical Algorithms


Automation of clinical algorithms

Automation of Clinical Algorithms

  • guide (but not directly provide) therapies

  • manage information flow

  • assist in diagnosis and treatment planning

  • provide a safety net for the patient for the times when the inevitable human / technical / system errors occur.


Automation of clinical algorithms1

Automation of Clinical Algorithms

  • Computers have no native intelligence

  • Algorithms must be as detailed as possible

    • streamline the implementation process

    • computerized algorithm must represent

      • what we want to do

      • not just want we told the computer to do.


Good algorithms required

Good Algorithms -- Required

  • Concise description

    • Content and intent of the algorithm

    • Patient groups to which it can and cannot be safely applied

  • Structured, repeatable algorithm

    • textual or graphical form

  • Fully specified concepts

    • (e.g., “high nasogastric tube output is defined as nasogastric tube output > 1200 cc/12 hr”)


  • Good algorithms required1

    Good Algorithms -- Required

    • Fully specified decision points

      • E.g., PaO2 >= 60 and PaO2 <= 80

  • Fully specified action steps,

    • Therapeutic interventions suggested by the algorithm

    • Calculations to be performed

    • Patient-specific recommendations


  • Good algorithms desired

    Good Algorithms -- Desired

    • Formal expression language

      • Describe the decision and action steps

      • Delineated scope and purpose

      • Define entry and exclusion criteria

  • Formalism to describe the flow of the algorithm from one state to the next

  • Encoded links

    • Didactics

    • Reference materials

    • On-line resources


  • Bad algorithms

    Bad Algorithms

    • Full of vagaries (“weasel words”)

      • “optimize patient’s respiratory status”

    • Fail to adequately describe the decisions and actions that are required to care for the patient

    • Important entry or exclusion criteria and conditional values missing

    • Concepts poorly defined

      • “high NG output”


    Ugly algorithms

    Ugly Algorithms

    • Unstructured / poorly structured algorithm

    • Algorithm follows no sequential order

    • Important entry or exclusion criteria appear at the end of the algorithm or in footnotes

    • No standard formalism used to describe algorithm


    Algorithm classifications

    Algorithm Classifications

    • Proposal to HL7 Clinical Decision Support Technical Committee

    • 5 levels

      • 0 – 4

      • Increasing detail with higher classification #


    Class 0

    Class 0

    • Often encoded only in textual form.

    • Full of vagaries

    • Fail to adequately describe the decisions and actions that are required to care for the patient

    • Actual algorithm

      • often unstructured or poorly structured

      • may follow no sequential order

    • Important entry or exclusion criteria and conditional values often appear at the end of the algorithm or in footnotes, if at all.


    Class 1

    Class 1

    • Improve upon Class 0 algorithms

    • All of the entry and exclusion criteria specified at the beginning of the description.

    • Algorithms steps are coarsely structured and are arranged in a temporal or logical progression.

    • Algorithms are usually still represented in textual form, but may also be represented in other forms.


    Class 2

    Class 2

    • Improve upon Class 1 algorithms

    • Explicitly defining all thresholds and decisions within the algorithms.

    • Some action steps are also defined.


    Class 3

    Class 3

    • Distinguished from Class 2 algorithms by

      • Representation format

      • Presence of definitions for all steps

    • Represented using structured formalism

      • flow diagrams

      • formal, structured text (pseudo-code)


    Class 4

    Class 4

    • Include all of the details necessary for a non-expert or computer to negotiate the algorithm in a reliable and repeatable manner.

    • All logical and clinical concepts are explicitly spelled out and are described in terms of patient-specific values.

    • Most often disseminated as either flow diagrams or encoded using a knowledge base formalism.


    Intermediate classifications

    Intermediate Classifications

    • A given clinical algorithm may fulfill all of the requirements for a given classification and part of the requirements for a higher classification

    • May be necessary to classify the algorithm as a intermediate value.

    • Separate the two levels with a forward slash (/), such as, “Class 3 / 4”.

    • This notation, while less precise than a decimal or true fractional notation, has the advantage of being simple and efficient.


    Classification overview

    Classification Overview


    Class 0 aed algorithm

    Class 0 AED Algorithm

    • ABC’s, start CPR, apply AED

    • Push “analyze”, if indicated defibrillate at 200 J

    • If no conversion, defibrillate at 300 J

    • If no conversion, defibrillate at 360 J

    • Check pulse, if present, support airway

    • If no pulse, CPR for one minute

    • Check pulse, if absent press “analyze”

    • If advised, defibrillate up to three times at 360 J

    • Repeat steps 2 thru 8 until arrival at medical facility


    Class 0 aed algorithm cont

    Class 0 AED Algorithm (cont.)

    Notes:

    • Single rescuer with AED should verify unresponsiveness, open airway give two breaths, and check pulse. If full arrest, AED should be attached and proceed with algorithm.

    • Pulse checks are not required after shocks 1, 2, 4, and 5 unless “no shock indicated” is displayed

    • Only to be used on pulse-less, non-pediatric patients

    • If advanced personnel are present, they can use the manual mode

    • Advanced personnel can enter the above algorithm at any point and continue with appropriate advanced protocol


    Class 1 aed algorithm

    Class 1 AED Algorithm

    Notes:

    • If advanced personnel can use the manual mode

    • Advanced personnel can enter the algorithm at any point and continue with appropriate advanced protocol


    Class 1 aed algorithm cont

    Class 1 AED Algorithm (cont.)

    • If patient has pulse or is a pediatric patient then do not continue with algorithm. Instead use alternate algorithms for VF

    • Single rescuer with AED should verify unresponsiveness, open airway give two breaths, and check pulse. If full arrest, AED should be attached and proceed with algorithm. If multiple rescuers then ABC’s, start CPR, apply AED

    • Push “analyze”, if indicated defibrillate at 200 J

    • If “no shock indicated” then check pulse

    • If no conversion, defibrillate at 300 J

    • If “no shock indicated” then check pulse

    • If no conversion, defibrillate at 360 J

    • Check pulse, if present, support airway

    • If no pulse, CPR for one minute

    • Check pulse, if absent press analyze

    • If advised, defibrillate up to three times at 360 J

    • Repeat steps 3 thru 11 until arrival at medical facility


    Class 2 aed algorithm

    Class 2 AED Algorithm

    Notes:

    • If advanced personnel can use the manual mode

    • Advanced personnel can enter the algorithm at any point and continue with appropriate advanced protocol


    Class 2 aed algorithm cont

    Class 2 AED Algorithm (cont.)

    • If patient has pulse or patient age <= 8 years then do not continue with algorithm. Instead use alternate algorithms for VF

    • Single rescuer with AED should verify unresponsiveness, open airway give two breaths, and check pulse. If full arrest, AED should be attached and proceed with algorithm. If multiple rescuers then ABC’s, start CPR, apply AED

    • Push “analyze”, if AED displays “shock indicated”, defibrillate at 200 J

    • If “no shock indicated” then check pulse

    • If AED displays “shock indicated” (no conversion), defibrillate at 300 J

    • If “no shock indicated” then check pulse

    • If AED displays “shock indicated” (no conversion), defibrillate at 360 J

    • Check pulse, if present, support airway

    • If no pulse, CPR for one minute

    • Check pulse, if absent press analyze

    • If AED displays “shock indicated”, defibrillate up to three times at 360 J

    • Repeat steps 3 thru 11 until arrival at medical facility


    Class 3 aed algorithm

    Class 3 AED Algorithm


    Class 4 aed algorithm part 1

    Class 4 AED Algorithm (Part 1)


    Class 4 aed algorithm part 2

    Class 4 AED Algorithm (Part 2)


    Critically evaluating algorithms

    Critically Evaluating Algorithms

    • Identify target audience

      • Experts

      • Novices

      • Related fields

    • Identify intended use

      • Author’s

      • Yours

    • Look for well-defined decision and action targets (no “weasel words”)

    • Look for individual-based outputs


    Critically evaluating algorithms1

    Critically Evaluating Algorithms

    • Look for well-defined decision and action targets (no “weasel words”)

    • Look for individual-based outputs

    • Use the table to help classify algorithms


    Writing good algorithms

    Writing Good Algorithms

    • Start with general and work to specific

      • Iterative process

    • Avoid Gotchas -- later slide

    • Think like a child (or engineer)

      • Simple, discrete, decisions

    • Keep it simple at first

    • Add complexity as needed


    Clinical care algorithms the good the bad and the ugly

    Tips

    • Simple binary (yes / no) decisions involving 1 or 2 data points

      • X < 25

      • X > 36 or Y <= 18

    • String together lots of small steps rather than having one or two big ones

    • Nest complexities away


    Gotchas

    Gotchas

    • Over generalizations

    • “Weasel Words”

    • Being Too Ambitious

    • Not Understanding Problem Domain

    • Trying to Solve Wrong Problem

    • Trying to Use Wrong Techniques


    Summary

    Summary

    • Algorithms – many uses: for good, for bad

    • Good, bad, and ugly algorithms

    • Good algorithms share expertise

    • Algorithm classifications: 0 (low) – 4 (high)

    • Critically evaluate algorithms

    • Writing good algorithms is about attention to details


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