Clinical decision support for complex patients – what foundation doctors need

Dr Adrian Khaw is currently a Foundation Doctor in NHS Tayside. He graduated from the University of Edinburgh. His current role as a junior doctor involves daily patient care and ward-based procedures, occasionally having the wonderful opportunity of assisting in theatre and minor surgeries.


It’s 5am in the acute admissions unit, the effects of the coffee you had a few hours ago is starting to wear off, and you just don’t have the time or energy to make another. Many times, it seems like your brain does not function as efficiently as it should as you reach the end of a 13-hour shift. With more patients awaiting your clerking and review, you often worry about patient management, especially when trying to initiate treatment or make decisions on withholding medications in patients with multiple comorbidities and polypharmacy. Being in an acute unit, we are always focused on addressing our patients’ acute problem but many of us sometimes neglect patients’ background medical problems until these comorbidities become an acute issue. This is a common event that we all struggle with daily.

A few months ago, I came across the Comorbidities tool on BMJ Best Practice. This tool is exactly what all foundation doctors need to make decisions on management in patients with comorbidities. Through this tool, foundation doctors are able to select the main presenting diagnosis and add any comorbidities that the patient might have. The tool then automatically produces a comprehensive plan so that you can address each individual problem. This system also highlights important investigations and treatments to initiate or continue. This means that our patients’ overall care is optimised without overlooking any aspects of patient management.

A good example would be from my experience while working in the acute medical admissions unit. Many our patients presented with a wide range of medical issues. I commonly saw patients with an acute exacerbation of chronic obstructive pulmonary disease (COPD), with a background of hypertension, diabetes, and impaired renal function.

Using BMJ Best Practice Comorbidities I was able to select acute exacerbation of COPD as the patient’s primary diagnosis and then include their comorbidities. The tool then recommends first-line treatments such as short-acting beta-2 agonists, steroids, oxygen (titrated to target saturations), antibiotics if needed, and ventilation in patients where indicated. But the tool also highlights the importance of reviewing diabetes medications and managing insulin. Last but not least, I’m also reminded to monitor my patient’s comorbidities by monitoring renal function and blood glucose, and to perform a diabetic foot examination.

My experience has shown that this tool is very helpful for foundation doctors. Therefore, I highly recommend making use of the Comorbidity tool to boost patient safety in your everyday practice.

Competing interests