Clinical decision support for patients with comorbidities in the emergency setting

Dr Harry Achterberg, Medical Director, Emergency Department, Telemark Hospital Trust, Skien, Norway
Dr Kieran Walsh, Clinical Director, BMJ

Emergency medicine is a busy specialty and the pace is very fast. Emergency medicine physicians need clinical decision support just like all other physicians - but the types of patients that they see and their work setting means that they have particular requirements that must be met.

One vitally important starting point is that patients in the emergency setting don’t always have a clear diagnosis initially and so emergency medicine physicians often need to think in terms of symptoms. The symptoms vary depending on specialty – but the main medical symptoms are chest pain, dyspnoea, “unwellness”, abdominal pain, fever, and syncope.

On top of that an Emergency Physician will have to assume that every patient has a time-critical condition and could possibly deteriorate at any given moment. It is therefore mandatory for physicians to see every patient in the Emergency Department, regardless of their symptoms as someone who could have a life-threatening condition and might need immediate treatment.

These initial symptoms should then lead seamlessly on to the diagnoses which are based on the particular symptoms. For example, the top underlying diagnoses for dyspnoea would be acute coronary syndrome, pulmonary embolism, acute exacerbation of COPD, and pulmonary hypertension. These might be the most important diagnoses or sometimes the diagnoses that are most important to refute.

The next and slightly more complicated step is linking the acute condition to background conditions that the patient might have. These comorbidities most commonly include chronic non-communicable diseases such as COPD, diabetes, chronic kidney disease, heart failure, and/or dementia.

The purpose of BMJ Best Practice Comorbidities is to help with this final step – that is, to help the doctor to manage a patient with more than one condition. Newly qualified doctors are usually very knowledgeable. But they can struggle to put their knowledge together into a framework that will help the patient.

One example of an acute condition on top of a chronic disease is that of acute exacerbation of COPD and type 2 diabetes. Steroids will help the COPD exacerbation, but might make the diabetes worse. Another example is that of a patient with chronic kidney disease and pneumonia. If you treat with antibiotics like erythromycin or gentamycin, you might quickly run into problems.

The purpose of BMJ Best Practice Comorbidities is to help in practical situations such as this. Junior doctors tend to focus on single conditions - usually the acute presenting condition. What they need to develop is a skillset so that they can see the connections between different conditions. BMJ Best Practice Comorbidities is aimed at junior doctors – but it is not just for this group. More senior doctors may also appreciate the confidence that comes from being reassured that they are doing the right thing.

In a working environment that is hectic and fast-paced, they need something that is easily accessible and that will tell them what they need to know quickly. Usually, they are just looking for a single piece of information and so do not want to “drink from the garden hose”. Of course, if they need more information, they can click through to the underlying guidance or references.

One final point relates to the importance of the education of junior doctors. Ultimately, we all need people who can take over from us. And so the focus needs to be on education for the next generation of doctors. The purpose of clinical decision support for patients with complex conditions is to support younger doctors in time-critical situations where they can't find a Harrison's Principles of Internal Medicine (as previous generations would have done). And to give them access to the “just in time” information that they need.

Competing interests
KW works for BMJ.