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Overview
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
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
Financial
Administrative
Resource allocation
Care Path(way)
Knowledge Base
Practice
Guideline
Care Plan
Procedure
This is not a hierarchy diagram, just a terminology
Didactics
Reference materials
On-line resources
Bad Algorithms
Full of vagaries (weasel words)
optimize patients respiratory status
Ugly Algorithms
Algorithm Classifications
Proposal to HL7 Clinical Decision
Support Technical Committee
5 levels
04
Increasing detail with higher classification #
Class 0
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
Improve upon Class 1 algorithms
Explicitly defining all thresholds and
decisions within the algorithms.
Some action steps are also defined.
Class 3
Distinguished from Class 2 algorithms by
Representation format
Presence of definitions for all steps
Class 4
Include all of the details necessary for a nonexpert 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
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
Algorithm Class
0 1 2 3 4
+/- + + + +
concise description of content and intent of algorithm
+/- + + + +
description of inclusion and exclusion patient groups
+/- +/- + + +
structured repeatable algorithm
- +/- + + +
fully specified concepts
- - + + +
fully specified decision points
- - +/- + +
fully specified action steps
- - - +/- +
formal expression language
- - - - +
formalism to describe the flow of the algorithm
encoded links to didactics, references, on-line resources - - - - +/Elements of a Good Algorithm
+ := always present
- := always absent
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
If patient has pulse or patient age <= 8 years then do not continue with
algorithm. Instead use alternate algorithms for VF
2. 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 ABCs, start CPR,
apply AED
3. Push analyze, if AED displays shock indicated, defibrillate at 200 J
4. If no shock indicated then check pulse
5. If AED displays shock indicated (no conversion), defibrillate at 300 J
6. If no shock indicated then check pulse
7. If AED displays shock indicated (no conversion), defibrillate at 360 J
8. Check pulse, if present, support airway
9. If no pulse, CPR for one minute
10. Check pulse, if absent press analyze
11. If AED displays shock indicated, defibrillate up to three times at 360 J
12. Repeat steps 3 thru 11 until arrival at medical facility
yes
pulse present?
yes
responsive
no
no
performs ABCs
open airway
no
yes
# rescuers = 1
yes
initiate CPR
"shock advised" ?
breathing
press "analyze"
no
give 2 breaths
yes
perform CPR for 1 min.
defib. at 200 J
yes
pulse ?
check pulse
conversion ?
no
defib. at 300 J
yes
no
yes
yes
pulse ?
no
defib. at 360 J
conversion ?
no
yes
conversion ?
defib. at 360 J
no
defib. at 360 J
support airway
yes
pulse ?
conversion ?
no
no
yes
no
defib. at 360 J
at hospital?
use alternate
algorithm
yes
end
check pulse
no
yes
check pulse
pulse present?
yes
# rescuers = 1
yes
responsive
no
no
performs ABCs
open airway
initiate CPR
breathing
no
yes
"shock advised" ?
press "analyze"
yes
conversion ?
no
yes
pulse ?
no
defib. at 360 J
conversion ?
no
yes
conversion ?
defib. at 360 J
no
defib. at 360 J
support airway
yes
pulse ?
conversion ?
no
no
yes
no
defib. at 360 J
at hospital?
use alternate
algorithm
pulse ?
give 2 breaths
check pulse
check pulse
defib. at 300 J
yes
no
no
yes
defib. at 200 J
yes
yes
yes
end
AED brand = X ?
attach first pad in the anterior position -right (patient's right) of the upper sternum (breast
bone) and below the clavicle (collar bone)
attach second pad in the apex position -left (patient's left) of the nipple with the
center of the electrode in the midaxillary line
(where the chest and armpit meet)
Experts
Novices
Related fields
+ := always present
- := always absent
Tips
Simple binary (yes / no) decisions
involving 1 or 2 data points
X < 25
X > 36 or Y <= 18
Gotchas
Over generalizations
Weasel Words
Being Too Ambitious
Not Understanding Problem Domain
Trying to Solve Wrong Problem
Trying to Use Wrong Techniques
Summary