Abstract

Background and ObjectivesChildren with congenital heart disease (CHD) are at risk of deterioration in the face of common childhood illnesses, and their resuscitation and acute treatment requires guidance of CHD experts. Many children with CHD, however, present to their local emergency departments (ED) with gastrointestinal and respiratory symptoms that closely mimic symptoms of CHD related heart failure. This can lead to incorrect or delayed diagnosis and treatment where CHD expertise is limited. An understanding of the differences in cognitive decision-making processes between CHD experts and ED physicians can inform how best to support ED physicians when treating CHD patients.MethodsCardiac intensivists (CHD experts) and pediatric emergency department physicians (ED physicians) in a major academic cardiac center were interviewed using the critical decision method. Interview transcripts were coded deductively based on Schubert and Klein's macrocognitive frameworks and inductively to allow for new or modified characterization of dimensions.ResultsIn total, 6 CHD experts and 7 ED physicians were interviewed for this study. Although both CHD experts and ED physicians spent a lot of time sensemaking, their approaches to sensemaking differed. CHD experts reported readily recognizing the physiology of complex congenital heart disease and focused primarily on ruling out cardiac causes for the presenting illness. ED physicians reported a delay in attributing the signs and symptoms of the presenting illness to congenital heart disease, because these clinical findings were often non-specific, and thus explored different diagnoses. CHD experts moved quickly to treatment and more time anticipating potential problems and making specific contingency plans, while ED physicians spent more time gathering a range of data prior to arriving at a diagnosis. These findings were then applied to develop a prototype web-based decision support application for patients with CHD.ConclusionThere are differences in the cognitive processes used by CHD experts and ED physicians when managing CHD patients. An understanding of differences in the cognitive processes used by CHD experts and ED physicians can inform the development of potential interventions, such as clinical decision support systems and training pathways, to support decision making pertaining to the acute treatment of pediatric CHD patients.

Highlights

  • Children born with anatomic defects of their heart, called congenital heart disease (CHD), can have a wide range of defects that affect how blood flows through the heart and lungs and to the body

  • There were 1,087 verbal references related to 8 macrocognitive dimensions across both CHD experts and emergency departments (ED) physicians

  • In comparing the macrocognitive processes of CHD experts and ED physicians, this study highlights some key differences in their decision-making pertaining to acutely ill pediatric CHD patients

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Summary

Introduction

Children born with anatomic defects of their heart, called congenital heart disease (CHD), can have a wide range of defects that affect how blood flows through the heart and lungs and to the body. This could lead to delays and errors in diagnosis and care in the absence of an assessment by clinicians with CHD expertise It is not known whether CHD experts and ED physicians apply different cognitive processes to understand and treat acutely ill pediatric CHD patients. An understanding of these differences can be used to augment training and develop interventions to help clinicians better recognize cues and patterns of acutely ill pediatric CHD patients presenting to EDs. Children with congenital heart disease (CHD) are at risk of deterioration in the face of common childhood illnesses, and their resuscitation and acute treatment requires guidance of CHD experts. An understanding of the differences in cognitive decision-making processes between CHD experts and ED physicians can inform how best to support ED physicians when treating CHD patients

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