About

This ebook presents emergent clinical situations and the core tasks required of healthcare professionals needing to recognize, navigate and safely manage them. It’s really about how to perform the ABCs while protecting yourself, the patient and others; attempting to establish therapeutic relationships; and respecting patients’ values and wishes. When first called upon to manage acutely ill patients, the healthcare team must initiate their ABCs to support and keep patients alive even though information is lacking (i.e., the undifferentiated situation). As information trickles in, the team’s mental model evolves and becomes more refined. This allows resuscitative efforts to be modified and enables the introduction of more specific measures to directly address the source of the problem.

Given an undifferentiated situation (e.g., severe hypoxemia) or goal (e.g., initiate mechanical ventilation), the authors of this ebook were asked to identify which tasks should be carried out and when. These time-sensitive tasks are presented using maps to better illustrate their sequence and interaction with one another. These maps are designed to help clinicians develop a common approach to life-threatening situations, thus facilitating the development of shared mental models. Effective teamwork saves lives, and we echo opinions stating that individuals working within healthcare teams benefit from having a shared language, collective anticipatory thinking structure, and evidence-informed method to guide what should and must be done.[1] Our hope is that these maps will help healthcare professionals to better lead and supportively follow each other to rescue and avoid harming patients; through improved communication, coordination, member checking and backup behaviour.

Information architecture

The ebook architecture is somewhat different from traditional work, which is rooted in a deep understanding of basic science, pathophysiology, and analytic problem-solving. Traditionally, learners have been expected to take many knowledge parts, put them together and develop their own approach through encounters with real or simulated patients. In this ebook, the core material, organized through temporal maps, is presented first, informing learners of what they should consider and actually do given certain situations. Unlike traditional books, the rationale supporting each task is available upon request (i.e., the reader must click on the task to obtain additional information). While practical approaches to critical situations are presented first, we believe that understanding basic science concepts and supporting clinical studies still remains essential, even if only to critique and improve the work. In addition, this deeper understanding no doubt enables teams to modify their initial approaches in real life given different clinical contexts and evolving situations.

Cognitive learning theory

The ebook structure was informed in part by medical reasoning literature examining how experts process information when making clinical practice decisions. Clinical reasoning is thought to involve “Systems 1 & 2 cognitive processing” (recognition-primed versus analytic decisions) and the construct of “illness scripting.”[2],[3],[4] Although a complex and controversial topic, illness scripts can be most simply explained as the many familiar illness patterns and management actions (i.e., prototypical situations and tasks) experts have encountered through diverse experience and use.[2],[4],[5] Experts rely on these scripts to reduce cognitive load and rapidly make decisions based on whether a new situation fits with contextual information previously stored as meaningful.

Figure 1 – Systems Thinking Examples

Many would argue that basing practice actions on pattern recognition alone is a potentially dangerous cognitive bias, given that clinical information is dynamic and inevitably does not always fit into existing illness scripts.[3],[4],[5] In these instances, experts also resort to and rely on basic scientific knowledge and analytical reasoning to consistently re-evaluate whether the current situation and most appropriate course of action has correctly been identified.[3] Klein first developed the Recognition-primed Decision Model, which integrates System 1 &2 cognitive processes, describing how experts make decisions in natural settings when situations are rapidly evolving.[6] Klein showed that experts, having recognized a situation as familiar, already have a plan in mind and thus can focus all their cognitive resources on task execution. In contrast, when a situation is less familiar or does not unfold as expected, the initial standardized plan needs to be modified (sometimes abandoned), often resulting in the implementation of the first modified plan that comes to the expert’s mind and is also deemed doable.

By linking situations and tasks into clinical management strategy maps, this ebook attempts to replicate the knowledge organization and processing structures used by experts. However, as experts do, we expect that the readers will also need to modify the idealized clinical approaches presented here. This ebook can help, but is not meant to replace the thoughtful and contextually adaptable clinician needing to manage real-life, complex situations with multiple issues, limited resources and sometimes conflicting treatment goals. 

Iterative, innovative design and quality control

Free, open access medical education (FOAMed) has gained broad attention and international online momentum. Although reputable online learning resources exist (see ALiEM, LITFL), developers face greater credibility threats than publishers of more traditionally accepted information sources, such as scholarly journals.[7],[8] A challenge for consumers is being able to gauge the quality of this information.[7],[8],[9] Aware of these challenges, the authors of this ebook were carefully selected, and all work was peer-reviewed using a transparent process recommended by the International Committee of Medical Journal Editors (ICMJE) guidelines that informs the working standards of many high-impact medical journals. In addition, scholarship and editorial rigor was maintained by meeting and often exceeding FOAMed quality assurance standards and/or validated ratings criteria presently cited in the medical education literature.[7],[8],[9] 

The majority of content was authored and/or peer-reviewed using an interprofessional approach. Invited authors were recommended by national speciality societies, professional organizations, or peers and were further identified through scholarly publications, which helped to recruit committed, academic–clinician topic experts from various fields. Coordinating experienced clinicians through “think aloud” protocols that detail routine and collective clinical approaches to common situations requires strategic documentation and a need to "map out" the consensus view. This work was facilitated using Cmap tools, developed by the Florida Institute for Human and Machine Cognition,[10] which helped translate clinical approaches into initial visual and textual displays. Authoring team meetings were held, many Cmap iterations were developed, and then the final maps were subsequently peer-reviewed by external collaborators to ensure accuracy and continually improve the end products. In addition, to further enhance learning and ease of navigation, established multimedia learning principles[11] informed web page layout for the written content portions that are frequently integrated with knowledge objects, such as infographics and videos, to help support and explain difficult-to-understand concepts and to make the resource more interactive.

Although Cmaps were useful for documenting consensus on clinical approach, they were quite large and difficult to view or navigate outside of the Cmap viewer. Furthermore, when presented on screen, concerns over extraneous cognitive load were raised as a potential learning barrier for the target population. Given this problem, the editorial team and instructional designer worked to develop several prototypes using various technologies, such as Wikis and PDF ebooks. Ultimately, a combined solution that relies on standard web technologies for ease of development and deployment was agreed upon. This transformation allows for a reduced number of steps or sequences shown on screen at one time. This solution also allowed for the Cmaps to be transformed into more interactive approaches that "unfold" as a user moves through each aspect.

Future

At this juncture (February 2018) the work has been released but is not entirely finished. In the future, expanding upon these core situations or potentially contextualizing them to different settings, such as rural centres, could be beneficial. We hope that the ebook also created a credible and easily accessed practice-based resource for healthcare teams and a reputable knowledge repository to inform acute care simulation-based curricula and assessment instruments.

We also hope to encourage users to disseminate this content widely through their professional and peer networks by various means. It is our intent to generate new questions and debate and to stimulate further discussions that can potentially be advanced through educational research or other forms of healthcare scholarship. We are very thankful for the efforts of the more than 100 contributors to this project and look forward to working with others who can continually help us explore and expand the healthcare education best practice for the next generation of clinicians.

References