Clinical guideline redesign
By: Joel Thomas Ballard
Tags: Information Architecture, Ambulance, UX, Healthcare, Medicine

This post reviews a real emergency ambulance clinical practice guideline to treat diving-related medical conditions.

The overall purpose is to demonstrate a new guideline design process that can be applied to any clinical document, and therefore, the specific content here can be overlooked.

Analysis

Good stuff

Precise instruction

Technical accuracy

Plenty of useful & relevant content — pathophysiology, clinical rationale, management tips

Stuff that is holding it back

Long and un-descriptive name

Special Notes / General Care section: jumbled + word heavy + insufficient structure for the volume of information present means it is very difficult for the reader to orient themselves or find information quickly (rapid referencing being an essential feature in clinical resources).

Some key pieces of information hidden away here that probably qualify for inclusion in the flowchart

We need to be careful that these information boxes aren’t used to “dump” large quantities of information where there may be more appropriate places

Instruction to perform standard assessments (PSA, RSA, GCS) is probably not required and is taking up precious visual space

Flowchart branches — it isn’t immediately clear what they are trying to tell us — What does stable and unstable mean in terms of the specific conditions we’re worried about?

More clarity regarding decision-making: The flowchart uses GCS alone to determine pathway, however hidden notes state LOC or seizure are just as relevant

Redundancy: “GCS < 15” and right under it, “altered conscious state”.

17 treatment steps is way too much to expect clinicians to recall without a supporting structure. There’s a lot going on here and it’s not clear what’s important and what is less important. We need to bear in mind what we know about the human mind’s limited ability to hold information in working memory when writing these instructions.

Some of the dot points are just instructions to go and look at other dot points. This can be communicated through layout instead.

Confusing order of tasks: potentially we’re placing an IV to give antiemetics before considering high-flow O2, for example. In case parts of the guideline are forgotten in any given episode of care, we need to ensure our highest priority items are first to maximise the chance they are performed.

And finally there is 1 possible technical error here — ambiguity whether the “Perfusion” box can be considered in the asymptomatic patient (for which there is no flowchart arm)

Proposal

The below guideline is not approved for use

This guideline concept has been produced without any loss of information. In other words, the function performed by each Special Notes / General Care item has been preserved.

Title

My understanding is that this guideline is generally treating one condition: Decompression Illness (DCI), and another condition which is a subset of DCI (CAGE).

This is the name I have chosen to give more meaning to the original title but another name similarly descriptive could also be used

It’s important for paramedics to have the right words to describe and understand the patient they are treating

Structure

The order of our information must follow real practice and real clinician psychology.

That means flowing from broad (orienting) information to specific (instructional) information.

What are we treating? What are the priorities and why? List the treatments in order Other information

A lot of variation in practice comes from guidelines that can be interpreted in many different ways — that means we also need to be very explicit in our writing.

The logical origin for a guideline is the condition treated — this may require a small amount of pathophysiology information and signs / symptoms to ensure the guideline is used for its intended purpose The primary condition treated is centred and its entire flow is in one straight line In this case there is a secondary condition that has some special information but is largely managed the same as the primary — thus there is an offshoot which rejoins the primary flow at the logical place These structures will change depending on the thinking behind the specific guideline Care Objectives outline priorities and rationale for quick orientation and easy review Important treatment information is in green, less important supplementary information is in grey

Any other information that was not important enough to be listed as a part of the preceding structures is briefly stated in Further Notes

Any other information that is not relevant or important is deleted or moved to a more appropriate location e.g. supplementary learning materials or work instructions. There is absolutely no room in any guideline for anything that does not need to be there.

Start with the condition(s)

Clear labelling of condition name as box heading

Improves ability to find information

Brief relevant description of condition and signs / symptoms leaves absolutely no room for confusion. This provides a greater degree of control over how the guideline is used as the writers can communicate their intention very easily and clearly.

Descriptive headings provide an understandable structure to the guideline and a name to what is happening to the patient

Outline what you most want your paramedics to get right

The human mind can only hold a small number of pieces of information in working memory at once. We need to design our guidelines to work with this fact to achieve the desired outcome.

Therefore, it is imperative to spell out the absolute priorities for the patient type. The fewer the better.

Humans are also less likely to perform a task if they don’t understand why it is important

Therefore, the CPG needs to — in the briefest terms — provide rationale for every action

Only then, detail the treatments

Again, descriptive headings actually show you how these three “Action” boxes differ — and help you “wayfind” to the appropriate section without reading the content of each box

Separating by management type also helps to compartmentalise treatments in the paramedic’s mind and allows them to mentally “step” through the guideline more easily from memory

Grey supplementary information boxes provide a location for “special notes” that apply directly to that section. There is no need to refer elsewhere.

And save supporting information for LAST

Even after all important information from Special Notes / General Care has been inserted into its correct location in the above guideline structure, there will always be some supplementary information remaining.

If it is determined that it is important enough to remain in the guideline, but not important enough to exist in any other part of the guideline, then it can be placed under a final information box.

Although it can seem like an extra task to perform, we must always weigh the value of every single element of our guidelines, and create our designs accordingly — to assign too many equal importance is to remove the emphasis that important treatment priorities and helpful learning structures require to be effective

This might not be right yet

This is not the perfect clinical guideline.

There will be ways that we can advance these concepts to provide us even better, easier, clearer and safer guidelines.

What matters is that we begin moving along a path such as this — writing and designing with consciousness and intention — using psychology and design alongside our clinical knowledge to correctly diagnose and solve our problems at their point of origin.

Instead of treating the symptoms of our problems, let’s commit to a definitive solution.