By Suresh Yannamani, president, Exela Technologies.
The emergency room is a place of extreme efficiency. In many ways, this is by necessity and by design. In the ER, there’s often more work to be done than people available to do it. ER staffers aren’t typically working to cure anyone; they’re most likely just trying to keep them alive. Decisions in the ER happen quickly because failure to do so can have lethal consequences.
When faced with a demand for care that far outstrips the supply of doctors and nurses, ER staff use a triage method to establish the order in which medical staff sees patients. People with more minor injuries can afford to wait, but others with very serious conditions must be tended to immediately if they are to survive at all.
The job of processing and ranking patients is primarily left to triage nurses and their application of the Emergency Severity Index, or ESI. The ESI provides a one-to-five scale that nurses use to help quickly prioritize patient needs and distribute medical resources accordingly. This scale helps triage nurses make difficult decisions more quickly and more fairly, but the process still has its limitations.
The pace of work in the ER means that staff must often rely on fast modes of thinking and default heuristics — or generalized, rule-based cognition — as opposed to slow, careful deliberations. This fast thinking tends to be more based on routine or habits of mind, and it’s potentially more prone to certain errors. Although triage and the ESI are intended to objectively rank patients in the order that they need care, the blind spots and biases of ER staff can lead to sub-optimal decisions that adversely impact outcomes and put lives in danger.
Cognitive Errors in the ER
Whenever decisions must be made under conditions of great stress and very limited time, mistakes are likely to occur. This is certainly the case in the ER, where a course of action has to be chosen within seconds and life or death might be on the line. A triage nurse who is forced to make a snap decision might rely on the standard course of action and a simple ESI application. There might be no opportunity to consider the specifics of each case. Instead, the nurse has to use default modes of thinking, and this is where mistakes could be made.
One reasoning error that’s particularly common in the ER is bounded rationality. Given limited information and very limited time, triage nurses are likely to settle on decisions that are “good enough,” rather than attempting to optimize. Essentially, this is to place boundaries on what’s considered relevant and possible and to only focus on the immediate and the obvious.