Clinical Care Algorithms:

The Good, The Bad,

and The Ugly

R. Matthew Sailors, PhD

UTH Medical School
Department of Surgery

Overview

Modern World / Why Use Algorithms

Types of / Uses for Algorithms
Clinical Care Algorithms
Types, Use, Automation

Good, Bad, and Ugly Algorithms

Algorithm Classification & Examples
Evaluating Algorithms
Writing Good Algorithms

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

Why Do We Use Algorithms?

Share or extend expertise
Training
Disseminate processes / procedures

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

Clinical Care Algorithm

Specifically clinical (patient care)
NOT

Financial
Administrative
Resource allocation

Neutral, high-level term

No biases or preconceptions

Clinical Care Algorithm

Description of a process intended to
guide sequential clinical (therapeutic or
palliative) interventions.
Usually single patient-centric
Time or data-driven
Evidence-based, models, heuristic, WAG

Clinical Care Algorithm

Protocol (I)
Protocol (II)

Care Path(way)

Knowledge Base

Practice

Guideline
Care Plan

Procedure
This is not a hierarchy diagram, just a terminology

Use of Clinical Algorithms

Serve only as guides

Only good inside the design envelope
Professional clinical judgment override

Handle routine situations

Allows experts to concentrate on difficult
cases

Automation of Clinical Algorithms

guide (but not directly provide) therapies

manage information flow
assist in diagnosis and treatment
planning
provide a safety net for the patient for
the times when the inevitable human /
technical / system errors occur.

Automation of Clinical Algorithms

Computers have no native intelligence
Algorithms must be as detailed as
possible
streamline the implementation process
computerized algorithm must represent
what we want to do
not just want we told the computer to do.

Good Algorithms -- Required

1. Concise description

Content and intent of the algorithm

Patient groups to which it can and cannot
be safely applied

2. Structured, repeatable algorithm

textual or graphical form

3. Fully specified concepts

(e.g., high nasogastric tube output is defined

as nasogastric tube output > 1200 cc/12 hr)

Good Algorithms -- Required

4. Fully specified decision points

E.g., PaO2 >= 60 and PaO2 <= 80

5. Fully specified action steps,

Therapeutic interventions suggested by the

algorithm
Calculations to be performed
Patient-specific recommendations

Good Algorithms -- Desired

1. Formal expression language

Describe the decision and action steps

Delineated scope and purpose
Define entry and exclusion criteria

2. Formalism to describe the flow of the

algorithm from one state to the next
3. Encoded links

Didactics
Reference materials
On-line resources

Bad Algorithms
Full of vagaries (weasel words)
optimize patients respiratory status

Fail to adequately describe the decisions

and actions that are required to care for
the patient
Important entry or exclusion criteria and
conditional values missing
Concepts poorly defined
high NG output

Ugly Algorithms

Unstructured / poorly structured algorithm

Algorithm follows no sequential order
Important entry or exclusion criteria appear
at the end of the algorithm or in footnotes
No standard formalism used to describe
algorithm

Algorithm Classifications
Proposal to HL7 Clinical Decision
Support Technical Committee
5 levels
04
Increasing detail with higher classification #

Class 0

Often encoded only in textual form.

Full of vagaries
Fail to adequately describe the decisions and
actions that are required to care for the patient
Actual algorithm
often unstructured or poorly structured
may follow no sequential order

Important entry or exclusion criteria and

conditional values often appear at the end of
the algorithm or in footnotes, if at all.

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

Represented using structured formalism

flow diagrams
formal, structured text (pseudo-code)

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

+/- := may be present

Class 0 AED Algorithm

1.
2.
3.
4.
5.
6.
7.
8.
9.

ABCs, start CPR, apply AED

Push analyze, if indicated defibrillate at 200 J
If no conversion, defibrillate at 300 J
If no conversion, defibrillate at 360 J
Check pulse, if present, support airway
If no pulse, CPR for one minute
Check pulse, if absent press analyze
If advised, defibrillate up to three times at 360 J
Repeat steps 2 thru 8 until arrival at medical facility

Class 0 AED Algorithm (cont.)

Notes:
A. 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.
B. Pulse checks are not required after shocks 1, 2, 4, and 5
unless no shock indicated is displayed
C. Only to be used on pulse-less, non-pediatric patients
D. If advanced personnel are present, they can use the
manual mode
E. Advanced personnel can enter the above algorithm at any
point and continue with appropriate advanced protocol

Class 1 AED Algorithm

Notes:
A. If advanced personnel can use the
manual mode
B. Advanced personnel can enter the
algorithm at any point and continue
with appropriate advanced protocol

Class 1 AED Algorithm (cont.)

1.
2.

3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

If patient has pulse or is a pediatric patient then do not continue with

algorithm. Instead use alternate algorithms for VF
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
Push analyze, if indicated defibrillate at 200 J
If no shock indicated then check pulse
If no conversion, defibrillate at 300 J
If no shock indicated then check pulse
If no conversion, defibrillate at 360 J
Check pulse, if present, support airway
If no pulse, CPR for one minute
Check pulse, if absent press analyze
If advised, defibrillate up to three times at 360 J
Repeat steps 3 thru 11 until arrival at medical facility

Class 2 AED Algorithm

Notes:
A. If advanced personnel can use the
manual mode
B. Advanced personnel can enter the
algorithm at any point and continue
with appropriate advanced protocol

Class 2 AED Algorithm (cont.)

1.

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

Class 3 AED Algorithm

start
yes
no

yes

pt. age > 8 yrs

pulse present?

yes
responsive

no

no

performs ABCs

open airway

no

wait 1-3 minutes

no

yes

# rescuers = 1

yes

initiate CPR

"shock advised" ?

breathing

apply AED and

turn unit on

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

Class 4 AED Algorithm (Part 1)

start

no

yes

pt. age > 8 yrs

check pulse

pulse present?

yes

# rescuers = 1

yes

responsive

no

no

performs ABCs

open airway

initiate CPR

breathing

no

wait 1-3 minutes

no

yes

"shock advised" ?

press "analyze"

apply AED and

turn unit on

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

perform CPR for 1 min.

defib. at 200 J

yes

yes

yes
end

Class 4 AED Algorithm (Part 2)

remove patient clothing
that may interfere with
AED use

AED brand = X ?

turn AED on by lifting monitor

screen to "up" postition

turn AED on by pressing

power switch

clear area for AED and

rescurer on patient's left side?

open first defibrillator pad

place AED close to supine
patient's left ear

place AED close to supine

patient's right ear

rescuer position on patient's

left side

rescuer position on patient's

right side

attach first pad in the anterior position -right (patient's right) of the upper sternum (breast
bone) and below the clavicle (collar bone)

open second defibrillator pad

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)

Critically Evaluating Algorithms

Identify target audience

Experts
Novices
Related fields

Identify intended use

Authors
Yours

Look for well-defined decision and action

targets (no weasel words)
Look for individual-based outputs

Critically Evaluating Algorithms

Look for well-defined decision and action
targets (no weasel words)
Look for individual-based outputs
Use the table to help classify algorithms
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

+/- := may be present

Writing Good Algorithms

Start with general and work to specific
Iterative process

Avoid Gotchas -- later slide

Think like a child (or engineer)
Simple, discrete, decisions

Keep it simple at first

Add complexity as needed

Tips
Simple binary (yes / no) decisions
involving 1 or 2 data points
X < 25
X > 36 or Y <= 18

String together lots of small steps rather

than having one or two big ones
Nest complexities away

Gotchas

Over generalizations
Weasel Words
Being Too Ambitious
Not Understanding Problem Domain
Trying to Solve Wrong Problem
Trying to Use Wrong Techniques

Summary

Algorithms many uses: for good, for bad

Good, bad, and ugly algorithms
Good algorithms share expertise
Algorithm classifications: 0 (low) 4 (high)
Critically evaluate algorithms
Writing good algorithms is about attention
to details