Cognitive biases in clinical decision-making in prehospital critical care; a scoping review

Abstract

Purpose: Every day, critical care providers in the prehospital setting respond to time sensitive and outcome-critical emergencies, often in unfamiliar environments with little or no prior knowledge about the patient. In these demanding situations, they must make multifactorial clinical decisions that may be critical for the patient's life and future health. Errors in this complex decision-making have identified as a significant cause of patient harm and, consequently, there is increasing research focus upon clinical decision-making and risk mitigation in prehospital critical care. Cognitive biases have been identified as a common cause of these systematic errors in the hospital environment and these studies inspired the aim of this article to map current evidence and investigate, "What cognitive biases affects clinical decision-making in prehospital critical care".

Materials and methods: A scoping review was conducted following Joanna Briggs Institute`s framework, by searching OVID MEDLINE and PubMed, EMBASE, and Cochrane for articles, no restrictions were set for type of article. Articles describing cognitive biases and clinical decision-making in pre-, and in-hospital critical care were included. Additionally, a search in Google scholar was conducted using keywords identified in included articles.

Results: Five hundred unique articles were identified through the search, of which 16 articles examining cognitive biases and clinical decision making in critical care were included, with only two articles focussed exclusively on prehospital critical care. Twenty-eight unique cognitive biases were identified in these articles. The most identified cognitive biases were, anchoring bias, framing effect, availability bias, confirmation bias, overconfidence bias, premature closure, and omission bias. Twelve articles described contributing factors for cognitive biases and these were categorized into 3 main categories. The main categories identified were lack of unbiased feedback, social behaviour and beliefs, and time pressure. Eleven articles proposed mitigation factors, which were categorized into 3 categories, consisting of feedback and follow-up, organizational culture, and education and training.

Conclusions: This scoping review has identified several cognitive biases that affect clinical decision-making, as well as research gaps in both pre- and in-hospital critical care. Identified evidence suggest that both clinicians and organisations are affected by cognitive biases in clinical decision-making in critical care. Future research should aim to establish how these cognitive biases affect clinical decisions in prehospital critical care, and what measures may mitigate the consequent errors, may reduce patient harm, and improve outcomes.

Keywords: Clinical decision-making; Cognitive biases; Critical care; Prehospital; Scoping review.

Fig. 1

Endsley’s situation awareness model [11]

Fig. 2

PRISMA Flow diagram. From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71 [13]

Fig. 3

Identified cognitive biases categorized by level of situation awareness from Endsley`s model [11]