Comment on the MedNav decision support system
Editor – I read with interest the paper by Duffy et al on the MedNav decision support system for helping midwives manage neonatal resuscitation in poor resource settings.1 Unfortunately the clinical flow diagram in Fig 1 contains numerous, serious structural and logical errors some of which are described below.
Although the baby's heart rate is assessed, there is no input of heart rate data into the algorithm.
There is no assessment and input of the baby's muscle tone into the algorithm.
The algorithm will fail to pick up a baby with normal breathing that might need resuscitation if its heart rate is abnormal or its tone is abnormal (ie is floppy) or both.
This algorithm will always decide that that the baby has airway obstruction due to meconium (Fig 1 inset) which is erroneous. I have redesigned this part of the flow diagram to show the correct logic (Fig 1).
In the bottom left-hand corner of the algorithm the diamond-shaped box containing the words ‘If visualisation selected’ followed by the same words in a rectangular box does not make sense. By convention, processes should appear in rectangular boxes and decisions in diamond-shaped boxes.2,3
When the baby's breathing is satisfactory the algorithm will terminate before assessment of the baby's heart rate.
The question ‘HR from >60 to <60 bpm?’ in the diamond-shaped box in the cardiac resuscitation part of the diagram does not make sense so the algorithm will fail here.
The word ‘Done’ appears throughout the flow diagram. Although this word may appear on the computer screen, it is not conventional to show it in the flow chart describing the software.
While I admire the authors’ diligent work on this project, designing complex, time-based, multivariable, clinical flow charts like this one is fraught with difficulties and I have so far identified 20 different types of error in this mode of graphical communication.4 I hope that the flow diagram in the original paper is a poor representation of the actual data flow and logic in the production software for the sake of patient safety.
Conflicts of interest
The author has no conflict of interest to declare.
- © Royal College of Physicians 2018. All rights reserved.
References
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- Duffy S
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- Colman A
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- Colman A
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