@saibolla/ada 0.1.2

package/skills/clinical-decision-support/references/clinical_decision_algorithms.md

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+# Clinical Decision Algorithms Guide
+
+## Overview
+
+Clinical decision algorithms provide systematic, step-by-step guidance for diagnosis, treatment selection, and patient management. This guide covers algorithm development, validation, and visual presentation using decision trees and flowcharts.
+
+## Algorithm Design Principles
+
+### Key Components
+
+**Decision Nodes**
+- **Question/Criteria**: Clear, measurable clinical parameter
+- **Binary vs Multi-Way**: Yes/no (simple) vs multiple options (complex)
+- **Objective**: Lab value, imaging finding vs Subjective: Clinical judgment
+
+**Action Nodes**
+- **Treatment**: Specific intervention with dosing
+- **Test**: Additional diagnostic procedure
+- **Referral**: Specialist consultation, higher level of care
+- **Observation**: Watchful waiting with defined follow-up
+
+**Terminal Nodes**
+- **Outcome**: Final decision point
+- **Follow-up**: Schedule for reassessment
+- **Exit criteria**: When to exit algorithm
+
+### Design Criteria
+
+**Clarity**
+- Unambiguous decision points
+- Mutually exclusive pathways
+- No circular loops (unless intentional reassessment cycles)
+- Clear entry and exit points
+
+**Clinical Validity**
+- Evidence-based decision criteria
+- Validated cut-points for biomarkers
+- Guideline-concordant recommendations
+- Expert consensus where evidence limited
+
+**Usability**
+- Maximum 7 decision points per pathway (cognitive load)
+- Visual hierarchy (most common path highlighted)
+- Printable single-page format preferred
+- Color coding for urgency/safety
+
+**Completeness**
+- All possible scenarios covered
+- Default pathway for edge cases
+- Safety-net provisions for unusual presentations
+- Escalation criteria clearly stated
+
+## Clinical Decision Trees
+
+### Diagnostic Algorithms
+
+**Chest Pain Evaluation Algorithm**
+
+```
+Entry: Patient with chest pain
+
+├─ STEMI Criteria? (ST elevation ≥1mm in ≥2 contiguous leads)
+│  ├─ YES → Activate cath lab, aspirin 325mg, heparin, clopidogrel 600mg
+│  │        Transfer for primary PCI (goal door-to-balloon <90 minutes)
+│  └─ NO → Continue evaluation
+
+├─ High-Risk Features? (Hemodynamic instability, arrhythmia, troponin elevation)
+│  ├─ YES → Admit CCU, serial troponins, cardiology consultation
+│  │        Consider early angiography if NSTEMI
+│  └─ NO → Calculate TIMI or HEART score
+
+├─ TIMI Score 0-1 or HEART Score 0-3? (Low risk)
+│  ├─ YES → Observe 6-12 hours, serial troponins, stress test if negative
+│  │        Discharge if all negative with cardiology follow-up in 72 hours
+│  └─ NO → TIMI 2-4 or HEART 4-6 (Intermediate risk)
+
+├─ TIMI Score 2-4 or HEART Score 4-6? (Intermediate risk)
+│  ├─ YES → Admit telemetry, serial troponins, stress imaging vs CT angiography
+│  │        Medical management: Aspirin, statin, beta-blocker
+│  └─ NO → TIMI ≥5 or HEART ≥7 (High risk) → Treat as NSTEMI
+
+Decision Endpoint: Risk-stratified pathway with 30-day event rate documented
+```
+
+**Pulmonary Embolism Diagnostic Algorithm (Wells Criteria)**
+
+```
+Entry: Suspected PE
+
+Step 1: Calculate Wells Score
+  Clinical features points:
+  - Clinical signs of DVT: 3 points
+  - PE more likely than alternative diagnosis: 3 points  
+  - Heart rate >100: 1.5 points
+  - Immobilization/surgery in past 4 weeks: 1.5 points
+  - Previous PE/DVT: 1.5 points
+  - Hemoptysis: 1 point
+  - Malignancy: 1 point
+
+Step 2: Risk Stratify
+  ├─ Wells Score ≤4 (PE unlikely)
+  │  └─ D-dimer test
+  │     ├─ D-dimer negative (<500 ng/mL) → PE excluded, consider alternative diagnosis
+  │     └─ D-dimer positive (≥500 ng/mL) → CTPA
+  │
+  └─ Wells Score >4 (PE likely)
+     └─ CTPA (skip D-dimer)
+
+Step 3: CTPA Results
+  ├─ Positive for PE → Risk stratify severity
+  │  ├─ Massive PE (hypotension, shock) → Thrombolytics vs embolectomy
+  │  ├─ Submassive PE (RV strain, troponin+) → Admit ICU, consider thrombolytics
+  │  └─ Low-risk PE → Anticoagulation, consider outpatient management
+  │
+  └─ Negative for PE → PE excluded, investigate alternative diagnosis
+
+Step 4: Treatment Decision (if PE confirmed)
+  ├─ Absolute contraindication to anticoagulation?
+  │  ├─ YES → IVC filter placement, treat underlying condition
+  │  └─ NO → Anticoagulation therapy
+  │
+  ├─ Cancer-associated thrombosis?
+  │  ├─ YES → LMWH preferred (edoxaban alternative)
+  │  └─ NO → DOAC preferred (apixaban, rivaroxaban, edoxaban)
+  │
+  └─ Duration: Minimum 3 months, extended if unprovoked or recurrent
+```
+
+### Treatment Selection Algorithms
+
+**NSCLC First-Line Treatment Algorithm**
+
+```
+Entry: Advanced/Metastatic NSCLC, adequate PS (ECOG 0-2)
+
+Step 1: Biomarker Testing Complete?
+  ├─ NO → Reflex testing: EGFR, ALK, ROS1, BRAF, PD-L1, consider NGS
+  │       Hold systemic therapy pending results (unless rapidly progressive)
+  └─ YES → Proceed to Step 2
+
+Step 2: Actionable Genomic Alteration?
+  ├─ EGFR exon 19 deletion or L858R → Osimertinib 80mg daily
+  │  └─ Alternative: Erlotinib, gefitinib, afatinib (less preferred)
+  │
+  ├─ ALK rearrangement → Alectinib 600mg BID
+  │  └─ Alternatives: Brigatinib, lorlatinib, crizotinib (less preferred)
+  │
+  ├─ ROS1 rearrangement → Crizotinib 250mg BID or entrectinib
+  │
+  ├─ BRAF V600E → Dabrafenib + trametinib
+  │
+  ├─ MET exon 14 skipping → Capmatinib or tepotinib
+  │
+  ├─ RET rearrangement → Selpercatinib or pralsetinib
+  │
+  ├─ NTRK fusion → Larotrectinib or entrectinib
+  │
+  ├─ KRAS G12C → Sotorasib or adagrasib (if no other options)
+  │
+  └─ NO actionable alteration → Proceed to Step 3
+
+Step 3: PD-L1 Testing Result?
+  ├─ PD-L1 ≥50% (TPS)
+  │  ├─ Option 1: Pembrolizumab 200mg Q3W (monotherapy, NCCN Category 1)
+  │  ├─ Option 2: Pembrolizumab + platinum doublet chemotherapy
+  │  └─ Option 3: Atezolizumab + bevacizumab + carboplatin + paclitaxel
+  │
+  ├─ PD-L1 1-49% (TPS)
+  │  ├─ Preferred: Pembrolizumab + platinum doublet chemotherapy
+  │  └─ Alternative: Platinum doublet chemotherapy alone
+  │
+  └─ PD-L1 <1% (TPS)
+     ├─ Preferred: Pembrolizumab + platinum doublet chemotherapy
+     └─ Alternative: Platinum doublet chemotherapy ± bevacizumab
+
+Step 4: Platinum Doublet Selection (if applicable)
+  ├─ Squamous histology
+  │  └─ Carboplatin AUC 6 + paclitaxel 200 mg/m² Q3W (4 cycles)
+  │      or Carboplatin AUC 5 + nab-paclitaxel 100 mg/m² D1,8,15 Q4W
+  │
+  └─ Non-squamous histology  
+     └─ Carboplatin AUC 6 + pemetrexed 500 mg/m² Q3W (4 cycles)
+         Continue pemetrexed maintenance if responding
+         Add bevacizumab 15 mg/kg if eligible (no hemoptysis, brain mets)
+
+Step 5: Monitoring and Response Assessment
+  - Imaging every 6 weeks for first 12 weeks, then every 9 weeks
+  - Continue until progression or unacceptable toxicity
+  - At progression, proceed to second-line algorithm
+```
+
+**Heart Failure Management Algorithm (AHA/ACC Guidelines)**
+
+```
+Entry: Heart Failure Diagnosis Confirmed
+
+Step 1: Determine HF Type
+  ├─ HFrEF (EF ≤40%)
+  │  └─ Proceed to Guideline-Directed Medical Therapy (GDMT)
+  │
+  ├─ HFpEF (EF ≥50%)
+  │  └─ Treat comorbidities, diuretics for congestion, consider SGLT2i
+  │
+  └─ HFmrEF (EF 41-49%)
+     └─ Consider HFrEF GDMT, evidence less robust
+
+Step 2: GDMT for HFrEF (All patients unless contraindicated)
+
+Quadruple Therapy (Class 1 recommendations):
+
+1. ACE Inhibitor/ARB/ARNI
+   ├─ Preferred: Sacubitril-valsartan 49/51mg BID → titrate to 97/103mg BID
+   │  └─ If ACE-I naïve or taking <10mg enalapril equivalent
+   ├─ Alternative: ACE-I (enalapril, lisinopril, ramipril) to target dose
+   └─ Alternative: ARB (losartan, valsartan) if ACE-I intolerant
+
+2. Beta-Blocker (start low, titrate slowly)
+   ├─ Bisoprolol 1.25mg daily → 10mg daily target
+   ├─ Metoprolol succinate 12.5mg daily → 200mg daily target
+   └─ Carvedilol 3.125mg BID → 25mg BID target (50mg BID if >85kg)
+
+3. Mineralocorticoid Receptor Antagonist (MRA)
+   ├─ Spironolactone 12.5-25mg daily → 50mg daily target
+   └─ Eplerenone 25mg daily → 50mg daily target
+   └─ Contraindications: K >5.0, CrCl <30 mL/min
+
+4. SGLT2 Inhibitor (regardless of diabetes status)
+   ├─ Dapagliflozin 10mg daily
+   └─ Empagliflozin 10mg daily
+
+Step 3: Additional Therapies Based on Phenotype
+
+├─ Sinus rhythm + HR ≥70 despite beta-blocker?
+│  └─ YES: Add ivabradine 5mg BID → 7.5mg BID target
+│
+├─ African American + NYHA III-IV?
+│  └─ YES: Add hydralazine 37.5mg TID + isosorbide dinitrate 20mg TID
+│           (Target: hydralazine 75mg TID + ISDN 40mg TID)
+│
+├─ Atrial fibrillation?
+│  ├─ Rate control (target <80 bpm at rest, <110 bpm with activity)
+│  └─ Anticoagulation (DOAC preferred, warfarin if valvular)
+│
+└─ Iron deficiency (ferritin <100 or <300 with TSAT <20%)?
+   └─ YES: IV iron supplementation (ferric carboxymaltose)
+
+Step 4: Device Therapy Evaluation
+
+├─ EF ≤35%, NYHA II-III, LBBB with QRS ≥150 ms, sinus rhythm?
+│  └─ YES: Cardiac resynchronization therapy (CRT-D)
+│
+├─ EF ≤35%, NYHA II-III, on GDMT ≥3 months?
+│  └─ YES: ICD for primary prevention
+│           (if life expectancy >1 year with good functional status)
+│
+└─ EF ≤35%, NYHA IV despite GDMT, or advanced HF?
+   └─ Refer to advanced HF specialist
+      ├─ LVAD evaluation
+      ├─ Heart transplant evaluation
+      └─ Palliative care consultation
+
+Step 5: Monitoring and Titration
+
+Weekly to biweekly visits during titration:
+- Blood pressure (target SBP ≥90 mmHg)
+- Heart rate (target 50-60 bpm)
+- Potassium (target 4.0-5.0 mEq/L, hold MRA if >5.5)
+- Creatinine (expect 10-20% increase, acceptable if <30% and stable)
+- Symptoms and congestion status (daily weights, NYHA class)
+
+Stable on GDMT:
+- Visits every 3-6 months
+- Echocardiogram at 3-6 months after GDMT optimization, then annually
+- NT-proBNP or BNP trending (biomarker-guided therapy investigational)
+```
+
+## Risk Stratification Tools
+
+### Cardiovascular Risk Scores
+
+**TIMI Risk Score (NSTEMI/Unstable Angina)**
+
+```
+Score Calculation (0-7 points):
+☐ Age ≥65 years (1 point)
+☐ ≥3 cardiac risk factors (HTN, hyperlipidemia, diabetes, smoking, family history) (1)
+☐ Known CAD (stenosis ≥50%) (1)
+☐ ASA use in past 7 days (1)
+☐ Severe angina (≥2 episodes in 24 hours) (1)
+☐ ST deviation ≥0.5 mm (1)
+☐ Elevated cardiac biomarkers (1)
+
+Risk Stratification:
+├─ Score 0-1: 5% risk of death/MI/urgent revasc at 14 days (Low)
+│  └─ Management: Observation, stress test, outpatient follow-up
+│
+├─ Score 2: 8% risk (Low-intermediate)
+│  └─ Management: Admission, medical therapy, stress imaging
+│
+├─ Score 3-4: 13-20% risk (Intermediate-high)
+│  └─ Management: Admission, aggressive medical therapy, early invasive strategy
+│
+└─ Score 5-7: 26-41% risk (High)
+   └─ Management: Aggressive treatment, urgent angiography (<24 hours)
+```
+
+**CHA2DS2-VASc Score (Stroke Risk in Atrial Fibrillation)**
+
+```
+Score Calculation:
+☐ Congestive heart failure (1 point)
+☐ Hypertension (1)
+☐ Age ≥75 years (2)
+☐ Diabetes mellitus (1)
+☐ Prior stroke/TIA/thromboembolism (2)
+☐ Vascular disease (MI, PAD, aortic plaque) (1)
+☐ Age 65-74 years (1)
+☐ Sex category (female) (1)
+
+Maximum score: 9 points
+
+Treatment Algorithm:
+├─ Score 0 (male) or 1 (female): 0-1.3% annual stroke risk
+│  └─ No anticoagulation or aspirin (Class IIb)
+│
+├─ Score 1 (male): 1.3% annual stroke risk
+│  └─ Consider anticoagulation (Class IIa)
+│      Factors: Patient preference, bleeding risk, comorbidities
+│
+└─ Score ≥2 (male) or ≥3 (female): ≥2.2% annual stroke risk
+   └─ Anticoagulation recommended (Class I)
+      ├─ Preferred: DOAC (apixaban, rivaroxaban, edoxaban, dabigatran)
+      └─ Alternative: Warfarin (INR 2-3) if DOAC contraindicated
+
+Bleeding Risk Assessment (HAS-BLED):
+H - Hypertension (SBP >160)
+A - Abnormal renal/liver function (1 point each)
+S - Stroke history
+B - Bleeding history or predisposition
+L - Labile INR (if on warfarin)
+E - Elderly (age >65)
+D - Drugs (antiplatelet, NSAIDs) or alcohol (1 point each)
+
+HAS-BLED ≥3: High bleeding risk → Modifiable factors, consider DOAC over warfarin
+```
+
+### Oncology Risk Calculators
+
+**MELD Score (Hepatocellular Carcinoma Eligibility)**
+
+```
+MELD = 3.78×ln(bilirubin mg/dL) + 11.2×ln(INR) + 9.57×ln(creatinine mg/dL) + 6.43
+
+Interpretation:
+├─ MELD <10: 1.9% 3-month mortality (Low)
+│  └─ Consider resection or ablation for HCC
+│
+├─ MELD 10-19: 6-20% 3-month mortality (Moderate)
+│  └─ Transplant evaluation if within Milan criteria
+│      Milan: Single ≤5cm or ≤3 lesions each ≤3cm, no vascular invasion
+│
+├─ MELD 20-29: 20-45% 3-month mortality (High)
+│  └─ Urgent transplant evaluation, bridge therapy (TACE, ablation)
+│
+└─ MELD ≥30: 50-70% 3-month mortality (Very high)
+   └─ Transplant vs palliative care discussion
+      Too ill for transplant if MELD >35-40 typically
+```
+
+**Adjuvant! Online (Breast Cancer Recurrence Risk)**
+
+```
+Input Variables:
+- Age at diagnosis
+- Tumor size
+- Tumor grade (1-3)
+- ER status
+- Node status (0, 1-3, 4-9, ≥10)
+- HER2 status
+- Comorbidity index
+
+Output: 10-year risk of:
+- Recurrence
+- Breast cancer mortality
+- Overall mortality
+
+Treatment Benefit Estimates:
+- Chemotherapy: Absolute reduction in recurrence
+- Endocrine therapy: Absolute reduction in recurrence
+- Trastuzumab: Absolute reduction (if HER2+)
+
+Clinical Application:
+├─ Low risk (<10% recurrence): Consider endocrine therapy alone if ER+
+├─ Intermediate risk (10-20%): Chemotherapy discussion, genomic assay
+│  └─ Oncotype DX score <26: Endocrine therapy alone
+│  └─ Oncotype DX score ≥26: Chemotherapy + endocrine therapy
+└─ High risk (>20%): Chemotherapy + endocrine therapy if ER+
+```
+
+## TikZ Flowchart Best Practices
+
+### Visual Design Principles
+
+**Node Styling**
+```latex
+% Decision nodes (diamond)
+\tikzstyle{decision} = [diamond, draw, fill=yellow!20, text width=4.5em, text centered, inner sep=0pt]
+
+% Process nodes (rectangle)
+\tikzstyle{process} = [rectangle, draw, fill=blue!20, text width=5em, text centered, rounded corners, minimum height=3em]
+
+% Terminal nodes (rounded rectangle)
+\tikzstyle{terminal} = [rectangle, draw, fill=green!20, text width=5em, text centered, rounded corners=1em, minimum height=3em]
+
+% Input/Output (parallelogram)
+\tikzstyle{io} = [trapezium, draw, fill=purple!20, text width=5em, text centered, minimum height=3em]
+```
+
+**Color Coding by Urgency**
+- **Red**: Life-threatening, immediate action required
+- **Orange**: Urgent, action within hours
+- **Yellow**: Semi-urgent, action within 24-48 hours
+- **Green**: Routine, stable clinical situation
+- **Blue**: Informational, monitoring only
+
+**Pathway Emphasis**
+- Bold arrows for most common pathway
+- Dashed arrows for rare scenarios
+- Arrow thickness proportional to pathway frequency
+- Highlight boxes around critical decision points
+
+### LaTeX TikZ Template
+
+```latex
+\documentclass{article}
+\usepackage{tikz}
+\usetikzlibrary{shapes, arrows, positioning}
+
+\begin{document}
+
+\tikzstyle{decision} = [diamond, draw, fill=yellow!20, text width=4em, text centered, inner sep=2pt, font=\small]
+\tikzstyle{process} = [rectangle, draw, fill=blue!20, text width=6em, text centered, rounded corners, minimum height=2.5em, font=\small]
+\tikzstyle{terminal} = [rectangle, draw, fill=green!20, text width=6em, text centered, rounded corners=8pt, minimum height=2.5em, font=\small]
+\tikzstyle{alert} = [rectangle, draw=red, line width=1.5pt, fill=red!10, text width=6em, text centered, rounded corners, minimum height=2.5em, font=\small\bfseries]
+\tikzstyle{arrow} = [thick,->,>=stealth]
+
+\begin{tikzpicture}[node distance=2cm, auto]
+    % Nodes
+    \node [terminal] (start) {Patient presents with symptom X};
+    \node [decision, below of=start] (decision1) {Criterion A met?};
+    \node [alert, below of=decision1, node distance=2.5cm] (alert1) {Immediate action};
+    \node [process, right of=decision1, node distance=4cm] (process1) {Standard evaluation};
+    \node [terminal, below of=process1, node distance=2.5cm] (end) {Outcome};
+    
+    % Arrows
+    \draw [arrow] (start) -- (decision1);
+    \draw [arrow] (decision1) -- node {Yes} (alert1);
+    \draw [arrow] (decision1) -- node {No} (process1);
+    \draw [arrow] (process1) -- (end);
+    \draw [arrow] (alert1) -| (end);
+\end{tikzpicture}
+
+\end{document}
+```
+
+## Algorithm Validation
+
+### Development Process
+
+**Step 1: Literature Review and Evidence Synthesis**
+- Systematic review of guidelines (NCCN, ASCO, ESMO, AHA/ACC)
+- Meta-analyses of clinical trials
+- Expert consensus statements
+- Local practice patterns and resource availability
+
+**Step 2: Draft Algorithm Development**
+- Multidisciplinary team input (physicians, nurses, pharmacists)
+- Define decision nodes and criteria
+- Specify actions and outcomes
+- Identify areas of uncertainty
+
+**Step 3: Pilot Testing**
+- Retrospective application to historical cases (n=20-50)
+- Identify scenarios not covered by algorithm
+- Refine decision criteria
+- Usability testing with end-users
+
+**Step 4: Prospective Validation**
+- Implement in clinical practice with data collection
+- Track adherence rate (target >80%)
+- Monitor outcomes vs historical controls
+- User satisfaction surveys
+
+**Step 5: Continuous Quality Improvement**
+- Quarterly review of algorithm performance
+- Update based on new evidence
+- Address deviations and reasons for non-adherence
+- Version control and change documentation
+
+### Performance Metrics
+
+**Process Metrics**
+- Algorithm adherence rate (% cases following algorithm)
+- Time to decision (median time from presentation to treatment start)
+- Completion rate (% cases reaching terminal node)
+
+**Outcome Metrics**
+- Appropriateness of care (concordance with guidelines)
+- Clinical outcomes (mortality, morbidity, readmissions)
+- Resource utilization (length of stay, unnecessary tests)
+- Safety (adverse events, errors)
+
+**User Experience Metrics**
+- Ease of use (Likert scale survey)
+- Time to use (median time to navigate algorithm)
+- Perceived utility (% users reporting algorithm helpful)
+- Barriers to use (qualitative feedback)
+
+## Implementation Strategies
+
+### Integration into Clinical Workflow
+
+**Electronic Health Record Integration**
+- Clinical decision support (CDS) alerts at key decision points
+- Order sets linked to algorithm pathways
+- Auto-population of risk scores from EHR data
+- Documentation templates following algorithm structure
+
+**Point-of-Care Tools**
+- Pocket cards for quick reference
+- Mobile apps with interactive algorithms
+- Wall posters in clinical areas
+- QR codes linking to full algorithm
+
+**Education and Training**
+- Didactic presentation of algorithm rationale
+- Case-based exercises
+- Simulation scenarios
+- Audit and feedback on adherence
+
+### Overcoming Barriers
+
+**Common Barriers**
+- Algorithm complexity (too many decision points)
+- Lack of awareness (not disseminated effectively)
+- Disagreement with recommendations (perceived as cookbook medicine)
+- Competing priorities (time pressure, multiple patients)
+- Resource limitations (recommended tests/treatments not available)
+
+**Mitigation Strategies**
+- Simplify algorithms (≤7 decision points per pathway preferred)
+- Champion network (local opinion leaders promoting algorithm)
+- Customize to local context (allow flexibility for clinical judgment)
+- Measure and report outcomes (demonstrate value)
+- Provide resources (ensure algorithm-recommended options available)
+
+## Algorithm Maintenance and Updates
+
+### Version Control
+
+**Change Log Documentation**
+```
+Algorithm: NSCLC First-Line Treatment
+Version: 3.2
+Effective Date: January 1, 2024
+Previous Version: 3.1 (effective July 1, 2023)
+
+Changes in Version 3.2:
+1. Added KRAS G12C-mutated pathway (sotorasib, adagrasib)
+   - Evidence: FDA approval May 2021/2022
+   - Guideline: NCCN v4.2023
+
+2. Updated PD-L1 ≥50% recommendation to include pembrolizumab monotherapy as Option 1
+   - Evidence: KEYNOTE-024 5-year follow-up
+   - Guideline: NCCN Category 1 preferred
+
+3. Removed crizotinib as preferred ALK inhibitor, moved to alternative
+   - Evidence: ALEX, CROWN trials showing superiority of alectinib, lorlatinib
+   - Guideline: NCCN/ESMO Category 1 for alectinib as first-line
+
+Reviewed by: Thoracic Oncology Committee
+Approved by: Dr. [Name], Medical Director
+Next Review Date: July 1, 2024
+```
+
+### Trigger for Updates
+
+**Mandatory Updates (Within 3 Months)**
+- FDA approval of new drug for algorithm indication
+- Guideline change (NCCN, ASCO, ESMO Category 1 recommendation)
+- Safety alert or black box warning added to recommended agent
+- Major clinical trial results changing standard of care
+
+**Routine Updates (Annually)**
+- Minor evidence updates
+- Optimization based on local performance data
+- Formatting or usability improvements
+- Addition of new clinical scenarios encountered
+
+**Emergency Updates (Within 1 Week)**
+- Drug shortage requiring alternative pathways
+- Drug recall or safety withdrawal
+- Outbreak or pandemic requiring modified protocols
+