Marc A. Probst

A conceptual model of emergency physician decision making for head computed tomography in mild head injury.

The use of computed tomographic scanning in blunt head trauma has increased dramatically in recent years without an accompanying rise in the prevalence of injury or hospital admission for serious conditions. Because computed tomography is neither harmless nor inexpensive, researchers have attempted to optimize utilization, largely through research that describes which clinical variables predict intracranial injury, and use this information to develop clinical decision instruments. Although such techniques may be useful when the benefits and harms of each strategy (neuroimaging vs observation) are quantifiable and amenable to comparison, the exact magnitude of these benefits and harms remains unknown in this clinical scenario. We believe that most clinical decision instrument development efforts are misguided insofar as they ignore critical, nonclinical factors influencing the decision to image. In this article, we propose a conceptual model to illustrate how clinical and nonclinical factors influence emergency physicians making this decision. We posit that elements unrelated to standard clinical factors, such as personality of the physician, fear of litigation and of missed diagnoses, patient expectations, and compensation method, may have equal or greater impact on actual decision making than traditional clinical factors. We believe that 3 particular factors deserve special consideration for further research: fear of error/malpractice, financial incentives, and patient engagement. Acknowledgement and study of these factors will be essential if we are to understand how emergency physicians truly make these decisions and how test-ordering behavior can be modified.

Perceived Appropriateness of Shared Decision-making in the Emergency Department: A Survey Study

OBJECTIVES The objective was to describe perceptions of practicing emergency physicians (EPs) regarding the appropriateness and medicolegal implications of using shared decision-making (SDM) in the emergency department (ED). METHODS We conducted a cross-sectional survey of EPs at a large, national professional meeting to assess perceived appropriateness of SDM for different categories of ED management (e.g., diagnostic testing, treatment, disposition) and in common clinical scenarios (e.g., low-risk chest pain, syncope, minor head injury). A 21-item survey instrument was iteratively developed through review by content experts, cognitive testing, and pilot testing. Descriptive and multivariate analyses were conducted. RESULTS We approached 737 EPs; 709 (96%) completed the survey. Two-thirds (67.8%) of respondents were male; 51% practiced in an academic setting and 44% in the community. Of the seven management decision categories presented, SDM was reported to be most frequently appropriate for deciding on invasive procedures (71.5%), computed tomography (CT) scanning (56.7%), and post-ED disposition (56.3%). Among the specific clinical scenarios, use of thrombolytics for acute ischemic stroke was felt to be most frequently appropriate for SDM (83.4%), followed by lumbar puncture to rule out subarachnoid hemorrhage (73.8%) and CT head for pediatric minor head injury (69.9%). Most EPs (66.8%) felt that using and documenting SDM would decrease their medicolegal risk while a minority (14.2%) felt that it would increase their risk. CONCLUSIONS Acceptance of SDM among EPs appears to be strong across management categories (diagnostic testing, treatment, and disposition) and in a variety of clinical scenarios. SDM is perceived by most EPs to be medicolegally protective.

Shared Decisionmaking in the Emergency Department: A Guiding Framework for Clinicians

&NA; Shared decisionmaking has been proposed as a method to promote active engagement of patients in emergency care decisions. Despite the recent attention shared decisionmaking has received in the emergency medicine community, including being the topic of the 2016 Academic Emergency Medicine Consensus Conference, misconceptions remain in regard to the precise meaning of the term, the process, and the conditions under which it is most likely to be valuable. With the help of a patient representative and an interaction designer, we developed a simple framework to illustrate how shared decisionmaking should be approached in clinical practice. We believe it should be the preferred or default approach to decisionmaking, except in clinical situations in which 3 factors interfere. These 3 factors are lack of clinical uncertainty or equipoise, patient decisionmaking ability, and time, all of which can render shared decisionmaking infeasible. Clinical equipoise refers to scenarios in which there are 2 or more medically reasonable management options. Patient decisionmaking ability refers to a patient’s capacity and willingness to participate in his or her emergency care decisions. Time refers to the acuity of the clinical situation (which may require immediate action) and the time that the clinician has to devote to the shared decisionmaking conversation. In scenarios in which there is only one medically reasonable management option, informed consent is indicated, with compassionate persuasion used as appropriate. If time or patient capacity is lacking, physician‐directed decisionmaking will occur. With this framework as the foundation, we discuss the process of shared decisionmaking and how it can be used in practice. Finally, we highlight 5 common misconceptions in regard to shared decisionmaking in the ED. With an improved understanding of shared decisionmaking, this approach should be used to facilitate the provision of high‐quality, patient‐centered emergency care.

The association between advanced diagnostic imaging and ED length of stay.

OBJECTIVE There has been a rise in advanced diagnostic imaging (ADI) use in the emergency department (ED). Increased utilization may contribute to longer length of stay (LOS), but prior reports have not considered improved methods for modeling skewed LOS data. METHODS The 2010 National Hospital Ambulatory Medical Care Survey data were analyzed by 5 common ED chief complaints. Generalized linear model (GLM) was compared to quantile and ordinary least squares (OLS) regression to evaluate the association between ADI and ED LOS. Receipt of computed tomography or magnetic resonance imaging was the primary exposure. Emergency department LOS was the primary outcome. RESULTS Of the 33,685 ED visits analyzed, 17% involved ADI. The median LOS for patients without ADI was 138 minutes compared to 252 minutes for those who received ADI. Overall, GLM offered the most unbiased estimates, although it provided similar adjusted point estimates to OLS for the marginal change in LOS associated with ADI. The effect of imaging differed by LOS quantile, especially for patients with abdominal pain, fever, and back symptoms. CONCLUSIONS Generalized linear model offered an improved modeling approach compared to OLS and quantile regression. Consideration of such techniques may facilitate a more complete view of the effect of ADI on ED LOS.

Diagnostic Accuracy of Venous Blood Gas Electrolytes for Identifying Diabetic Ketoacidosis in the Emergency Department

OBJECTIVES Diagnosing diabetic ketoacidosis (DKA) has traditionally required a venous blood gas (VBG) to obtain serum pH and a serum chemistry panel to obtain electrolyte values. Because newer blood gas analyzers have the ability to report electrolyte values and glucose in addition to pH, this diagnostic process could theoretically be condensed. However, neither the diagnostic accuracy of the VBG for DKA nor the agreement between the VBG electrolytes and the serum chemistry electrolytes, including sodium, chloride, and bicarbonate, has been evaluated in the context of acute hyperglycemia. The purpose of this study was to assess the accuracy of VBG electrolytes for diagnosing DKA using serum chemistry electrolytes measures as the criterion standard and to describe the correlation between VBG and serum chemistry electrolytes in a sample of hyperglycemic patients seen in the emergency department (ED). METHODS The authors prospectively identified a convenience sample of ED patients with serum blood glucose ≥ 250 mg/dL and examined their paired VBG and serum chemistry electrolytes. The diagnosis of DKA was made by using American Diabetes Association (ADA) criteria including serum glucose ≥ 250 mg/dL, serum anion gap > 10 mEq/L, bicarbonate ≤ 18 mEq/L, serum pH ≤ 7.30, and presence of ketosis. Serum chemistry electrolyte values were considered to be the criterion standard. Diagnostic test characteristics of VBG electrolytes including sensitivity and specificity were compared against this standard. In addition, correlation coefficients for individual electrolytes and anion gap between VBG and chemistry electrolytes were calculated. RESULTS Paired VBG and serum chemistry panels were available for 342 patients, of whom 46 (13.5%) had DKA. The sensitivity and specificity of the VBG electrolytes for diagnosing DKA was 97.8% (95% confidence interval [CI] = 88.5% to 99.9%) and 100% (95% CI = 98.8% to 100%), respectively. One case of DKA was missed by the VBG. Correlation coefficients between VBG and serum chemistry were 0.90, 0.73, 0.94, and 0.81 for sodium, chloride, bicarbonate, and anion gap, respectively. CONCLUSIONS The VBG electrolytes were 97.8% sensitive and 100% specific for the diagnosis of DKA in hyperglycemic patients. These preliminary findings support the use of VBG electrolytes in lieu of VBG along with serum chemistry analysis to rule in or rule out DKA.

National Cost Savings From Observation Unit Management of Syncope

OBJECTIVES Syncope is a frequent emergency department (ED) presenting complaint and results in a disproportionate rate of hospitalization with variable management strategies. The objective was to estimate the annual national cost savings, reduction in inpatient hospitalizations, and reduction in hospital bed hours from implementation of protocolized care in an observation unit. METHODS We created a Monte Carlo simulation by building a model that reflects current clinical practice in the United States and uses inputs gathered from the most recent available peer-reviewed literature and national survey data. ED visit volume was adjusted to reflect observation unit availability and the portion of observation visits requiring subsequent inpatient care. A recent multicenter randomized controlled study informed the cost savings and length of stay reduction per observation unit visit model inputs. The study population included patients aged 50 years and older with syncope deemed at intermediate risk for serious 30-day cardiovascular outcomes. RESULTS The mean (±SD) annual cost savings was estimated to be

Can patients with brain herniation on cranial computed tomography have a normal neurologic exam

108 million (±

How can we improve management of syncope in the emergency department

89 million) from avoiding 235,000 (±13,900) inpatient admissions, resulting in 4,297,000 (±1,242,000) fewer hospital bed hours. CONCLUSIONS The potential national cost savings for managing selected patients with syncope in a dedicated observation unit is substantial. Syncope is one of many conditions suitable for care in an observation unit as an alternative to an inpatient setting. As pressure to decrease hospital length of stay and bill short-stay hospitalizations as observation increases, syncope illustrates the value of observation unit care.

Prevalence of Herniation and Intracranial Shift on Cranial Tomography in Patients With Subarachnoid Hemorrhage and a Normal Neurologic Examination

OBJECTIVES Herniation of the brain outside of its normal intracranial spaces is assumed to be accompanied by clinically apparent neurologic dysfunction. The authors sought to determine if some patients with brain herniation or significant brain shift diagnosed by cranial computed tomography (CT) might have a normal neurologic examination. METHODS This is a secondary analysis of the National Emergency X-Radiography Utilization Study (NEXUS) II cranial CT database compiled from a multicenter, prospective, observational study of all patients for whom cranial CT scanning was ordered in the emergency department (ED). Clinical information including neurologic examination was prospectively collected on all patients prior to CT scanning. Using the final cranial CT radiology reports from participating centers, all CT scans were classified into three categories: frank herniation, significant shift without frank herniation, and minimal or no shift, based on predetermined explicit criteria. These reports were concatenated with clinical information to form the final study database. RESULTS A total of 161 patients had CT-diagnosed frank herniation; 3 (1.9%) had no neurologic deficit. Of 91 patients with significant brain shift but no herniation, 4 (4.4%) had no neurologic deficit. CONCLUSIONS A small number of patients may have normal neurologic status while harboring significant brain shift or brain herniation on cranial CT.

Estimating the cost of care for emergency department syncope patients: Comparison of three models

Syncope is a common and challenging presenting complaint to the Emergency Department (ED). Despite substantial research efforts, there is still considerable uncertainty about the optimal ED management of syncope. There is continued interest among clinicians and researchers in improving diagnostic algorithms and optimizing resource utilization. In this paper, we discuss 4 strategies to improve the emergency care of syncope patients: (1) Development of accurate and consistent risk-stratification, (2) Increased use of syncope observation protocols, (3) Evaluation of a discharge with ambulatory monitoring pathway, (4) Use of shared decision-making for disposition decisions. Since current risk-stratification tools have fallen short with regard to subsequent validation and implementation into clinical practice, we outline key factors for future risk-stratification research. We propose that observation units have the potential to safely decrease length-of-stay and hospital costs for hemodynamically stable, intermediate risk patients without adversely affecting clinical outcomes. For appropriate patients with a negative ED evaluation, we recommend consideration of direct discharge, with ambulatory monitoring and expedited follow-up, as a means of decreasing costs and reducing iatrogenic harms. Finally, we advocate for the use of shared decision-making regarding the ultimate disposition of select, intermediate risk patients who have not had a serious condition revealed in the ED. If properly implemented, these four strategies could significantly improve the care of ED syncope patients by helping clinicians identify truly high-risk patients, decreasing unnecessary hospitalizations, and increasing patient satisfaction.