Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
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Shared decision making (SDM) has been advocated as an approach to selecting medical tests and treatments for many situations. The goal of SDM is to ensure that patients are well informed, are meaningfully involved in decisions, and receive treatments that meet their goals and preferences. ⋯ However, fairly little is known about the applicability of the tools and measures in the emergency department (ED) setting. This article builds on insights from two keynote lectures presented at the 2016 Academic Emergency Medicine Consensus Conference discussing the state of the science for measurement of SDM and the design of patient decision aids to promote SDM conversations and highlights some key areas for further research to advance SDM in the ED.
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Diagnostic testing is an integral component of patient evaluation in the emergency department (ED). Emergency clinicians frequently use diagnostic testing to more confidently exclude "worst-case" diagnoses rather than to determine the most likely etiology for a presenting complaint. Increased utilization of diagnostic testing has not been associated with reductions in disease-related mortality but has led to increased overall healthcare costs and other unintended consequences (e.g., incidental findings requiring further workup, unnecessary exposure to ionizing radiation or potentially nephrotoxic contrast). ⋯ This article introduces the challenges and opportunities associated with incorporating SDM into emergency care by summarizing the conclusions of the diagnostic testing group at the 2016 Academic Emergency Medicine Consensus Conference on SDM. Three primary domains emerged: 1) characteristics of a condition or test appropriate for SDM, 2) critical elements of and potential barriers to SDM discussions on diagnostic testing, and 3) financial aspects of SDM applied to diagnostic testing. The most critical research questions to improve engagement of patients in their acute care diagnostic decisions were determined by consensus.
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Although studies suggest that patients with limited health literacy and/or low numeracy skills may stand to gain the most from shared decision making (SDM), the impact of these conditions on the effective implementation of SDM in the emergency department (ED) is not well understood. In this article from the proceedings of the 2016 Academic Emergency Medicine Consensus Conference on Shared Decision Making in the Emergency Department we discuss knowledge gaps identified and propose consensus-driven research priorities to help guide future work to improve SDM for this patient population in the ED.
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Behavioral health-related emergency department (ED) visits have been linked with ED overcrowding, an increased demand on limited resources, and a longer length of stay (LOS) due in part to patients being admitted to the hospital but waiting for an inpatient bed. This study examines factors associated with the likelihood of hospital admission for ED patients with behavioral health conditions at 16 hospital-based EDs in a large urban area in the southern United States. ⋯ The block of enabling factors was the strongest predictor of hospitalization following an ED visit compared to predisposing and need factors. Our findings also provide evidence of disparities in hospitalization of the uninsured and racial and ethnic minority patients with ED visits for behavioral health conditions. Thus, improved access to community-based behavioral health services and an increased capacity for inpatient psychiatric hospitals for treating indigent patients may be needed to improve the efficiency of ED services in our region for patients with behavioral health conditions. Among need factors, a discharge diagnosis of schizophrenia/psychotic spectrum disorder, an affective disorder, a personality disorder, an impulse control disorder, or dementia as well as secondary diagnoses of suicidal ideation and/or suicidal behavior increased the likelihood of hospitalization following an ED visit, also suggesting an opportunity for improving the efficiency of ED care through the provision of psychiatric services to stabilize and treat patients with serious mental illness.