Physician-identified barriers to and facilitators of shared decision-making in the Emergency Department: an exploratory analysis.

OBJECTIVES: Shared decision-making (SDM) is receiving increasing attention in emergency medicine because of its potential to increase patient engagement and decrease unnecessary healthcare utilisation. This study sought to explore physician-identified barriers to and facilitators of SDM in the ED. METHODS: We conducted semistructured interviews with practising emergency physicians (EP) with the aim of understanding when and why EPs engage in SDM, and when and why they feel unable to engage in SDM. Interviews were transcribed verbatim and a three-member team coded all transcripts in an iterative fashion using a directed approach to qualitative content analysis. We identified emergent themes, and organised themes based on an integrative theoretical model that combined the theory of planned behaviour and social cognitive theory. RESULTS: Fifteen EPs practising in the New England region of the USA were interviewed. Physicians described the following barriers: time constraints, clinical uncertainty, fear of a bad outcome, certain patient characteristics, lack of follow-up and other emotional and logistical stressors. They noted that risk stratification methods, the perception that SDM decreased liability and their own improving clinical skills facilitated their use of SDM. They also noted that the culture of the institution could play a role in discouraging or promoting SDM, and that patients could encourage SDM by specifically asking about alternatives. CONCLUSIONS: EPs face many barriers to using SDM. Some, such as lack of follow-up, are unique to the ED; others, such as the challenges of communicating uncertainty, may affect other providers. Many of the barriers to SDM are amenable to intervention, but may be of variable importance in different EDs. Further research should attempt to identify which barriers are most prevalent and most amenable to intervention, as well as capitalise on the facilitators noted.

Validity of STONE scores in younger patients presenting with suspected uncomplicated renal colic.

OBJECTIVES: Recent studies have cast doubt on the routine need for emergent computed tomographic (CT) scan in patients with suspected renal colic. A clinical prediction rule, the STONE score, was recently published with the goal of helping clinicians predict obstructive kidney stones in noninfected flank pain patients before CT scan. We sought to examine the validity of this score in younger, noninfected flank pain patients. METHODS: A secondary analysis of a retrospective cohort study was performed to determine the validity of STONE scores for predicting the outcome of obstructive kidney stone in patients age 18 to 50 years presenting with flank pain suggestive of uncomplicated ureterolithiasis. Validity was measured by calculation of the area under the curve of the receiver operating characteristic curve. Sensitivity, specificity, negative predictive value, positive predictive value, and ±likelihood ratios were calculated for various cutoff values. RESULTS: Of 134 patients who met inclusion criteria, 56.7% were female, average age was 37 years, and 52% had an obstructing kidney stone by CT scan. The receiver operating characteristic curve for the STONE score had an area under the curve of 0.87 (95% confidence interval, 0.80-0.93) and indicated that a cutoff of greater than or equal to 8 would have a sensitivity of 78.6%, specificity of 84.4%, negative predictive value of 78.3%, positive predictive value of 84.6%, and +likelihood ratio of 4.9. CONCLUSIONS: This analysis suggests that the STONE score is valid in younger populations. It can aid in determining pretest probability and help inform conversations about the likelihood of the diagnosis of renal colic before imaging, which may be useful for decision making.

Mobile vitreous opacities on ocular ultrasonography are not always pathologic: a cross-sectional survey in an asymptomatic population.

BACKGROUND: Ultrasonography is often used in the evaluation of patients with ocular concerns; however, several pathologic conditions and even some age-related changes can have similar sonographic appearances. One approach that clinicians use is to assume that unilateral findings visible at normal gain are acute, whereas bilateral findings requiring high gain are chronic, especially in the elderly population. To date, no studies have systematically evaluated this assumption. OBJECTIVES: The objectives are to determine the prevalence of monocular and binocular mobile vitreous opacities (MVOs) in the vitreous chamber in an asymptomatic population at normal and high gain levels and to determine its prevalence with higher age stratifications. METHODS: We conducted a cross-sectional survey using 2-dimensional ultrasonography with a high-frequency transducer of 105 asymptomatic subjects aged 20-89 years and evaluated each subject's eyes for the presence of MVOs at both normal and high gain levels in progressive age stratifications. RESULTS: Ultrasonographic scans were obtained on 105 subjects. At normal gain levels, MVO was present in only 1 subject (0.95%; 95% confidence interval, 0.0%-5.0%). At high gain levels, MVO was present in 28.6% (30/105) of subjects. Of the subjects with MVO at high gain, 60% (18/30) had unilateral MVO. Mobile vitreous opacity was found more frequently with advancing age, being present in 23 subjects older than 59 years, compared with 7 subjects 59 years and younger (51.1% vs 11.7%, P < .001). CONCLUSIONS: Mobile vitreous opacity in the vitreous chamber visualized at high gain levels is relatively common and may not be pathologic, even if unilateral and occurring at a relatively young age.

Closing the gender pay gap in emergency medicine: Paradigms to consider for leaders, faculty, and trainees.

The gender pay gap among physicians is a well documented and persistent problem and has a profound impact on earnings over a career lifetime. This paper describes examples of concrete initiatives three institutions took to identify and address gender pay gaps. Salary audits at two academic emergency departments highlight the importance of not only ensuring equity in salary among physicians of the same rank but also monitoring whether women are achieving equal representation at higher academic ranks and leadership, elements that typically contribute to compensation. These audits reveal how senior rank and formal leadership roles are significantly associated with salary disparities. A third school of medicine-wide initiative entailed conducting comprehensive salary audits followed by review and adjustment of faculty compensation to achieve pay equity. Graduating residents and fellows seeking first jobs out of training and faculty looking to be compensated equitably would benefit from understanding the elements that drive their compensation and advocating for frameworks that are understandable and transparent.

Advanced practice providers in academic emergency medicine: A national survey of chairs and program directors.

BACKGROUND: The Society for Academic Emergency Medicine Board of Directors convened a task force to elucidate the current state of workforce, operational, and educational issues being faced by academic medical centers related to advanced practice providers (APPs). The task force surveyed academic emergency department (ED) chairs and residency program directors (PDs). METHODS: The survey was distributed to the Association of Academic Chairs of Emergency Medicine (AACEM)-member chairs and their respective residency PDs in 2021. We surveyed 125 chairs with their self-identified PDs. The survey sampled hiring, state-independent practice laws, scope of practice, teaching and supervision, training opportunities, delegation of procedures between physician learners and APPs, and perceptions of the impact on resident and medical student education. RESULTS: Of the AACEM-member chairs identified, 73% responded and 47% of PDs responded. Most (98%) employ either physician assistants or nurse practitioners. Among responding departments, 86% report APPs working in fast-track settings, 80% work in the main ED, and 54% work in the waiting room. In 44% of departments, APPs and residents evaluate patients concurrently, and 2% of respondents reported that APPs manage high-acuity patients without attending involvement. Two-thirds of chairs believe that APPs contribute positively to the quality of patient care, while 44% believe that APPs contribute to the academic environment. One-third of PDs believe that the presence of APPs interferes with resident education. Although 75% of PDs believe that residents require training to work effectively with APPs in the ED, almost half (49%) report zero hours of training around APP supervision or collaborative skills. CONCLUSIONS: APPs are ubiquitous across academic EDs. Future research is required for academic ED leaders to balance physician and APP deployment across the academic ED within the context of patient care, resident education, institutional resources, professional development opportunities for APP staff, and standardization of APP EM training.

A Review of Interprofessional Variation in Education: Challenges and Considerations in the Growth of Advanced Practice Providers in Emergency Medicine.

The employment and utilization of advanced practice providers (APPs) in the emergency department has been steadily increasing. Physicians, physician assistants (PAs), and nurse practitioners (NPs) have vastly different requirements for admission to graduate programs, clinical exposure, and postgraduate training. It is important that as supervisory physicians, patients, hospital administrators, and lawmakers, we understand the differences to best create a collaborative, supportive, and educational framework within which PAs/NPs can work effectively as part of a care team. This paper reviews the trends, considerations, and challenges of an evolving clinician workforce in the specialty of emergency medicine (EM). Subsequently, the following parameters of APP training are examined and discussed: the divergence in physician, PA, and NP education and training; requirements of PA and NP degree programs; variation in clinical contact hours; degree-specific licensing and postgraduate EM certification; opportunities for specialty training; and the evolution and availability of residency programs for APPs. The descriptive review is followed by a discussion of contemporary and timely issues that impact EM and considerations brought forth by the expansion of APPs in EM such as the current drive to independent practice and the push for reimbursement parity. We review current position statements from pertinent professional organizations regarding PA and NP capabilities, responsibilities, and physician oversight as well as billing implications, care outcomes and medicolegal implications.

Safety Assessment of a Noninvasive Respiratory Protocol for Adults With COVID-19.

As evidence emerged supporting noninvasive strategies for coronavirus disease 2019 (COVID-19)-related respiratory distress, we implemented a noninvasive COVID-19 respiratory protocol (NCRP) that encouraged high-flow nasal cannula (HFNC) and self-proning across our healthcare system. To assess safety, we conducted a retrospective chart review evaluating mortality and other patient safety outcomes after implementation of the NCRP protocol (April 3, 2020, to April 15, 2020) for adult patients hospitalized with COVID-19, compared with preimplementation outcomes (March 15, 2020, to April 2, 2020). During the study, there were 469 COVID-19 admissions. Fewer patients underwent intubation after implementation (10.7% [23 of 215]), compared with before implementation (25.2% [64 of 254]) (P < .01). Overall, 26.2% of patients died (24% before implementation vs 28.8% after implementation; P = .14). In patients without a do not resuscitate/do not intubate order prior to admission, mortality was 21.8% before implementation vs 21.9% after implementation. Overall, we found no significant increase in mortality following implementation of a noninvasive respiratory protocol that decreased intubations in patients with COVID-19.

A Case-Control Study of Sonographic Maximum Ovarian Diameter as a Predictor of Ovarian Torsion in Emergency Department Females With Pelvic Pain.

BACKGROUND: Color and power Doppler ultrasound are commonly used in the evaluation of ovarian torsion but are unreliable. Because normal-sized ovaries are unlikely to cause torsion, maximum ovarian diameter (MOD) could theoretically be used as a screening test in the ED. Identification of MOD values below which torsion is unlikely would be of benefit to providers interpreting radiology department or point-of-care pelvic ultrasound. OBJECTIVES: The objective was to determine if sonographic MOD can be used as a screening tool to rule out torsion in selected patients. METHODS: Via a retrospective case-control study spanning a 14-year period, we examined the ultrasound characteristics of patients with torsion and age-matched controls, all presenting to the emergency department with lower abdominal pain and receiving a radiology department pelvic ultrasound for "rule-out torsion." Standardized data collection forms were utilized. Distributions of MOD were compared and sensitivity, specificity, and likelihood ratios were calculated for multiple cutoffs. RESULTS: We identified 92 cases of surgically confirmed ovarian torsion and selected 92 age-matched controls. In postmenarchal patients the sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 3- and 5-cm MODs were 100% (96%-100%), 30% (20%-41%), 1.4 (1.3-1.7), and 0 and 91% (83%-97%), 92% (83%-97%), 11.2 (5.5-22.9), and 0.09 (0.04-0.19), respectively. The 5-cm MOD, however, excluded an additional 52 of 84 (62%) postmenarchal patients. CONCLUSIONS: A threshold MOD of 5 cm on pelvic ultrasound may be useful to rule out ovarian torsion in postmenarchal females presenting with lower abdominal and pelvic pain.

Integration of Advanced Practice Providers in Academic Emergency Departments: Best Practices and Considerations.

As emergency department (ED) visits continue to increase nationwide, the utilization of advanced practice providers (APPs) has been steadily increasing. Academic centers face unique challenges in the inclusion of APP staff into the educational and teaching environment. Effort should be made to both take advantage of and support the educational mission of academic centers while bolstering clinical care provided by APP staff. This paper highlights some of the considerations and challenges in incorporating APPs into academic EDs as discussed at the Society for Academic Emergency Medicine Annual Meeting in Indianapolis, Indiana, in May 2018. The panel included representation from Massachusetts General Hospital, Yale New Haven Hospital, Warren Alpert Medical School of Brown University, and University of Massachusetts Medical School-Baystate. Distillation of our common experience shows that best practices in supervision favor uniformity between resident and APP staff except with low-acuity patients. Likewise, professional development takes advantage of the educational environment to provide feedback and identify areas for improvement as well as development of formal clinical and educational curricula for APPs working in academic institutions. Already established medical doctor residencies can be leveraged to provide postgraduate education for APPs in either formal or informal training programs.

A Qualitative Analysis of Attending Physicians' Use of Shared Decision-Making: Implications for Resident Education.

BACKGROUND: Physicians need to rapidly and effectively facilitate patient-centered, shared decision-making (SDM) conversations, but little is known about how residents or attending physicians acquire this skill. OBJECTIVE: We explored emergency medicine (EM) attending physicians' use of SDM in the context of their experience as former residents and current educators and assessed the implications of these findings on learning opportunities for residents. METHODS: We used semistructured interviews with a purposeful sample of EM physicians. Interviews were transcribed verbatim, and 3 research team members performed iterative, open coding of transcripts, building a provisional codebook as work progressed. We analyzed the data with a focus on participants' acquisition and use of skills required for SDM and their use of SDM in the context of resident education. RESULTS: Fifteen EM physicians from academic and community practices were interviewed. All reported using SDM techniques to some degree. Multiple themes noted had negative implications for resident acquisition of this skill: (1) the complex relationships among patients, residents, and attending physicians; (2) residents' skill levels; (3) the setting of busy emergency departments; and (4) individual attending factors. One theme was noted to facilitate resident education: the changing culture-with a cultural shift toward patient-centered care. CONCLUSIONS: A constellation of factors may diminish opportunities for residents to acquire and practice SDM skills. Further research should explore residents' perspectives, address the modifiable obstacles identified, and examine whether these issues generalize to other specialties.

The Physician-as-Stakeholder: An Exploratory Qualitative Analysis of Physicians' Motivations for Using Shared Decision Making in the Emergency Department.

BACKGROUND: Shared decision making (SDM) is increasingly recognized as an important facet of patient-centered care. Despite growing interest in SDM in the emergency department (ED), little is known about emergency physicians' (EPs') motivations for using SDM. Understanding current patterns of SDM use and EP's rationale for using SDM is essential for the development of interventions to increase use. OBJECTIVES: Recognizing the EP as an important stakeholder in SDM research, we sought to identify and explore factors that may motivate EPs' engagement in SDM. METHODS: In this qualitative study, informed by the Theory of Planned Behavior and Social Cognitive Theory, we conducted semistructured interviews with a purposeful sample of EPs. Interviews were recorded and transcribed verbatim. Using a directed qualitative content analysis approach, three members of the research team performed open coding of the transcripts in an iterative process, building a provisional code book as coding progressed. Respondent validation was employed to ensure methodologic rigor. RESULTS: Fifteen EPs, ages 31-65, from both academic and community practice settings, were interviewed. Several had not heard of the specific phrase "shared decision making," but all understood the concept and felt that they used SDM techniques to some degree. Most noted they had often had an agenda when they used SDM, which often motivated them to have the conversation. Agendas described included counteracting an algorithmic or defensive approach to diagnosis and treatment, avoiding harmful tests, or sharing uncertainty. All participants believed that patients benefited from SDM in terms of satisfaction, engagement, or education. Nearly all participants identified research outcomes that they felt would encourage their use of SDM (e.g., improvements in patient engagement, mitigation of risk) and many prioritized patient-centered outcomes over systems outcomes such as improved resource utilization. Little consensus was seen, however, regarding the importance of individual outcomes: of eight potential research outcomes participants endorsed, no single outcome was endorsed by even half of the physicians interviewed. CONCLUSION: Emergency physicians identified many factors that motivated them to use SDM. This study informs current research on SDM in the ED, particularly regarding the motivations of the physician-as-stakeholder.

Young patients with suspected uncomplicated renal colic are unlikely to have dangerous alternative diagnoses or need emergent intervention.

INTRODUCTION: In the United States there is debate regarding the appropriate first test for new-onset renal colic, with non-contrast helical computed tomography (CT) receiving the highest ratings from both Agency for Healthcare Research and Quality and the American Urological Association. This is based not only on its accuracy for the diagnosis of renal colic, but also its ability to diagnose other surgical emergencies, which have been thought to occur in 10-15% of patients with suspected renal colic, based on previous studies. In younger patients, it may be reasonable to attempt to avoid immediate CT if concern for dangerous alternative diagnosis is low, based on the risks of radiation from CTs, and particularly in light of evidence that patients with renal colic have a very high likelihood of having multiple CTs in their lifetimes. The objective is to determine the proportion of patients with a dangerous alternative diagnosis in adult patients age 50 and under presenting with uncomplicated (non-infected) suspected renal colic, and also to determine what proportion of these patients undergo emergent urologic intervention. METHODS: Retrospective chart review of 12 months of patients age 18-50 presenting with "flank pain," excluding patients with end stage renal disease, urinary tract infection, pregnancy and trauma. Dangerous alternative diagnosis was determined by CT. RESULTS: Two hundred and ninety-one patients met inclusion criteria. One hundred and fifteen patients had renal protocol CTs, and zero alternative emergent or urgent diagnoses were identified (one-sided 95% CI [0-2.7%]). Of the 291 encounters, there were 7 urologic procedures performed upon first admission (2.4%, 95% CI [1.0-4.9%]). The prevalence of kidney stone by final diagnosis was 58.8%. CONCLUSION: This small sample suggests that in younger patients with uncomplicated renal colic, the benefit of immediate CT for suspected renal colic should be questioned. Further studies are needed to determine which patients benefit from immediate CT for suspected renal colic, and which patients could undergo alternate imaging such as ultrasound.

Implementation of a successful incentive-based ultrasound credentialing program for emergency physicians.

INTRODUCION: With the rapid expansion of emergency ultrasound, resident education in ultrasound has become more clearly developed and broadly integrated. However, there still exists a lack of guidance in the training of physicians already in practice to become competent in this valuable skill. We sought to employ a step-wise, goal-directed, incentive-based credentialing program to educate emergency physicians in the use of emergency ultrasound. Successful completion of this program was the primary outcome. METHODS: The goal was for the physicians to gain competency in 8 basic ultrasound examinations types: aorta, focused assessment with sonography in trauma, cardiac, renal, biliary, transabdominal pelvic, transvaginal pelvic, and deep venous thrombosis. We separated the 2.5 year training program into 4 distinct blocks, with each block focusing on 2 of the ultrasound examination types. Each block consisted of didactic and hands-on sessions with the goal of the physician completing 25 technically-adequate studies of each examination type. There was a financial incentive associated with completion of these requirements. RESULTS: A total of 31 physicians participated in the training program. Only one physician, who retired prior to the end of the 2.5 year period, did not successfully complete the program. All have applied for and received hospital privileging in emergency ultrasound and incorporated it into their daily practice. CONCLUSION: We found that a step-wise, incentive-based ultrasound training program with a combination of didactics and ample hands-on teaching was successful in the training of physicians already in practice.