Shared Decision‐making in the Emergency Department: Respecting Patient Autonomy When Seconds Count

Shared decision‐making (SDM), a collaborative process in which patients and providers make health care decisions together, taking into account the best scientific evidence available, as well as the patient's values and preferences, is being increasingly advocated as the optimal approach to decision‐making for many health care decisions. The rapidly paced and often chaotic environment of the emergency department (ED), however, is a unique clinical setting that offers many practical and contextual challenges. Despite these challenges, in a recent survey emergency physicians reported there to be more than one reasonable management option for over 50% of their patients and that they take an SDM approach in 58% of such patients. SDM has also been selected as the topic on which to develop a future research agenda at the 2016 Academic Emergency Medicine consensus conference, “Shared Decision‐making in the Emergency Department: Development of a Policy‐relevant Patient‐centered Research Agenda” ( http://www.saem.org/annual-meeting/education/2016-aem-consensus-conference ). In this paper the authors describe the conceptual model of SDM as originally conceived by Charles and Gafni and highlight aspects of the model relevant to the practice of emergency medicine. In addition, through the use of vignettes from the authors' clinical practices, the applicability of SDM to contemporary EM practice is illustrated and the ethical and pragmatic implications of taking an SDM approach are explored. It is hoped that this document will be read in advance of the 2016 Academic Emergency Medicine consensus conference, to facilitate group discussions at the conference.     

The Emerging Imperative for Health Care Quality Improvement

There are widespread and growing concerns about the variable and too often inadequate quality of health care in the United States. As a result, health care quality is being questioned and subjected to scrutiny as never before. Awareness of the quality deficits, combined with rising health care expenditures and changing attitudes of payers and consumers, has given rise to a nascent but growing quality improvement movement. Multiple barriers must be surmounted by this movement, but substantive work is under way on all fronts. Emergency medicine will definitely be affected by the quality improvement movement and should quickly move forward to define and establish performance measures for high-quality emergency care in an era when chronic disease dominates the agenda. Emergency medicine should also aggressively work to operationalize a culture of quality to minimize medical errors, to practice evidence-based medicine, to translate research results into clinical practice in a timely manner, and to establish accountability mechanisms for quality improvement and clinical excellence.     

Research Methods of Inquiry

Incidents of significant consequence that create surge may require special research methods to provide reliable, generalizable results. This report was constructed through a process of literature review, expert panel discussion at the journal's consensus conference, and iterative development. Traditional clinical research methods that are well accepted in medicine are exceptionally difficult to use for surge incidents because the incidents are very difficult to reliably predict, the consequences vary widely, human behaviors are heterogeneous in response to incidents, and temporal conditions prioritize limited resources to response, rather than data collection. Current literature on surge research methods has found some degree of reliability and generalizability in case-control, postincident survey methods, and ethnographical designs. Novel methods that show promise for studying surge include carefully validated simulation experiments and survey methods that produce validated results from representative populations. Methodologists and research scientists should consider quasi-experimental designs and case-control studies in areas with recurrent high-consequence incidents (e.g., earthquakes and hurricanes). Specialists that need to be well represented in areas of research include emergency physicians and critical care physicians, simulation engineers, cost economists, sociobehavioral methodologists, and others.     

Public Health Considerations in Knowledge Translation in the Emergency Department

Effective preventive and screening interventions have not been widely adopted in emergency departments (EDs). Barriers to knowledge translation of these initiatives include lack of knowledge of current evidence, perceived lack of efficacy, and resource availability. To address this challenge, the Academic Emergency Medicine 2007 Consensus Conference, “Knowledge Translation in Emergency Medicine: Establishing a Research Agenda and Guide Map for Evidence Uptake,” convened a public health focus group. The question this group addressed was “What are the unique contextual elements that need to be addressed to bring proven preventive and other public health initiatives into the ED setting?” Public health experts communicated via the Internet beforehand and at a breakout session during the conference to reach consensus on this topic, using published evidence and expert opinion. Recommendations include 1) to integrate proven public health interventions into the emergency medicine core curriculum, 2) to configure clinical information systems to facilitate public health interventions, and 3) to use ancillary ED personnel to enhance delivery of public health interventions and to obtain successful funding for these initiatives. Because additional research in this area is needed, a research agenda for this important topic was also developed. The ED provides medical care to a unique population, many with increased needs for preventive care. Because these individuals may have limited access to screening and preventive interventions, wider adoption of these initiatives may improve the health of this vulnerable population.     

Continuing the transformation: charting the path for the future delivery of Veteran emergency care

Important changes in the delivery of Veteran emergency care in the early 2000s in the Department of Veteran Affairs (VA) emergency departments and urgent care clinics substantially elevated the role of emergency medicine (EM) in Veteran health care. Focused on enhancing the quality of care, emergency care visits in both VA and non-VA (community) care locations have nearly doubled from the 1980s to more than 3 million visits in Fiscal Year 2022. Recognizing the need to plan for continued growth and the opportunity to address key research priorities, the VA Office of Emergency Medicine, together with the VA Health Services Research and Development Service, collaborated to convene a State of the Art Conference on Veteran Emergency Medicine (SAVE) in the winter of 2022. The goal of this conference was to identify research gaps and priorities for implementation of policies for three priority groups: geriatric Veterans, Veterans with mental health and substance use complaints, and Veterans presenting to non-VA (community) emergency care sites. In this article we discuss the rationale for the SAVE conference including a brief history of VA EM and the planning process and conclude with next steps for findings from the conference.     

Gender‐specific Regulatory Challenges to Product Approval: A Panel Discussion

On May 13, 2014, a 1‐hour panel discussion session titled “Gender‐specific Regulatory Challenges to Product Approval” was held during the Academic Emergency Medicine consensus conference, “Gender‐specific Research in Emergency Medicine: Investigate, Understand, and Translate How Gender Affects Patient Outcomes.” The session sought to bring together leaders in emergency medicine (EM) research, authors, and reviewers in EM research publications, as well as faculty, fellows, residents, and students engaged in research and clinical practice. A panel was convened involving a representative from the Office of Women's Health of the U.S. Food and Drug Administration, two pharmaceutical executives, and a clinical EM researcher. The moderated discussion also involved audience members who contributed significantly to the dialogue. Historical background leading up to the session along with the main themes of the discussion are reproduced in this article. These revolve around sex‐ and gender‐specific research, statistical analysis of sex and gender, clinical practice, financial costs associated with pharmaceutical development, adaptive design, and specific recommendations on the regulatory process as it affects the specialty of EM.     

2022 consensus conference on diversity,equity, and inclusion: Developing an emergency medicine research agenda for addressing racism through health care research

Racism in emergency medicine (EM) health care research is pervasive but often underrecognized. To understand the current state of research on racism in EM health care research, we developed a consensus working group on this topic, which concluded a year of work with a consensus-building session as part of the overall Society for Academic Emergency Medicine (SAEM) consensus conference on diversity, equity, and inclusion: “Developing a Research Agenda for Addressing Racism in Emergency Medicine,” held on May 10, 2022. In this article, we report the development, details of preconference methods and preliminary results, and the final consensus of the Healthcare Research Working Group. Preconference work based on literature review and expert opinion identified 13 potential priority research questions that were refined through an iterative process to a list of 10. During the conference, the subgroup used consensus methodology and a “consensus dollar” (contingent valuation) approach to prioritize research questions. The subgroup identified three research gaps: remedies for racial bias and systematic racism, biases and heuristics in clinical care, and racism in study design, and we derived a list of six high-priority research questions for our specialty.     

Consensus Statement on Advancing Research in Emergency Department Operations and Its Impact on Patient Care

The consensus conference on “Advancing Research in Emergency Department (ED) Operations and Its Impact on Patient Care,” hosted by The ED Operations Study Group (EDOSG), convened to craft a framework for future investigations in this important but understudied area. The EDOSG is a research consortium dedicated to promoting evidence‐based clinical practice in emergency medicine. The consensus process format was a modified version of the NIH Model for Consensus Conference Development. Recommendations provide an action plan for how to improve ED operations study design, create a facilitating research environment, identify data measures of value for process and outcomes research, and disseminate new knowledge in this area. Specifically, we call for eight key initiatives: 1) the development of universal measures for ED patient care processes; 2) attention to patient outcomes, in addition to process efficiency and best practice compliance; 3) the promotion of multisite clinical operations studies to create more generalizable knowledge; 4) encouraging the use of mixed methods to understand the social community and human behavior factors that influence ED operations; 5) the creation of robust ED operations research registries to drive stronger evidence‐based research; 6) prioritizing key clinical questions with the input of patients, clinicians, medical leadership, emergency medicine organizations, payers, and other government stakeholders; 7) more consistently defining the functional components of the ED care system, including observation units, fast tracks, waiting rooms, laboratories, and radiology subunits; and 8) maximizing multidisciplinary knowledge dissemination via emergency medicine, public health, general medicine, operations research, and nontraditional publications.     

Quality and Education

Juxtaposing quality with education in emergency medicine (EM) generates two distinct issues: 1) the quality of education in EM, and 2) educating about quality in EM. There is considerable overlap between the two, and neither should be considered without the other. This paper focuses on education about quality in EM, with some discussion of the quality of EM education. Despite its apparent importance, there is a relative paucity of research on this topic.     

Mental Health Aspects of Emergency Medical Services for Children Summary of a Consensus Conference

OBJECTIVE: To address the mental health needs of children involved in emergency medical services (EMS). METHODS: A multidisciplinary consensus conference convened to identify mental health needs of children and their families related to pediatric medical emergencies, to examine the impact of psychological aspects of emergencies on recovery and satisfaction with care, and to delineate research questions related to mental health aspects of medical emergencies involving children. RESULTS: The consensus group found that psychological and behavioral factors affect physical as well as emotional recovery after medical emergencies. Children's reactions are critically affected by age and developmental level, characteristics of the emergency medical event, and parent reactions. As frontline health care providers, EMS staff members are in a pivotal position to recognize and effectively manage the mental health needs of patients and their families. CONCLUSIONS: Ecological changes in emergency departments, such as linkages to mental health follow-up services, training of EMS providers and mental health professionals, and focused research that provides an empirical basis for practice, are necessary components for improving current standards of health care.     

Emergency Medicine Resident Errors Identification and Educational Utilization

OBJECTIVES: To evaluate the error management systems emergency medicine residency directors (EMRDs) use to identify and report clinical errors made by emergency medicine residents and their satisfaction with error-based teaching as an educational tool. METHODS: All 112 EMRDs listed by the Accreditation Council for Graduate Medical Education in 1996 were sent a 15-item survey. Five areas of error evaluation and management were assessed: 1) systems for tracking and reporting clinical errors; 2) resident participation in the systems; 3) resident remediation; 4) EMRD-perceived satisfaction with current error-reporting mechanisms, their educational value, and their ability to identify and prevent errors; and 5) EMRDs' perceptions of faculty and resident satisfaction with the systems. RESULTS: The response rate was 86%. All EMRDs indicated that methods are in place to track and report errors at their institutions. These include morbidity and mortality conference (94%), quality assurance case review conference (76%), and continuous quality improvement audits (60%). A majority of programs (58%) present resident cases anonymously in order to enhance teaching (39%), to avoid embarrassment (28%), and to avoid individual blame (24%). While mandated resident remediation is not required at 48% of the programs, 24% require lectures, 17% require written reports, and 6% require extra clinical shifts. The EMRDs rated the educational value of morbidity and mortality conference as outstanding (11%) or excellent (53%), and rated their systems for identifying key resident errors as outstanding (0%), excellent (14%), or good (47%). CONCLUSIONS: All emergency medicine residency programs have systems to track and report resident errors. Resident participation varies widely, as does resident remediation processes. Most EMRDs are satisfied with their systems but few EMRDs rate them as excellent in the detection or prevention of clinical errors.     

Injury Due to Mechanical Falls: Future Directions in Gender‐specific Surveillance,Screening, and Interventions in Emergency Department Patients

The Centers for Disease Control and Prevention report that among older adults (≥65 years), falls are the leading cause of injury‐related death. Fall‐related fractures among older women are more than twice as frequent as those for men. Gender‐specific evidence‐based fall prevention strategy and intervention studies show that improved patient‐centered outcomes are elusive. There is a paucity of emergency medicine literature on the topic. As part of the 2014 Academic Emergency Medicine (AEM) consensus conference on “Gender‐Specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes,” a breakout group convened to generate a research agenda on priority questions to be answered on this topic. The consensus‐based priority research agenda is presented in this article.     

Using Patient Care Quality Measures to Assess Educational Outcomes

Objectives To report the results of a project designed to develop and implement a prototype methodology for identifying candidate patient care quality measures for potential use in assessing the outcomes and effectiveness of graduate medical education in emergency medicine. Methods A workgroup composed of experts in emergency medicine residency education and patient care quality measurement was convened. Workgroup members performed a modified Delphi process that included iterative review of potential measures; individual expert rating of the measures on four dimensions, including measures quality of care and educational effectiveness; development of consensus on measures to be retained; external stakeholder rating of measures followed by a final workgroup review; and a post hoc stratification of measures. The workgroup completed a structured exercise to examine the linkage of patient care process and outcome measures to educational effectiveness. Results The workgroup selected 62 measures for inclusion in its final set, including 43 measures for 21 clinical conditions, eight medication measures, seven measures for procedures, and four measures for department efficiency. Twenty‐six measures met the more stringent criteria applied post hoc to further stratify and prioritize measures for development. Nineteen of these measures received high ratings from 75% of the workgroup and external stakeholder raters on importance for care in the ED, measures quality of care, and measures educational effectiveness; the majority of the raters considered these indicators feasible to measure. The workgroup utilized a simple framework for exploring the relationship of residency program educational activities, competencies from the six Accreditation Council for Graduate Medical Education general competency domains, patient care quality measures, and external factors that could intervene to affect care quality. Conclusions Numerous patient care quality measures have potential for use in assessing the educational effectiveness and performance of graduate medical education programs in emergency medicine. The measures identified in this report can be used as a starter set for further development, implementation, and study. Implementation of the measures, especially for high‐stakes use, will require resolution of significant measurement issues.     

Wellness for the Future: Cultural and Systems‐based Challenges and Solutions

The goal of the 2019 Society for Academic Emergency Medicine Consensus Conference was to explore the current cultural and systemic issues in emergency medicine that impact the individual well‐being of every emergency physician and to make recommendations for future study. Burnout is epidemic in emergency medicine. Physician wellness is required to enhance patient clinical outcomes as well as to ensure professional satisfaction and longevity. For conference preparation, a consensus steering committee was created, and a decision was made to use the groundbreaking model of the National Academy of Medicine’s “Factors Affecting Clinician Well‐Being and Resilience” to further identify areas of needed study. On May 14, 2019, the Wellness Consensus Conference was attended by over 50 faculty physicians from across the United States. These attendees discussed key concepts and prior research presented by content experts. Groups of participants engaged in crowdsourcing techniques to consolidate ideas derived from those discussions. These consensus concepts were recorded and are presented within this article. A repetitive theme noted at the conference was the overwhelming effect of the system and organization factors on individual physician well‐being. The concept of ongoing assessment of professional fulfillment over the life span of the emergency physician was felt to be crucial in guiding wellness and resilience interventions in a timely manner. Examining ways to enable physicians to flourish rather than experience burnout are strong future directions for study.     

The structure,process and outcome of emergency medicine training

A study was conducted of 85 graduates of the Australasian College for Emergency Medicine to determine their perceptions of the quality of their graduate training and the status of their current practice. Participants were asked to use a scale of 1 to 5 (with 1 being a low or very poor rating, 5 being a high or very good rating) to rate their satisfaction with the structure of their training, the adequacy of the learning environment during training and the adequacy of their training relative to the emergency medicine curriculum. A response rate of 94% was achieved. Training in emergency departments (EDs) rated 4.0. Training in off-service rotations rated 3.6. The learning environment during training rated 3.8. The scope of educational experiences, access to teaching and research resources, and the quality and quantity of supervision by non-emergency physician specialists rated the lowest. The adequacy of their training relative to the curriculum rated 3.5, with a number of clinical areas including paediatrics, administrative aspects of emergency medicine and emergency medical systems, rated among the lowest. These perceptions in the context of the current practice of most graduates will help highlight the aspects of training that need further monitoring and improvement.     

Regionalized Care for Time‐critical Conditions: Lessons Learned From Existing Networks

The 2010 Academic Emergency Medicine (AEM) consensus conference “Beyond Regionalization” aimed to place the design of a 21st century emergency care delivery system at the center of emergency medicine’s (EM’s) health policy research agenda. To examine the lessons learned from existing regional systems, consensus conference organizers convened a panel discussion made up of experts from the fields of acute care surgery, interventional cardiology, acute ischemic stroke, cardiac arrest, critical care medicine, pediatric EM, and medical toxicology. The organizers asked that each member provide insight into the barriers that slowed network creation and the solutions that allowed them to overcome barriers. For ST‐segment elevation myocardial infarction (STEMI) management, the American Heart Association’s (AHA’s) Mission: Lifeline aims to increase compliance with existing guidelines through improvements in the chain of survival, including emergency medical services (EMS) protocols. Increasing use of therapeutic hypothermia post–cardiac arrest through a network of hospitals in Virginia has led to dramatic improvements in outcome. A regionalized network of acute stroke management in Cincinnati was discussed, in addition to the effect of pediatric referral centers on pediatric capabilities of surrounding facilities. The growing importance of telemedicine to a variety of emergencies, including trauma and critical care, was presented. Finally, the importance of establishing a robust reimbursement mechanism was illustrated by the threatened closure of poison control centers nationwide. The panel discussion added valuable insight into the possibilities of maximizing patient outcomes through regionalized systems of emergency care. A primary challenge remaining is for EM to help to integrate the existing and developing disease‐based systems of care into a more comprehensive emergency care system. Academic Emergency Medicine 2010; 17:1354–1358 © 2010 by the Society for Academic Emergency Medicine     

Evaluation of Missed Diagnoses for Patients Admitted from the Emergency Department

OBJECTIVE: To define a quality assurance instrument to evaluate errors in diagnostic processes made by physicians in the emergency department (ED). METHODS: This was a retrospective clinical investigation of inpatient ED records. Over a six-year period, 5,000 medical records of admitted patients were randomly selected for evaluation. Each record was initially examined by one of five physician evaluators. If the primary ED diagnosis differed from the primary discharge diagnosis, the ED record was inspected to determine reasons for the misdiagnosis. The authors considered several aspects of the diagnostic process, including patient history, tests ordered, interpretation of clinical data, choice and performance of procedures, injury pattern recognition, reasoning, and evaluation. Records that demonstrated errors in the diagnostic process were reevaluated for the same diagnostic process errors by a sixth physician. Disagreements regarding suspected errors in the diagnostic process were settled by discussion. Finally, to determine potential medical consequences of the misdiagnosis, one individual reviewed the complete medical records of patients whose ED medical records were scored with errors by both evaluators. Interevaluator reliability was assessed using Cochran's Q-test with a selected series of medical records. RESULTS: Twenty-eight records (0.6%) were found to contain one or more errors in the diagnostic process that contributed to misdiagnosis. For these patients appropriate diagnosis was not made until one to 16 days after admission. Three patients of 18 whose records were available for detailed review may have suffered complications that resulted, in part, from the delay in diagnosis and subsequent treatment. Significant interevaluator reliability for identification of errors in the diagnostic process was obtained (p > 0.1). CONCLUSIONS: A two-tiered evaluation of ED records selected by inconsistent initial and final diagnoses can be used reliably to screen for errors in the diagnostic process made by emergency physicians (EPs). The rate of physician error contributing to a misdiagnosis is very low, suggesting that EPs are delivering quality patient care.     

Emergency Department Performance Measures and Benchmarking Summit

The findings are presented of a consensus group created to address the standardization of performance measures for emergency medicine. This group, whose members have affiliations with most major organizations interested in emergency medicine performance, benchmarking and quality improvement, was tasked with standardizing definitions pertinent to emergency department performance measures, creating a set of general and operational measures, developing a comparison system for benchmarking and creating a plan for the dissemination of this information. The formation of this group, the problem statement, and the mission statement for the summit are all described, and the consensus document is presented.     

Practical implications of implementing emergency department crowding interventions: summary of a moderated panel

Emergency department (ED) crowding continues to be a major public health problem in the United States and around the world. In June 2011, the Academic Emergency Medicine consensus conference focused on exploring interventions to alleviate ED crowding and to generate a series of research agendas on the topic. As part of the conference, a panel of leaders in the emergency care community shared their perspectives on emergency care, crowding, and some of the fundamental issues facing emergency care today. The panel participants included Drs. Bruce Siegel, Sandra Schneider, Peter Viccellio, and Randy Pilgrim. The panel was moderated by Dr. Jesse Pines. Dr. Siegel's comments focused on his work on Urgent Matters, which conducted two multihospital collaboratives related to improving ED crowding and disseminating results. Dr. Schneider focused on the future of ED crowding measures, the importance of improving our understanding of ED boarding and its implications, and the need for the specialty of emergency medicine (EM) to move beyond the discussion of unnecessary visits. Dr. Viccellio's comments focused on several areas, including the need for a clear message about unnecessary ED visits by the emergency care community and potential solutions to improve ED crowding. Finally, Dr. Pilgrim focused on the effect of effective leadership and management in crowding interventions and provided several examples of how these considerations directly affected the success or failure of well-constructed ED crowding interventions. This article describes each panelist's comments in detail.