Clinical Decision Guidelines
Elizabeth Schoenfeld, MD, MS
Department of Emergency Medicine, Institute of Healthcare Delivery and Population Science; University of Massachusetts Medical School - Baystate
Disclosure Relationship(s): Nothing to disclose
Background: Every year approximately 2 million patients are seen in US EDs for suspected renal colic, and the majority receive a CT scan. Because of recent evidence demonstrating equivalent clinical outcomes between CT and ultrasound, emergency physicians have noted that this to be an appropriate clinical scenario for the use of shared decision-making (SDM). The objective of our study was to develop a stakeholder-informed conversation aid to help clinicians use SDM in the context of the decision regarding CT scanning in patients with suspected renal colic.
Methods: Using a published decision aid development framework (Coulter et el), and under the direction of a multi-disciplinary Steering Committee, we engaged a diverse set of stakeholders via qualitative methods. EM clinicians (attendings, residents, and advanced practitioners), urologists, radiologists, researchers, and emergency department patients participated in focus groups and semi-structured interviews. All groups were recorded, transcribed, and analyzed in an iterative process by a four-person coding team. Emergent themes were identified, discussed, and organized. A decision aid prototype was developed and iteratively refined.
Results: A total of 8 interviews and 7 focus groups were conducted with 36 stakeholders (local ED patients and clinicians, and clinicians and researchers from diverse regions of the US and Canada). The following four themes emerged: 1. Patient participants consistently reported a desire to be involved in this decision and wanted more information about radiation exposure, cost, and how the CT scan would change the plan of care. 2. Clinicians were comfortable diagnosing kidney stones without a CT scan, however, some were hesitant and felt that clinical uncertainty was a barrier to SDM. 3. Clinicians, researchers, and patients all identified strategies to facilitate this conversation such as check-lists and visual aids. 4. Both patients and clinicians felt that a “nudge” would be an acceptable aspect of a conversation aid. Based on this multidisciplinary input, a prototype was developed and refined.
Conclusion: Using stakeholder input, we developed a communication tool to facilitate an SDM conversation around the use of CT in suspected renal colic. Further testing will assess whether this tool can safely improve patient engagement and decrease low yield CT usage.