Danielle M. McCarthy

Background: A significant proportion of patients leave the emergency department (ED) without a definitive diagnosis, leading to challenges in the post-discharge period due to diagnostic uncertainty. Building on previous work aimed at improving discharge communication, we developed the Targeted Electronic Health Record (EHR)-based Communication about Uncertainty (TECU) Best Practice Advisory (OPA) to address this issue by alerting clinicians in real time when a patient receives discharge orders from the ED without a definitive diagnosis. Methods: This pilot study aimed to evaluate the feasibility and usability of the TECU OPA in an ED setting. Conducted at Thomas Jefferson University Hospital (TJUH), the study enrolled clinicians who participated in three phases of pilot testing, from May to August 2024, to refine the OPA’s design and functionality. The TECU OPA is an alert triggered when a symptom-based diagnosis is entered in the EHR, prompting clinicians to initiate a structured discharge conversation about diagnostic uncertainty. After engagement, clinicians evaluated the acceptability, feasibility, and usability of the OPA, while patients provided feedback on their understanding and satisfaction with the discharge process. Discussion: Clinicians were satisfied with the OPA’s usability and relevance in guiding discharge conversations. Patients appreciated the clarity and simplicity of the discharge communication. The iterative process of refining the OPA based on feedback ensured its accuracy in identifying eligible patients and facilitated its integration into clinical practice. This study provides promising initial data for implementing an OPA in the EHR to improve discharge transitions for patients with diagnostic uncertainty. Further testing is needed to explore the broader applicability and long-term impact of this approach. Trial registrations: n/a

Background: Transitions of care are high‐risk periods for patient safety in the emergency department (ED), particularly for patients who are still in the diagnostic process and are discharged with diagnostic uncertainty. Care transitions must be improved for these patients, as one third of discharged ED patients have diagnostic uncertainty. Yet there are no validated measures that assess the quality of care transitions from the ED, limiting the ability to assess the impact of interventions. Thus, we developed and validated the ED Transitions (EDT) measure. Methods: This mixed methods study was conducted across a large healthcare system in three phases: item generation, cognitive interviewing, and large‐scale validation. Scale items were generated by experts and then iteratively refined using feedback from cognitive interviews ( n = 11). The measure was then validated on a large sample of patients ( n = 301) recently discharged from the ED. Exploratory structural equation modeling (ESEM) was employed to assess factor structure. Bivariate correlations were used to assess discriminant and convergent validity using the Care Transition Measure (CTM‐3) and the Communication Assessment Tool‐Teams (CAT‐T). Results: The measure was iteratively refined by way of an expert panel and cognitive interviews which resulted in a 15‐item measure to be used for validation. The validation sample ( n = 301) was 62% women, 49% White, and the majority having Medicare and/or Medicaid (68%). Sequential comparisons between confirmatory factor analyses and ESEM resulted in a final 10‐item two‐factor structure. Reliability was excellent (0.93), and bivariate correlations indicated positive correlations between the EDT, CTM‐3, and CAT‐T. Conclusion: The EDT measure demonstrates content validity, structural validity, convergent validity, discriminant validity, and high internal consistency (i.e., reliability). This newly developed patient reported outcome measure can be used in future clinical and research work to better understand the impact of ED interventions on quality‐of‐care transitions for patients with diagnostic uncertainty.

Objectives: More than one‐third of discharged emergency department (ED) patients leave without a clear diagnosis for their symptoms. In 2019–2020, we implemented a simulation‐based mastery learning curriculum across two academic medical centers to train emergency medicine residents to discuss diagnostic uncertainty during ED discharge, guided by the Uncertainty Communication Checklist (UCC). We sought to assess if this cohort continues to apply skills learned and to obtain trainee insights into the most valuable checklist items.Methods: A survey was emailed to all 109 participants who completed the training in 2019–2020. Questions assessed how often participants currently encountered uncertainty and used the skills learned in the curriculum. Additionally, participants rated how important it was to keep each of the 21 UCC items in future uncertainty communication training (4‐point Likert scale: very important/important/low importance/not important). Means and proportions are reported.Results: Sixty‐five individuals responded (60%). Mean age was 33; and 30.8% were female. More than 90% encountered diagnostic uncertainty more than once per shift, and 74% applied skills learned in the training “often” or “all the time.” Seven of the 21 UCC items received endorsement by more than 70% of respondents as “very important” to retain in future trainings. The item receiving the most endorsement as “very important” (90%) was to “Clearly state that either ‘life‐threatening’ or ‘dangerous’ conditions have not been found.” Items with lower rankings related to generally accepted communication best‐practices (e.g., “make eye contact”).Conclusion: Four years following diagnostic uncertainty training completion, most respondents frequently employ skills learned from uncertainty communication training.

Purpose. There are no standardized approaches for communicating with patients discharged from the emergency department with diagnostic uncertainty. This trial tested efficacy of the Uncertainty Communication Education Module, a simulation-based mastery learning curriculum designed to establish competency in communicating diagnostic uncertainty. Method. Resident physicians at 2 sites participated in a 2-arm waitlist randomized controlled trial from September 2019-June 2020. After baseline (T1) assessment of all participants via a standardized patient encounter using the Uncertainty Communication Checklist (UCC), immediate access physicians received training in the Uncertainty Communication Education Module, which included immediate feedback, online educational modules, a smartphone-based application, and telehealth deliberate practice with standardized patients. All physicians were retested 16-19 weeks later (T2) via in-person standardized patient encounters; delayed access physicians then received the intervention. A final test of all physicians occurred 11-15 weeks after T2 (T3). The primary outcome measured the percentage of physicians in the immediate versus delayed access groups meeting or exceeding the UCC minimum passing standard at T2. Results. Overall, 109 physicians were randomized, with mean age 29 years (range 25-46). The majority were male (n = 69, 63%), non-Hispanic/Latino (n = 99, 91%), and White (n = 78, 72%). At T2, when only the immediate access group had received the curriculum, immediate access physicians demonstrated significantly increased mastery (n = 29, 52.7%) compared to delayed access physicians (n = 2, 3.7%, P < .001; estimated adjusted odds ratio of mastery for the immediate access group, 31.1 [95% CI, 6.8–143.1]). There were no significant differences when adjusting for training site or stage of training. Conclusions. The Uncertainty Communication Education Module significantly increased mastery in communicating diagnostic uncertainty at the time of first post-intervention test among emergency physicians in standardized patient encounters. Further work should assess the impact of clinical implementation of these communication skills.