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Uncertainty a Common Cause for Repeat Emergency Department Visits


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Until now, the reasons why patients return to the emergency department after an initial visit have been anyone’s guess.

“We don’t do a good job of predicting which patients will come back to the emergency department, which means we don’t have a good understanding of why patients are coming back and how we could be assisting them in having a safer transition home from the first emergency department visit,” Kristin Rising, MD, director of acute care transitions and associate professor of emergency medicine at Jefferson in Philadelphia, says in a news release.

However, through interview-based studies, Rising identified a common theme among these patients—uncertainty.

To better understand, document, and create effective solutions to address uncertainty—whether it be about managing symptoms or a disease process—Rising and a team of Jefferson researchers developed the Uncertainty Scale.

“As a field, we’ve had difficulty finding an approach that consistently works to identify and address individual patient needs. The Uncertainty Scale we developed gives us a tool to help do that,” Rising says.

Reasons for Uncertainty

The researchers took a patient-centered approach and developed the U-Scale based on direct patient input and listening sessions. The team spent two 6-hour days with two groups, each of about 20 patients, who had recently been patients in the ED. The patients brainstormed the types of uncertainty people have when they experience symptoms that may trigger an ED visit. They then worked with the research team to map the ideas into categories.

Some of the categories were:
 

  1. Concern over treatment quality, which may lead a patient to return in hopes of a second opinion
  2. Concern about lack of a diagnosis, thus leaving a patient with no satisfying explanation for their symptoms
  3. Lack of clarity regarding self-management, such that patients are unsure how to deal with symptoms at home
  4. Lack of self-efficacy, manifesting as patients not knowing where to go for help for certain symptoms
  5. Lack of clarity about the decision to seek care, meaning that patients do not know which symptoms are serious enough to warrant seeing a health professional
  6. Psychosocial factors, including worries that getting medical care might interfere with home and work commitments
  7. General worries and concerns

    

Improve Provider-Patient Conversations

Rising advocates for training healthcare professionals about patient struggles related to uncertainty. She is working to develop a curriculum to teach physician residents to have more effective discharge conversations with patients when testing has not identified a definitive cause of their symptoms.

“As emergency physicians, we focus primarily on acute care, fixing the most immediate life-threatening problems. Facilitating a safe and effective transition home for patients who do not appear to have a life-threatening problem is also a really critical part of our job that is often overlooked,” Rising says.

The research has changed how Rising delivers news to her patients. She realized what she considers good news – that tests are normal and a patient’s symptoms do not appear to be life threatening – could actually be experienced as bad news from the patient perspective. She now takes time to acknowledge and validate potential patient struggles related to ongoing uncertainty.

“If a patient comes in with a problem and I tell him that testing is normal and I haven’t found a cause of his symptoms, it might give momentary relief, but that patient still is no closer to understanding what is causing his distress. It’s not all good news, and we have to acknowledge that we have not improved patients’ sense of uncertainty about their disease with this news,” she says.

The team of researchers plans to continue to refine and validate the U-Scale, and use it to test interventions to alleviate different categories of uncertainty.

The results the research team’s work were published in the Journal of Health Psychology.