"Everything looks reassuring.": Managing uncertainty during the emergency department discharge process.

Abstract

Diagnostic uncertainty is prevalent in the emergency department (ED) setting. We examined how uncertainty was communicated during naturally occurring interactions between clinicians (physicians, physician assistants, nurse practitioners, and nurses) and adult patients during the ED discharge process. We audio-recorded conversations during the discharge process of 40 adult patients (age 18 and older). Each patient participant had an interaction with an RN recorded and 15 also had an interaction with an HCP (defined as physician, physician assistant or nurse practitioner) recorded. There were 10 HCPs, including six physicians, three physician assistants, and one nurse practitioner. We used conversation analysis, a qualitative method, to explore how uncertainty is communicated during discharge conversations. HCPs use results of diagnostic testing, expert recommendation, and their own assessment as sources of evidence for their decision to discharge patients from the ED. HCPs check in with patients to confirm patient alignment with the plan for discharge and outpatient follow-up or to verify the usefulness of treatment. Emergency HCPs account for their decision to discharge patients home from the ED despite uncertainty. They provide patients with evidence that the workup was thorough, the most dangerous conditions have been ruled out, and they are safe to be discharged with outpatient follow-up. Our study showed that in the high-stakes environment of the ED, HCPs do communicate uncertainty. Despite the uncertainty, HCPs showed they were accountable to patients to demonstrate they were safe to go home. Checking in with the patient might be a way to assess their feelings of safety but further study is necessary.