Navigating uncertainty with GRACE: Society for Academic Emergency Medicine’s guidelines for reasonable and appropriate care in the emergency department

Carpenter, Christopher R.; Bellolio, M. Fernanda; Upadhye, Suneel; Kline, Jeffrey A.

doi:10.1111/acem.14297

Cited by 18 publications

(12 citation statements)

References 39 publications

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“…Analogous to the case with ultrasound then, I expect now to hear some grumbling about having to learn new skills to distinguish peripheral from central causes of nonmedical dizziness. Based on multiple studies, discovered and processed using the rigorous GRADE methodology, the expert panel sets forth the evidence‐based rational to compel us to learn the head impulse test and the Dix–Hallpike test, and Epley and supine roll maneuvers 2,9 . (Note, whether you use the HINTS or STANDING methodology, both require the head impulse test.)…”

Section: Figurementioning

confidence: 99%

GRACE‐3: Be the baller

Meziani

2023

Academic Emergency Medicine

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Section: Figurementioning

confidence: 99%

GRACE‐3: Be the baller

Meziani

2023

Academic Emergency Medicine

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“…Low‐risk undifferentiated abdominal pain has been identified by the Society for Academic Emergency Medicine's (SAEM) Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE‐2) Steering Committee as a high‐priority clinical scenario 13 . Frequently, emergency physicians provide care for patients with recurrent episodes of abdominal pain after a prior ED evaluation that included imaging and must weigh the potential benefits and risks of reimaging after the index evaluation.…”

Section: Introductionmentioning

confidence: 99%

“…The objective of this evidence synthesis was to perform a systematic review to accompany the Grading of Recommendations Assessment Development and Evaluation (GRADE)‐adherent SAEM GRACE‐2 guideline 13 for “recurrent low‐risk abdominal pain” on the question of repeat CT imaging within 12 months of a prior indeterminate CT with the outcomes of (1) hospital or intensive care unit (ICU) admission rate within 30 days; (2) abdominal surgery or other invasive procedure within 30 days; (3) 30‐day mortality; (4) identification of potentially life‐threatening diagnoses; and (5) return ED visits within 30 days.…”

Section: Introductionmentioning

confidence: 99%

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Repeat computed tomography in recurrent abdominal pain: An evidence synthesis for guidelines for reasonable and appropriate care in the emergency department

Carpenter

Griffey

Mills

et al. 2021

Academic Emergency Medicine

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Objective: Computed tomography (CT) imaging is frequently obtained for recurrent abdominal pain after a prior emergency department (ED) evaluation. We evaluate the utility of repeat CT imaging following an indeterminate index CT in low-risk abdominal pain adult ED patients.Methods: An electronic search was designed for the patient-intervention-controloutcome-timing (PICOT) question: (P) adult patients with low-risk, recurrent, and previously undifferentiated atraumatic abdominal pain presenting to the ED after an index-negative CT within 12 months; (I) repeat CT versus (C) no repeat CT; for (O) abdominal surgery or other invasive procedure, mortality, identification of potentially life-threatening diagnosis, and hospital and intensive care unit admission rates; and return ED visit (T), all within 30 days. Four reviewers independently selected evidence for inclusion and then synthesized the results around the most prevalent themes of repeat CT timing, diagnostic yield, ionizing radiation exposure, and predictors of repetitive imaging.Results: Although 637 articles and abstracts were identified, no direct evidence was found. Thirteen documents were synthesized as indirect evidence. None of the indirect evidence defined a low-risk subset of abdominal pain nor did investigators describe whether reimaging occurred for complaints similar to the initial ED evaluation.Included studies did not describe the index CT findings and some reported explanatory findings noted on the original CT for which repeat CTs might have been indicated.The time frame for a repeat CT ranged from hours to 1 year. The frequency of repeat CTs (2%-47%) varied across studies as did the yield of imaging to alter downstream clinical decision making (range = 5%-67%). Conclusion:Due to the absence of direct evidence our scoping review is unable to provide high-quality evidence-based recommendations upon which to confidently INTRODUC TI ONNontraumatic abdominal pain is the most common principal reason to visit an emergency department (ED) in the United States, representing 8.5% of visits based on data from the National Hospital Ambulatory Medical Care Survey (2018). 1 The frequency of repeat ED visits for "low-risk" and "undifferentiated" abdominal pain is unknown, but repeated visits for abdominal pain are common. In 2014, abdominal pain accounted for 15%-34% of all ED superutilizer visits, defined as patients with annual ED visits exceeding two standard deviations above the mean stratified by payer and age group. Among superutilizers, abdominal pain was the most common diagnosis in all age groups and payer types, with the sole exception of Medicareinsured patients aged 65 years and greater, in which it was the third most common diagnosis (Table 1). 2Computed tomography (CT) imaging for abdominal pain in the ED increased significantly over the past three decades. 3-5 CT often facilitates timely surgical diagnoses, excludes intraabdominal pathology, increases clinician and patient confidence in diagnosis, and can facilitate discharge rather than admiss...

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“…The objective of this evidence synthesis was to support the Society for Academic Emergency Medicine (SAEM) in developing clinical practice guidelines 17 on the management of recurrent abdominal pain in the ED, specifically on the question about screening for depression and/or anxiety.…”

Section: Introductionmentioning

confidence: 99%

Depression and anxiety screening in emergency department patients with recurrent abdominal pain: An evidence synthesis for a clinical practice guideline

Silva

Prakken

Meltzer

et al. 2021

Academic Emergency Medicine

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Background Recurrent abdominal pain in the emergency department (ED) might represent an opportunity for screening of depression and/or anxiety. Methods We systematically searched five databases for studies evaluating the effect of screening for depression and/or anxiety in ED patients with recurrent and undifferentiated abdominal pain. Given paucity of direct evidence, we also searched for indirect evidence including studies that assessed prevalence of depression and/or anxiety in EDs (not necessarily recurrent abdominal pain), diagnostic accuracy of screening tools, effectiveness of screening in other settings, and outcomes such as repeat ED visits of patients with abdominal pain who were screened in the ED. Two methodologists evaluated certainty in the evidence using the GRADE approach. Results A total of 4,337 citations were reviewed, and zero studies were found on the effect of screening in patients with recurrent and undifferentiated abdominal pain in the ED. A total of 35 studies were included as relevant indirect evidence. In studies of ED patients with abdominal pain, depression ranged from 10% to 29%, while anxiety ranged from 18% to 50%. False positives appear to be an issue given relatively low specificity of screening tools. One randomized trial including ED patients with vague symptoms evaluated the effect of depression screening on a composite outcome of depression recognition, psychiatric consultation, or referral by the emergency physician (risk ratio = 1.49, 95% confidence interval [CI] = 0.49 to 4.53, very low certainty). One study reported that patients with undifferentiated abdominal pain who screened positive for depression have had increased ED recidivism (odds ratio = 3.17, 95% CI = 1.14 to 8.85, very low certainty). Conclusions We were unable to identify any evidence that confirms that depression or anxiety screening in ED patients with recurrent and undifferentiated abdominal pain improves outcomes or changes management downstream.

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Navigating uncertainty with GRACE: Society for Academic Emergency Medicine’s guidelines for reasonable and appropriate care in the emergency department

Cited by 18 publications

References 39 publications

GRACE‐3: Be the baller

GRACE‐3: Be the baller

Repeat computed tomography in recurrent abdominal pain: An evidence synthesis for guidelines for reasonable and appropriate care in the emergency department

Depression and anxiety screening in emergency department patients with recurrent abdominal pain: An evidence synthesis for a clinical practice guideline

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