Dissemination and Implementation of Shared Decision Making Into Clinical Practice: A Research Agenda.

Shared decision making (SDM) is essential to advancing patient-centered care in emergency medicine. Despite many documented benefits of SDM, prior research has demonstrated persistently low levels of patient engagement by clinicians across many disciplines, including emergency medicine. An effective dissemination and implementation (D&I) framework could be used to alter the process of delivering care and to facilitate SDM in routine clinical emergency medicine practice. Here we outline a research and policy agenda to support the D&I strategy needed to integrate SDM into emergency care.

The Role of Education in the Implementation of Shared Decision Making in Emergency Medicine: A Research Agenda.

Shared decision making (SDM) is a patient-centered communication skill that is essential for all physicians to provide quality care. Like any competency or procedural skill, it can and should be introduced to medical students during their clerkships (undergraduate medical education), taught and assessed during residency training (graduate medical education), and have documentation of maintenance throughout an emergency physician's career (denoted as continuing medical education). A subgroup representing academic emergency medicine (EM) faculty, residents, content experts, and patients convened at the 2016 Academic Emergency Medicine Consensus Conference on SDM to develop a research agenda toward improving implementation of SDM through sustainable education efforts. After developing a list of potential priorities, the subgroup presented the priorities in turn to the consensus group, to the EM program directors (CORD-EM), and finally at the conference itself. The two highest-priority questions were related to determining or developing EM-applicable available tools and on-shift interventions for SDM and working to determine the proportion of the broader SDM curriculum that should be taught and assessed at each level of training. Educating patients and the community about SDM was also raised as an important concept for consideration. The remaining research priorities were divided into high-, moderate-, and lower-priority groups. Moreover, there was consensus that the overall approach to SDM should be consistent with the high-quality educational design utilized for other pertinent topics in EM.

Interruptions of Trauma Resuscitations for Radiographic Procedures.

BACKGROUND: Although x-ray studies provide important diagnostic information during trauma resuscitations, they may also lead to significant interruptions in care. OBJECTIVES: We sought to determine the frequency and duration of interruptions for chest x-ray studies (CXR) and pelvic x-ray studies (PXR) and the frequency of lead apron use among providers who exited trauma rooms during resuscitation. METHODS: Using a convenience sampling method, we conducted a prospective, observational study from August 2013 to March 2014, enrolling adult trauma patients at a Level I trauma center who received CXR and PXR in the first 30 min of evaluation. An observer stood outside resuscitation rooms and recorded the time elapsed from the first provider exiting the room to the last provider returning. We recorded how many exiting providers wore lead aprons and whether unused aprons were available. RESULTS: Of the 156 trauma cases observed, 67.3% were of male patients with a mean age of 52 years (interquartile range [IQR] 34-67 years); 97.4% (184/189) of radiographs resulted in interruptions of trauma evaluation. Mean and median interruption times were 67 s and 50 s, respectively (IQR 25-95) for CXR; 37 s and 27 s, respectively (IQR 16-43) for PXR; and 160 s and 180 s, respectively (IQR 120-180) for combined CXR/PXR. A mean of 3.5 providers (IQR 3-5) left the immediate bedside and exited the room during x-ray studies. Most (91%) providers leaving the room were not wearing lead aprons, and extra aprons were available in the room 91% (167/184) of the time. CONCLUSIONS: Radiographic procedures often result in interruptions of trauma resuscitations despite the availability of lead aprons.

Access to transport for women with hypovolemic shock differs according to weeks of pregnancy.

OBJECTIVE: To examine whether women with hypovolemic shock secondary to obstetric hemorrhage are transported to referral hospitals differently depending on weeks of pregnancy in Zambia. METHODS: In a retrospective study, transport type, wait time, and transit time were assessed for women with obstetric hemorrhage and hypovolemic shock transported from 26 primary health centers to three referral hospitals during 2007-2012. A mean arterial pressure of less than 60 mm Hg was used to indicate severe shock. Women were split into two categories on the basis of the number of weeks of pregnancy (<24 weeks vs ≥24 weeks). RESULTS: Overall, 616 women were included. Mode of transport differed significantly by group (P<0.001). 414 (93.0%) of 445 women at 24 weeks of pregnancy or more were transported by ambulance versus 114 (66.7%) of 171 women at less than 24 weeks. Among those in severe shock, 106 (93.0%) of 114 women at 24 weeks of pregnancy or more were transported in ambulances versus 26 (52.0%) of 50 women at less than 24 weeks (P<0.001). CONCLUSION: Women at 24 weeks of pregnancy or more were given preference for ambulance transport even when signs of shock were equivalent. Policy-makers aiming to lower maternal mortality need to address transport issues regardless of the etiology of hemorrhage or week of pregnancy.

Outcomes after total skin-sparing mastectomy and immediate reconstruction in 657 breasts.

BACKGROUND: Total skin-sparing mastectomy (TSSM), a technique comprising removal of all breast and nipple tissue while preserving the entire skin envelope, is increasingly offered to women for therapeutic and prophylactic indications. However, standard use of the procedure remains controversial as a result oft concerns regarding oncologic safety and risk of complications. METHODS: Outcomes from a prospectively maintained database of patients undergoing TSSM and immediate breast reconstruction from 2001 to 2010 were reviewed. Outcome measures included postoperative complications, tumor involvement of the nipple-areolar complex (NAC) on pathologic analysis, and cancer recurrence. RESULTS: TSSM was performed on 657 breasts in 428 patients. Indications included in situ cancer [111 breasts (16.9%)], invasive cancer [301 breasts (45.8%)], and prophylactic risk-reduction [245 breasts (37.3%)]. A total of 210 patients (49%) had neoadjuvant chemotherapy, 78 (18.2%) had adjuvant chemotherapy, and 114 (26.7%) had postmastectomy radiotherapy. Nipple tissue contained in situ cancer in 11 breasts (1.7%) and invasive cancer in 9 breasts (1.4%); management included repeat excision (7 cases), NAC removal (9 cases), or radiotherapy without further excision (4 cases). Ischemic complications included 13 cases (2%) of partial nipple loss, 10 cases (1.5%) of complete nipple loss, and 78 cases (11.9%) of skin flap necrosis. Overall locoregional recurrence rate was 2% (median follow-up 28 months), with a 2.4% rate observed in the subset of patients with at least 3 years' follow-up (median 45 months). No NAC skin recurrences were observed. CONCLUSIONS: In this large, high-risk cohort, TSSM was associated with low rates of NAC complications, nipple involvement, and locoregional recurrence.

Outcome of long term active surveillance for estrogen receptor-positive ductal carcinoma in situ.

INTRODUCTION: An option for active surveillance is not currently offered to patients with ductal carcinoma in situ (DCIS); however a small number of women decline standard surgical treatment for noninvasive cancer. The purpose of this study was to assess outcomes in a cohort of 14 well-informed women who elected non-surgical active surveillance with endocrine treatment alone for estrogen receptor-positive DCIS. METHODS: Retrospective review of 14 women, 12 of whom were enrolled in an IRB-approved single-arm study of 3 months of neoadjuvant endocrine therapy prior to definitive surgical management. The patients in this report withdrew from the parent study opting instead for active surveillance with endocrine treatment and imaging. RESULTS: 8 women had surgery at a median follow up of 28.3 months (range 10.1-70 months), 5 had stage I IDC at surgical excision, and 3 had DCIS alone. 6 women remain on surveillance without evidence of invasive disease for a median of 31.8 months (range 11.8-80.8 months). CONCLUSION: Long-term active surveillance for DCIS is feasible in a well-informed patient population, but is associated with risk of invasive cancer at surgical excision.

The impact of preoperative magnetic resonance imaging on surgical treatment and outcomes for ductal carcinoma in situ.

BACKGROUND: Although magnetic resonance imaging (MRI) is a useful imaging modality for invasive cancer, its role in preoperative surgical planning for ductal carcinoma in situ (DCIS) has not been established. We sought to determine whether preoperative MRI affects surgical treatment and outcomes in women with pure DCIS. PATIENTS AND METHODS: We reviewed consecutive records of women diagnosed with pure DCIS on core biopsy between 2000 and 2007. Patient characteristics, surgical planning, and outcomes were compared between patients with and without preoperative MRI. Multivariable regression was performed to determine which covariates were independently associated with mastectomy or sentinel lymph node biopsy (SLNB). RESULTS: Of 149 women diagnosed with DCIS, 38 underwent preoperative MRI. On univariate analysis, patients undergoing MRI were younger (50 years vs. 59 years; P < .001) and had larger DCIS size on final pathology (1.6 cm vs. 1.0 cm; P = .007) than those without MRI. Mastectomy and SLNB rates were significantly higher in the preoperative MRI group (45% vs. 14%, P < .001; and 47% vs. 23%, P = .004, respectively). However, there were no differences in number of re-excisions, margin status, and margin size between the two groups. On multivariate analysis, preoperative MRI and age were independently associated with mastectomy (OR, 3.16, P = .018; OR, 0.95, P = .031, respectively), while multifocality, size, and family history were not significant predictors. CONCLUSION: We found a strong association between preoperative MRI and mastectomy in women undergoing treatment for DCIS. Additional studies are needed to examine the increased rates of mastectomy as a possible consequence of preoperative MRI for DCIS.

Impact of chemotherapy on postoperative complications after mastectomy and immediate breast reconstruction.

OBJECTIVES: To determine the impact of chemotherapy and the timing of chemotherapy on postoperative outcomes after mastectomy and immediate breast reconstruction. DESIGN: Retrospective review. SETTING: University tertiary care institution. PATIENTS: One hundred sixty-three consecutive patients undergoing mastectomy and immediate breast reconstruction. INTERVENTION: Systemic chemotherapy for breast cancer. MAIN OUTCOME MEASURES: Postoperative complications following mastectomy and immediate breast reconstruction. RESULTS: One hundred sixty-three patients underwent mastectomy and immediate breast reconstruction during the study period, with a mean postoperative follow-up of 19.2 months. Sixty-six percent of the patients had expander/implant reconstruction, while 33% underwent autologous reconstruction. Fifty-seven patients received neoadjuvant chemotherapy and 41 received postoperative chemotherapy. Eighteen patients (44%) in the adjuvant chemotherapy cohort developed postoperative infections, compared with 13 patients (23%) in the neoadjuvant chemotherapy group and 16 patients (25%) who did not receive any chemotherapy (P = .05). Overall, 31% of patients had a complication requiring an unplanned return to the operating room; this rate did not differ between groups (P = .79). Of patients who underwent expander/implant reconstruction, 8 women (26%) in the neoadjuvant chemotherapy cohort, 7 women (22%) in the adjuvant chemotherapy cohort, and 8 women (18%) without chemotherapy required expander or implant removal (P = .70). CONCLUSIONS: Although the highest rate of surgical site infections was in the adjuvant chemotherapy group, there were no differences between groups with respect to unplanned return to the operating room, expander loss, and donor-site complications. Neither the inclusion of chemotherapy nor the timing of its administration significantly affected the complication rates after mastectomy and immediate breast reconstruction in this population.