Managing and Communicating Diagnostic Uncertainty in Pediatric Emergency Care: National Insights and Opportunities for Intervention.

backgroundEffective management and communication of diagnostic uncertainty are critical, yet understudied, drivers of patient safety in pediatric emergency care. We explored how clinicians manage and communicate diagnostic uncertainty and identified opportunities for intervention.

methodsFour 1-hour-long focus groups were conducted with 19 geographically diverse emergency medicine physicians. Discussions focused on clinical vignettes with diagnostic uncertainty. Reflexive thematic analysis was used to generate themes.

resultsParticipants described diagnostic uncertainty as a multidimensional experience involving complex interactions between the clinician, caregiver, and context. We identified 3 distinct themes: (1) Intersection of clinician's usual practice pattern with caregiver and contextual factors: Within the guardrails of safety and evidence-based care, clinicians adjust management and communication to caregiver expectations, health literacy, resources, acuity, and volume. (2) Synergies at the clinician, caregiver, and context interfaces: Shared decision-making, decision support tools, and primary care continuity facilitate clinician-caregiver alignment and safety. (3) Tensions at the interfaces: Perceived misaligned clinician-caregiver expectations, space constraints, and limited access to care promote additional work-up and hinder communication. Participants highlighted intervention opportunities to promote patient safety in uncertainty and reduce ED work-up: (1) standard tools to communicate uncertainty, (2) disease-specific risk prediction models with visual aids to effectively communicate risk, (3) improvements to the physical space, and (4) interventions to streamline access to primary care.

conclusionDiagnostic uncertainty in pediatric emergency care is a multidimensional experience influenced by synergies and tensions between the clinician, caregiver, and context. Communication tools, decision-support strategies, and systems-level interventions can strengthen diagnostic safety in pediatric emergency care.