Department of Surgery, Amsterdam University Medical Center at the University of Amsterdam, Location AMC, Amsterdam, the Netherlands.
Faculty of Medicine, University of Amsterdam, Amsterdam, the Netherlands.
Acad Emerg Med. 2024 Oct;31(10):1037-1049. doi: 10.1111/acem.14998. Epub 2024 Aug 23.
The objective was to systematically review all studies focusing on barriers, facilitators, and tools currently available for shared decision making (SDM) in emergency departments (EDs).
Implementing SDM in EDs seems particularly challenging, considering the fast-paced environment and sometimes life-threatening situations. Over 10 years ago, a previous review revealed only a few patient decision aids (PtDAs) available for EDs.
Literature searches were conducted in MEDLINE, Embase, and Cochrane library, up to November 2023. Observational and interventional studies were included to address barriers or facilitators for SDM or to investigate effects of PtDAs on the level of SDM for patients visiting an ED.
We screened 1946 studies for eligibility, of which 33 were included. PtDAs studied in EDs address chest pain, syncope, analgesics usage, lumbar puncture, ureterolithiasis, vascular access, concussion/brain bleeding, head-CT choice, coaching for elderly people, and activation of patients with appendicitis. Only the primary outcome was meta-analyzed, showing that PtDAs significantly increased the level of SDM (18.8 on the 100-point OPTION scale; 95% CI 12.5-25.0). PtDAs also tended to increase patient knowledge, decrease decisional conflict and decrease health care services usage, with no obvious effect on overall patient satisfaction. Barriers and facilitators were identified on three levels: (1) patient level-emotions, health literacy, and their own proactivity; (2) clinician level-fear of medicolegal consequences, lack of SDM skills or knowledge, and their ideas about treatment superiority; and (3) system level-time constraints, institutional guidelines, and availability of PtDAs.
Circumstances in EDs are generally less favorable for SDM. However, PtDAs for conditions seen in EDs are helpful in overcoming barriers to SDM and are welcomed by patients. Even in EDs, SDM is feasible and supported by an increasing number of tools for patients and physicians.
系统回顾所有关注目前在急诊科（ED）中实施共享决策（SDM）的障碍、促进因素和工具的研究。
考虑到快节奏的环境和有时危及生命的情况，在 ED 中实施 SDM 似乎特别具有挑战性。十多年前，之前的一项综述仅发现了少数几种适用于 ED 的患者决策辅助工具（PtDA）。
检索 MEDLINE、Embase 和 Cochrane 图书馆中的文献，截至 2023 年 11 月。纳入观察性和干预性研究，以解决 SDM 的障碍或促进因素，或调查 PtDA 对 ED 就诊患者 SDM 水平的影响。
我们对 1946 项研究进行了筛选，以确定其是否符合纳入标准，其中 33 项研究被纳入。在 ED 中研究的 PtDA 针对胸痛、晕厥、镇痛药使用、腰椎穿刺、输尿管结石、血管通路、 concussion/brain bleeding、头部 CT 选择、老年人辅导和阑尾炎患者激活。仅对主要结局进行了荟萃分析，结果表明 PtDA 显著提高了 SDM 水平（100 分 OPTION 量表上为 18.8；95%CI 12.5-25.0）。PtDA 还倾向于增加患者知识，降低决策冲突，减少医疗服务使用，对总体患者满意度没有明显影响。障碍和促进因素在三个层面上被识别：（1）患者层面——情绪、健康素养和他们自身的积极性；（2）临床医生层面——对医疗法律后果的恐惧、缺乏 SDM 技能或知识，以及他们对治疗优势的看法；（3）系统层面——时间限制、机构指南和 PtDA 的可用性。
ED 中的情况通常不利于 SDM。然而，适用于 ED 中情况的 PtDA 有助于克服 SDM 的障碍，并且受到患者的欢迎。即使在 ED 中，SDM 也是可行的，并得到越来越多的患者和医生工具的支持。
