Targeted EHR-based Communication of Diagnostic Uncertainty in the ED

Uncertainty Scale (U-Scale)

The Uncertainty Scale (U-Scale) is a 30-item scale designed to measure patient-level uncertainty related to acute symptoms independent of underlying disease. The scale uses a 5-point Likert-style response format, asking respondents to indicate agreement with each statement from "strongly disagree" (1) to "strongly agree" (5) and leading to a nominal score range of 30-150. Higher scores indicate greater uncertainty.

The Care Transition Measure (CTM)-3

The Care Transition Measure (CTM)-3 , an abbreviated form of the Care Transition Measure, will be used to assess the quality of the care transition. The CTM-3 has been highlighted as a useful measure to capture the quality of ED-to-home care transitions to aid quality improvement. Scores can range from 0-100; the score reflects the overall quality of the care transition, with lower scored indicating a poorer quality transition, and higher scores indicating a better transition.

Transitions During Uncertainty (TDU) questionnaire

The TDU will be used to assess the quality of the care transition. The TDU was designed to assess care transitions upon ED discharge, to measure both the quality of existing care transition practices and the impact of care transition interventions.

Normalisation MeAsure Development questionnaire (NoMAD)

The NoMAD assesses staff perceptions of factors relevant to embedding the TECU intervention that change their work practices. The investigators will explore early implementation outcomes using the NoMAD with clinicians exposed to the TECU intervention.

Return emergency department (ED) visits

As the TECU is designed to improve quality of the ED discharge for patients with diagnostic uncertainty, the investigators hypothesize that ED recidivism will decrease for patients receiving the TECU-guided discharge. The investigators will evaluate rates of ED return at 9 days and 30 days. Rates of ED return and subsequent outpatient care encounters will be assessed through patient self-report at T2 (30 days) and EHR review.

Return emergency department (ED) visits

As the TECU is designed to improve quality of the ED discharge for patients with diagnostic uncertainty, the investigators hypothesize that ED recidivism will decrease for patients receiving the TECU-guided discharge. The investigators will evaluate rates of ED return at 9 days and 30 days. Rates of ED return and subsequent outpatient care encounters will be assessed through patient self-report at T2 (30 days) and EHR review.

Composite healthcare utilization

The investigators acknowledge that it is possible that, when better informed about their lack of a diagnosis, total healthcare utilization may increase as patients continue to pursue a diagnosis through outpatient visits with their primary physician or specialists. The investigators will assess 30-day composite counts of all healthcare interactions including: ED and clinic visits, admissions, testing appointments, telephone or EHR-message interactions. Data will be obtained through patient self report as well as EHR queries.

Spielberger State-Trait Anxiety Inventory (STAI-AD)

The 6-item short-form of the Spielberger State-Trait Anxiety Inventory (STAI-AD) scale of this gold-standard measure provides a reliable and sensitive measure of anxiety in relation to an event. The 6-item STAI-ID is scored using a 4-point Likert scale (1: Not at all, 2: Somewhat, 3: Moderately so, 4: Very much so), with higher scores indicating more anxiety. Scores can range from 6-24; Scores above 15 indicate the presence of anxiety symptoms.