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• W3087049021 abstract "Parents of febrile young infants who present to the emergency department (ED) are frequently overwhelmed, surprised by the potential seriousness of their child's condition and the need for extensive testing and possible hospitalization.1 In this stressful context, communication can be challenging. Emergency physicians are faced with the responsibilities of explaining the need for testing, answering questions, addressing concerns, and providing support. Yet, a clear exchange of information between the medical team and the family is the foundation of shared decision making (SDM). SDM aims to engage parents and clinicians in a partnership to make medical decisions that are supported by the best available evidence and aligned with the patient's values, preferences, and treatment goals.2, 3 SDM is appropriate in situations meeting at least one of the following criteria: 1) clinical equipoise; 2) high-risk intervention with uncertain or variable efficacy; 3) invasive, low-yield interventions; or 4) lack of definitive evidence regarding the optimal choice.4 The questions associated with the management of the febrile young infant meet these criteria. Patient decision aids are evidence-based tools that inform the SDM process by helping families make informed choices among several reasonable health care options. They facilitate conversation among stakeholders and improve patient engagement.4, 5 In adult patients, the use of patient decision aids leads to a greater knowledge of management options and increasing accuracy of risk perception without determinantal effects on anxiety, patient satisfaction, or health outcomes.5 While data for SDM in children are more limited, SDM interventions seem to increase patient/family knowledge and reduce decisional conflict.2 In this month's issue of Academic Emergency Medicine, Aronson et al.6 describe the development and testing of a Web-based SDM application that was created to assist in the communication between clinicians and parents of infants ≤ 60 days of age who are undergoing evaluation for fever. The authors used a four-phase approach to identify preferences of parents and clinicians for a communication and SDM tool, creation of a storyboard, development of a prototype, and usability testing of this tool. This app sought to inform parents about the management of their febrile young infants, explaining the rationale and the types of tests to be performed. For febrile infants ≤ 28 days of age, the app then explains what happens after ED testing (i.e., administration of antibiotics and hospitalization). For infants 29 to 60 days of age, the app categorized these infants into one of three possible categories: high risk for invasive bacterial disease, probable urinary tract infection but low risk for invasive disease, and low risk for any bacterial infection. For the latter two categories, the app discussed the option of lumbar puncture or no lumbar puncture. There is much to be commended about the development process for this tool. The creators addressed many of the barriers to effective SDM. They incorporated input from both parent and provider stakeholders, reaching thematic saturation. The app underwent an iterative revision process, and the designer ensured both readability and usability. The app provided the rationale for testing and addressed the benefits and risks of lumbar puncture while acknowledging the family's values and priorities. While this tool was designed address the needs of the family stakeholders, the degree to which the authors incorporate physician engagement is less clear. The febrile young infant decision rule used to serve as the roadmap for risk stratification in this decision tool was not specified. What criteria did they stratify patients into high-risk and low-risk categories? How were urinary tract infections defined? These details are important, because there is substantial practice variation in the performance of tests (and not just lumbar puncture) and admission thresholds among emergency providers.7-9 A clinician's trust in a particular approach to the evaluation of the febrile young infant will undoubtedly influence physician directiveness, even in this SDM model.10 Further study of this SDM tool might want to include provider-centric outcome measures, such as the effects on provider productivity, resource utilization, and medicolegal risk.11 Additionally, the creators of this tool deemed that febrile neonates ≤ 28 days of age are at too high risk for serious outcomes and must undergo lumbar puncture and admission. Effectively, these patients were ineligible for the “shared” component of the SDM. The authors decreed this despite the fact that the absolute rates of invasive bacterial infection are low.12-14 How low is low enough to forgo lumbar puncture, antibiotics and admission? In fact, these are questions that may be best answered by SDM. Shared decision tools have been recently created for pediatric appendicitis15 and minor head injury,16 and the benefits from those tools remain unclear. It remains to be seen if this app will have a positive impact on patient and family-centered measures and clinical outcomes. Because SDM is affected by many factors such race,17 culture,18 and health literacy,19 the effectiveness of this tool will have to be assessed in different settings. Furthermore, because of the perpetually evolving approach to febrile young infants,20-22 this tool will likely require continued refinement and revision. However, this tool seems like the logical extension of the work done already by Aronson and his colleagues on SDM in the febrile young infant,23-25 and the authors have done a significant service by describing this development process, which will undoubtedly be beneficial to others looking to develop similar SDM aids." @default.
• W3087049021 created "2020-09-25" @default.
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• W3087049021 date "2020-10-13" @default.
• W3087049021 modified "2023-10-17" @default.
• W3087049021 title "Sharing Is Caring: Can an App Help?" @default.
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• W3087049021 doi "https://doi.org/10.1111/acem.14133" @default.
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