The implication of such a call is magnified by the scope of the training. In the studies in which clinicians accurately applied the HINTS examination, the training consisted of an initial six hours of lectures and workshops which was repeated seven months later. It is costly to ask the entire emergency-medicine workforce to undergo specialized training with an in-person workshop, let alone a second, followup episode. There is no evidence yet whether other training frameworks are adequate, nor is there evidence to inform the frequency or intensity with which HINTS skills require reinforcement. Absent an easier path forward for upskilling the workforce, the reliance of GRACE-3 on HINTS to inform its practice recommendations limits its present real-world application.

These are just the initial pieces of work under the banner of attempting to inform “reasonable” care in the emergency department. The most striking aspect of most of this work is how little evidence directly informs the sorts of decisions facing clinicians every day. Having identified these gaps provides a road map for future research, and one hopes some of these questions can be revisited in the future with more robust recommendations.

Dr. Radecki is an emergency physician and informatician with Christchurch Hospital in Christchurch, New Zealand. He is the Annals of Emergency Medicine podcast co-host and Journal Club editor and can be found on Twitter @emlitofnote.

References

1. Society for Academic Emergency Medicine. About SAEM. SAEM website. Accessed July 14, 2023.
2. Musey PI, et al. Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low‐risk chest pain in the emergency department. Acad Emerg Med. 2021;28(7):718-744.
3. Broder JS, et al. Guidelines for reasonable and appropriate care in the emergency department 2 (GRACE‐2): Low‐risk, recurrent abdominal pain in the emergency department. Academic Emergency Medicine. 2022;29(5):526-560.
4. Edlow JA, et al. Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department. Academic Emergency Medicine. 2023;30(5):442-486.
5. Westafer, L. New guidelines aim to help the evaluation of chest pain. ACEP Now. 2021;40(9):17.