Gradually Circling Around the GRACE Project’s “Reasonable Practice”

There is no shortage of guidelines, protocols, or quality measures across emergency medicine. Regardless of the domain, somewhere an expert panel has convened to issue a pronouncement informing all of the ideal care of patients under their specialty umbrella, indirectly extending to their care in the emergency department. A common limitation to many of these guidelines, however, is the lack of recognition of available resources or the unique challenges of certain patient groups. In an environment in which patients may have their entire work-up in the waiting room, or attend a critical access hospital staffed by non-emergency physicians, or lack the financial support to follow up with an appropriate specialist, a pragmatic approach to care is required.

This real-world pragmatism is the guiding principle embodied by the Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE) project, published by the Society for Academic Emergency Medicine. Rather than focus on the narrow evidence supporting recommendations for a precisely diagnosed clinical syndrome, these guidelines try to create an expert consensus for the approach, as stated on their website, “to the care of the most common chief complaints that can be seen on the tracking board of any emergency department in the country.”1

To date, there have been three GRACE publications. The first describes approaches to chest pain, the second, abdominal pain, and the more recent third, vertigo.2-4 A fourth is planned for publication in late 2023, and will address non-opioid substance dependence. Each of these chooses a set of practice-based questions and applies the grading of recommendations assessment development and evaluation (GRADE) methodology, a framework for rating the quality of the best available evidence and developing clinical practice recommendations.

The first, GRACE-1, addresses adult patients with “recurrent, low-risk chest pain,” a patient population commonly encountered in emergency departments. The specific recommendations from this publication have already been covered in a prior issue by Lauren Westafer, DO, MPH, MS, with an overview of the mixed-strength clinical guidance across the spectrum of chest-pain representations.5 An important theme, however, begins to emerge regarding how little evidence directly informs a substantial fraction of clinical practice, and the extent to which we rely on indirect generalization.

The second, GRACE-2, addresses adult patients with “low-risk, recurrent abdominal pain” in the emergency department. While “low-risk” chest pain is more easily described using scoring systems, undifferentiated abdominal pain is less well-defined. In this instance, the authors describe a population based in sensible clinical judgement, including an absence of trauma, recent abdominal surgery, cancer, and concerning physical findings.