Evaluating User Satisfaction and Organisational Benefits of Electronic Medication Management System in an Australian Hospital

In this conceptual paper, we speculate on the possibility that a PhD by Artefact and Exegesis (A&E) may be legitimate in the Information Systems (IS) discipline. Research, as creative process and product with the intention of yielding new knowledge, takes many forms across the spectrum of academic disciplines. Other disciplines, particularly in the humanities’ fields of arts and design, have artefacts as a discrete part of their PhD product accompanied by an exegesis of one form or another. It may be that some research in the IS discipline lends itself to the A&E approach. This paper considers A&E PhDs in Humanities and how practice-based research is presented. We explore how A&E might apply to IS research, through comparison with the design science approach. We suggest tentative impacts on candidates, supervisors and examiners then conclude with the issues and open questions raised by our investigations

Behavioural ‘nudging’ interventions to reduce low-value care for low back pain in the emergency department (NUDGED): protocol for a 2×2 factorial, before-after, cluster randomised trial

Introduction:Opioids and imaging are considered low-value care for most people with low back pain. Yet around one in three people presenting to the emergency department (ED) will receive imaging, and two in three will receive an opioid. NUDG-ED aims to determine the effectiveness of two different behavioural ‘nudge’ interventions on low-value care for ED patients with low back pain. Methods and analysis:NUDG-ED is a 2×2 factorial, open-label, before-after, cluster randomised controlled trial. The trial includes 8 ED sites in Sydney, Australia. Participants will be ED clinicians who manage back pain, and patients who are 18 years or over presenting to ED with musculoskeletal back pain. EDs will be randomly assigned to receive (i) patient nudges, (ii) clinician nudges, (iii) both interventions or (iv) no nudge control. The primary outcome will be the proportion of encounters in ED for musculoskeletal back pain where a person received a non-indicated lumbar imaging test, an opioid at discharge or both. We will require 2416 encounters over a 9-month study period (3-month before period and 6-month after period) to detect an absolute difference of 10% in use of low-value care due to either nudge, with 80% power, alpha set at 0.05 and assuming an intra-class correlation coefficient of 0.10, and an intraperiod correlation of 0.09. Patient-reported outcome measures will be collected in a subsample of patients (n≥456) 1 week after their initial ED visit. To estimate effects, we will use a multilevel regression model, with a random effect for cluster and patient, a fixed effect indicating the group assignment of each cluster and a fixed effect of time. Ethics and dissemination:This study has ethical approval from Southwestern Sydney Local Health District Human Research Ethics Committee (2023/ETH00472). We will disseminate the results of this trial via media, presenting at conferences and scientific publications.</p

Analysis of an 8-hour acetylcysteine infusion protocol for repeated supratherapeutic ingestion (RSTI) of paracetamol

Objectives: In Australia, the treatment guideline for patients with repeated supratherapeutic ingestion (RSTI) of paracetamol recommends an abbreviated acetylcysteine regimen if the paracetamol concentration is low (1000 IU/L). No patients with an initial ALT <50 IU/L developed hepatotoxicity. Median duration of acetylcysteine infusion for those receiving a non-abbreviated regimen was 20 hours (IQR 20–25) vs. 10.4 hours (IQR 4.8–12.0) who received an abbreviated regimen. There were no re-presentations with hepatotoxicity. Conclusions: An 8-hour acetylcysteine infusion regimen for treatment of paracetamol RSTI may be safe and is likely to reduce length of stay for patients at low risk of hepatotoxicity. Larger prospective studies are needed to examine the efficacy of this abbreviated acetylcysteine protocol

A clinical decision instrument for head CT in intoxicated patients presenting to the emergency department: the DITCH study

AbstractPerforming head CT in intoxicated patients presenting to the emergency department (ED) is common, yet low yield. In our previous study, acute findings were found only in patients with at least one of: neurological Deficits, Intubation, Trauma, Convulsions or Headache. We hypothesise that the absence of these DITCH clinical features rules out the need for immediate CT. We collected data for intoxicated patients attending EDs in our district from March 2021 to May 2022 inclusive. We recorded clinical presentation features, agents, disposition and head CT results. There were 1,308 intoxicated patients out of a total of 219,273 ED presentations. Median age was 38 years. Common ingestions were ethanol, stimulants, GABA-ergics and opioids. 407 patients (31%) had head CT, with 31 patients (7.6%) having 36 acute findings: 19 intracranial haemorrhages, 8 fractures, 2 cerebral oedema and 7 haematomas. All patients with acute CT findings had one of the DITCH features, and all had trauma. The sensitivity and NPV of the hypothesis were 100%. In patients that were not scanned, there were no re-presentations.Our internal validation study is further evidence that acute findings on head CT in intoxicated patients presenting to the ED are only found in those who had one of the DITCH features

Patient-centric implementation of an electronic medication management system at a tertiary hospital in Western Sydney

Background: Traditional implementations of electronic medication management (EMM) systems have involved two common formats – a ‘big bang’ approach on the day of go-live, or a phased ward-by-ward approach over months. Objective: To describe the patient-centric roll-out, a novel implementation model in converting from paper to EMM. Method: This model iteratively converted a large tertiary teaching hospital to electronic from paper medication charts, commencing the roll-out in the emergency department (ED). The tenet of ‘one patient, one chart’ was maintained with new patients commenced on EMM, while existing inpatients were maintained on paper charts until their discharge. In the second week, all other intake points commenced patients on EMM, and in the third week, all remaining patients were manually converted to EMM. The implementation was assessed with training completion rates, staff satisfaction surveys, focus group interviews and incident logs. Results: At go-live, 79% of doctors, 68% of nurses and 90% of pharmacists were trained in the EMM system. The ED converted to electronic prescribing within 24 hours; by day 20, all patients were on EMM. Two hundred and thirty issues were logged, none critical, of which 22 were escalated. Of the 51,063 medications administered, there were 13 EMM-related clinical incidents including three double dosing errors, none of which led to an adverse event or death. Overall, 77% of staff surveyed were satisfied with the EMM implementation. Conclusions: The patient-centric roll-out model represents an innovative and safe approach with a single medication chart reducing transcription and improved medication safety for the patient and the organisation

Fewer adverse effects with a modified two-bag acetylcysteine protocol in paracetamol overdose

Objective: Acetylcysteine (NAC), an effective antidote for paracetamol poisoning, is commonly associated with adverse reactions. This has been postulated to be related to the rapid initial infusion rate (150mg/kg over 1h) of the traditional three-bag protocol. We hypothesized that a slower rate would result in fewer adverse reactions. Our institution in Western Sydney moved to a modified two-bag protocol in February 2015 - first bag: 200mg/kg over 4h (50mg/kg/h) and second bag: (100mg/kg over 16h).Methods: Data was extracted from our database on paracetamol overdoses treated with NAC from August 2010 to September 2016. We compared adverse reactions in patients receiving the modified two-bag protocol with a historical control (traditional three-bag regimen with initial bolus of 150mg/kg/h).Results: Over the study period 1011 paracetamol poisonings presented to our toxicology service, of which 476 required NAC (three-bag=313, two-bag=163). Demographic characteristics of the two groups were similar. Fewer anaphylactoid reactions (itch, rash, and swelling) occurred using the two-bag regimen (14% versus 5%, p=.002), a relative reduction of 66%. Similarly, there were fewer prescriptions of anti-allergy medications in the two-bag group (11% versus 4%, p=.01). There was no difference in incidence of hepatotoxicity.Conclusions: Adverse reactions to NAC were less common with the two-bag regimen. These results add to the accumulating evidence that reducing the initial NAC infusion rate reduces the risk of adverse reactions