A Study of the Contextual Factors Influencing Emergency Department Clinician’s Diagnostic Test Ordering Decision Making

Australia’s total number of pathology tests and imaging services covered by the Medicare Benefits Schedule has increased by over 50% in the last decade. Given that 20-25% of the common pathology tests were considered inappropriate nationwide, an increasing burden is being placed on the whole healthcare system by unnecessary diagnostic tests (UDTs). The objective of this exploratory study is to identify the contextual factors that could influence a clinician’s diagnostic test ordering decision-making (DTODM) in an Emergency Department (ED). Semi-structured interviews were conducted with 19 ED clinicians. Four factors have been identified, including organizational context, patient/family preferences, resource availability, and influences by senior clinicians. The study offers new lenses in clinical reasoning for emergency medicine teaching and training through the eyes of ED clinicians. It also outlines an opportunity to introduce novel clinical decision support to assist with clinicians’ test ordering without causing alert fatigue or bringing stress

The Australasian Resuscitation In Sepsis Evaluation : fluids or vasopressors in emergency department sepsis (ARISE FLUIDS), a multi-centre observational study describing current practice in Australia and New Zealand

Objectives: To describe haemodynamic resuscitation practices in ED patients with suspected sepsis and hypotension. Methods: This was a prospective, multicentre, observational study conducted in 70 hospitals in Australia and New Zealand between September 2018 and January 2019. Consecutive adults presenting to the ED during a 30-day period at each site, with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation, were eligible. Data included baseline demographics, clinical and laboratory variables and intravenous fluid volume administered, vasopressor administration at baseline and 6- and 24-h post-enrolment, time to antimicrobial administration, intensive care admission, organ support and in-hospital mortality. Results: A total of 4477 patients were screened and 591 were included with a mean (standard deviation) age of 62 (19) years, Acute Physiology and Chronic Health Evaluation II score 15.2 (6.6) and a median (interquartile range) systolic blood pressure of 94 mmHg (87–100). Median time to first intravenous antimicrobials was 77 min (42–148). A vasopressor infusion was commenced within 24 h in 177 (30.2%) patients, with noradrenaline the most frequently used (n = 138, 78%). A median of 2000 mL (1500–3000) of intravenous fluids was administered prior to commencing vasopressors. The total volume of fluid administered from pre-enrolment to 24 h was 4200 mL (3000–5661), with a range from 1000 to 12 200 mL. Two hundred and eighteen patients (37.1%) were admitted to an intensive care unit. Overall in-hospital mortality was 6.2% (95% confidence interval 4.4–8.5%). Conclusion: Current resuscitation practice in patients with sepsis and hypotension varies widely and occupies the spectrum between a restricted volume/earlier vasopressor and liberal fluid/later vasopressor strategy

Why Are You Doing This: A Dual-Process-Model-Based Clinical Decision-Making Framework for Diagnostic Test Ordering

Many interventions were conducted to reduce unnecessary diagnostic tests. Although the interventions proved effective, the sustainability of the interventions was questionable. In order to understand why clinicians over-order and design sustainable interventions, it is imperative to investigate clinician’s decision-making process of diagnostic test ordering. This research aims to establish a relation between clinician’s decision-making patterns with clinician experience and patient complexity by adopting dual process theory (DPT) from behavioral economics as the theoretical foundation. DPT holds that human decisions are made by two systems, fast and skilled System 1 and slow and analytical System 2. The contributions in our study are clinical decision-making models and framework for diagnostic test ordering. The clinical decision-making models depict different cognitive pathways of System 1 and System 2. The framework highlights the patient complexity and clinician’s experience level as potential factors to influence the reasoning mode about ordering a diagnostic test

Predicting Patient Length of Stay in Australian Emergency Departments Using Data Mining

Length of Stay (LOS) is an important performance metric in Australian Emergency Departments (EDs). Recent evidence suggests that an LOS in excess of 4 h may be associated with increased mortality, but despite this, the average LOS continues to remain greater than 4 h in many EDs. Previous studies have found that Data Mining (DM) can be used to help hospitals to manage this metric and there is continued research into identifying factors that cause delays in ED LOS. Despite this, there is still a lack of specific research into how DM could use these factors to manage ED LOS. This study adds to the emerging literature and offers evidence that it is possible to predict delays in ED LOS to offer Clinical Decision Support (CDS) by using DM. Sixteen potentially relevant factors that impact ED LOS were identified through a literature survey and subsequently used as predictors to create six Data Mining Models (DMMs). An extract based on the Victorian Emergency Minimum Dataset (VEMD) was used to obtain relevant patient details and the DMMs were implemented using the Weka Software. The DMMs implemented in this study were successful in identifying the factors that were most likely to cause ED LOS &gt; 4 h and also identify their correlation. These DMMs can be used by hospitals, not only to identify risk factors in their EDs that could lead to ED LOS &gt; 4 h, but also to monitor these factors over time

First case of Mycobacterium ulcerans disease (Bairnsdale or Buruli ulcer) acquired in New South Wales

Mycobacterium ulcerans is a slow-growing environmental bacterium that causes Buruli ulcer (also known as Bairnsdale ulcer in Victoria and Daintree ulcer in northern Queensland). We describe two patients with laboratory-confirmed Buruli ulcer who were infected either in New South Wales or overseas. A molecular epidemiological investigation demonstrated that, while one case was probably acquired in Papua New Guinea, the other was most likely to have been acquired in southern NSW. To our knowledge, this is the first case of M. ulcerans infection acquired in NSW