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Laboratory tests have an important role in informing diagnosis and aiding in the determination of appropriate courses of management and/or treatment in the Emergency Department setting. Over-ordering of laboratory tests can lead to increased costs and/or unnecessary patient procedures, whilst under-ordering can lead to patient safety concerns and/or diagnostic error. Reducing over/under ordering through appropriate use of pathology has the potential to improve patient safety and/or reduce healthcare costs. As a dynamic electronic decision support tool, the Emergency Department Pathology Order Support Tool (ED POST) aims to facilitate effective ordering of pathology tests. This protocol details the methodological approach to be undertaken during the design and development of ED POST, commencing from the outset of the initial development of a prototype design. The research will undertake qualitative methods (interviews, focus group, and think-aloud observations) to develop business process models through collaboration with Emergency Department clinicians. The pre-development research will constitute stage 1 of the approach, with stage 2 focussed on evaluating the utility, usability and business process impact of the prototype to refine the prototype's design. The collaborative and qualitative multi-method approach aims to elucidate an in-depth understanding of existing laboratory test ordering and decision-making processes in the Emergency Department, serving to inform the development of a relevant and practicable solution. Health researchers and digital health developers can draw on this approach to inform research planning activities for health information technology intervention design projects and can follow the developmental journey of ED POST as its outcomes are reported in the literature. [ABSTRACT FROM AUTHOR]

The purpose of this qualitative study was to identify differences in the utilisation of an electronic medical record test–result management system between two acute care departments. Field observations (130 min) and semi-structured interviews (n = 24) were conducted in the Intensive Care Unit and Emergency Department of an Australian hospital. Work processes identified from audio transcripts were modelled using business process modelling. Comparison of the Emergency Department and Intensive Care Unit identified the following: (1) test ordering variations according to clinical roles, (2) differences in the use of electronic medical record functionality according to specific demands of the clinical environment and (3) the non-linear components of the test–result management process. Variations were identified in the number of process decisions, external collaborations and temporal process workflows. Modelling the business processes, collaboration and communication needs of individual clinical environments can aid in enhancing the quality and appositeness of health information technology interventions and thus contribute to improving patient safety. Future health information technology interventions/evaluations aimed at improving the safety of test–result management processes need to address both the nuances of the clinical environment and accommodate the individual work practices of clinicians within that environment. [ABSTRACT FROM AUTHOR]

Background: The inadequate follow-up of test results is a key patient safety concern, carrying severe consequences for care outcomes. Patients discharged from the emergency department are at particular risk of having test results pending at discharge due to their short lengths of stay, with many hospitals acknowledging that they do not have reliable systems for managing such results. Health information technology hold the potential to reducing errors in the test result management process. This study aimed to measure changes in the proportion of acknowledged radiology reports pre and post introduction of an electronic result acknowledgement system and to determine the proportion of reports with abnormal results, including clinically significant abnormal results requiring follow-up action.Methods: A before and after study was conducted in the emergency department of a 450-bed metropolitan teaching hospital in Australia. All radiology reports for discharged patients for a one-month period before and after implementation of the electronic result acknowledgement system were reviewed to determine; i) those that reported abnormal results; ii) evidence of test result acknowledgement. All unacknowledged radiology results with an abnormal finding were assessed by an independent panel of two senior emergency physicians for clinical significance.Results: Of 1654 radiology reports in the pre-implementation period 70.6% (n = 1167) had documented evidence of acknowledgement by a clinician. For reports with abnormal results, 71.6% (n = 396) were acknowledged. Of 157 unacknowledged abnormal radiology reports reviewed by an independent emergency physician panel, 34.4% (n = 54) were identified as clinically significant and 50% of these (n = 27) were deemed to carry a moderate likelihood of patient morbidity if not followed up. Electronic acknowledgement occurred for all radiology reports in the post period (n = 1423), representing a 30.4% (95% CI: 28.1-32.6%) increase in acknowledgement rate, and an increase of 28.4% (95% CI: 24.6-32.2%) for abnormal radiology results.Conclusions: The findings of this study demonstrate the potential of health information technology to improve the safety and effectiveness of the diagnostic process by increasing the rate of follow up of results pending at hospital discharge. [ABSTRACT FROM AUTHOR]

Objective: To examine the impact of an electronic Results Acknowledgement (eRA) system on emergency physicians' test result management work processes and the time taken to acknowledge microbiology and radiology test results for patients discharged from an Emergency Department (ED).Methods: The impact of the eRA system was assessed in an Australian ED using: a) semi-structured interviews with senior emergency physicians; and b) a time and motion direct observational study of senior emergency physicians completing test acknowledgment pre and post the implementation of the eRA system.Results: The eRA system led to changes in the way results and actions were collated, stored, documented and communicated. Although there was a non-significant increase in the average time taken to acknowledge results in the post period, most types of acknowledgements (other than simple acknowledgements) took less time to complete. The number of acknowledgements where physicians sought additional information from the Electronic Medical Record (EMR) rose from 12% pre to 20% post implementation of eRA.Conclusions: Given that the type of results are unlikely to have changed significantly across the pre and post implementation periods, the increase in the time physicians spent accessing additional clinical information in the post period likely reflects the greater access to clinical information provided by the integrated electronic system. Easier access to clinical information may improve clinical decision making and enhance the quality of patient care. For instance, in situations where a senior clinician, not initially involved in the care process, is required to deal with the follow-up of non-normal results. [ABSTRACT FROM AUTHOR]

Objective The objective of the present study is to quantify utilisation of imaging for patients presenting to an ED with back pain, their characteristics and dispositions. Methods A retrospective cohort study of 1132 ED presentations for back pain to an Australian metropolitan ED in 2013 was performed. Patient demographics, rates of radiography, computed tomography or magnetic resonance imaging and rates of subsequent admission and ED re-presentation were analysed. Results Patients aged 26-35 years were the largest group presenting with back pain (19.4% of presentations), with the majority being female (52.3%). Imaging was requested at 29.5% ( n = 334) of presentations (radiography n = 297; advanced imaging n = 63). Patients over 70 years had higher imaging rates than younger patients (49.4% vs 25.5%, P < 0.001). Imaging was not associated with attendance during or outside office hours (29.3% vs 31.8%, P = 0.4). Of presentations, 34.1% resulted in admission, with no association between imaging and admission (31.8% vs 36.0%, P = 0.2) or ED re-presentation for back pain in the same year (6.5% vs 9.7%, P = 0.09). Conclusion This study provides benchmark data on the use of imaging for back pain in an Australian ED, an area which has been largely unexplored. The rate of imaging in the ED was higher than previously reported in a General Practice setting. Consistent with guidelines, patients older than 70 were more than twice as likely to receive imaging compared to younger patients. It was beyond the scope of the current study to determine whether these images were clinically indicated and further research is required to determine if initiatives to reduce imaging in this population are warranted. [ABSTRACT FROM AUTHOR]

Objectives The objective was to examine the relationship between laboratory testing (including test volume and turnaround time [ TAT]) and emergency department ( ED) length of stay ( LOS), using linked patient-level data from four hospitals across 4 years. Methods This was a retrospective, multisite cohort study of patients presenting to any one of four EDs in New South Wales, Australia, during a 2-month period (August and September) in 2008, 2009, 2010, and 2011. Data from ED information systems were linked to laboratory test data. A cross-classified random-effect modeling approach was applied to identify factors affecting ED LOS, taking into account the correlation between patients' presentations at the same hospital and/or in the same calendar year. Number of test order episodes (tests ordered at one point in time during the ED stay) and TAT (time from laboratory order receipt to result available) were examined. Results As the number of test order episodes increased, so did the duration of patient ED LOS (p < 0.0001). For every five additional tests ordered per test order episode, the median ED LOS increased by 10 minutes (2.9%, p < 0.0001); each 30-minute increase in TAT was, on average, associated with a 5.1% (17 minutes; p < 0.0001) increase in ED LOS, after adjustment for other factors. Patients presenting to the ED at night (7 p.m. to 7 a.m.) had longer stays than those presenting during the daytime, although the median TATs at nights were shorter than those during the daytime. Conclusions Laboratory testing has a direct effect on patients' LOS in ED. Laboratory TAT, number of testing episodes, and test volume influence ED LOS. Targeted increases of ED resources and staffing after-hours may also contribute to reductions in ED LOS. [ABSTRACT FROM AUTHOR]

Purpose: The objective of the present study was to identify and report on the key challenges confronted by emergency doctors following the introduction of Computerised Provider Order Entry system in a major metropolitan hospital in Sydney. Basic procedures: A qualitative study was undertaken during the period May 2006 to December 2006. The study included a series of eight interviews with three senior doctors and one focus group involving six registrars. Participants were chosen on the basis of their experience of planning for, or working with the new electronic ordering system. The study also incorporated five observation sessions and document analysis. Data were analysed iteratively, which led to the identification and elaboration of issues relevant to the research question. Findings: Three major issues emerged from the findings: (i) the implementation of the new system was accompanied by major shifts in ED work responsibilities and tasks; (ii) the appearance of dysfunctional consequences of the new system related to the excess time it took to electronically order and the usability of some features of the new system; and (iii) doctors' concerns that their views and opinions about the design and implementation of the new system had not been adequately addressed. Conclusion: The implementation of electronic ordering has important implications for ED functioning and the delivery of patient care. The complexity of the ED makes it vulnerable to disruption caused by inadequate system design and ineffective channels of communication across the hospital. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the communication processes involving test-related information in Australian Emergency Departments (EDs); specifically what and how ED clinicians communicate test-related information to patients, what patients know and understand about the provided information, and how patients view the potential to access their test-results electronically.Methods: We conducted face-to-face semi-structured interviews with clinicians (n = 26) and patients (n = 32) across three Australian EDs. Interviews were transcribed and analysed iteratively, following principles of qualitative content analysis and grounded theory.Results: Depending on various contextual (e.g. time pressures) and patient factors (e.g. perceived health literacy), ED clinicians provided, and patients recalled receiving, test-related information along a continuum, ranging from "no or limited" information to "specific" information. Many patients were confused about how to access their test-results. Patients welcomed the potential for future electronic access to results but viewed their individual health and/or computer literacy skills and knowledge as potential barriers.Conclusions: EDs are highly dynamic environments where contextual forces impinge on the amount and quality of test-related information that clinicians communicate to ED patients.Practice Implications: Systemic and patient factors need to be addressed to optimise the provision of test-related information in ED settings, improve patient understanding and foster patient empowerment. [ABSTRACT FROM AUTHOR]