Un-Necessary Tests in Emergency Departments (UNTIE), a Stepped-wedge Cluster Randomised Trial

This is a ten week step-wedged randomized control trial involving the generation of a novel UNTIE score for each of the 35 emergency department presentations covered by the study. The generation of these scores will be throughout the study period (irrespective of intervention phase) to provide baseline data collection. UNTIE scores are calculated as an UNTIE U and UNTIE N score. An UNTIE N score is the percentage of tests listed as ‘Perform’ for the specific presentation which were actually performed within the ED visit. A UNTIE-N score of <100% indicates potential under-utilization of necessary tests. An UNTIE U score is a percentage calculated as: NUMERATOR: number of tests actually performed within the ED visit, which are NOT listed in the ‘Perform’ or ‘Consider or Ask Supervisor’ categories for the specific presentation, divided by: DENOMINATOR: the number of tests listed within the ‘Perform’ category. The denominator is designed to capture the complexity of respective presenting problems. A UNTIE-U score of >0% indicates potential over-utilization of tests.. We will automate this to generate indicators on a fortnightly basis. The determination of 'Perform', 'Consider' or 'Ask supervisor categories' are based on a published joint statement by the Australian College of Emergency Medicine (ACEM) and the Royal College of Pathologists of Australia (RCPA) 2018 titled Pathology Testing in the Emergency Department guideline. This guidelines covers the 35 emergency department presentations reviewed in our study and provides guidance on investigation use for each of these presentations. This guidance forms the foundation for the calculation of the various UNTIE scores. Each site will then be randomized to an audit feedback intervention based on prospectively collected data on emergency department UNTIE score performances. The audit feedback intervention will involve fortnightly interactions with clinical staff including medical, nursing and technical and clinical assistant workforces outlining department performance for test ordering and encouraging patterns of behavior more compliant with suggested guidelines. Staff performing the audit will be a combination of local champions and research staff who are familiar with the models of care functioning within each emergency department. The audit feedback process will be multimodal and involve face to face presentations, recorded presentations, routine emails, and the use of posters and visual stimuli in appropriate clinical spaces to prompt behavioral change. All audit feedback data will be recorded in a study specific database. Data on ongoing performance will then be recorded over the duration of the intervention period. Every ten weeks an additional department will be included in the randomisation process.

This is a ten week step-wedged randomized control trial involving the generation of a novel UNTIE score for each of the 29 emergency department presentations covered by the study. The generation of these scores will be throughout the study period (irrespective of intervention phase) to provide baseline data collection. UNTIE scores are calculated as an UNTIE U and UNTIE N score. An UNTIE N score is the percentage of tests listed as ‘Perform’ for the specific presentation which were actually performed within the ED visit. A UNTIE-N score of 0% indicates potential over-utilization of tests.. We will automate this to generate indicators on a fortnightly basis. The determination of 'Perform', 'Consider' or 'Ask supervisor categories' are based on a published joint statement by the Australian College of Emergency Medicine (ACEM) and the Royal College of Pathologists of Australia (RCPA) 2023 titled Pathology Testing in the Emergency Department guideline. This guidelines covers the 29 emergency department presentations reviewed in our study and provides guidance on investigation use for each of these presentations. This guidance forms the foundation for the calculation of the various UNTIE scores. Each site will then be randomized to an audit feedback intervention based on prospectively collected data on emergency department UNTIE score performances. The audit feedback intervention will involve fortnightly interactions with clinical staff including medical, nursing and technical and clinical assistant workforces outlining department performance for test ordering and encouraging patterns of behavior more compliant with suggested guidelines. Staff performing the audit will be a combination of local champions and research staff who are familiar with the models of care functioning within each emergency department. The audit feedback process will be multimodal and involve face to face presentations, recorded presentations, routine emails, and the use of posters and visual stimuli in appropriate clinical spaces to prompt behavioral change. All audit feedback data will be recorded in a study specific database. Data on ongoing performance will then be recorded over the duration of the intervention period. Every ten weeks an additional department will be included in the randomisation process.

This is a fifty-week stepped-wedge cluster randomised controlled trial involving the generation of a novel UNTIE score for each of the 29 emergency department presentations covered by the study. UNTIE scores are generated throughout the study period (irrespective of intervention phase) to provide baseline and ongoing measurement. UNTIE scores are calculated as two indicators: UNTIE-U and UNTIE-N. UNTIE-U (Unnecessary Testing Index) is the percentage of tests performed that are not classified as 'Perform' or 'Consider/Ask Supervisor' in the guideline, divided by the number of 'Perform' tests for that presentation. A UNTIE-U score > 0% indicates potential over-utilization of tests. UNTIE-N (Necessary Testing Index) is the percentage of tests listed as 'Perform' for the specific presentation that were actually performed during the ED visit. A UNTIE-N score < 100% indicates potential under-utilization of necessary tests. Both indicators are automated and generated on a fortnightly basis. The determination of 'Perform', 'Consider' or 'Ask Supervisor' categories is based on the 2023 joint guideline by the Australasian College for Emergency Medicine (ACEM) and the Royal College of Pathologists of Australasia (RCPA) titled Pathology Testing in the Emergency Department. This guideline covers the 29 emergency department presentations reviewed in our study and forms the foundation for the calculation of all UNTIE scores. Each site is randomised to commence an audit-feedback intervention at ten-week intervals, based on prospectively collected UNTIE score performance data. The audit-feedback intervention involves fortnightly interactions with clinical staff — including medical, nursing, and technical and clinical assistant workforces — outlining departmental performance for test ordering and encouraging practice more concordant with guideline recommendations. Staff delivering the audit will be a combination of local clinical champions and research staff familiar with the models of care at each site. The audit-feedback process is multimodal and involves face-to-face presentations, recorded presentations, routine emails, and the use of posters and visual prompts in appropriate clinical spaces to support behavioural change. All audit-feedback data will be recorded in a study-specific database. Every ten weeks an additional site is included in the randomisation process.