Un-Necessary Tests in Emergency Departments (UNTIE), a Stepped-wedge Cluster Randomised Trial
A Step-wedged cluster randomised trial comparing audit feedback vs observation in improving appropriate pathology test ordering practices in Emergency Departments
Western Sydney Local Health District
150,000 participants
Feb 3, 2025
Interventional
Conditions
Summary
Hypothesis: We hypothesise that audit-feedback will be more effective than usual practice in improving appropriate pathology test ordering in Emergency Departments, as measured by a reduction in UNTIE-U and an improvement in UNTIE-N. Population: All consecutive ED visits at Auburn, Blacktown/Mount Druitt, Nepean, and Westmead Hospital Emergency Departments over the fifty-week study period, where the patient presentation maps to one of the 29 clinical presentations covered by the 2023 ACEM–RCPA Pathology Testing in the Emergency Department guideline. Intervention: Automated generation of UNTIE-U and UNTIE-N scores for each eligible presentation, derived from routinely collected pathology and administrative data. Following randomisation to the intervention phase, scores are presented to clinical staff via a multimodal audit-feedback program delivered fortnightly, including face-to-face sessions, recorded presentations, emails, and visual prompts. UNTIE scores continue to be collected throughout the intervention period to monitor departmental performance. Comparison: Usual clinical practice. Sites in the control phase receive no audit-feedback contact from the research team. The control is concurrent rather than historical, as all sites begin in the control phase and cross over to the intervention at ten-week intervals. Outcome: The primary outcome is UNTIE-U and the secondary outcome is UNTIE-N. Both will be generated blinded to an ED's intervention/comparator status.
Eligibility
Inclusion Criteria30
- All consecutive ED visits at the four Western Sydney Local Health District Emergency Departments and Nepean Hospital over each time period, where the patient presentation maps to one of the 29 clinical presentations covered by the 2023 ACEM–RCPA Pathology Testing in the Emergency Department guideline:
- Abdominal pain — severe (upper/epigastric)
- Abdominal pain — severe (lower)
- Back pain — atraumatic
- Cellulitis (requiring admission)
- Cerebrovascular accident
- Chest pain — suspected ischaemic heart disease (IHD)
- Chest pain — suspected pulmonary embolism (PE)
- Confusion/Syncope
- Diabetic ketoacidosis
- Fever for investigation / Fever in returned traveller
- Fracture — neck of femur or other major long bone
- Fracture — requiring theatre
- Gastrointestinal bleeding
- Jaundice for investigation
- Oncology patients (febrile neutropenia)
- Overdose
- Per vaginal bleeding in first trimester
- Pneumonia (requiring admission)
- Pyelonephritis (not simple cystitis)
- Renal colic (first episode)
- Seizures (first episode)
- Seizures (recurrent)
- Sepsis
- Septic joint
- Shortness of breath — asthma
- Shortness of breath — suspected acute pulmonary oedema
- Shortness of breath — suspected chronic obstructive airways disease
- Snake bite
- Trauma
Exclusion Criteria2
- Not attending emergency department
- Presenting with a diagnosis beyond the 29 mapped presentations
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Interventions
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.
Locations(4)
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ACTRN12623001130651