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Diagnostic stewardship in emergency departments using the UNTIE framework: a stepped-wedge cluster randomised study
Pramod Chandru1, Naren Gunja2,3, Simon Poon4
1Emergency Department, Westmead Hospital, Westmead, New South Wales, Australia pramod.chandru@health.nsw.gov.au.
Introduction:
Pathology testing accounts for over half of non-labour costs in Australian Emergency Departments (EDs), yet up to one-fifth of tests are unnecessary. Despite national guidance from the Australasian College for Emergency Medicine (ACEM) and the Royal College of Pathologists of Australasia (RCPA), variation in test ordering persists across departments and across clinical presentations. The Unnecessary Tests in Emergency (UNTIE) study aims to evaluate whether audit and feedback using a novel indicator can reduce unnecessary pathology testing.
Methods And Analysis:
UNTIE is a multicentre, stepped-wedge cluster randomised trial conducted across five metropolitan EDs in New South Wales, Australia. All adult ED presentations that fall within the 29 clinical conditions covered by the 2023 ACEM-RCPA guideline will be included. Presentations were identified using routinely collected ED triage diagnoses. Because the ACEM-RCPA pathology guideline specifies clinical presentations rather than diagnostic codes, a mapping process was developed to align triage terms used in the electronic medical record with the guideline categories. Approximately 100 common triage diagnoses were reviewed by a panel of emergency physicians and mapped to the 29 eligible presentations. This mapping dictionary was used to automatically classify all ED encounters during data extraction. Ambiguous or unmapped triage terms were reviewed and assigned by consensus.The intervention comprises a multifaceted audit-feedback programme-combining local champions, education sessions, visual prompts and electronic dashboards. Two automated indicators will be generated for every eligible ED encounter: UNTIE-U (Unnecessary Testing Index) representing the proportion of tests performed but not recommended and UNTIE-N (Necessary Testing Index) representing the proportion of guideline-recommended tests performed. The primary outcome is change in UNTIE-U before and after intervention; the secondary outcome is change in UNTIE-N.
Ethics And Dissemination:
Ethics approval has been granted by the Western Sydney Local Health District Human Research Ethics Committee (HREC/17/WMEAD/274, 2022/STE03249). All analyses will use de-identified data. Findings will be disseminated through peer-reviewed publication, conference presentation and feedback to participating EDs.
Trial Registration Number:
Australian New Zealand Clinical Trials Registry: ACTRN12623001130651, UTN: U1111-1297-0386.
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