Does health information technology improve acknowledgement of radiology results for discharged Emergency Department patients? A before and after study.

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.

What is the impact of an electronic test result acknowledgement system on Emergency Department physicians' work processes? A mixed-method pre-post observational study.

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.

The Sydney Triage to Admission Risk Tool (START) to predict Emergency Department Disposition: A derivation and internal validation study using retrospective state-wide data from New South Wales, Australia.

BACKGROUND: Disposition decisions are critical to the functioning of Emergency Departments. The objectives of the present study were to derive and internally validate a prediction model for inpatient admission from the Emergency Department to assist with triage, patient flow and clinical decision making. METHODS: This was a retrospective analysis of State-wide Emergency Department data in New South Wales, Australia. Adult patients (age ≥ 16 years) were included if they presented to a Level five or six (tertiary level) Emergency Department in New South Wales, Australia between 2013 and 2014. The outcome of interest was in-patient admission from the Emergency Department. This included all admissions to short stay and medical assessment units and being transferred out to another hospital. Analyses were performed using logistic regression. Discrimination was assessed using area under curve and derived risk scores were plotted to assess calibration. RESULTS: 1,721,294 presentations from twenty three Level five or six hospitals were analysed. Of these 49.38% were male and the mean (sd) age was 49.85 years (22.13). Level 6 hospitals accounted for 47.70% of cases and 40.74% of cases were classified as an in-patient admission based on their mode of separation. The final multivariable model including age, arrival by ambulance, triage category, previous admission and presenting problem had an AUC of 0.82 (95% CI 0.81, 0.82). CONCLUSION: By deriving and internally validating a risk score model to predict the need for in-patient admission based on basic demographic and triage characteristics, patient flow in ED, clinical decision making and overall quality of care may be improved. Further studies are now required to establish clinical effectiveness of this risk score model.

Trends and characteristics of short-term and frequent representations to emergency departments: A population-based study from New South Wales, Australia.

OBJECTIVE: The objective of this study is to describe the trends and characteristics of short-term and frequent representations to EDs in New South Wales, Australia. METHODS: This was a retrospective analysis of a linked population-based registry of ED representations in New South Wales, conducted as part of the Demand for Emergency Services in Years 2010-2014 project. Trend analysis of unplanned representations to ED within 3 days of discharge from ED, readmission to an in-patient unit within 30 days of index in-patient admission from ED and demographic data and trends for frequent and very frequent ED presenters is discussed. RESULTS: A total of 10 798 797 ED presentations were identified from 4 188 283 individual patients. Within 1 year, 48.9% of ED presentations had a previous presentation, and 4.9% had represented within 3 days of a previous presentation. The readmission rate within 30 days was 2.8%, the proportion of frequent (representing 5212 [0.1%] individual patients) and very frequent representations (representing 1186 [0.03%] individual patients) were 1.7% and 1.0%, respectively. The overall rate of representations within 3 days has decreased from 5.1% in 2010 to 4.7% in 2014 (P < 0.001). The rate of readmissions within 30 days has increased from 2.4% in 2010 to 3.1% in 2014 (P < 0.001). CONCLUSIONS: In this population-based study, short-term representations were highest in the infant patient population, in-patient readmission rates were highest in the elderly and very frequent representations to ED were characterised by middle-aged patients with mental health or drug and alcohol related presentations.

Statewide retrospective study of low acuity emergency presentations in New South Wales, Australia: who, what, where and why?

OBJECTIVE: The present study aims to use a statewide population-based registry to assess the prevalence of low acuity emergency department (ED) presentations, describe the trend in presentation rates and to determine whether they were associated with various presentation characteristics such as the type of hospital as well as clinical and demographic variables. DESIGN AND SETTING: This was a retrospective analysis of a population-based registry of ED presentations in New South Wales (NSW). Generalised estimating equations with log links were used to determine factors associated with low acuity presentations to account for repeat presentations and the possibility of clustering of outcomes. PARTICIPANTS: Patients were included in this analysis if they presented to an ED between January 2010 and December 2014. The outcomes of interest were low acuity presentation, defined as those who self-presented (were not transported by ambulance), were assigned a triage category of 4 or 5 (semiurgent or non-urgent) and discharged back to usual residence from ED. RESULTS: There were 10.7 million ED presentations analysed. Of these, 45% were classified as a low acuity presentation. There was no discernible increase in the rate of low acuity presentations across NSW between 2010 and 2014. The strongest predictors of low acuity ED presentation were age <40 years of age (OR 1.77); injury or musculoskeletal administrative and non-urgent procedures (OR 2.96); ear, nose and throat, eye or oral (OR 5.53); skin or allergy-type presenting problems (OR 2.84). CONCLUSIONS: Low acuity ED presentations comprise almost half of all ED presentations. Alternative emergency models of care may help meet the needs of these patients.

Demand for Emergency Services Trends in New South Wales Years 2010-2014 (DESTINY): Age and Clinical Factors Associated with Ambulance Transportation to Emergency Departments.

OBJECTIVES: The study aimed to analyze ambulance transportations to Emergency Departments (EDs) in New South Wales (NSW) and to identify temporal changes in demographics, acuity, and clinical diagnoses. METHODS: This was a retrospective analysis of a population based registry of ED presentations in New South Wales. The NSW Emergency Department data collection (EDCC) collects patient level data on presentations to designated EDs across NSW. Patients that presented to EDs by ambulance between January 2010 and December 2014 were included. Patients dead on arrival, transferred from another hospital, or planned ED presentations were excluded. RESULTS: A total of 10.8 million ED attendances were identified of which 2.6 million (23%) were transported to ED by ambulance. The crude rate of ambulance transportations to EDs across all ages increased by 3.0% per annum over the five years with the highest rate observed in those 85 years and over (620.5 presentations per 1,000 population). There was an increase in the proportion of category 1 and 2 (life-threatening or potentially life-threatening) cases from 18.1% to 24.0%. CONCLUSION: Demand for ambulance services appears to be driven by older patients presenting with higher acuity problems. Alternative models of acute care for elderly patients need to be planned and implemented to address these changes.

Understanding drivers of Demand for Emergency Service Trends in Years 2010-2014 in New South Wales: An initial overview of the DESTINY project.

OBJECTIVE: This study aims to describe the general characteristics and data definitions used in a population-based data set of ED presentations in New South Wales (NSW), used to form the basis of future-trend analyses. METHODS: Retrospective analysis of the Emergency Department Data Collection registry, which provided clinical and demographic information of ED presentations across all EDs in NSW between 2010 and 2014. Presenting problems and ED diagnoses were classified using broad clinical categories including injury/musculoskeletal, respiratory, cardiovascular, ear nose and throat, and mental health. Presentations were linked by patient to allow for analysis of representations, and population data were obtained from the Australian Bureau of Statistics. RESULTS: There were 11.8 million presentations that were analysed from 150 EDs (80.6% of all EDs). The rate of ED presentations was highest in those aged 85 years and older and appears to increase across all age groups between 2010 and 2014. The most common ED diagnosis categories were injury/musculoskeletal (27.5%) followed by abdominal/gastrointestinal (12.3%), respiratory (9%) and cardiovascular (8%). Both the Systematised Nomenclature of Medicine Clinical Terms (66%) and the International Classification of Diseases (24%) were used to code ED diagnoses. CONCLUSIONS: The elderly population had the highest rate of ED attendances. The use of diverse diagnosis classifications and source information systems may present problems with further analysis. Patterns and characteristics of ED presentations in NSW were broadly consistent with those reported in other states in Australia.

Emergency physicians' views of direct notification of laboratory and radiology results to patients using the Internet: a multisite survey.

BACKGROUND: Patients are increasingly using the Internet to communicate with health care providers and access general and personal health information. Missed test results have been identified as a critical safety issue with studies showing up to 75% of tests for emergency department (ED) patients not being followed-up. One strategy that could reduce the likelihood of important results being missed is for ED patients to have direct access to their test results. This could be achieved electronically using a patient portal tied to the hospital's electronic medical record or accessed from the relevant laboratory information system. Patients have expressed interest in accessing test results directly, but there have been no reported studies on emergency physicians' opinions. OBJECTIVE: The aim was to explore emergency physicians' current practices of test result notification and attitudes to direct patient notification of clinically significant abnormal and normal test results. METHODS: A cross-sectional survey was self-administered by senior emergency physicians (site A: n=50; site B: n=39) at 2 large public metropolitan teaching hospitals in Australia. Outcome measures included current practices for notification of results (timing, methods, and responsibilities) and concerns with direct notification. RESULTS: The response rate was 69% (61/89). More than half of the emergency physicians (54%, 33/61) were uncomfortable with patients receiving direct notification of abnormal test results. A similar proportion (57%, 35/61) was comfortable with direct notification of normal test results. Physicians were more likely to agree with direct notification of normal test results if they believed it would reduce their workload (OR 5.72, 95% CI 1.14-39.76). Main concerns were that patients could be anxious (85%, 52/61), confused (92%, 56/61), and lacking in the necessary expertise to interpret their results (90%, 55/61). CONCLUSIONS: Although patients' direct access to test results could serve as a safety net reducing the likelihood of abnormal results being missed, emergency physicians' concerns need further exploration: which results are suitable and the timing and method of direct release to patients. Methods of access, including secure Web-based patient portals with drill-down facilities providing test descriptions and result interpretations, or laboratories sending results directly to patients, need evaluation to ensure patient safety is not compromised and the processes fit with ED clinician and laboratory work practices and patient needs.

Does an integrated Emergency Department Information System change the sequence of clinical work? A mixed-method cross-site study.

OBJECTIVES: (1) to describe Emergency Department (ED) physicians' and nurses' perceptions about the sequence of work related to patient management with use of an integrated Emergency Department Information System (EDIS), and (2) to measure changes in the sequence of clinician access to patient information. METHODS: A mixed method study was conducted in four metropolitan EDs. Each used the same EDIS which is a module of the hospitals' enterprise-wide clinical information system composed of many components of an electronic medical record. This enabled access to clinical and management information relating to patients attending all hospitals in the region. Phase one - data were collected from ED physicians and nurses (n=97) by 69 in-depth interviews, five focus groups (28 participants), and 26 h of observations. Phase two - physicians (n=34) in one ED were observed over 2 weeks. Data included whether and what type of information was accessed from the EDIS prior to first examination of the patient. RESULTS: Clinicians reported, and phase 2 observations confirmed, that the integrated EDIS led to changes to the order of information access, which held implications for when tests were ordered and results accessed. Most physicians accessed patient information using EDIS prior to taking the patients' first medical history (77/116; 66.4%, 95% CI: 57.8-75.0%). Previous discharge summaries (74%) and past test results (61%) were most frequently accessed and junior doctors were more likely to access electronic past history information than their senior colleagues (χ(2)=20.717, d.f.=1, p<0.001). CONCLUSIONS: The integrated EDIS created new ways of working for ED clinicians. Such changes could hold positive implications for: time taken to reach a diagnosis and deliver treatments; length of stay; patient outcomes and experiences.

A cohort study of chest pain patients discharged from the emergency department for early outpatient treadmill exercise stress testing.

OBJECTIVE: Guidelines on intermediate-risk chest pain, based on consensus alone, recommend inpatient provocative testing after infarct exclusion. Inpatient testing exceeds capacity in many hospitals, so guidelines concede outpatient testing within 72 h is acceptable. We performed a cohort study of chest pain patients having early outpatient treadmill exercise stress testing (EST). METHODS: All chest pain patients discharged from our emergency with booked outpatient treadmill EST during the 2008 to 2010 calendar years were included. There were no exclusions. The primary outcome was diagnosis of major coronary artery disease among stress test attendees. Secondary outcomes were time to stress test booking, representations with chest pain or death within 30 days. RESULTS: The cohort consisted of 657 patients: 59% men, mean age 53.2 years. Time from discharge to stress test averaged 10.6 days and 73% of patients attended. Of patients who attended, 14% had a positive test and 13% an inconclusive result. These patients were older than those with negative results (P < 0.001). Four patients (0.8% of attendees) were diagnosed with major coronary artery disease. There were no representations with acute myocardial infarction and no deaths identified. CONCLUSIONS: Outpatient treadmill EST an average of 10 days post-discharge from emergency with chest pain did not result in adverse events despite reasonably high positive stress test rates. Consensus-based recommendations for inpatient testing or outpatient testing within 72 h of discharge should be reviewed in light of these data.

Impact of an electronic medication management system on hospital doctors' and nurses' work: a controlled pre-post, time and motion study.

OBJECTIVE: To quantify and compare the time doctors and nurses spent on direct patient care, medication-related tasks, and interactions before and after electronic medication management system (eMMS) introduction. METHODS: Controlled pre-post, time and motion study of 129 doctors and nurses for 633.2 h on four wards in a 400-bed hospital in Sydney, Australia. We measured changes in proportions of time on tasks and interactions by period, intervention/control group, and profession. RESULTS: eMMS was associated with no significant change in proportions of time spent on direct care or medication-related tasks relative to control wards. In the post-period control ward, doctors spent 19.7% (2 h/10 h shift) of their time on direct care and 7.4% (44.4 min/10 h shift) on medication tasks, compared to intervention ward doctors (25.7% (2.6 h/shift; p=0.08) and 8.5% (51 min/shift; p=0.40), respectively). Control ward nurses in the post-period spent 22.1% (1.9 h/8.5 h shift) of their time on direct care and 23.7% on medication tasks compared to intervention ward nurses (26.1% (2.2 h/shift; p=0.23) and 22.6% (1.9 h/shift; p=0.28), respectively). We found intervention ward doctors spent less time alone (p=0.0003) and more time with other doctors (p=0.003) and patients (p=0.009). Nurses on the intervention wards spent less time with doctors following eMMS introduction (p=0.0001). CONCLUSIONS: eMMS introduction did not result in redistribution of time away from direct care or towards medication tasks. Work patterns observed on these intervention wards were associated with previously reported significant reductions in prescribing error rates relative to the control wards.

The effect of computerized provider order entry systems on clinical care and work processes in emergency departments: a systematic review of the quantitative literature.

STUDY OBJECTIVE: We undertake a systematic review of the quantitative literature related to the effect of computerized provider order entry systems in the emergency department (ED). METHODS: We searched MEDLINE, EMBASE, Inspec, CINAHL, and CPOE.org for English-language studies published between January 1990 and May 2011. RESULTS: We identified 1,063 articles, of which 22 met our inclusion criteria. Sixteen used a pre/post design; 2 were randomized controlled trials. Twelve studies reported outcomes related to patient flow/clinical work, 7 examined decision support systems, and 6 reported effects on patient safety. There were no studies that measured decision support systems and its effect on patient flow/clinical work. Computerized provider order entry was associated with an increase in time spent on computers (up to 16.2% for nurses and 11.3% for physicians), with no significant change in time spent on patient care. Computerized provider order entry with decision support systems was related to significant decreases in prescribing errors (ranging from 17 to 201 errors per 100 orders), potential adverse drug events (0.9 per 100 orders), and prescribing of excessive dosages (31% decrease for a targeted set of renal disease medications). CONCLUSION: There are tangible benefits associated with computerized provider order entry/decision support systems in the ED environment. Nevertheless, when considered as part of a framework of technical, clinical, and organizational components of the ED, the evidence base is neither consistent nor comprehensive. Multimethod research approaches (including qualitative research) can contribute to understanding of the multiple dimensions of ED care delivery, not as separate entities but as essential components of a highly integrated system of care.

Perceptions of the effect of information and communication technology on the quality of care delivered in emergency departments: a cross-site qualitative study.

STUDY OBJECTIVE: We identify and describe emergency physicians' and nurses' perceptions of the effect of an integrated emergency department (ED) information system on the quality of care delivered in the ED. METHODS: A qualitative study was conducted in 4 urban EDs, with each site using the same ED information system. Participants (n=97) were physicians and nurses with data collected by 69 detailed interviews, 5 focus groups (28 participants), and 26 hours of structured observations. RESULTS: Results revealed new perspectives on how an integrated ED information system was perceived to affect incentives for use, awareness of colleagues' activities, and workflow. A key incentive was related to the positive effect of the ED information system on clinical decisionmaking because of improved and quicker access to patient-specific and knowledge-base information compared with the previous stand-alone ED information system. Synchronous access to patient data was perceived to lead to enhanced awareness by individual physicians and nurses of what others were doing within and outside the ED, which participants claimed contributed to improved care coordination, communication, clinical documentation, and the consultation process. There was difficulty incorporating the use of the ED information system with clinicians' work, particularly in relation to increased task complexity; duplicate documentation, and computer issues related to system usability, hardware, and individuals' computer skills and knowledge. CONCLUSION: Physicians and nurses perceived that the integrated ED information system contributed to improvements in the delivery of patient care, enabling faster and better-informed decisionmaking and specialty consultations. The challenge of electronic clinical documentation and balancing data entry demands with system benefits necessitates that new methods of data capture, suited to busy clinical environments, be developed.

Computational recognition of SNOMED CT codes from ED case notes.

This paper is a study of patient notes from an emergency department and a determination of their consistency for correct SNOMED CT encoding of the diagnosis, and comparison with a clinical language processing (CLP) system that determined the SCT diagnoses. Three set of notes were reviewed by a clinician with 500 records in each where: the clinician and CLP codes where the same (Matched Set); where they were different (Unmatched Set); and, where the clinicians had failed to enter a code (Unassigned Set) giving accuracies of 75%, 33.4% and 44.9% respectively.

A qualitative analysis of Emergency Department physicians' practices and perceptions in relation to test result follow-up.

Follow-up of abnormal test results for discharged Emergency Department (ED) patients is a critical safety issue. This study aimed to explore ED physicians' perceptions, practices, and suggestions for improvements of test result follow-up when using an electronic provider order entry system to order all laboratory and radiology tests and view results. Interviews were conducted with seven ED physicians and one clinical information system support person. Interviews were analyzed to elicit key concepts relating to physicians' perceptions of test result follow-up and how the process could be improved. Results described the current electronic test result follow-up system with two paper-based manual back-up systems for microbiology and radiology results. The key issues for physicians were: responsibility for test follow-up; the unique ED environment and time pressures, and the role of the family physician in test result follow-up. The key suggestion for improvement was a complete integrated electronic information system with on-line result endorsement. The study highlighted the complexity of the test result follow-up process and the importance of engaging clinicians in devising solutions for improvements.

Blood withdrawn through a cannula valve connector does not result in clinically significant haemolysis.

OBJECTIVE: To assess the impact of cannula valve connectors on haemolysis of blood samples drawn from newly inserted cannulae. METHODS: In a semi-blinded, randomized study paired blood samples, with and without cannula valve connector, were obtained from patients within the ED and tested for haemolysis, defined as haemolysis index of greater than 120 mg/dL. Patients were randomized as to which sample was collected first. Cannula size was standardized and vacutainer systems provided consistent draw pressures. Time taken for the tube to fill was recorded as a measure of blood flow. RESULTS: Two hundred and ninety patients were randomized, with six subsequently excluded from analysis because of samples being lost or insufficient for testing. Average patient age was 60.8 years and 52.5% were male. There were no significant differences between the randomization groups. The overall rate of haemolysis was 2.6%, being 2.8% in the valve first group and 2.5% in the no valve first group (P = 1.0). Time for collection averaged 7.7 s in the valve first group and 7.5 s in the no-valve first group (P = 0.22). Mean serum potassium level was 4.4 mmol/L in both groups (P = 0.46). The rate of hyperkalaemia was not different between valve first and no-valve first groups (12.7% and 13.7%, respectively, P = 1.0). CONCLUSION: The attachment of a cannula connector valve to a peripheral cannula prior to blood sampling is not associated with an increase in the rate of haemolysis or hyperkalaemia.

The impact of interruptions on clinical task completion.

BACKGROUND: Interruptions and multitasking are implicated as a major cause of clinical inefficiency and error. OBJECTIVE: The aim was to measure the association between emergency doctors' rates of interruption and task completion times and rates. METHODS: The authors conducted a prospective observational time and motion study in the emergency department of a 400-bed teaching hospital. Forty doctors (91% of medical staff) were observed for 210.45 h on weekdays. The authors calculated the time on task (TOT); the relationship between TOT and interruptions; and the proportion of time in work task categories. Length-biased sampling was controlled for. RESULTS: Doctors were interrupted 6.6 times/h. 11% of all tasks were interrupted, 3.3% more than once. Doctors multitasked for 12.8% of time. The mean TOT was 1:26 min. Interruptions were associated with a significant increase in TOT. However, when length-biased sampling was accounted for, interrupted tasks were unexpectedly completed in a shorter time than uninterrupted tasks. Doctors failed to return to 18.5% (95% CI 15.9% to 21.1%) of interrupted tasks. CONCLUSIONS: It appears that in busy interrupt-driven clinical environments, clinicians reduce the time they spend on clinical tasks if they experience interruptions, and may delay or fail to return to a significant portion of interrupted tasks. Task shortening may occur because interrupted tasks are truncated to 'catch up' for lost time, which may have significant implications for patient safety.

Use of information and communication technologies to support effective work practice innovation in the health sector: a multi-site study.

BACKGROUND: Widespread adoption of information and communication technologies (ICT) is a key strategy to meet the challenges facing health systems internationally of increasing demands, rising costs, limited resources and workforce shortages. Despite the rapid increase in ICT investment, uptake and acceptance has been slow and the benefits fewer than expected. Absent from the research literature has been a multi-site investigation of how ICT can support and drive innovative work practice. This Australian-based project will assess the factors that allow health service organisations to harness ICT, and the extent to which such systems drive the creation of new sustainable models of service delivery which increase capacity and provide rapid, safe, effective, affordable and sustainable health care. DESIGN: A multi-method approach will measure current ICT impact on workforce practices and develop and test new models of ICT use which support innovations in work practice. The research will focus on three large-scale commercial ICT systems being adopted in Australia and other countries: computerised ordering systems, ambulatory electronic medical record systems, and emergency medicine information systems. We will measure and analyse each system's role in supporting five key attributes of work practice innovation: changes in professionals' roles and responsibilities; integration of best practice into routine care; safe care practices; team-based care delivery; and active involvement of consumers in care. DISCUSSION: A socio-technical approach to the use of ICT will be adopted to examine and interpret the workforce and organisational complexities of the health sector. The project will also focus on ICT as a potentially disruptive innovation that challenges the way in which health care is delivered and consequently leads some health professionals to view it as a threat to traditional roles and responsibilities and a risk to existing models of care delivery. Such views have stifled debate as well as wider explorations of ICT's potential benefits, yet firm evidence of the effects of role changes on health service outcomes is limited. This project will provide important evidence about the role of ICT in supporting new models of care delivery across multiple healthcare organizations and about the ways in which innovative work practice change is diffused.

Total access block time: a comprehensive and intuitive way to measure the total effect of access block on the emergency department.

OBJECTIVE: Access block refers to delayed transfer of admitted patients in the ED to wards from lack of an inpatient bed. Existing measures are crude indicators of its impact on ED function. Our aim was to devise measures of the total burden of access block on ED function which better measured the impact on ED function, yet were intuitive and easy to communicate. METHODS: Current access block measures, reported as percentage of total inpatient admissions, are based upon time intervals and cut points. 'Total access block time' (TABT) is obtained by summing the minutes in excess of 8 h that admitted patients spend in the ED. We describe derivation of TABT with reference to its intuitive comprehensibility and potential to improve understanding and communication of access block issues. Two examples of months with similar traditional measures but different TABT are used to highlight its advantages. RESULTS: TABT varies over a greater range than traditional measures. High TABT months had higher presentations, higher admissions, more admitted patients with long ED stays and impaired ability to meet triage benchmarks. Differences in these parameters are considered intermediate end-points which reflect the degree of impairment of ED function. CONCLUSIONS: TABT is a comprehensive, sensitive indicator of total impact of access block on ED function. Unlike current access block measures, TABT is reflective of long-stay ED patients. Descriptive statistics derived from TABT, in terms of effective beds and bed-days lost, will likely improve the communication and comprehension of access block issues.

Management and outcome of spontaneous pneumothoraces at three urban EDs.

OBJECTIVE: Spontaneous pneumothoraces predominantly affect young people. Substantial morbidity arises from the disease, invasive procedures and hospitalization. The literature is inconsistent regarding optimal management. This retrospective study aimed to define factors affecting the outcome of these patients. METHODS: Patients were identified from databases at three EDs for explicit retrospective medical record review. Iatrogenic and traumatic pneumothoraces were excluded. Data collected included demographic details, treatment and outcome. The primary outcome was failure of initial treatment, defined as the need for a second treatment modality (including inpatient pleurodesis for persistent air leak) or re-presentation within 5 days of treatment cessation. Associations with the primary outcome in primary spontaneous pneumothorax were assessed using logistic regression. RESULTS: One hundred and twenty-one spontaneous pneumothoraces were identified. There was poor correlation between clinician estimates and objective measurement of pneumothorax size. Pneumothorax size, measured using the average interpleural distance method, was the only independent predictor of treatment failure. Initial treatment modality demonstrated a confounder relationship with outcome. Subgroup analysis for patients treated with continuous pleural drainage compared small and large calibre drainage tubes, with no significant difference found. CONCLUSIONS: Objective measurement of pneumothorax size was the only independent predictor of treatment failure, with initial treatment modality having a confounding effect. Algorithms regarding initial treatment modalities are usually based on pneumothorax size and presence or absence of symptoms. The present study illustrates the importance of objective assessment of pneumothorax size in both clinical research and clinical practice.