Klein Robert Peter, Velan Gary, Razee Husna, Coggins Andrew, Lai Kevin, Shetty Amith, Young Noel, Moscova Michelle
School of Biomedical Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia.
Office of Medical Education, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia.
Emerg Med J. 2025 Jul 22;42(8):511-518. doi: 10.1136/emermed-2024-214416.
Medical imaging use has increased progressively, prompting discussions about its clinical impact. Interventions to reduce low-value imaging have had varying success, as they generally do not consider the influence of the clinical environment on decision-making. Factors affecting imaging ordering decisions by Emergency Department (ED) medical officers (MOs) and how these factors differ between day and night shifts are poorly understood.
This mixed methods study was conducted in 2021 at a major tertiary hospital in Western Sydney. Observations and interviews with ED MOs for 20 day-shift and 26 night-shift clinical encounters were analysed to understand how and why imaging decisions were made, along with usage of imaging guidelines. Demographic and clinical patient data (including patient disposition) were obtained retrospectively from medical records to assess the impact of imaging.
During night shifts, 18 of the 26 observed clinical encounters used diagnostic imaging, compared with 12 of the 20 observed clinical encounters during day shifts. Factors affecting decision-making during night shifts included limited resources, fatigue, reduced support for junior ED MOs and higher patient load. Interviews suggested CT was more likely to be used during night shifts as a screening tool to expedite decisions and as a substitute for unavailable imaging modalities. In contrast, imaging decisions by day shift junior MOs were influenced by the need to justify their decisions to senior MOs, prompting them to research presenting complaints and imaging indications. Generally, there was minimal reference to imaging decision-making guidelines across both shifts.
Differing factors impact imaging decisions by ED MOs during day and night shifts. This needs consideration when designing and implementing targeted physician support strategies and interventions to reduce low-value imaging. Limited resources and MO fatigue should be considered when modifying guidelines/strategies aiming to support MOs during ED night shifts.
医学影像的使用逐渐增加，引发了关于其临床影响的讨论。减少低价值影像检查的干预措施取得了不同程度的成功，因为它们通常没有考虑临床环境对决策的影响。急诊科医生做出影像检查医嘱决策的影响因素以及这些因素在白班和夜班之间的差异尚不清楚。
这项混合方法研究于2021年在西悉尼的一家大型三级医院进行。对急诊科医生在20次白班和26次夜班临床会诊中的观察和访谈进行了分析，以了解影像检查决策的方式和原因，以及影像检查指南的使用情况。从病历中回顾性获取患者的人口统计学和临床数据（包括患者处置情况），以评估影像检查的影响。
在夜班期间，观察到的26次临床会诊中有18次使用了诊断性影像检查，而白班期间观察到的20次临床会诊中有12次使用了诊断性影像检查。影响夜班决策的因素包括资源有限、疲劳、对初级急诊科医生的支持减少以及患者负荷增加。访谈表明，夜班期间CT更有可能被用作筛查工具以加快决策速度，并作为无法使用的影像检查方式的替代。相比之下，白班初级医生的影像检查决策受到需要向高级医生证明其决策合理性的影响，这促使他们研究患者的主诉和影像检查指征。总体而言，两个班次对影像检查决策指南的参考都很少。
不同因素影响急诊科医生在白班和夜班期间的影像检查决策。在设计和实施有针对性的医生支持策略和干预措施以减少低价值影像检查时，需要考虑这一点。在修改旨在支持急诊科夜班医生的指南/策略时，应考虑资源有限和医生疲劳的问题。
