<scp>Emergency department</scp> in perspective: How e<scp>mergency department</scp> culture drives over‐investigation

‘I think you've got chest wall pain, or costochondritis’, I say to a 20-year-old patient I have seen from the waiting room of a busy ED. ‘Take some pain relief, and expect to feel better in a few days’. ‘But what about the test results?’, she asks. I check the electronic medical record: the up-front investigations for chest pain have triggered a full blood count, electrolytes, troponin and a CXR. I could respond with ‘You'll have to wait for the results, and I'll let you know’, but instead, I apologise for the unnecessary tests,1 reiterate the diagnosis and advise her to go home. I offer to contact her if anything does turn up on those tests. Unsurprisingly, there was no need. ‘Front-loaded tests’, ‘routine bloods’ or ‘just-in-case’ investigations are relatively new terminology. These represent a change in practice that has become embedded in busy, overcrowded EDs, driven by multiple factors: the desire to meet key performance indicators where test ordering defaults to ‘time seen’; concern about missing a serious diagnosis; and the need to objectively justify admission under inpatient teams. A recent paper reported ED nursing and medical staff viewed ‘front-loaded’ pathology investigations positively.2 A phlebotomist embedded in the triage team improved satisfaction by enabling early pathology testing, with results often available by the time patients were assessed, potentially expediting care. Additional positive commentary suggested early identification of abnormality on a venous blood gas led to earlier recognition of deterioration and intervention in an overcrowded waiting room. However, this paper did not explore how many additional investigations were ordered that had no impact on care or did not follow guidelines, nor if the number of tests per presentation increased and how this would translate into escalating pathology costs, increased waste and a less sustainable healthcare system. Evidence has shown ED clinicians, particularly those with less experience, when busy or where orientation and supervision were insufficient, ordered pathology investigations that did not follow agreed guidelines up to 40% of the time.3 Radiological studies have highlighted similar inefficiencies, with 30% of radiological investigations deemed unnecessary,4 contributing little to patient care, but increasing costs and resource strain to the healthcare system. Certain groups, such as patients with mental health presentations,5 or recurrent seizures,6 were significantly prone to over-investigation resulting in increased time in ED with little or no additional clinical benefit. Amid increasing demand, financial strain, and ED overcrowding, clinicians face a dilemma: do we order a barrage of tests that may not be clinically indicated to facilitate flow, or do we pause to assess their true necessity and re-embrace our role as resources stewards to lead a charge back to an era of responsible, evidence-based guidelines to support care and reduce waste? Prior to the COVID-19 pandemic, ACEM spearheaded the Choosing Wisely initiative in Australasia. This widely embraced action involved national meetings and strong representation at ACEM conferences, focusing on promoting rational investigations and reducing waste.7 ACEM's endorsed guidelines,8 and those concurrently developed by other Colleges, including the Royal Australian College of Physicians EVOLVE program campaign,9 advanced evidence-based care to curb unnecessary tests and treatments. There was a focus on supporting cost-savings, reducing waste, avoiding over-investigation and over-diagnosis, and educating patients about their health. Multidisciplinary initiatives evolved: physiotherapists were engaged, pharmacy colleagues were leading deprescribing initiatives, and end-of-life-care advocacy approaches involved patients, carers and clinicians to ensure appropriate care was provided in the last stages of life. However, progress stalled. First, funding models changed, impacting the governance of the Choosing Wisely programme and leading to a loss in momentum and engagement. Second, the unprecedented challenges of a global pandemic drastically impacted care delivery. Suddenly, it became very difficult to involve patients in shared decision making as to why certain investigations and treatments were not indicated. Interacting remotely, via iPads, through glass doors and from different rooms, combined with constant gowning and gloving, made consultations challenging. It seemingly became more efficient to order investigations first and see the patient with the results once these were available. Concerns about complications, such as cardiomyopathy and PE, prompted widespread ordering of D-dimers, troponins and CXRs for COVID-positive patients, and later, mRNA vaccinated patients,10 with chest pain, often before seeing a clinician. This practice has expanded, with evidence demonstrating increased use of CT in the investigation of abdominal pain during the pandemic.11 Studies suggest up to 30% of healthcare practices are wasteful, with 10% causing harm.12 Anecdote over evidence has crept into many aspects of care, and extends beyond over-investigation, to include over-treatment: practices including steroids for low-risk low back pain, opioids for migraines, intravenous magnesium for ectopic beats and stat doses of intravenous antibiotics for cellulitis13 remain strongly entrenched practices in EDs. These approaches are in direct conflict with our role as clinicians, as resource stewards, as evidence-based practitioners, as doctors who talk with, listen to and discuss care with our patients. My belief is the best clinicians order the least number of tests and ensure their patients understand why.14 This engagement and communication with patients and families is key. Medicine is complex, and all clinicians harbour concerns about missing diagnoses and the increasing threat of litigation. However, the most common complaints I have heard over the last 25 years relate to doctors not communicating or not explaining why decisions are made. Delays to diagnoses of appendicitis, torsion and pneumonia have not resulted in complaints where clinicians have been transparent about the lack of diagnostic clarity but have ensured patients understand the need to return if symptoms are changing: informed, shared decision making. But I have observed complaints arise from over-reliance on tests, and failure to provide patients with adequate explanation, advice and plans. Medical education does not teach clinicians systems thinking, but this knowledge needs to be embedded into training and clinical practice. ACEMs Sustainable Emergency Medicine and Climate and Health Advocacy Network is seeking to promote rational investigation, consequently reducing unhelpful pathology, radiology, treatments and medications. This is part of a larger Sustainable ED program, leading to decarbonising ED care and contributing to a safer, stable and sustainable environment and future. In New South Wales, an initiative promoting rational investigations and prescribing is seeing reductions in clinical waste and costs, and increases in carbon savings, without a compromise in patient care.15 In Victoria, the health department, with the support of ACEM, will shortly launch a similar state-wide initiative,16 and we are hoping to see this move through other states and territories. We are in an era of over-consumption, over-investigation and over-heating of the globe; every unnecessary test we initiate or treatment we commence has consequences.17 The negative impacts on our health, our health systems and that of our communities is clear and present. As healthcare leaders, we need to choose to lead the change towards a healthier future. And that, my friends, is the wisest choice we can all make. None declared.