Reinforcing informed medication prescription for low back pain in the emergency department (RIME): a controlled interrupted time series implementation study protocol.

INTRODUCTION: Management guidelines for low back pain (LBP) recommend exclusion of serious pathology, followed by simple analgesics, superficial heat therapy, early mobilisation and patient education. An audit in a large metropolitan hospital emergency department (ED) revealed high rates of non-recommended medication prescription for LBP (65% of patients prescribed opioids, 17% prescribed benzodiazepines), high inpatient admission rates (20% of ED LBP patients), delayed patient mobilisation (on average 6 hours) and inadequate patient education (48% of patients). This study aims to improve medication prescription for LBP in this ED by implementing an intervention shown previously to improve guideline-based management of LBP in other Australian EDs. METHODS AND ANALYSIS: A controlled interrupted time series study will evaluate the intervention in the ED before (24 weeks; 20 March 2023-3 September 2023) and after (24 weeks; 27 November 2024-12 May 2024) implementation (12 weeks; 4 September 2023-26 November 2023), additionally comparing findings with another ED in the same health service. The multicomponent implementation strategy uses a formalised clinical flow chart to support clinical decision-making and aims to change clinician behaviour, through clinician education, provision of alternative treatments, educational resources, audit and feedback, supported by implementation champions. The primary outcome is the percentage of LBP patients prescribed non-recommended medications (opioids, benzodiazepines and/or gabapentinoids), assessed via routinely collected ED data. Anticipated sample size is 2000 patients (n=1000 intervention, n=1000 control) based on average monthly admissions of LBP presentations in the EDs. Secondary outcomes include inpatient admission rate, time to mobilisation, provision of patient education, imaging requests, representation to the ED within 6 months and healthcare costs. In nested qualitative research, we will study ED clinicians' perceptions of the implementation and identify how benefits can be sustained over time. ETHICS AND DISSEMINATION: This study received ethical approval from the Metro North Human Research Ethics Committee (HREC/2022/MNHA/87995). Study findings will be published in peer-reviewed journals and presented at international conferences and educational workshops. TRIAL REGISTRATION NUMBER: ACTRN12622001536752.

Adherence to recommended guidelines for low back pain presentations to an Australian emergency department: Barriers and enablers.

OBJECTIVE: This study sought to evaluate the adherence to guidelines for the management of mechanical Low Back Pain within a single tertiary metropolitan Emergency Department setting. Our objectives were: METHODS: A two-stage multi-methods study design was undertaken. Stage 1 involved a retrospective chart audit of patients presenting with a diagnosis of mechanical Low Back Pain to establish documented adherence to clinical guidelines. Stage 2 explored clinicians' perspectives towards factors influencing adherence to the guidelines via a study-specific survey and follow up focus groups. RESULTS: The audit demonstrated low adherence to the following guidelines: (i) appropriate prescription of analgesia, (ii) targeted education and advice, and (iii) attempts to mobilise. Three major themes were identified as factors influencing adherence to the guidelines: (1) clinician driven influences and factors, (2) workflow processes, and (3) patient expectations and behaviours. CONCLUSION: There was low adherence to some published guidelines and factors influencing adherence to the guidelines were multi-factorial. Understanding the factors that influence care decisions and developing strategies to address these can improve Emergency Department management of mechanical Low Back Pain.

Patients' experiences of readiness for discharge following a total hip replacement.

In recent years there has been a reduction in the length of stay of patients undergoing total hip replacement, as hospitals have attempted to reduce costs. A reduced length of stay requires patients undergoing total hip replacement to achieve independence over increasingly shorter periods. Clinical experience indicates that many of these patients feel unready or reluctant to be discharged to home, even though they are physically capable. Information is required about psychosocial factors that may affect or delay discharge. This naturalistic study used grounded theory methodology to explore the perceptions of discharge readiness of people who had undergone a total hip replacement. Using purposive sampling, five participants were interviewed prior to discharge from an acute hospital. The analysis resulted in the emergence of three categories: 'Confidence', 'Family and friends', and 'Feeling safe'. Participants wanted to feel safe both in the hospital and at home. Their own confidence levels and the presence of family and friends at home had a strong influence on feelings of safety. The core category and main concern of participants appeared to be about feeling safe. Participants who felt safe perceived they were ready to be discharged. Healthcare professionals can recognise and question patients about some of these factors that influence feelings of safety and readiness for discharge. Recognising concerns of patients prior to discharge will promote good patient care and discharge planning that is more acceptable to patients and carers.