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Factors influencing variation in investigations after a negative CT brain scan in suspected subarachnoid haemorrhage: a qualitative study
  1. Kevin Chu1,2,
  2. Carol Windsor3,
  3. Jennifer Fox3,
  4. Tegwen Howell1,
  5. Gerben Keijzers4,5,6,
  6. Robert Eley2,7,
  7. Frances Kinnear2,8,
  8. Jeremy Furyk9,
  9. Ogilvie Thom2,10,
  10. Nathan J Brown1,2,
  11. Anthony F T Brown1,2
  1. 1 Emergency and Trauma Centre, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
  2. 2 Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
  3. 3 Faculty of Health, Queensland University of Technology, Kelvin Grove, Queensland, Australia
  4. 4 Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
  5. 5 School of Medicine, Bond University, Gold Coast, Queensland, Australia
  6. 6 School of Medicine, Griffith University, Gold Coast, Queensland, Australia
  7. 7 Department of Emergency Medicine, The Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
  8. 8 Emergency and Children’s Services, The Prince Charles Hospital, Chermside, Queensland, Australia
  9. 9 Department of Emergency Medicine, University Hospital Geelong, Geelong, Victoria, Australia
  10. 10 Department of Emergency Medicine, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
  1. Correspondence to Associate Professor Kevin Chu, Emergency and Trauma Centre, Royal Brisbane and Women’s Hospital, Herston QLD 4029, Australia; k.chu{at}


Introduction Variation in the approach to the patient with a possible subarachnoid haemorrhage (SAH) has been previously documented. The purpose of this study was to identify factors that influence emergency physicians’ decisions about diagnostic testing after a normal CT brain scan for ED patients with a headache suspicious of a SAH.

Methods We conducted an interview-based qualitative study informed by social constructionist theory. Fifteen emergency physicians from six EDs across Queensland, Australia, underwent individual face-to-face or telephone interviews. Content analysis was performed whereby transcripts were examined and coded independently by two co-investigators, who then jointly agreed on the influencing factors.

Results Six categories of influencing factors were identified. Patient interaction was at the forefront of the identified factors. This shared decision-making process incorporated ‘what the patient wants’ but may be biased by how the clinician communicates the benefits and harms of the diagnostic options to the patient. Patient risk profile, practice evidence and guidelines were also important. Other influencing factors included experiential factors of the clinician, consultation with colleagues and external influences where practice location and work processes impose constraints on test ordering external to the preferences of the clinician or patient. The six categories were organised within a conceptual framework comprising four components: the context, the evidence, the experience and the decision.

Conclusions When clinicians are faced with a diagnostic challenge, such as the workup of a patient with suspected SAH, there are a number of influencing factors that can result in a variation in approach. These need to be considered in approaches to improve the appropriateness and consistency of medical care.

  • neurology, stroke
  • clincial management
  • qualitative research

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  • Patient consent for publication Not required.

  • Contributors KC conceived the study, conducted the interviews and drafted the manuscript. CW and JF provided methodological expertise, analysed the data and formulated the theoretical framework. TH coordinated the interviews, took field notes and transcribed the audio recordings. GK, RE, FK, JF and OT assisted KC and CW in the grant application including study design and sampling, and interpretation of the results. NJB and AFTB provided critical scientific and editorial input. All authors contributed to the revision of the manuscript with KC being responsible for the overall content as guarantor.

  • Funding This work was supported by the Emergency Medicine Foundation, Australia, grant number EMPG200R19.

  • Competing interests None declared.

  • Ethics approval The study was approved by the Human Research Ethics Committee, Royal Brisbane and Women’s Hospital, Brisbane, Australia.

  • Provenance and peer review Not commissioned; externally peer reviewed.