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.