2025

Session 3A (Room 2.21)
Chair: Nicola Cunningham

3.A.1 Diagnostic Errors: Understanding Healthcare Practitioners’ Medico-Legal Liability

Dr Pamela J. Ferrada, Member Education, Knowledge and Research Manager, Risk Education, Medical Indemnity Protection Society

Key words (max 5):
missed diagnosis, medico-legal liability, patient safety, risk management, claims, medical indemnity

Background & Aims:
Diagnostic errors represent a significant medico-legal challenge for healthcare practitioners. Legal frameworks regarding allegations of medical negligence and delayed or missed diagnosis are complex and multifaceted, and often a source of confusion for doctors.

This presentation aims to establish a foundational understanding of some of the legal aspects of health practitioner liability arising from diagnostic errors. Key concepts in medical negligence laws, and professional duties related to anticipating, preventing and mitigating medicolegal risks will be discussed.

Methodology, Approach, Innovation or Intervention:
The presentation will use an analogy as an educational tool to illustrate how key legal terminology is applied to a real-world scenario. The example focuses on the concept of duty of care and how it impacts the outcome of a medical negligence allegation.

Discussion, Outcomes or Findings:
Using a case study and an analogy can leverage analogical reasoning as a powerful strategy to help medical practitioners grasp complex legal frameworks and foster conceptual understanding and long-term knowledge retention.

Educational impact, Further development or Future applications:
This presentation will improve medical practitioners’ legal literacy and awareness of their professional responsibilities around the legal and regulatory aspects that arise in case of diagnostic errors.

Lessons learnt/take-home messages:Healthcare practitioners have a legal duty of care to provide a reasonable standard of care. Misdiagnosis, delayed or failure to diagnose may constitute a breach of this duty, leading to potential claims or complaints. Understanding the legal principles of medical negligence frameworks may assist clinicians in mitigating risks and improving patient safety.

3.A.2 Could it be HIV Increasing HIV Testing in Clinical Indicator Settings?

Louise Owen, Statewide Sexual Health Service, Tasmania, School of Medicine, University of Tasmania

Key words (max 5):
HIV testing in medical situations

Background & Aims:
Of the estimated 30,010 people with HIV in Australia, 2360 people (8%) are unaware of their HIV status.  Late diagnosis often leads to increased health concerns and poor outcomes among patients and is linked with significantly higher rates of transmission and increased health care costs.

Many people with delayed HIV diagnosis have often interacted with different healthcare services in the years before their diagnosis. Often, they have presented with clinical indicators that should prompt healthcare professionals to test for HIV, even if they do not fit the typical risk profile. We must increase proactive HIV testing within clinical settings and empower healthcare professionals to offer these individuals a HIV test. By proactively recognising these indicators and testing for HIV, any positive cases, previously undiagnosed, can receive prompt medical intervention to improve medical outcomes and impact HIV transmission, or HIV can be ruled out.

Methodology, Approach, Innovation or Intervention:Integrating HIV testing into standard clinical practice for all patients presenting with potential signs and symptoms of HIV, regardless of their sexual orientation or number of sexual partners, will help normalise HIV testing and decrease stigma and fear. This approach can lead to earlier diagnosis and better health outcomes for individuals living with HIV. Testing for HIV also remains cost-effective, even when the initial likelihood of a positive result is as low as 1 in 1,000 cases,

Raising awareness to broad groups of clinicians, including at college level to enact change in guidelines to normalise HIV testing will help achieve the goal of zero HIV transmissions in Aust by 2030.

There are a number of great resources for clinicians ASHM

• ‘Could It Be HIV’ Toolkit, a 2-page resource that provides clear instructions for HIV testing, including indications for testing and interpretation of serology results. It also highlights key clinical indicator conditions for testing and offers guidance on treatment options.
• HIV Testing Portal, a concise online source of standardised, currently available information to inform those involved in ordering and performing Human Immunodeficiency Virus (HIV) testing.

Discussion, Outcomes or Findings:
HIV taskforce, chaired by Hon Minister for Health (Federal) combination work with Australasian Chapter of Sexual Health Medicine and ASHM, peak body representing the HIV/STI/Hepatitis Workforce -all working to raise awareness to not leave anyone behind.  Heterosexuals and older people are disproportionately represented in the stats for delayed HIV diagnosis in Australia, despite great leaps in HIV prevention (Kirby UNSW, ref avail).

Educational impact, Further development or Future applications:
Could include opt out testing in Emergency departments, Working with GPs to raise awareness. Representation on national guideline committees e.g. National Cervical Cancer Guidelines, EviQ chemotherapy guidelines, to ensure HIV testing is recommended, normalised. Medical school educational opportunities- currently adhoc.

Lessons learnt/take-home messages:Normalise HIV testing in multiple clinical situations and empower clinicians to feel comfortable to test, rule out HIV and ensure this cheap, sensitive and specific test is used early on in the diagnostic cascade for many clinical indicator conditions;

• ‘Could It Be HIV’ Toolkit, a 2-page resource that provides clear instructions for HIV testing, including indications for testing and interpretation of serology results. It also highlights key clinical indicator conditions for testing and offers guidance on treatment options.

3.A.3 Exploration of in-hospital code stroke activation

Nadja Korajkic, Lauren Sanders - Department of Neurosciences, St Vincent’s Hospital, Melbourne, VIC, Australia

Key words (max 5):
Inpatient, stroke code, quality improvement

Background & Aims:
Inpatient acute stroke codes pose unique challenges to diagnosis and management, in comparison to code strokes activated from the community, due to concurrent medical and surgical comorbidities. Whilst there have been significant improvements in pre-hospital and emergency department management of hyperacute stroke over recent years, the translation of these processes to in-hospital stroke is less clear. We aimed to determine the incidence, diagnostic accuracy and associated factors for code stroke activation for inpatients at our institution.

Methodology, Approach, Innovation or Intervention:
Quality audit was performed for all inpatient stroke codes at St Vincent’s Hospital, Melbourne between 2023 and 2025. Incidence of inpatient stroke code was determined from hospital switchboard records. Patient demographics (age, gender), bedcard, symptoms prompting code activation and reperfusion therapy were extracted from the medical records. Confirmation of stroke diagnosis was determined by review of associated imaging.

Data were evaluated against recommended stroke key performance indicators, as well as exploration for common factors associated with stroke code activation

Discussion, Outcomes or Findings:
A total of 114 inpatient stroke codes were identified. Mean age was 67.6±13 years with 43% female. The most common symptoms prompting code activation were weakness, facial droop, altered GCS, aphasia and dysarthria. Cardiothoracics (n=24), Stroke (n=13), Neurosurgery (n=12), General Medicine (n=12) and Cardiology (n=10) were the most common units to call a stroke code. Median time from code activation to multimodal CT imaging was 24 minutes (IQR 18-37). Stroke was diagnosed in 46 (40.3%), 31 (27.2%) on CT, and 15 (13.2%) on MRI following a negative CT. Diagnostic accuracy was relatively high for Cardiothoracics (n=11, 45.8%), Stroke (n=9, 69.7%) and Cardiology (n=7, 70%) and lower for General Medicine (n=3, 25%). Hyperacute management with thrombolysis occurred in 3 cases (2.63%), and 13 (11.4%) proceeded to thrombectomy.

Educational impact, Further development or Future applications:
Data from this audit will be used to inform continuous improvement interventions for the stroke service. Further work is now being undertaken with units where elevated risk for inpatient stroke has been identified, to explore speciality specific factors and hopefully identify opportunities to mitigate this risk.  Additionally, education relating to stroke recognition and code stroke activation is being developed, including in-hospital stroke simulation.

Lessons learnt/take-home messages:Inpatients under some units are at a higher risk of experiencing inpatient stroke with requirement for acute stroke treatment. Exploring interventions to identify and minimise this risk may be of benefit.

3.A.4 The Outpatient Emergency Department Pathway to Cancer Diagnosis: Healthcare Engagement and Rural Treatment Disparities

Caroline Thompson, University of North Carolina at Chapel Hill

Key words (max 5):
Cancer diagnosis, emergency department, rural health, diagnostic delay, healthcare access, surgical oncology

Background & Aims:
Emergency departments increasingly serve patients with undifferentiated symptoms as healthcare access challenges intensify, particularly in rural areas. While emergency presentations leading to immediate hospital admission and cancer diagnosis have been well-studied, a critical diagnostic pathway remains underappreciated: patients evaluated and discharged from the ED with cancer diagnosed shortly thereafter. We aimed to characterize this outpatient ED pathway, including patient engagement patterns, cancer-specific risks, and treatment outcomes, with attention to rural-urban disparities.

Methodology, Approach, Innovation or Intervention:
We analyzed US SEER-Medicare data—linking cancer registry records with claims for adults aged ≥65—for 927,410 patients diagnosed 2007-2017 across sixteen cancer types. We defined the outpatient ED pathway as ED contact without admission in the 30 days preceding diagnosis. We compared healthcare utilization patterns (primary care and ED visits in the preceding year), examined cancer-type variation, and assessed treatment receipt using multivariable models adjusting for demographics, stage, comorbidity, and frailty.

Discussion, Outcomes or Findings:
Overall, 6% followed this pathway, with substantially higher rates rurally (11% vs 6% metropolitan). Certain cancers showed elevated odds of ED discharge rather than admission: uterine, ovarian, bladder, esophageal, and kidney cancers compared to lung (adjusted for age, sex, stage), potentially reflecting symptom profiles appearing non-urgent despite representing malignancy. Contrary to assumptions about lacking access, 90% had primary care contact in the preceding year (62% with 5+ visits), and 93% of high ED utilizers also had frequent primary care contact. This high engagement indicates coordination failure between systems rather than patient disengagement. Engagement patterns were heterogeneous: 30% highly primary-care-engaged without prior ED use (acute escalation), 59% moderate engagement, and only 7% disengaged from both systems. Rural patients showed modestly lower primary care engagement (22% vs 25%) and higher disengagement (9% vs 7%), insufficient to explain their substantially higher pathway prevalence. Even engaged rural patients face diagnostic follow-through failures, likely reflecting limited specialist availability and geographic barriers. After adjusting for comorbidity, frailty, year, and region, the pathway was associated with 17% increased treatment risk in non-metropolitan areas (RR=1.17) but no excess in metropolitan areas (RR=1.04). This persistent rural gap, driven by lower surgical receipt, suggests structural barriers to accessing surgical oncology infrastructure.

Educational impact, Further development or Future applications:
This work identifies a system-level diagnostic vulnerability requiring multi-component interventions: enhanced ED-to-primary care communication, safety-netting protocols for discharged patients with persistent symptoms, and strengthened referral pathways connecting rural patients to regional surgical oncology centers.

Lessons learnt/take-home messages:The outpatient ED pathway affects engaged patients across healthcare settings, representing coordination failure rather than patient disengagement. Rural patients face compounding vulnerabilities: higher pathway prevalence despite similar engagement, and subsequent treatment barriers particularly for surgical oncology.

3.A.5 Absent Initial Clinical Impressions in ED: Time to Get Back to Basics

Prof Diana Egerton-Warburton*1,3,  A/Prof Lisa Kuhn 3,4, Joanne Enticott 2,3, Suzanne Bumpstead 1,3, Dr Neil Goldie 3, Dr Helen Pshiogios 3 et al.
*Presenting author

Affiliations

1. Monash University, School of Clinical Science at Monash Health, 
2. Monash University, Monash Centre for Health Research and Implementation
3. Monash Health, Emergency Care
4. Australian Catholic University, School of Nursing, Midwifery and Paramedicine 

Key words (max 5):
'Clinical Impression'; 'Clinical decision making'; 'Differential diagnoses'; 'Emergency department'; 'Electronic medical record review'

Background & Aims:
Approximately 15% of hospital patient encounters are affected by diagnostic error and around 80% may be preventable. Documentation of clinical impressions in Emergency Departments (EDs) electronic medical records (EMR) is essential for diagnostic decision-making and effective patient management. EMR nudges have been shown to improve clinical-decision making when they are made to frame information and enable choice in the clinical environment. ‘DotPhrases’ have been demonstrated as useful tools for improving efficiency especially in time-pressured contexts by promoting quicker note completion and high level consistency of documentation.

This study aims to assess the adequacy of the initial clinical impression and management plans documented in EMR for adult patients presenting to EDs.

Methodology, Approach, Innovation or Intervention:
A retrospective medical record review of 500 randomly selected adult patients from 16,431 who presented to four EDs in a health service between 1–31 August 2024 was conducted. The primary outcome was a documented clinical impression in the ED initial medical assessment. Secondary outcomes included analyses of relationships between predefined patient or clinical factors and documentation of a clinical impression.

Discussion, Outcomes or Findings:
432 eligible patient records were analysed. Clinical impressions were absent in 23.4% of cases (95% CI 20%–28%, margin of error 3.9%). This was consistent across levels of clinician experience and triage categories, except for category 5 with higher rates of absent clinical impressions (67%; 95% CI 31%–91%). Differential diagnoses were documented in 39% of cases. High urgency patients had more clinical decision rules documented (4%; 95% CI 2%–7% vs 14%; 95% CI 8%–23%). Inter-rater reliability for primary outcome demonstrated strong agreement (κ=0.91).

Almost one-quarter of adult ED patients lacked a documented clinical impression in their initial medical assessment, irrespective of clinician experience and the four most urgent triage categories. This gap should be addressed rapidly to improve diagnostic decision-making and optimise patient safety.

Educational impact, Further development or Future applications:
It is proposed that a co-designed EMR Nudge (‘DotPhrase’), for documenting a clinical impression and management plan in ED initial assessments, is developed and introduced as standard practice. A stepped-wedge cluster-controlled analysis of the impact would quantify whether the implementation of the ‘DotPhrase’can improve documentation of ED clinical impressions and management plans in the EMR.

Lessons learnt/take-home messages: The absence of clinical impressions should be addressed rapidly to improve diagnostic decision-making and optimise patient safety.

3.A.6 Implementation of a structured clinical impression and management dotphrase in the electronic medical record as standard practice at Monash Health Emergency Departments: A stepped-wedge cluster-controlled analysis of the impact

Prof Diana Egerton-Warburton*1,3, Joanne Enticott 2,3, Parneet Sethi 2,3, Suzanne Bumpstead 1,3, Sophie Balzat 3, Veena Peacock 3 et al.
*Presenting author

Affiliations

1. Monash University, School of Clinical Science at Monash Health,
2. Monash University, Monash Centre for Health Research and Implementation
3. Monash Health, Emergency Care

Key words (max 5):
'emergency department', 'clinical impression', 'Nudge tool', 'DotPhrase', 'electronic medical record'

Background & Aims:
Thorough history, examination and formulation of a clinical impression form the backbone of clinical medicine, and facilitates correct diagnosis the majority of the time. A thoughtful initial clinical impression is a time tested and invaluable method to reduce diagnostic errors contributing to patient harm. Our recent research has demonstrated that a documented clinical impression is absent in more than one quarter of adult ED patients. Electronic Medical Record (EMR) technology including nudge tools can be used to help streamline care by prompting quicker and more consistent note completion.

This study aims to measure the impact of the introduction of a co-designed EMR Nudge (‘DotPhrase’) for clinical impression and management in initial assessments in Emergency Departments (ED) patients.

Methodology, Approach, Innovation or Intervention:
The co-designed EMR nudge tool was rolled out sequentially across four Monash Health Emergency Departments (EDs). Implementation was driven by the Learning Health System and Behaviour of Change Wheel for optimisation. Data was collected over a period of 12 weeks. Weeks 1-2: baseline data, Weeks 3-6: step-wise implementation of the ‘DotPhrase’ across the sites, Weeks 7-12: sustainability phase across all sites.  The use of the ‘DotPhrase’, components of the clinical impression and management plan and patient satisfaction were assessed. An interim analysis consisting of a before-and-after statistical analysis was performed (Week 2 compared to Week 12). A mixed effects analysis with covariates is currently being conducted.

Discussion, Outcomes or Findings:
The interim analysis: 1007 charts met inclusion criteria in Week 2, and 1028 charts in Week 12. In Week 12, 36.1% of ED Initial Assessments utilised the DotPhrase. There was a statistically significant improvement in the documentation of a clinical impression (5.0% increase (95% CI: [2.1, 7.8%])), differential diagnosis (14.4% increase (95% CI: [10.2, 18.5%])) and discussion with a senior (18.9% increase (95% CI: [14.6, 23.1%])) in the post-implementation phase compared to the pre-implementation phase. There was also an increase in overall adult patient satisfaction, as well as patients reporting communication of the diagnostic process. Results are still pending for the mixed effects analysis with covariates.

Educational impact, Further development or Future applications:
Further refinement of the ‘EMR ‘DotPhrase’ and ongoing education regarding its use, is expected to improve clinician use of the nudge tool and embed its use in standard practice.

Lessons learnt/take-home messages:DotPhrase use is associated with improved documentation of clinical impressions, differential diagnosis and cross-checking. The DotPhrase shows promise in its role as a clinical decision-making adjunct. Monitoring and providing feedback to staff regarding the use of the EMR ‘DotPhrase’ together with ongoing education regarding the importance of documenting a clinical impression and management plan in the ED Initial Assessment, is essential to ensure sustainable change.

Session 3B (Room 2.31)
Chair: Julia Harrison

3.B.1 Humanities in Monash Medicine - A Visual Arts Program to Enhance Skills

Deborah Leach, Monash Medical School

Key words (max 5):
humanities, observation, listening, teamwork, ambiguity

Background & Aims:
Monash Medicine recognises the compelling reasons to embrace Humanities teaching into Medical Education. The practice of medicine is an art as well as a science.

Humanities based teaching in medicine is acknowledged to be an effective method to develop core clinical skills underpinning diagnostic excellence.

It provides an opportunity for  re-conceptualising the ways in which we teach students to observe, listen, work with others and reflect on their attitudes and cognition.

Methodology, Approach, Innovation or Intervention:
A visual arts program (Art of Seeing) was introduced in 2025 to enhance students' skills of close observation, generous listening, teamwork and tolerance of ambiguity.

Sessions using an array of curated activities such as Personal response Tour (PRT) and Visual Thinking Strategies (VTS) were offered at strategic points in the medicine course including major transition points, curriculum with challenging topics and sessions specifically designed to support professionalism development in students. Most sessions were run in the National Gallery of Victoria but sessions were also successfully run in campus based classrooms using a transportable collection of gallery images.

This program intentionally complements the current curriculum through the course which includes mindfulness teaching (pre-clinical), Healer's Art (Year 3B) and compassion training (final year).

Not only do students benefit from skills acquisition, but the inclusion of humanities also injects joy into learning.

Discussion, Outcomes or Findings:
Students have embraced this offering with high ratings for overall satisfaction, engagement and applicability to developing skills needed in the world of clinical medicine. Whether sessions were mandatory or optional, students had the same positive responses.

Specific comments about what students had learned related to important aspects of clinical thinking, not leaping to conclusions and careful listening to members of the care team. Many students reflected on the importance of observing and listening to understand both team and patient perspectives so that the goals for each patient are achieved.

Educational impact, Further development or Future applications:
Exploring the place of Art of Seeing in the Monash Medicine course will open up opportunities to further articulate with important areas of curriculum.

In 2026 Art of Seeing will be expanded to provide Indigenous Health teaching to metropolitan final year students in addition to the other activities offered in 2025.

Development of faculty to help design and facilitate sessions will be critical to the success and sustainability of the program.

Lessons learnt/take-home messages:Introducing a program that is very different from usual university teaching methods requires time, patience, careful integration and a view to creating sustainability.

3.B.2 Designing a Decision-Making Flowchart to Reduce Unnecessary CXR Ordering in the Emergency Department

Dereck Luk, Joseph Miller, Bronwyn Kirkwood, Elizabeth Cole, Rae-lee Wilkinson, Sarah Zheng, Raewyn Szelag, Shaun Eccles-Smith, Ilya Kardailsky, Erin Woodward, Paul Roche, Paul Buntine

Key words (max 5):
X-Rays, Low-Value Care, Incidental Findings, Clinical Decision Support

Background & Aims:
Chest X-rays (CXRs) are among the most frequently ordered imaging investigations in emergency departments, sometimes with limited diagnostic value or impact on patient management. This can expose patients to unnecessary radiation and increase staff workload unnecessarily. To promote diagnostic and resource stewardship, a decision-making flowchart was designed and is being tested at Eastern Health Emergency Departments to guide appropriate CXR ordering.

Our aims are as follows:

1. To evaluate the difference in diagnostic yield between CXRs ordered after clinicians viewed the flowchart compared to those ordered by clinicians not following the flowchart.

2. To compare the yield of positive findings between patients seen by a doctor and those unseen at the time of CXR ordering.

3. To assess the rate and nature of incidental findings (i.e. abnormalities not related to the presenting complaint) that require follow-up.

Ultimately, the goal is to reduce inappropriate CXR orders while maintaining diagnostic safety.

Methodology, Approach, Innovation or Intervention:
A retrospective review of CXR orders before and after implementation is being conducted, entailing comparisons of yield and ordering rates across three Eastern Health Emergency Department sites.

Data collection includes patient details, initial presenting complaints, CXR indication, CXR report findings, diagnosis, and final treatment or management outcomes.

Findings will be classified as follows:

• Positive yield: CXR results that are clinically significant and correlated with management or final diagnosis.
• Incidental findings: Unrelated CXR findings that potentially require follow-up.

Approximately 60–100 cases will be reviewed under the new flowchart. Comparisons will be made between flowchart-adherent and non-adherent cases, as well as between patients who have and have not been seen face-to-face by a clinician.

Discussion, Outcomes or Findings:
Preliminary results show a positive yield of 25% (3/12) in the flowchart-compliant group, compared to 0% (0/8) in the non-compliant group, and 0% (0/3) in unseen patients.

These early findings form the foundation of our expected outcomes, suggesting that adherence to the flowchart improves diagnostic yield while premature ordering does not improve diagnostic yield.

The current sample size is too small to permit statistical significance testing, but we will continue with data collection with the goal of highlighting opportunities to improve diagnostic efficiency and reduce low-value imaging.

Educational impact, Further development or Future applications:
Contingent on results of ongoing data collection, a final CXR flowchart will be implemented across all Eastern Health Emergency Department sites on an ongoing basis, with support from Clinical Directors.

Lessons learnt/take-home messages:
A CXR decision-making flowchart has the potential to increase diagnostic yield and reduce low-value care in an emergency setting.

3.B.3 Developing Diagnostic Competencies for Nurse-led Pathways in the Emergency Department

Deborah Digman Royal Victorian Eye and Ear Hospital, Melbourne

Key words (max 5):
nursing diagnostic competencies, team diagnosis

Background & Aims:
To develop nursing diagnostic competencies for Fast Track conditions in the ED

Methodology, Approach, Innovation or Intervention:
In collaboration with consultant ophthalmologists, we developed a nursing diagnostic competency framework and applied the framework to fast track conditions in our specialty  emergency department. Fast track conditions included corneal abrasion, mild chemical eye injury, chalazion, conjunctivitis. and subtarsal foreign body.

Nurses first completed a competency in the use of the slit lamp to ensure their foundational diagnostic skills were sound.

Following this they progressed to completing diagnostic competencies in the above fast track conditions, with case by case oversight by consultant ophthalmologists.

Discussion, Outcomes or Findings:
Diagnosis is a team-based process. This project entailed embedding nurse-led pathways in fast track using consultant ophthalmologists to help develop nursing diagnostic competencies. In this project, nurse sign off as having achieved competency requires seeing and being assessed on 5 patients with a particular fast track condition.

Consultant ophthalmologists or senior eye registrars will continue to work closely with the nursing staff, even once a competency has been achieved, modelling ongoing diagnostic cross- checking and team- based diagnosis.

Educational impact, Further development or Future applications:
In the future, nursing diagnostic competencies for ear, nose and throat fast track conditions will be developed using the same framework.

Lessons learnt/take-home messages:
Nursing diagnostic competencies can be used to improve team-based diagnosis in the ED.

Team-based diagnosis requires medical and nursing clinicians and educators to work closely together. In this project, this included working together both in the development of nursing diagnostic competencies and in the application of these competencies on the ED floor to ensure diagnostic excellence.

3.B.4 Investigation Framework

Birks J, Birks R, Seach K, Haigh C  Monash Rural Health Gippsland

Key words (max 5):
investigation framework structure differential diagnosis

Background & Aims:
We aim to support medical students in selecting investigations as they develop clinical reasoning skills. Medical students in their early clinical years often find it difficult to systematically select appropriate clinical investigations.  Clinical reasoning begins with generating differential diagnoses. Following this is the development of an understanding of which tests can help distinguish these differentials into more and less likely.  Initially a ‘scatter gun’ approach to selecting investigations is often taken by early clinical students, where an excessive number of tests are ordered in the hope that one that is useful is included.  With this more random approach, clinically useful tests may be overlooked.

Methodology, Approach, Innovation or Intervention:
A search of medical textbooks and the literature did not yield a simple framework to provide to medical students.  Such an Investigation Framework was thus generated, with tests categorised in a structured manner. Categories include bedside tests, pathology (including blood tests, swabs, biopsies and sputum cultures), imaging (including plain films, ultrasound, CT and MRI) and finally special tests such as stress echocardiography.  A pilot study with a small group of medical students was undertaken to test the utility of the framework.  Students were asked to complete a short survey related to their use of the Investigation Framework.

Discussion, Outcomes or Findings:
An exploration of the utility of the Investigation Framework will be presented, with student feedback initially very positive.

Educational impact, Further development or Future applications:
A structured approach to requesting investigations will allow students to select their investigations more appropriately.  This will facilitate development of clinical reasoning and prevent squandered resources associated with unnecessary ordering of irrelevant tests.  An expanded study is planned to assess the Investigation Framework in a larger group of students.

Lessons learnt/take-home messages:This pilot study of an Investigation Framework to structure the learning of clinical reasoning for medical students has been well received. Students appreciate guidance as they navigate the overwhelming number of options when requesting investigations.

3.B.5 Learning to Diagnose: Leveraging cognitive load theory (CLT) and metacognition to reduce diagnostic errors

Dr Pamela J. Ferrada, Member Education, Knowledge and Research Manager, Medical Indemnity Protection Society

Key words (max 5):
cognitive load, metacognition, misdiagnosis, delayed diagnosis, adult learning theories.

Background & Aims:
Cognitive Load Theory (CLT) and metacognition are useful frameworks to explain the human cognitive architecture; the limitations of working memory and how self-reflective practices can improve learning.

This presentation aims to establish explicit connections between CLT, metacognition, and their practical application in clinical work, particularly in relation to minimising the risk of missed or delayed diagnosis. Key concepts related to cognitive load types (extraneous, intrinsic and germane) will be discussed and their relevance in the content of minimising diagnostic errors.

Methodology, Approach, Innovation or Intervention:
The presentation will use a case scenario as an educational tool to illustrate how CLT and metacognitive processes are applied in real clinical practice. The example focuses on the concepts of working memory and its limitations, the bottleneck effect and how metacognition can promote schema formation, long term knowledge retention thus minimising the likelihood of diagnostic errors.

Discussion, Outcomes or Findings:
Understanding the link between cognitive load, metacognitive processes and missed diagnosis, assists clinicians in better appreciating their cognitive architecture and the competing mental processes at play when they work through a diagnostic process, often under time constraints and within unpredictable and complex clinical settings.

Educational impact, Further development or Future applications:
This presentation will expand attendees’ ability to manage complex information without cognitive load, potentially leading to better diagnostic reasoning, reduced errors and improved patient outcomes.

Lessons learnt/take-home messages:
Working memory has a limited capacity and when overloaded, learning and performance are impaired. Fostering metacognitive practices and self-reflection optimises germane load, which in turn improves clinical decision-making and diagnostic reasoning. Effective teaching practices should minimise extraneous cognitive load, and ensure intrinsic cognitive load is attuned to the learner’s expertise level and readiness to learn.

3.B.6 Evaluation of the Diagnostic Yield of CT and MR Modalities in Clinical Indications of Cranial Nerve Palsies

Aaron Avenido, Melbourne Medical School, The University of Melbourne

A/Prof Jean Lee, Department of Public Imaging Services, St Vincent's Hospital Melbourne

Key words (max 5):
cranial nerve palsy, diagnostic yield, CT, MR

Background & Aims:
There is ongoing debate amongst diagnosticians regarding the usefulness of neuroimaging in the clinical assessment of acute cranial nerve palsies, a heterogenous group of intracranial nerve defects affecting core ocular and facial function. Intracranial microvascular compromise is a leading causative process for these presentations, with digital subtraction angiography considered to be the gold-standard neuroimaging. However, computed tomography (CT) and magnetic resonance (MR) modalities have become modern mainstays in diagnosis due to their lower patient risk and greater availability and accessibility.

Although CT angiography is now the modality of choice for emergent neuroimaging of oculomotor nerve palsies, due to its speed and high sensitivity for aneurysms, there is limited consensus regarding the benefit of CT and MR neuroimaging in other palsies. Namely, whether clinically useful intracranial causes can be found. In fact, MR is traditionally contraindicated in those aged over 50 years old, due to the lower epidemiological likelihood of detecting non-aneurysmal pathologies.

Consequently, this study aims to investigate and compare the diagnostic yield of CT and MR modalities in clinically suspected and diagnosed cases of cranial nerve palsies at St Vincent's Hospital Melbourne. This is a major metropolitan tertiary centre with a sufficient case load of ocular palsies.

Methodology, Approach, Innovation or Intervention:
A single-centre retrospective data analysis of digital medical records and radiological investigations involving all patients who had undertaken CT and/or MR neuroimaging at St Vincent's Hospital Melbourne from July 2020 to July 2025 for clinically suspected or diagnosed cranial nerve palsies (n = 1,000 imaging reports). The primary outcome is determining and comparing the diagnostic yield of CT and MR neuroimaging in ascertaining intracranial pathologies which are causative for these presentations. Secondary outcomes include determining any broader data trends, such as over-imaging and the patient or pathological characteristics correlating to diagnosis.

Discussion, Outcomes or Findings:
Based on a preliminary analysis of 110 imaging reports, 5% of CT identified masses; 3%, 5%, and 11% of CTA identified aneurysms, masses, and other pathologies, respectively; and 6%, 8%, and 15% of MR identified non-aneurysmal microvascular pathologies, masses, and other pathologies, respectively.

Educational impact, Further development or Future applications:
Clinicians tend to request neuroimaging to determine intracranial causes for cranial nerve palsies. The findings from this study will be used to evaluate the practicality and necessity of requesting CT and MRI modalities as proxy for any over/underutilisation of such resources at an institutional or unit level. Thus, improving clinical efficiency and patient outcomes, whilst minimising radiation exposure and healthcare expenses.

Lessons learnt/take-home messages:
N/A at this stage. Study is ongoing.

Session 3C (Room 2.37)
Chair: Carmel Crock

3.C.1 A Worried Parent is the Most Vital Sign

Erin Mills (Monash Uni/School of Clin Sciences/Dept of Paediatrics, Monash Health/Paediatric ED), Phyllis Lin (Monash Uni/School of Clin Sciences/Dept of Paediatrics, Monash Health/Paediatric ED), Mohammad Asghari-Jafarabadi (Monash Uni/School of Public Health and Preventative Medicine, Monash University/Department of Clinical Sciences/Department of Psychiatry, Monash Health/Paediatric ED), Adam West (Monash Uni/School of Clin Sciences/Dept of Paediatrics, Monash Health/Paediatric ED), Simon Craig (Monash Uni/School of Clin Sciences/Dept of Paediatrics, Monash Health/Paediatric ED)

Key words (max 5):
paediatric; critical illness; deterioration; carer concern; parent concern

Background & Aims:
In high-income countries critical illness in children is rare, and often difficult for physicians to distinguish from common minor illness until late in the disease. Parents or carers are well positioned to detect early and subtle signs of deterioration, but the relationship between their concerns and patient outcomes is unknown. This study examines the relationship between carer concern for clinical deterioration and critical illness in paediatric patients presenting to hospital.

Methodology, Approach, Innovation or Intervention:
This prospective observational cohort study was conducted in a tertiary paediatric emergency department (ED) in Melbourne, Australia over 26 months. It included patients aged <19 years with a documented response to the question “Are you worried your child is getting worse?” during their ED visit or hospital admission. Multivariable analysis assessed whether carer concern for clinical deterioration predicted ICU admission, mechanical ventilation, or death.

Discussion, Outcomes or Findings:
Of 78,733 eligible ED presentations, 24,239 had at least one documented response for ‘Parent/Carer Concern’. Of 189,708 responses, 4·7% indicated concern for clinical deterioration. Compared to patients with unworried carers, those with a carer concerned for clinical deterioration were more likely to be admitted to ICU (6·9% vs 1·9%), to be mechanically ventilated (1·1% vs 0·2%), or die during admission (0·1% vs 0·02%). Multivariable analysis showed carer concern for clinical deterioration independently predicted ICU admission (adjusted odds ratio [AOR] 1·77, 95%CI 1·47-2·14) and mechanical ventilation (AOR 2·12; 95%CI, 1·33-3·39), but not death (AOR 0·97, 95%CI 0·18-5·34). Carer concern was a stronger predictor for ICU admission than abnormal vital signs.

Educational impact, Further development or Future applications:
Carer concern for clinical deterioration is associated with worse outcomes for paediatric patients, and is a stronger predictor of ICU admission or mechanical ventilation than abnormal vital signs. Rapid response systems should incorporate proactive assessment of parent or carer concerns for deterioration.

Lessons learnt/take-home messages:A parent or carer expressing concern about clinical deterioration in their child is more strongly associated with critical illness in that child than any abnormal vital sign. The authors advocate that the concerns of parents or carers should be proactively sought by staff as part of routine clinical care.

3.C.2 The Relationship Between Patient or Caregiver Concern for Clinical Deterioration and Critical Illness in an Adult Population - A Retrospective Observational Cohort Study

Tom Truscott (Monash University/School of Clinical Sciences), Erin Mills (Monash Uni/School of Clin Sciences/Dept of Paediatrics, Monash Health/Paediatric ED), Phyllis Lin (Monash Uni/School of Clin Sciences/Dept of Paediatrics, Monash Health/Paediatric ED), Simon Craig (Monash Uni/School of Clin Sciences/Dept of Paediatrics, Monash Health/Paediatric ED)

Key words (max 5):
adult; critical illness; deterioration; caregiver concern; patient concern

Background & Aims:
Early recognition of clinical deterioration in a hospital setting is crucial for prevention of adverse health outcomes. Proactive questioning of adult patients or caregivers for concerns about worsening clinical status may improve early recognition and prevent serious outcomes, such as death. However, there was previously little information on the prognostic value of such information.

The aims of this work were:

- to determine the relationship between patient or caregiver concern for deterioration and critical illness in an adult hospital population, and

- to compare the association between patient or caregiver concern for clinical deterioration and critical illness with the association between abnormal vital signs and critical illness.

Methodology, Approach, Innovation or Intervention:
A retrospective observational cohort study was conducted across a 12-month period in four Victorian hospitals within a single health service. Univariable and multivariable logistic regression was performed to analyse the relationship between patient or caregiver concern for deterioration, and three health outcomes: intensive care unit (ICU) admission, mechanical ventilation, and death.

Discussion, Outcomes or Findings:
Out of 78,979 included patients, those reporting concern for deterioration (10,030) compared to those who did not (68,949) were more likely to be admitted to ICU (4.2% vs 2.1%), to be mechanically ventilated (1.6% vs 0.7%), or to die (3.5% vs 1.3%). Adjusting for confounding variables, such as abnormal vital signs, multivariable analysis showed a significant relationship between patient or caregiver concern and: ICU admission (adjusted odds ratio [aOR] 1.20, 95% confidence interval [CI] 1.06-1.35); mechanical ventilation (aOR 1.47, 95% CI 1.21-1.78); and death (aOR 1.72, 95% CI 1.48-1.99). All abnormal vital signs, including heart rate (aOR 2.04, 95% CI: 1.81-2.31), respiratory rate (aOR 2.16, 95% CI:1.89-2.47), blood pressure (aOR 5.00, 95% CI:4.48-5.58), oxygen saturation (aOR 3.02, 95% CI:2.68-3.40), and conscious state (aOR 2.23, 95% CI:1.99-2.50) were more strongly associated with ICU admission than patient or caregiver concern for clinical deterioration (aOR 1.20, 95% CI 1.06-1.35).

Educational impact, Further development or Future applications:
Patient or caregiver concern for deterioration is independently associated with critical illness in adult patients, though not as strongly as abnormal vital signs. Proactive assessment of patient or caregiver concerns for deterioration should be incorporated into hospital early warning systems to assist in the early recognition and response to serious illness.

Lessons learnt/take-home messages:
A worried adult patient or their caregiver is associated with increased odds of ICU admission, mechanical ventilation or death. In approximately 25% of cases concerns are voiced by patients and families before vital signs become abnormal, giving the opportunity for intervention. Concerns should be proactively sought by clinicians as part of routine assessment, and systems implemented to review if concerns about deterioration are present.

*note this is a follow-on to our work in paediatrics (abstract titled "A worried parent is the most vital sign"), and follows very similar methodology. Happy to present one or the other, a talk combining the two, or back-to-back presentations*

3.C.3 How Creating a Safe Space for Patients Leads to Greater Diagnostic Accuracy

A/Prof Jennifer Neil, Monash Medical School, Monash University

Key words (max 5):
Trauma and violence informed care, psychological safety, diagnostic accuracy

Background & Aims:
A trauma and violence informed care (TVIC) approach in clinical practice creates a safe and supportive environment for patients. Abuse and violence is common worldwide and survivors commonly present to their health professionals with a variety of mental, reproductive and physical presentations including psychosomatic complaints. When patients feel psychologically safe, they are more likely to disclose to their health professional about their experiences of abuse and violence leading to greater diagnostic accuracy.

Methodology, Approach, Innovation or Intervention:
This oral presentation will use a case-based format to introduce TVIC principles showing how this approach can lead to greater diagnostic accuracy.

Discussion, Outcomes or Findings:
Participants will reflect on both organisational and individual strategies that they could use to create a psychologically safe space for patients in their own clinical setting and how they can teach TVIC principles in the medical educational setting.

Educational impact, Further development or Future applications:
Participants will be able to utilise TVIC principles in their own clinical practice as well as incorporate them into medical education settings leading to enhanced diagnostic accuracy.

Lessons learnt/take-home messages:TVIC is a universal approach that recognises that any patients may have a history of abuse and violence. Patients with a history of abuse and violence commonly present to their health professional with physical, mental and reproductive issues. Through both organisational and individual approaches, a TVIC approach creates a safe space for patients to disclose their experiences of abuse and violence which not only brings diagnostic clarity but also allows patients to start the process of healing both physically and psychologically.

3.C.4 Communicating Difficult Diagnoses in the Emergency Department

Gifar Hassan, RVEEH

Key words (max 5):
communication, difficult diagnoses, emergency department

Background & Aims:
In our specialty ophthalmic emergency department potentially serious sight and life threatening diagnoses frequently need to be communicated to patients. The way a diagnosis is communicated can have profound effect on patients and optimising considered and patient centered communication is critical. In many instances, there is diagnostic uncertainty and this adds a layer of complexity to the delivery of a diagnosis.

Methodology, Approach, Innovation or Intervention:
In this talk I will discuss the challenges in undertaking communication of difficult diagnoses in a busy ED, using case studies. I will review key literature on delivering bad news in the ED and relate this to the everyday experience of a trainee.

Discussion, Outcomes or Findings:
Trainees often receive little instruction in communicating difficult diagnoses, yet this is an integral part of the work in ED. Considered communication of life changing diagnoses is critical to excellence in patient care and requires special attention in the chaotic environment of a busy ED.

In our department these difficult diagnoses include brain tumours, multiple sclerosis, giant cell arteritis, cerebral aneurysms and stroke.

As clinicians in the ED, our role is to assess and initiate urgent treatments. We are often in the position where a patient wants more clarity  regarding diagnosis and prognosis, however we can find ourselves unable to provide these answers.

My talk will discuss these challenges and how we can improve patient- clinician communication and the patient experience.

Educational impact, Further development or Future applications:
My talk will form the basis of ongoing education and training within our hospital diagnostic excellence program, to improve our communication of difficult diagnoses in the ED.

Lessons learnt/take-home messages:Discussion of difficult and life changing diagnoses with patients requires preparation and training to improve the patient experience.

3.C.5 Let‘s talk about HIV – Showcasing an Educational Partnership with People Living with HIV and Health Care Workers to Address Diagnostic Stigma

Jen Johnson, Living Positive Victoria; Richard Keane (presenting), Living Positive Victoria; Elizabeth Crock, Bolton Clarke.

Key words (max 5):
HIV, psychological safety, stigma, education

Background & Aims:
HIV diagnosis is now less complex but remains deeply impactful. Psychological safety during diagnosis can be supported by healthcare providers who are informed and actively mitigate HIV stigma during testing discussions. Current guidelines recommend routine HIV testing during STI screening, but timely diagnosis depends on clinicians feeling confident and comfortable normalising HIV testing. This is influenced by their attitudes toward people with HIV. Healthcare workers in low HIV-caseload settings often lack opportunities for professional development or reflective practice around HIV, and limited experience working with HIV-positive individuals.

Stigma remains the greatest barrier to care with healthcare settings being common sites of discrimination and privacy breaches. There are no brief video interventions specifically targeting this workforce.

Methodology, Approach, Innovation or Intervention:
This project aimed to create a short video focused on practical strategies and actionable insights for providing safe, stigma-free care to people living with HIV (PLHIV). Living Positive Victoria (LPV) conducted focus groups to identify key themes and develop the video script. Input was gathered from healthcare workers at Bolton Clarke and people living with HIV (PLHIV), with iterative refinement of the script. A Q&A format was chosen, featuring real healthcare workers and PLHIV. The video was produced in-house and designed to support low-caseload healthcare workers in providing safe, respectful care.

Discussion, Outcomes or Findings:
Simple actions can create a welcoming environment for PLHIV. Disclosure of HIV status is not required in healthcare settings and people with HIV often choose not to disclose due to past experiences of discrimination and inappropriate care. Clinicians should only document or inquire about HIV status when clinically relevant. Standard precautions are sufficient for all clinical care. Providers should update their HIV knowledge and avoid relying on patients for education. Being an HIV ally significantly improves access to care.

Educational impact, Further development or Future applications:
The video received positive feedback, with many clinicians noting that they were unaware that PLHIV often do not disclose their status.

Lessons learnt/take-home messages:
Healthcare providers can build confidence in HIV testing and care by engaging with lived experiences and reflecting on best practices. Avoid intrusive questions when engaging with people with HIV and instead ask, “How can I help?” or “Are you happy with your HIV care?”.  Spend five minutes updating your HIV knowledge, including current indications for HIV testing, and be sure to include HIV in all STI screening conversations.  Partnerships between healthcare and peer support organisations strengthen education.

3.C.6 The Art of Transforming Patient Feedback About Diagnostic Error into Diagnostic Excellence

Carmel Crock, Royal Victorian Eye and Ear Hospital

Key words (max 5):
patient feedback diagnostic error/ excellence

Background & Aims:
Patient feedback is an often overlooked source of learning from diagnostic errors.

In this study we sought to collate and analyse feedback from patients relating to diagnostic safety events in a busy emergency department.

Methodology, Approach, Innovation or Intervention:
In our hospital patient feedback is entered into an incident monitoring system.

We examined incidents entered into the system from the emergency department in the last 12 months and identified those relating to delayed, wrong or missed diagnoses.

Themes of the patient feedback will be discussed from both the written feedback and oral feedback later solicited from the patient. Themes from a smaller number of diagnostic safety incidents reported by family members and carers will also be discussed.

Discussion, Outcomes or Findings:
The National Academy of Medicine report on Improving Diagnosis in Health Care stressed the importance of co creation of a diagnosis, with the patient voice central to accurate and timely diagnosis.

Listening to feedback from patients in the advent of a diagnostic error is crucial to understanding contributing factors, learning from error as well as contributing to the healing process for patients and rebuilding trust.

Ideally healthcare organisations would routinely collect patient feedback on diagnosis as part of the patient experience. Proposed methods for systematically gathering patient feedback to enhance the diagnostic process will be discussed.

Such measures would ensure meaningful patient engagement in the diagnostic process, leading to a culture of continuous improvement in diagnosis and diagnostic excellence.

Educational impact, Further development or Future applications:
Patient education around the diagnostic process must include their vital role in providing feedback to healthcare professionals.

Lessons learnt/take-home messages:For patients to be fully engaged in the diagnostic process, their feedback must be sought and valued.