Teaching Hospital In Melbourne Research Articles

Does cardiology intervention improve mortality for post-operative troponin elevations after emergency orthopaedic–geriatric surgery? A randomised controlled study

ObjectivesTroponin elevations are common after emergency orthopaedic surgery and confer a higher mortality at one year. The objective was to determine if comprehensive cardiology care after emergency orthopaedic surgery reduces mortality at one year in patients who sustain a post-operative troponin elevation versus standard care. MethodsA randomised controlled trial was conducted at a metropolitan teaching hospital in Melbourne, Australia. 187 consecutive patients were eligible with 70 patients randomised. Troponin I was tested peri-operatively and patients with a troponin elevation were randomised to cardiology care versus standard ward management. The main outcome measure was one year mortality. ResultsThe incidence of a post-operative troponin elevation was 37.4% (70/187) and these 70 patients were randomised. In-hospital cardiac complications were similar between the randomised groups: standard care (7/35 or 20.0%) versus cardiology care (8/35 or 22.9%). There was no difference in 1 year mortality between the randomised groups (6/35 or 17.1% in each group). Multivariate predictors of 1 year mortality were post-operative troponin elevation OR 4.3 (95% CI, 1.1–16.4, p=0.035), age OR 1.1 (95% CI, 1.02–1.2, p=0.016) and number of comorbidities OR 2.1 (95% CI, 1.3–3.5, p=0.004). At 1 year 35/187 (18.7%) sustained a cardiac complication and 23/35 (65.7%) had a troponin elevation. ConclusionsThere was no difference in mortality between patients with a post-operative troponin elevation randomised to cardiology care compared with standard care. Troponin elevation predicted one year mortality. Further research is needed to find an effective intervention to reduce mortality.

Troponin testing in the emergency department: a longitudinal study to assess the impact and sustainability of decision support strategies

AimTo evaluate the impact of decision support on the proportion of troponin I (cTnI) tests and associated costs over the period 2000–7 for patients presenting with chest pain in an...

Medication communication between nurses and patients during nursing handovers on medical wards: A critical ethnographic study

BackgroundCommunication is central to safe medication management. Handover is a routine communication forum where nurses provide details about how patients’ medications are managed. Previous studies have investigated handover processes as general communication forums without specific focus on medication information exchange. The effects of social, environmental and organisational contexts on handover communication and medication safety have not been explored. ObjectivesTo examine dominant and submissive forms of communication and power relations surrounding medication communication among nurses, and between nurses and patients during handover. DesignA critical ethnographic approach was utilised to unpack the social and power struggles embedded in handover practices. SettingsThe study was conducted in two medical wards of a metropolitan teaching hospital in Melbourne, Australia from January to November 2010. ParticipantsAll registered nurses employed in the medical wards during the study time were eligible for participation. Patients were eligible if they were able to communicate with nurses about how their medications were managed. In total, 76 nurses and 27 patients were recruited for the study after giving written consent for participation. MethodsParticipant observations, field interviews, video-recordings and video reflexive focus groups were conducted. Fairclough's critical discourse analytic framework guided data analysis. ResultsNurse coordinators’ group handovers in private spaces prioritised organisational and biomedical discourses, with little emphasis on evaluating the effectiveness of medication treatment. The ward spatial structure provided an added complexity to how staff allocation occurred. Handovers involving patients in the public spaces at the bedside facilitated a partnership model in medication communication. Nurses exercised discretion during bedside handovers by discussing sensitive information away from the bedside. Handovers across different wards during patient transfers caused communication breakdowns because information was not exchanged between bedside nurses. ConclusionsNurse coordinators need to relinquish organisational control of the handover practice and appreciate the contribution of bedside nurses to patient information exchange. Bedside nurses need to be provided with opportunities to raise questions during the group handover. Designated meeting spaces need to be provided to reduce interruptions to the group handover process.

Cost-Benefit of Minimally Invasive Staging of Non-small Cell Lung Cancer: A Decision Tree Sensitivity Analysis

Accurate staging of non-small cell lung cancer (NSCLC) is critical for optimal management. Minimally invasive pathologic assessment of mediastinal lymphadenopathy is increasingly being performed. The cost-benefit (minimization of health care costs) of such approaches, in comparison with traditional surgical methods, is yet to be established. Decision-tree analysis was applied to compare downstream costs of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), conventional TBNA, and surgical mediastinoscopy. Calculations were based on real costs derived from actual patient data at a major teaching hospital in Melbourne, Australia. One- and two-way sensitivity analyses were undertaken to account for potential variation in input parameter values. For the base-case analysis, initial evaluation with EBUS-TBNA (with negative results being surgically confirmed) was the most cost-beneficial approach (AU$2961) in comparison with EBUS-TBNA (negative results not surgically confirmed) ($3344), conventional TBNA ($3754), and mediastinoscopy ($8859). The sensitivity of EBUS-TBNA for detecting disease had the largest impact on cost, whereas the prevalence of mediastinal lymph node metastases determined whether surgical confirmation of negative EBUS-TBNA results remained cost-beneficial. Our study confirms that minimally invasive staging of NSCLC is cost-beneficial in comparison with traditional surgical techniques. EBUS-TBNA was the most cost-beneficial approach for mediastinal staging of patients with NSCLC across all studied parameters.

Oxygen administration and monitoring for ward adult patients in a teaching hospital

The aims of this study were to describe oxygen administration and respiratory monitoring of ward patients in a tertiary teaching hospital, and to assess differences in characteristics and outcomes between patients who are receiving versus are not receiving oxygen. Prospective clinical audit of all non-ventilated adult ward patients in a tertiary teaching hospital in Melbourne, Victoria on 26 August 2009. All 323 eligible patients were audited (medical 218, surgical 105). At assessment, 76 patients (24%) were on oxygen therapy and of these, 57 patients (74%) received oxygen by nasal prongs. Overall, oxygen saturation was documented in 301 (93.2%) patients and respiratory rate (RR) documented in 283 patients (87.6%). Patients receiving oxygen had a lower median SpO(2) (94% vs 96%, P < 0.0001), higher median RR (20/min vs 18/min, P < 0.0005); and were older (68.8 v 63.1 years, P= 0.0094). The in-hospital mortality of patients receiving oxygen therapy was 15.8% compared with 5.3% for those not on oxygen (P < 0.0056). Oxygen is administered to one-quarter of ward patients in our hospital. Oxygen saturation and RR are not documented in approximately 10% of patients. Oxygen therapy in ward patients identifies individuals with increased mortality. Continuing educational interventions to increase awareness of the high-risk status of these patients and strategies to detect patients at risk of hypoxaemia are needed.

Improved susceptibility of Gram-negative bacteria in an intensive care unit following implementation of a computerized antibiotic decision support system

Emergence of multiresistant Gram-negative organisms in intensive care units (ICUs) throughout the world is a concerning problem. Therefore we undertook a study to follow the resistance patterns of the most common clinically isolated Gram-negative organisms within our ICU following an antibiotic stewardship intervention to evaluate whether a reduction in broad-spectrum antibiotics improves local antibiotic resistance patterns. This prospective study was conducted over a 7 year period within an ICU at a tertiary teaching hospital in Melbourne, Australia. All clinically isolated Gram-negative organisms were identified and extracted from the hospital pathology system. Three monthly antibiograms were created. The pre-interventional period occurred between January 2000 and June 2002 (10 quarters) and the post-interventional period was defined from July 2002 to December 2006 (18 quarters). Segmented linear regression was used to analyse for a difference in the rates of change in susceptibility. A total of 2838 Gram-negative organisms were isolated from clinical sites from ICU patients during the study period. There was significant improvement in susceptibility of Pseudomonas to imipenem 18.3%/year [95% confidence interval (CI): 4.9-31.6; P = 0.009] and gentamicin 11.6%/year (95% CI: 1.8-21.5; P = 0.02) compared with the pre-intervention trend. Significant changes in the rates of gentamicin and ciprofloxacin susceptibility were also observed in the inducible Enterobacteriaceae group although these were less clinically significant. This study demonstrates improved antibiotic susceptibility of ICU Gram-negative isolates including Pseudomonas following an intervention aimed at reducing broad-spectrum antibiotics.

Implementation of a community liaison pharmacy service: a randomised controlled trial

Abstract Objective The aim of this study was to provide a pharmacy service to improve continuity of patient care across the primary-secondary care interface. Setting The study involved patients discharged from two acute-care tertiary teaching hospitals in Melbourne, Australia, returning to independent living. Methods Consecutive patients admitted to both hospitals who met the study criteria and provided consent were recruited. Recruited patients were randomised to receive either standard care (discharge counselling, provision of compliance aids and communication with primary healthcare providers when necessary) or the intervention (standard care and a home visit from a community liaison pharmacist (CLP) within 5 days of discharge). Participant medication was reviewed during the visit according to set protocols and compliance and medication understanding was measured. All participants were telephoned 8–12weeks after discharge to assess the impact of the intervention on adherence and medication knowledge. Key findings The CLP visited 142 patients with a mean time of 4.2 days following hospital discharge (range = 1–14 days). Consultations lasted 15–105 min (mean, 49 min; SD, ± 21 min). The CLPs retrospectively coded 766 activities and interventions that occurred during home visits, subsequently categorised into three groups: counselling and education, therapeutic interventions and other interventions. No statistical difference was detected in the number of medications patients reported taking at follow-up: the mean value was 7.72 (SD, ± 3.27) for intervention patients and 7.55 (SD, ± 3.27) for standard-care patients (P = 0.662). At follow-up self-perceived medication understanding was found to have improved in intervention patients (P &amp;lt; 0.001) and significant improvements from baseline in medication adherence were found in both standard-care (P &amp;lt; 0.022) and intervention (P &amp;lt; 0.005) groups; however, adherence had improved more in intervention patients. Conclusion The community liaison pharmacy service provided critical and useful interventions and support to patients, minimising the risk of medication misadventure when patients were discharged from hospital to home.

The COACH Program Produces Sustained Improvements in Cardiovascular Risk Factors and Adherence to Recommended Medications—Two Years Follow-up

To assess whether The COACH Program could sustain its favourable impact on coronary risk factors (CRFs) and adherence to recommended medication for 18 months after the completion of The COACH Program. A clinical audit of a secondary prevention program performed in three teaching hospitals in Melbourne, Victoria for patients with coronary heart disease (CHD). The CRF targets were based on recommendations from the National Heart Foundation of Australia between 2003 and 2007. 656 patients were followed by telephone every 6 months from recruitment in hospital for 2 years. There was a substantial improvement in all CRF from discharge from hospital to the completion of active coaching 6 months after hospital discharge. There was also a significant increase in the proportion of patients taking statins and renin-angiotensin system antagonists in the same period of time. There was a small deterioration in CRF status in the 6 months after exit from The COACH Program but thereafter CRF status was maintained and substantially better than that on entry to The COACH Program. The use of the recommended cardio-protective medications remained at the levels achieved at exit from The COACH Program. The changes in CRF status and adherence to cardiac medications achieved at 6 months in The COACH Program are sustained for at least 18 months after cessation of The COACH Program.

Pushing the envelope: clinical handover from the aged‐care home to the emergency department

To evaluate the use and usefulness of an aged-care home (ACH) transfer- to-hospital envelope (the Envelope) as a tool to support safe clinical handover when an ACH resident is transferred to an emergency department (ED). Participants in the study were 26 ACHs (1545 beds), the EDs of six major metropolitan public teaching hospitals in Melbourne, and ambulance officers involved in transferring residents from ACHs to hospitals. Transfer data were collected over an 18-week period (January-May 2008). Evaluation methods included written surveys and semi-structured face-to-face interviews (interviewees were 19 ACH staff, 30 ED staff, and 7 ambulance officers familiar with the Envelope). Use, usefulness and ease of use of the Envelope; impact of using the Envelope on clinical handover; awareness of the need for clinical handover; sustainability of the project. The Envelope was used for the large majority of ACH residents transferred to hospital (ACH data: 317/355 [89%]; ED data: 85/101 [84%]); 163/165 ACH staff (99%) thought the Envelope was useful, and 148/165 (90%) said it was easy to use; 128/165 ACH staff (78%) and all interviewees believed that using the Envelope improved clinical handover; and 152/165 ACH staff (92%) indicated they would continue to use the Envelope. All interviewees thought that using the Envelope had raised awareness of the need for clinical handover. The Envelope is useful and easy to use. It is used in the large majority of transfers of ACH residents to EDs and is highly valued by ACH staff, ambulance officers and ED staff. Our results suggest that use of the Envelope makes clinical handover safer for patients.

The Profile of Health Problems in African Immigrants Attending an Infectious Disease Unit in Melbourne, Australia

The number of African immigrants living in Western countries is increasing. A retrospective audit of sub-Saharan African patients attending the infectious diseases clinics of a Melbourne teaching hospital was performed. A total of 375 patients were included. Helicobacter pylori gastritis was diagnosed in 60% of those tested (35/58), schistosomiasis in 41% (84/206), chronic hepatitis B in 19% (32/167), and strongyloidiasis in 18% (32/179). Active tuberculosis (TB) affected 18% (51/276) and latent TB 55% (152/276). Pathologic parasites were detected in stool in 21% (31/145). Vitamin D deficiency (< 50 nmol/L) affected 73% (139/191), anemia 17% (52/312), iron deficiency 15% (22/151), and low neutrophil count 25% (78/312). Infectious diseases, vitamin D deficiency, anemia, and latent TB were common in sub-Saharan African immigrants. Clinicians need to be aware of these conditions to meet the health needs of this group. Comprehensive health checks should be encouraged for new arrivals, particularly from high-risk areas.

A study of physiotherapy students’ and clinical educators’ perceptions of learning and teaching

Background: Clinical education is a key component to learning in the health professions.Aims: This qualitative study investigated how physiotherapy students and clinical educators perceived their respective roles in learning and teaching clinical skills during students’ first clinical placements.Methods: Separate physiotherapy student and educator focus groups were conducted in two major teaching hospitals in Melbourne, Australia during students’ first clinical placements.Results: The key difference between students’ and educators’ perspectives of their role was their description of how to build knowledge within clinical placement settings. Clinical educators’ focused on steps involved in their teaching tasks, rather than ways to facilitate learning. Their conception of teaching was to impart structured knowledge to students in response to knowledge deficits. Students also identified knowledge gaps but they proposed alternative practical ways to build their knowledge. Their conception of learning was to move from an initial static identification of knowledge deficits, to a more dynamic search for methods and people that might build their knowledge and understanding.Conclusions: The findings of this research were used to develop a set of teaching and learning statements and strategies that are grounded in the perspectives and experiences of students and educators in the clinical education setting.

Effect of emergency department fast track on emergency department length of stay: a case–control study

Objective:To examine the effect of fast track on emergency department (ED) length of stay (LOS).Design and setting:Pair-matched case–control design in a public teaching hospital in metropolitan Melbourne, Australia.Participants:Patients treated by...

Patterns of Psychosocial Adjustment Following Cardiac Surgery

The purpose of this research was to document the postoperative experiences of a group of cardiac surgery patients with a view to identifying factors relevant to postsurgical mood and adjustment. Forty-six cardiac surgery patients (mean age = 63.6 years, SD = 11.0) were recruited through a cardiac rehabilitation program at a large teaching hospital in Melbourne, Victoria, Australia. A semistructured interview (Austin CEP Interview) was used to canvass a broad range of postsurgical issues, and 3 mood questionnaires were administered to provide a quantitative assessment of mood at the time of interview. Three distinct patterns of adjustment and outcome following cardiac surgery were identified and described: "new well me," "new sick me," and "me as always." Undergoing major cardiac surgery per se did not predict mood and adjustment difficulties, whereas the presence of chronic and disabling cardiac symptoms prior to surgery did. Adjustment issues primarily manifested as the extent of change in a patient's identity relating to health and illness perceptions, with age acting as a predictor of the type of adjustment difficulties experienced. This study highlights the significance of psychosocial factors for assessing surgical outcomes and the importance of tailoring rehabilitation programs to the specific needs of individual patients.

Thyrotoxicosis during sunitinib treatment for renal cell carcinoma

Sunitinib malate is an oral tyrosine kinase inhibitor used in the treatment of renal cell carcinoma (RCC) and gastrointestinal stromal tumours. Hypothyroidism has been observed in patients treated with sunitinib, but the mechanism whereby sunitinib induces hypothyroidism is unknown. To describe a series of six patients who developed thyrotoxicosis while on sunitinib for metastatic RCC. The study was conducted at Austin Health, a tertiary teaching hospital in Melbourne, Australia. Two patients developed severe thyrotoxicosis within 10 weeks after commencing sunitinib. In contrast, in the four patients who presented with later onset (16-30 weeks) thyrotoxicosis, the thyrotoxicosis was relatively mild, self-limiting and rapidly progressed to hypothyroidism. These patients experienced recurrent episodes of thyrotoxicosis in temporal relation to their cyclical sunitinib treatment. One patient had cytological evidence of lymphocytic thyroiditis. These findings suggest that sunitinib-induced hypothyroidism may be a consequence of preceding thyroiditis with associated transient thyrotoxicosis. As predictive factors are currently unknown, we suggest regular monitoring of thyroid function in all patients commenced on sunitinib. Clinicians treating patients with sunitinib or other similar kinase inhibitors should to be alerted to thyroid dysfunction as a potential toxicity of these agents.

The Therapy ‘Pill’: Achieving Treatment Dose Within a Rehabilitation Trial

AbstractBackground: Developing high quality clinical trials within rehabilitation research is achievable and should be pursued wherever possible. One of the greatest challenges rehabilitation trialists face is defining experimental and control interventions and ensuring that the intervention dose is delivered as planned. Aim: We describe procedures employed within a pilot randomised controlled trial of a rehabilitation intervention to monitor therapy dose. Method: The trial setting was two acute stroke units in large teaching hospitals in Melbourne, Australia. The design was a randomised controlled trial of very early mobilisation (commenced within 24 hours of stroke onset) plus standard care (VEM) versus standard care alone. Assessors were blinded to group and analysis was intention to treat. All therapy data (both intervention and control) were acquired using personal digital assistants. Monitoring of therapy dose and feedback to trial staff was given 6 months into the trial by a researcher independent of the trial team. Results: Before feedback, therapists were barely meeting intervention protocol minimum targets. Following feedback, compliance with trial protocol was achieved. Conclusion: Monitoring of the therapy dose within a clinical trial is important to achieve trial quality. This article shows how monitoring including feedback leads to improved delivery of the therapy ‘pill’.

Family meetings in palliative care: Multidisciplinary clinical practice guidelines

BackgroundSupport for family carers is a core function of palliative care. Family meetings are commonly recommended as a useful way for health care professionals to convey information, discuss goals of care and plan care strategies with patients and family carers. Yet it seems there is insufficient research to demonstrate the utlility of family meetings or the best way to conduct them. This study sought to develop multidisciplinary clinical practice guidelines for conducting family meetings in the specialist palliative care setting based on available evidence and consensus based expert opinion.MethodsThe guidelines were developed via the following methods: (1) A literature review; (2) Conceptual framework; (3) Refinement of the guidelines based on feedback from an expert panel and focus groups with multidisciplinary specialists from three palliative care units and three major teaching hospitals in Melbourne, Australia.ResultsThe literature review revealed that no comprehensive exploration of the conduct and utility of family meetings in the specialist palliative care setting has occurred. Preliminary clinical guidelines were developed by the research team, based on relevant literature and a conceptual framework informed by: single session therapy, principles of therapeutic communication and models of coping and family consultation. A multidisciplinary expert panel refined the content of the guidelines and the applicability of the guidelines was then assessed via two focus groups of multidisciplinary palliative care specialists. The complete version of the guidelines is presented.ConclusionFamily meetings provide an opportunity to enhance the quality of care provided to palliative care patients and their family carers. The clinical guidelines developed from this study offer a framework for preparing, conducting and evaluating family meetings. Future research and clinical implications are outlined.

Electronic antibiotic stewardship--reduced consumption of broad-spectrum antibiotics using a computerized antimicrobial approval system in a hospital setting

Antibiotic stewardship is important, but the ideal strategy for providing stewardship in a hospital setting is unknown. A practical, sustainable and transferable strategy is needed. This study evaluates the impact of a novel computerized antimicrobial approval system on antibiotic-prescribing behaviour in a hospital. Effects on drug consumption, antibiotic resistance patterns of local bacteria and patient outcomes were monitored. The study was conducted at a tertiary referral teaching hospital in Melbourne, Australia. The system was deployed in January 2005 and guided the use of 28 restricted antimicrobials. Data were collected over 7 years: 5 years before and 2 years after deployment. Uptake of the system was evaluated using an in-built audit trail. Drug utilization was prospectively monitored using pharmacy data (as defined daily doses per 1000 bed-days) and analysed via time-series analysis with segmental linear regression. Antibiograms of local bacteria were prospectively evaluated. In-hospital mortality and length of stay for patients with Gram-negative bacteraemia were also reported. Between 250 and 300 approvals were registered per month during 2006. The gradients in the use of third- and fourth-generation cephalosporins (+0.52, -0.05, -0.39; P < 0.01), glycopeptides (+0.27, -0.53; P = 0.09), carbapenems (+0.12, -0.24; P = 0.21), aminoglycosides (+0.15, -0.27; P < 0.01) and quinolones (+0.76, +0.11; P = 0.08) all fell after deployment, while extended-spectrum penicillin use increased. Trends in increased susceptibility of Staphylococcus aureus to methicillin and improved susceptibility of Pseudomonas spp. to many antibiotics were observed. No increase in adverse outcomes for patients with Gram-negative bacteraemia was observed. The system was successfully adopted and significant changes in antimicrobial usage were demonstrated.

Decisions Made By Critical Care Nurses During Mechanical Ventilation and Weaning in an Australian Intensive Care Unit

Responsibilities of critical care nurses for management of mechanical ventilation may differ among countries. Organizational interventions, including weaning protocols, may have a variable impact in settings that differ in nursing autonomy and interdisciplinary collaboration. To characterize the role of Australian critical care nurses in the management of mechanical ventilation. A 3-month, prospective cohort study was performed. All clinical decisions related to mechanical ventilation in a 24-bed, combined medical-surgical adult intensive care unit at the Royal Melbourne Hospital, a university-affiliated teaching hospital in Melbourne, Victoria, Australia, were determined. Of 474 patients admitted during the 81-day study period, 319 (67%) received mechanical ventilation. Death occurred in 12.5% (40/319) of patients. Median durations of mechanical ventilation and intensive care stay were 0.9 and 1.9 days, respectively. A total of 3986 ventilation and weaning decisions (defined as any adjustment to ventilator settings, including mode change; rate or pressure support adjustment; and titration of tidal volume, positive end-expiratory pressure, or fraction of inspired oxygen) were made. Of these, 2538 decisions (64%) were made by nurses alone, 693 (17%) by medical staff, and 755 (19%) by nurses and staff in collaboration. Decisions made exclusively by nurses were less common for patients with predominantly respiratory disease or multiple organ dysfunction than for other patients. In this unit, critical care nurses have high levels of responsibility for, and autonomy in, the management of mechanical ventilation and weaning. Revalidation of protocols for ventilation practices in other clinical contexts may be needed.

Prospective study of cardiac troponin I release in patients with upper gastrointestinal bleeding

The rate of cardiac injury in upper gastrointestinal hemorrhage is unclear. The aims of this study were to determine prospectively the risk of cardiac troponin I release and associated adverse cardiac events in patients with acute upper gastrointestinal hemorrhage. From January to September 2003, we prospectively studied patients with documented hematemesis and melena referred to the gastroenterology unit in a tertiary teaching hospital in Melbourne, Australia. Serial assays for cardiac troponin I were performed at 0, 12 and 24 h. Serial creatine kinase levels and electrocardiographs were also performed. Clinical and biochemical data were collected. The primary endpoint was a troponin level >0.5 microg/L within 24 h of recruitment. Various clinical variables were then compared between the groups of patients with or without troponin rise. A total of 156 patients were included in the study. The mean age was 67 years (range 19-96). There were 104 (67%) male patients. A troponin level of greater than 0.5 microg/L was found in 30/156 (19%); 126 (81%) patients had normal troponin levels. Age greater than 65 years, signs of hemodynamic instability at presentation, a recent history of cardiac disease, cardiovascular compromise following endoscopy, and re-bleeding were associated with troponin release. Upper gastrointestinal bleeding is associated with a risk of cardiac injury of up to 19%. Troponin assay could be used to screen for cardiac damage, especially in elderly patients who present with hemodynamic instability.

Experienced physiotherapists as gatekeepers to hospital orthopaedic outpatient care

To investigate the impact, quality and acceptability of a musculoskeletal screening clinic provided by physiotherapists for patients referred to the outpatient orthopaedic department at a major metropolitan hospital. Prospective observational trial undertaken between 29 November 2005 and 6 June 2006 at the Northern Hospital (a tertiary teaching hospital in outer Melbourne) of 52 patients with non-urgent musculoskeletal conditions who were assessed by one of two physiotherapists with postgraduate qualifications and subsequently by an orthopaedic surgeon. Proportion of new patients referred who could have been managed without needing to see a surgeon; level of agreement between physiotherapists and orthopaedic surgeon on diagnoses and management decisions; and levels of satisfaction of patients, referring general practitioners and the orthopaedic surgeon with the physiotherapist-led screening initiative. 45 of 52 selected patients (31 women and 21 men; mean age, 53.3 years) attended their appointment with the physiotherapist; of these, 38 also attended a later appointment with the orthopaedic surgeon. Seven of the 38 patients were listed for surgery, and seven others needed management by the surgeon (injection for three, imaging for four). Almost two-thirds (63%) were appropriate for non-surgical management. The physiotherapists identified the same patient management plans as the surgeon for 74% of the group. Patients and doctors reported high levels of satisfaction with the physiotherapist-led service. Nearly two-thirds of patients with non-urgent musculoskeletal conditions referred by their GPs to one public outpatient orthopaedic department did not need to see a surgeon at the time of referral, and were appropriately assessed and managed by experienced, qualified physiotherapists.