5 “no-no’s” of Emergency Medicine…

saving wisely

The US based "Choosing Wisely" campaign is an initiative aiming to promote open conversations between doctors and patients around healthcare decisions. A series of 5 point lists have been released via their website and make enlightening reading. The concept itself should provoke thought around the discussions we have with patients about potential tests and treatments available. We can do many things; what should we be doing?

The American College of Emergency Physicians came up with 5 tests and procedures that we should think twice about before ordering or carrying out. Comment was made that these should "improve efficiency", reduce cost and maintain a high quality of care.

More recently, a group of Massachusetts based Emergency physicians published a Top-Five List for Emergency Medicine in JAMA. This project aimed to ensure the recommendations were practical, and actionable by Emergency physicians, and interestingly was commenced prior to the release of the top-5 chosen by ACEP. The 5 in each respective list do differ, but the point remains the same; we could and should be thinking more about investigations, medications, how and why we use them, and resource utilisation overall.

CHOOSING WISELY TOP FIVE

In summary:

1. No CT head in patients with minor head injury who are low risk based on a clinical decision rule.

# No specific validated clinical decision rule is given, however, the Canadian CT head rule and the New Orleans rule are within the references for this recommendation. ACEP do have their own rule, which are really an amalgamation of the existing CT head rules, and have been previously published in the Annals of EM.

# Maybe the availability of CT and the concept of an earlier discharge being facilitated by a normal scan can sometimes push towards this investigation. I'd hope that a large proportion of EM physicians already rationalise their use of CT for head injury, and use our ability to observe patients as an alternative when required and possible.

# ACEPs guidelines can be found here, with comparisons of the two rules mentioned above found here and here.

2. Don't put a urinary catheter in unless absolutely necessary.

# So if a urine output is required, and the patient can manage a bottle/commode, then don't pop an IDC in. An interesting QI study was done looking at reduction of urinary catheter insertions in ED by prompting discussion and thought prior to insertion- find the abstract here.

# Indications FOR an IDC given are: 1. Urine output monitoring in critically ill patients; 2. Treatment of urinary obstruction; 3. For surgery; 4. End of life care.

3. Get palliative and hospice care involved from the ED.

# Easier said than done? It has been looked at before- see this abstract regarding facilitation of early transfer to hospice care directly from ED.

# However, the comments made on the website are around the discussion starting in the ED if appropriate in that patients case. Engaging patients and family in conversation around end of life care is entirely in our remit if it is apparent that it is going to be relevant. Liasing with any existing palliative care team involved can be extremely helpful when working out the disposition and management of a patient with a terminal diagnosis. An interesting inclusion on the list.

4. Avoid antibiotics and wound culture in uncomplicated skin/soft tissue abscesses if adequately treated by incision and drainage.

# The point here is that incision and drainage is the definitive treatment of these abscesses. With an immunocompetent patient, and a decent I&D, antibiotics do not add anything, and can potentially cause harm. And if there is no need for antibiotics- why do a culture? What would this change? It is declared that this is only an approach for those patients with "adequate medical follow up".

# It is not explicitly stated, but the implied exclusions here are those abscesses that are in immunocompromised patients, complicated in some way or inadequately drained.

5. Trial oral rehydration before IV in mild-moderately dehydrated children.

# Suggested is early administration of antiemetics if nausea or vomiting is an issue. This 2011 review article looks at ondansetron in this setting.

# Makes sense! And often EDs have a protocol for oral rehydration trials in kids, sometimes including use of ice lollies. This Cochrane review from 2006 showed no difference between oral and IV rehydration- read it here.

The link below takes you to the list on the Choosing Wisely website.

http://www.choosingwisely.org/doctor-patient-lists/american-college-of-emergency-physicians/

LESS IS MORE: A TOP FIVE LIST FOR EMERGENCY MEDICINE.

Schuur JD, Carney DP, Everett TL et al. A Top-Five List for Emergency Medicine. A Pilot Project to Improve the Value of Emergency Care. JAMA Int Med. 2014; 174(4)509-515.

The objective of this project was to draw up a top-5 list of "tests, treatments and disposition decisions that are of little value, are amenable to standardisation, and are actionable by emergency medicine clinicians". They used a modified version of the 'Delphi method', similar to that used by ACEP to develop their top-5. This involved surveys of EM physicians, ranking of the suggestions, resurveying the ranking, and then an expert decision panel.

An initial list of 17 items, including laboratory tests, medications, imaging studies and disposition studies were surveyed, all of which were deemed to be high cost, low benefit and within a physicians ability to change! From that the top-5 was extrapolated. Number 1 was the only item receiving unanimous support.

1. No CT C-spine for patients who are cleared by NEXUS or Canadian C-spine Rule.

# Self explanatory n'est pas?

# For the original comparison article from the NEJM, which has lovely flow-charts and overviews of both rules, click here.

2. Risk stratify for PE with pretest probability +/- D-dimer before CTPA.

# A pet project for many EM physicians- reducing the use of D-dimers and CTPAs in the assessment of PE. It makes sense; work out how likely you think a PE is before jumping in with the CT. There are options- the PERC route or the ol' fashioned Wells criteria. For more on PERC, click here and here.

3. No MRI for lumbar back pain unless high risk features.

# Another point that makes sense. The background for this entry into the top-5 is a clinical consensus from 2007 published in the Annals of Internal Medicine, which gives a series of recommendations for assessment and treatment of lower back pain. Freely available via this link.

4. No CT head for those with mild traumatic head injury if don't meet New Orleans Criteria or Canadian CT Head Rule.

5. No coagulation studies unless your patient is haemorrhaging or has a coagulopathy.

# I know for a fact that this has been discussed in the past within departments. Unless you suspect your patient has developed a coagulopathy secondary to a clinical condition, be that liver failure or trauma, or is on anticoagulants, don't do the coags. This 2008 systematic review from the UK will back you up on that... Click here

 

I would highly recommend a perusal of the Choosing Wisely website, and this article in its entirety. The remainder of the top 17 list also makes interesting and thought-provoking reading; the Choosing Wisely top-5 is represented within in some form. These are ideas that will be familiar to most who have worked in EDs before. There are limitations to both of these lists and the manner in which they are constructed, but the underlying motivation and push towards Emergency Physicians taking stewardship of resources is one we should be seriously considering.

 

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