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American Board of Internal Medicine

‘Choosing Wisely’ Protocols Can Reduce Testing While Improving Care

Posted on Wed, Feb 17, 2016
‘Choosing Wisely’ Protocols Can Reduce Testing While Improving Care

Michael Silverman, MD, FACEP
 
The Choosing Wisely initiative was initiated by the American Board of Internal Medicine’s (ABIM) Foundation to help providers and patients engage in conversations aimed at reducing the use of tests and procedures. The initiative also supports patients in their efforts to make smart and effective care choices.
 
The American College of Emergency Physicians (ACEP) has partnered with ABIM to support good clinician and patient decisions. ACEP has supported 10 recommendations that physicians and patients should question.
 
Why “Choosing Wisely” Is So Important
 

  • Approximately 1.5-2.0 percent of all cancers in the U.S. may be attributed to radiation from CT examinations. (Baumann BM, et al 2011)
  • In the United States, more than 2 million infections occur with resistant bacteria.
  • Avoidable costs were noted in a 2010 report by Thomson Reuters, which set the amount at $3.6 trillion.

The flipside to why we order so many tests are noted in multiple reports. The reasons include:
 
  • Malpractice concerns
  • To avoid missing a diagnosis and making an error
  • Because patients request or insist on tests and we are evaluated by the satisfaction of our patients 

For this post, I’ll focus on five key recommendations.
 
1 - Avoid CT with low pre-test probability of pulmonary embolism with either a negative Pulmonary Embolism Rule-out Criteria (PERC) or a negative D-dimer.
  • Studies overwhelmingly show the benefit of multiple decision rules to decrease risk of pulmonary embolism to below 2 percent.
  • PERC includes eight questions that, if negative in a low-risk patient, requires no further testing to rule out a significant pulmonary embolism.
  • Utilization of previously validated decision rules for PE along with a negative D-dimer reduces the probability to < 2%. 

2 - Avoid ordering head CT in asymptomatic adult patients with syncope, insignificant trauma and a normal neurological evaluation.
 
  • Literature is overwhelming that syncope does not necessitate a head CT except if the following exists before or after syncope:
    • Headache
    • Garbled speech
    • Weakness in one arm or leg or other focal deficit
    • Trouble walking
    • Confusion 

3 - Avoid antibiotics and wound cultures in ED patients with uncomplicated skin or soft tissue abscesses after successful incision and drainage in patients with adequate medical follow-up.
 
  • Choosing Wisely supports only using antibiotics in patients who are immunocompromised.
  • Author Note: Not part of Choosing Wisely, but literature may support also using antibiotics if the patient has systemic toxicity or lymphangitis. 

4 - Avoid placing indwelling urinary catheters in the ED for either urine output monitoring in stable patients who can void, or for patient/staff convenience.
 
  • Indwelling catheters may be appropriate for:
    • Output monitoring for critically ill patients
    • Relief of urinary obstruction
    • At the time of surgery
    • End-of-life care 

5 - Avoid head CT for ED patients with minor head injuries who are at low risk based on validated decision rules.
 
  • Choosing Wisely notes the following indications for ordering a head CT:
    • If loss of consciousness or post-traumatic amnesia and only if:
      • Headache
      • Vomiting
      • Age greater than 60 years
      • Drug or alcohol intoxication
      • Deficits in short-term memory
      • Physical evidence of trauma above the clavicle
      • Post-traumatic seizure
      • Glasgow Coma Scale (GCS) score less than 15
      • Focal neurologic deficit
      • Coagulopathy
  • Order a head CT for patients with no loss of consciousness or post-traumatic amnesia if:
    • Focal neurologic deficit
    • Vomiting
    • Severe headache
    • Age 65 years or greater
    • Physical signs of a basilar skull fracture
    • GCS score less than 15
    • Coagulopathy
    • Dangerous mechanism of injury
      • Injury includes ejection from a motor vehicle
      • Pedestrian struck
      • Fall from a height of more than 3 feet or 5 stairs 

The Choosing Wisely initiative focuses on evidence-based best practices that provide additional guidance in the care of our patients. The use of Choosing Wisely guidelines can foster a discussion with our patients, staff and consultants to improve patient care and avoid unnecessary tests and procedures.
 
As with anything in medicine, this tool is just that - a tool – and should be used along with clinical experience, individual circumstances and your current environment. Your decisions on any individual patient may vary.

Michael Silverman, MD
 
Michael Silverman, MD, FACEP, is the vice chairperson of the Emergency Department at Morristown Medical Center, Morristown, N.J. He is a diplomate of the American Board of Emergency Medicine and a fellow of the American College of Emergency Physicians. He is a member of the New Jersey Chapter of the American College of Emergency Physicians and is the former president of the New Jersey section of the Delaware Valley AAEM chapter. Dr. Silverman is also board-certified in internal medicine and undersea and hyperbaric medicine.

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