- The US spends $2.5 trillion/year on health care, more than twice the average of other industrialized nations.
- Despite this, our outcomes are worse.
- Wasteful spending likely accounts for up to 50% of all U.S. spending. The biggest area of excess is defensive medicine, including redundant, inappropriate or unnecessary tests and procedures.
Enter “Choosing Wisely“, a campaign hosted by the ABIM Foundation, to challenge organizations representing medical specialties to choose 5 tests or procedures commonly used in their field, whose necessity should be questioned by providers and should be discussed with patients. ACEP was late in the game but finally came up with the following for the Choosing Wisely Campaign:
1. Avoid computed tomography (CT) scans of the head in emergency department patients with minor head injury who are at low risk based on validated decision rules.
Minor head injury is a common reason for visiting an emergency department. The majority of minor head injuries do not lead to injuries such as skull fractures or bleeding in the brain that need to be diagnosed by a CT scan. As CT scans expose patients to ionizing radiation, increasing patients’ lifetime risk of cancer, they should only be performed on patients at risk for significant injuries. Physicians can safely identify patients with minor head injury in whom it is safe to not perform an immediate head CT by performing a thorough history and physical examination following evidence-based guidelines. This approach has been proven safe and effective at reducing the use of CT scans in large clinical trials. In children, clinical observation in the emergency department is recommended for some patients with minor head injury prior to deciding whether to perform a CT scan.
Indwelling urinary catheters are placed in patients in the emergency department to assist when patients cannot urinate, to monitor urine output or for patient comfort. Catheter-associated urinary tract infection (CAUTI) is the most common hospital-acquired infection in the U.S., and can be prevented by reducing the use of indwelling urinary catheters. Emergency physicians and nurses should discuss the need for a urinary catheter with a patient and/or their caregivers, as sometimes such catheters can be avoided. Emergency physicians can reduce the use of indwelling urinary catheters by following the Centers for Disease Control and Prevention’s evidence-based guidelines for the use of urinary catheters. Indications for a catheter may include: output monitoring for critically ill patients, relief of urinary obstruction, at the time of surgery and end-of-life care. When possible, alternatives to indwelling urinary catheters should be used.
3. Don’t delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit.
Palliative care is medical care that provides comfort and relief of symptoms for patients who have chronic and/or incurable diseases. Hospice care is palliative care for those patients in the final few months of life. Emergency physicians should engage patients who present to the emergency department with chronic or terminal illnesses, and their families, in conversations about palliative care and hospice services. Early referral from the emergency department to hospice and palliative care services can benefit select patients resulting in both improved quality and quantity of life.
4. Avoid antibiotics and wound cultures in emergency department patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up.
Skin and soft tissue infections are a frequent reason for visiting an emergency department. Some infections, called abscesses, become walled off and form pus under the skin. Opening and draining an abscess is the appropriate treatment; antibiotics offer no benefit. Even in abscesses caused by Methicillin-resistant Staphylococcus aureus (MRSA), appropriately selected antibiotics offer no benefit if the abscess has been adequately drained and the patient has a well-functioning immune system. Additionally, culture of the drainage is not needed as the result will not routinely change treatment.
So take a few minutes to talk to your patients. Let them know that they (and you) should chose wisely before ordering a test or performing a procedure that is at best a waste of time and at worst, harmful.
1. Head CT:
- Jagoda AS, et al; American College of Emergency Physicians; Centers for Disease Control and Prevention. Clinical policy: neuroimaging and decision-making in adult mild traumatic brain injury in the acute setting. Ann Emerg Med. 2008 Dec;52(6):714–48.
- Stiell IG, et al. Comparison of the Canadian CT head rule and the New Orleans criteria in patients with minor head injury. JAMA. 2005 Sep 28;294(12):1511–8.
- Haydel MJ, et al. Indications for computed tomography in patients with minor head injury. N Engl J Med. 2000 Jul 13;343(2):100–5.
- Smits M, et al. External validation of the Canadian CT head rule and the New Orleans criteria for CT scanning in patients with minor head injury. JAMA. 2005 Sep 28;294(12):1519–25.
- Umscheid CA, et al. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011 Feb;32:101–14.
- Lo E, Nicolle L, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals.Infect Control Hosp Epidemiol. 2008 Oct;29:S41–50.
- Munasinghe RL, Yazdani H, Siddique M, Hafeez W. Appropriateness of use of indwelling urinary catheters in patients admitted to the medical service. Infect Control Hosp Epidemiol.2001 Oct;22:647–9.
- Hazelett SE, Tsai M, Gareri M, Allen K. The association between indwelling urinary catheter use in the elderly and urinary tract infection in acute care. BMC Geriatr. 2006 Oct 12;6:15.
- Gardam MA, et al. Overutilization of indwelling urinary catheters and the development of nosocomial urinary tract infections.Clin Perform Qual Health Care. 1998 Jul-Sep;6:99–102.
- Gokula RR, Hickner JA, Smith MA. Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital. Am J Infect Control. 2004;32:196–9.
- Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA; Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for prevention of catheter-associated urinary tract infections 2009. Atlanta (GA): HICPAC; 2009. 67 p.
- Scott RA, Oman KS, Makic MB, Fink RM, Hulett TM, Braaten JS, Severyn F, Wald HL. Reducing indwelling urinary catheter use in the emergency department. A successful quality-improvement initiative. J Emerg Nurs. 2013 Mar 7. pii: S0099-1767(12)00344–3. [Epub ahead of print]
- DeVader TE, DeVader SR, Jeanmonod R. Reducing cost at the end of life by initiating transfer to inpatient hospice in the emergency department. Ann Emerg Med. 2012;60(4s):S73.
- Kenen J. We can’t save you: how to tell emergency room patients that they’re dying. Slate [Internet]. 2010 Aug 4 [cited 2013 Sep 4].
- Quest TE, Marco CA, Derse AR. Hospice and palliative medicine: new subspecialty, new opportunities. Ann Emerg Med. 2009;54:94–102.
- Smith AK, et al. Half of older Americans seen in emergency department in last month of life; most admitted to hospital, and many die there. Health Aff. 2012 Jun31:1277–85.
- Baumann BM, et al. Management of pediatric skin abscesses in pediatric, general academic and community emergency departments. West J Emerg Med. 2011May;12(2):159–67.
- Duong M, Markwell S, Peter J, Barenkamp S. Randomized, controlled trial of antibiotics in the management of community-acquired skin abscesses in the pediatric patient. Ann Emerg Med. 2010 May;55(5):401–7.
- Llera JL, Levy RC. Treatment of cutaneous abscess: a double-blind clinical study. Ann Emerg Med. 1985;14:15–9.
- Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 Emergency Department Summary. National health statistics reports. Hyattsville, [MD]: National Center for Health Statistics. 2010. 31 p. Report no.: 26.
- Szajewska H, Gieruszcak-Bialek D, Dylag M. Meta-analysis: ondansetron for vomiting in acute gastroenteritis in children. Aliment Pharmacol Ther. 2007;25:393–400.
- Roslund G, Hepps T, McQuillen K. The role of oral ondanestron in children with vomiting as a result of acute gastritis/gastroenteritis who have failed oral rehydration therapy: a randomized controlled trial. Ann Emerg Med. 2008;52(1); 22–9.
- Hartling L, et al. Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children. Cochrane Database System Rev. 2006;19(3):CD004390.