Healthcare News & Insights

Emergency physicians add their top 5 tests and procedures list to Choosing Wisely Campaign


Despite being a Choosing Wisely partner since February, the American College of Emergency Physicians (ACEP) finally released its recommendation of the five tests and procedures physicians and patients should question when it comes to necessity.

Choosing Wisely’s mission is to promote conversations among physicians and patients about using appropriate tests and treatments, and avoiding care when harm may outweigh benefits. To date, 54 socialites and 17 consumer groups have joined the campaign.

So why did it take so long for ACEP to come up with its top five list?

The recommendations, which were announced at the ACEP’s annual meeting in Seattle, were developed through a multi-step process that included research and input from an expert panel of emergency physicians and the ACEP Board of Directors.

Plus, all ACEP members were surveyed to help determine what could be done to improve efficiency and reduce costs without affecting the quality of care delivered.

5 tests and procedures

After much deliberation, here are the ACEP’s five Choosing Wisely recommendations:

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 injuries are a common reason for visiting an emergency department. The majority of minor head injuries don’t lead to injuries such as skull fractures or bleeding in the brain that need to be diagnosed by a CT scan, which exposes patients to ionizing radiation.

2. Avoid placing indwelling urinary catheters in the emergency department for either urine output monitoring in stable patients who can void, or for patient or staff convenience. 

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, and can be prevented by reducing the use of these catheters.

3. Don’t delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit.

Palliative care provides comfort and relief of symptoms for patients who have chronic and/or incurable diseases. 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, such as abscesses, become walled off and form pus under the skin. Opening and draining an abscess is the appropriate treatment; antibiotics offer no benefit.

5. Avoid instituting intravenous (IV) fluids before doing a trial of oral rehydration therapy in uncomplicated emergency department cases of mild to moderate dehydration in children. 

Many children who come to the emergency department with dehydration require fluid replacement. To avoid the pain and potential complications of an IV catheter, it’s preferable to give these fluids by mouth. Giving a medication for nausea may allow patients with nausea and vomiting to accept fluid replenishment orally. This strategy can eliminate the need for an IV.

“Emergency physicians are dedicated to improving emergency care and to reducing health care costs,” said Dr. Alex Rosenau, FACEP, president of ACEP said in a Choosing Wisely release. “These recommendations are evidence-based and developed with significant input from experts.”

 Growing numbers

To date, more than 50 specialty societies have now joined the campaign, and 30 plus societies will announce new lists in late 2013 and early 2014.

While the top 5 lists from each specialty group should be given careful consideration, Choosing Wisely recommends that physicians not use them to establish coverage decisions or exclusions. These recommendations are meant to spur conversation about what is appropriate and necessary treatment. Since each patient situation is different, physicians and patients should use the recommendations as guidelines to determine an appropriate treatment plan together.


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