ACEP Takes Second Swing at ‘Choosing Wisely’

ACEP’s newest additions to the Choosing Wisely campaign can appear embarrassingly basic, but the literature shows that these are areas of practice variation that, if improved, would truly help our patients.

ACEP’s newest additions to the Choosing Wisely campaign can appear embarrassingly basic, but the literature shows that these are areas of practice variation that, if improved, would truly help our patients.

After substantial feet dragging and an elaborate vetting process, on October 14, 2013 ACEP submitted to the Choosing Wisely project five practices that should cause EPs to think twice before doing. As of October 27, 2014, ACEP had submitted another five. As a brief reminder, the Choosing Wisely project was started by the Foundation of the American Board of Internal Medicine and it asked medical specialty societies to list five Things Physicians and Providers Should Question in an attempt to improve care and eliminate unnecessary tests and procedures. Currently over 60 specialty societies have participated and a large number of groups representing consumers are also involved. Specifically Consumer Reports in conjunction with various specialty societies has created a large number of patient-friendly resources to help educate patients regarding the practice of evidence-based, cost-effective medicine and, by so doing, helping to reinforce the recommendations of their providers.

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Here’s a run-down of the 10 items that ACEP has submitted to Choosing Wisely, along with my commentary:

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.

Seems like this is a no brainer – except the hook is the use of validated decision rules. There are a bunch of rules (or better still, guidelines) that have been validated regarding imaging in low risk head trauma, particularly in children, but who knows these rules? 

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I dare say no EP can recite the PECARN guidelines from memory. Although it may be very hard to come up with great, validated guidelines, it means nothing if no one knows them or uses them. This is where our EMRs and CPOE are supposed to come into play – to have these guidelines pop up when we are about to order a head CT (it’s called “decision support” and to my mind it’s one of the few benefits of an EMR and CPOE). So this Choosing Wisely submission will remain in limbo until there is some convenient way for clinicians to be made aware of the appropriate guidelines.

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.

This is definitely a no brainer and should have been expanded to just adopt the CDC guidelines. Apparently the ED is the department where most unindicated catheters are placed in the hospital. And unfortunately, many of these patients get admitted and the catheters go with them and it’s just a set-up for creating an infection.

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There are lots of studies showing how rapidly ED behavior regarding catheters can be changed through a process of education and monitoring and chastisement.

Here are the 2009 CDC guidelines for appropriate catheter use:

1. Acute urinary retention or bladder outlet obstruction
2. For accurate measurement of urinary output in critically ill patients
3. Perioperative use for selected surgical procedures
4. To assist in the healing of open sacral or perineal wounds in incontinent patients
5. For patients who require prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple trauma injuries such as pelvic fractures)
6. To improve comfort for end of life care if needed

Maybe I missed it, but I didn’t see in the CDC guidelines “for nursing convenience” or because someone got a slug of furosemide or “we need to fill up the bladder for a pelvic ultrasound” (another time-honored myth).  

And, as an aside, nobody gets paid for putting in a Foley catheter unless there is a specific physician order for it.

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

Who could possibly disagree with this? It’s been demonstrated that all sorts of benefits accrue to patients when palliative care is initiated early. The problem in smaller hospitals is that there is no palliative care team to call upon, and certainly not one available 24/7. So the challenge with this recommendation is to get the hospital to create a palliative care team or at least begin the process. We are all going to need it someday. And remember, there are lots of people who have terminal diseases that are not cancer (e.g., advanced CHF, COPD) who can benefit from palliative care.

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.

This is emergency medicine 101. All the clinical studies support this recommendation. The Infectious Diseases Society of America published its updated guidelines for the care of skin and soft tissue infections in September of 2014 and, although they are fond of cultures, they acknowledge that in routine cases they are not needed. And we all know from experience that, in reality, it would be the rare patient who would benefit from a culture in these cases. And the IDSA only promotes antibiotics for abscess treatment when there are signs of systemic illness – fever, leukocytosis, etc – not some localized cellulitis around an abscess.

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.

The literature says that American EPs really, really like to use IV fluids in children determined to be mildly to moderately dehydrated. This is despite the recommendations of the American Academy of Pediatrics, the CDC-P and the WHO that these children should be treated with the “sippy” diet – small, frequent amounts of appropriate fluids (Pedialyte or Rehydralyte or WHO – or their equivalents). With the widespread use of ondansetron in vomiting children, the failure rate of oral rehydration therapy is about 5%.

Advantages of oral rehydration include: the avoidance of an IV (which may be a challenge to start in a small child who is dehydrated – then the child is crying, the mother is upset and nobody is happy), ease of conducting the treatment at home and lower ED costs. Yes, the child may vomit once or twice during the process but be patient and start over – don’t feel the necessity to start an IV in these children. The vast, vast majority of children who are dehydrated in U.S. EDs are only mildly to moderately dehydrated. It should be the uncommon child who needs an IV for rehydration.

These preceeding recommendations were published in 2013. On October 27, 2014, ACEP added another five items to its Choosing Wisely list. Again, a very vigorous process was undertaken to generate the list.

6. Avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma and a normal neurological evaluation.

Wow, talk about a “gimme.” What possible value would a CT be in an asymptomatic syncope patient. What would you expect to find – a brain tumor or a bleed? Yet, the literature indicates a disappointingly large number of these patients get a head CT as part of their ED evaluation. Kind of scary if you ask me – but this is the case.

And “insignificant trauma and a normal neurologic evaluation” is also included. Why? ACEP didn’t just pull these obvious recommendations out of you-know-where. This recommendation would not exist if it weren’t for the fact that the literature demonstrates that we are doing head CTs on huge numbers of patients without even the slightest real indications. There is data indicating that this embarrassingly obvious recommendation needed to be made.

7. Avoid CT pulmonary angiography in emergency department patients with a low-pretest probability of pulmonary embolism and either a negative Pulmonary Embolism Rule-Out Criteria (PERC) or a negative D-dimer.

Again, this is emergency medicine 101. Unfortunately there are multiple papers in the literature affirming that the most simple of protocols for PE assessment are not being followed – even in major teaching hospitals. 

Here’s the simplest version and compared to the PECARN head trauma rules it is a true “no brainer.” First there is clinical stratification (use gestalt, Wells, modified Geneva – whatever). Low risk patients get a d-dimer. If the d-dimer is negative the work-up is over. Simple. Really simple.

Another more complicated option avoids the potential for false-positive d-dimers. Clinical stratification occurs first and if low risk (the substantial majority of patients are) and the patient is PERC-negative, the work-up is over. PERC negative? How will you possibly remember the PERC rules? Again, they should pop up on you CPOE screen in conjunction with the Wells rules or modified Geneva rules. Nobody will remember them.

Here are the PERC rules:

• Age less than 50 since those over 50 have one foot in the grave already
• Heart rate less than 100
• Oxygen saturation over 94%
• No unilateral leg swelling
• No hemoptysis
• No surgery or trauma within four weeks
• No prior DVT or PE
• No hormone use (includes oral, transdermal or intravaginal estrogens and some progestins)

There are lots of papers demonstrating EPs ordering CTPAs in low risk patients without doing a d-dimer test (or PERC) and not ordering a CTPA or other imaging study when they should. (Actually, as an aside, there is a growing argument to go back to using lung scans – they’re less likely to pick up subsegmental PEs in which the treatment can be more dangerous than the likelihood of serious recurrence of VTE.)

8. Avoid lumbar spine imaging in the emergency department for adults with non-traumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition (such as vertebral infection, cauda equine syndrome, or cancer with bony metastasis).

Guideline writers have been trying for decades to get physicians to back off on lumbar spine x-rays. In fact, guidelines for lumbar spine imaging were among the very first to be developed in any formal way in the U.S.

When it comes to low back pain, the only thing that EPs need to know in the setting of nontraumatic back pain are the red flags that are associated with serious pathology (infection, tumor, cord compression). All the rest really doesn’t matter given nontraumatic low back pain, without significant underlying pathology, is likely to get better no matter what you do. All that talk about muscle relaxers and physical therapy in the setting of acute low back pain is pretty much voodoo. And what are you going to do even if you see some disk space narrowing and osteophytes or the like – they don’t change what we do nor do they give us a specific diagnosis regarding the cause of the acute back pain.

9. Avoid prescribing antibiotics in the emergency department for uncomplicated sinusitis.

It is truly amazing the number of studies that have focused on the diagnosis and treatment of sinusitis – hundreds. You would think we would have the assessment and treatment of sinusitis down by now. Unfortunately sinusitis has fallen into the category of acceptable “itises” that warrant antibiotics. Its big brother is bronchitis. A detailed review of all of the myths surrounding sinusitis (like the color of the discharge matters / that antibiotic treatment needs to be given for at least two weeks / that one antibiotic is substantially better than the other) is beyond the scope of this critique. Here’s what ACEP says:

“Most patients with acute sinusitis do not require antibiotic treatment, because approximately 98% of acute sinusitis cases are caused by a viral infection and resolve in 10-14 days without treatment. For some patients with sinusitis, antibiotics might be appropriate, such as those patients taking drugs that reduce the effectiveness of the immune system, those with prolonged, severe symptoms, or those with worsening symptoms. Antibiotics can cause many side effects and have potentially severe complications, and these risks usually outweigh the benefits of their use for sinusitis. In addition, inappropriate antibiotic use for sinusitis can contribute to the development of antibiotic-resistant infections and contributes to avoidable health care costs.”

10. Avoid ordering CT of the abdomen and pelvis in young otherwise healthy emergency department patients (age <50) with known histories of kidney stones, or ureterolithiasis, presenting with symptoms consistent with uncomplicated renal colic.

In the EMA database we have a paper in which it was documented that one patient had 37 CTs for recurrent kidney stones. Bigillions of patients are getting repeat CTs every day for straightforward recurrent stones. On the assumption that the patient’s pain is similar to that associated with a prior stone and the patient had an initial CT at that time, consider ordering no more CTs. These patients can have an ultrasound if it is just impossible not to order some test – it will likely show some hydroureter. But what treatment will change? None. Follow-up is the answer along, with decent pain meds and, in most cases, time.

So I applaud the College for its participation in the Choosing Wisely initiative. At first I thought most of the recommendations were embarrassingly naïve and basic, but the facts in the literature bear out that the patients of many, many EPs will substantially benefit if all physicians take these recommendations to heart. We need to start out with baby steps and acknowledge that the variability in our clinical practice is enormous and, in many cases, very hard to defend. So what may appear obvious to some is not universally being practiced. Not by a mile.

Richard Bukata, MD is the editor of Emergency Medical Abstracts (www.ccme.org)