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Choosing Wisely: A Primer to the ACEP Recommendations

Choosing Wisely: A Primer to the ACEP Recommendations. WA ACEP November 2013. Outline. Disclaimers Background - Choosing Wisely Campaign 2013 ACEP Recommendations – Avoid: CT scan of the head for minor head trauma Indwelling urinary catheters if pt can void

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Choosing Wisely: A Primer to the ACEP Recommendations

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  1. Choosing Wisely:A Primer to the ACEP Recommendations WA ACEP November 2013

  2. Outline • Disclaimers • Background - Choosing Wisely Campaign • 2013 ACEP Recommendations – Avoid: • CT scan of the head for minor head trauma • Indwelling urinary catheters if pt can void • Delay in engaging palliative and hospice care • Antibiotics & cultures for uncomplicated soft tissue abscesses • IV fluids before a trial of oral rehydration • Conclusion

  3. Disclaimers • The following tests and procedures were recommended for inclusion in the “Choosing Wisely” campaign in 2013 by an expert panel of emergency physicians (EP) and the ACEP Board of Directors because they may not be cost effective in some situations. • However, these recommendations should not be construed or used to supersede the decision of the responsible provider, who possesses the knowledge, clinical judgment, and the situational awareness of the context and availability of appropriate resources.

  4. Disclaimers • The following summaries are intended to serve as a guide and facilitate increased awareness, but only represent a portion of the available information and references. Providers are encouraged to incorporate any and all references needed prior to implementation in clinical practice. • The authors of this presentation have no relevant conflicts of interest to disclose.

  5. Background • Originally conceived and piloted by the National Physicians Alliance along with Consumer Reports • Endorsed by the ABIM Foundation and over 20 medical specialty organizations • Identify tests and procedures commonly used in their field whose necessity should be questioned OR discussed with patients http://www.choosingwisely.org/ http://www.abimfoundation.org/Initiatives/Choosing-Wisely.aspx

  6. Background • ACEP initially declined participation because: • the impact on the unique nature of emergency medicine, liability concerns, and potential harm to physician reimbursement had not yet been appropriately examined, & • tests and procedures identified should be evidenced-based and have meaningful contribution to cost-effective care. • In Feb 2013, after review by an expert panel of EPs, the ACEP Board of Directors elected to participate in the campaign and recommended the following five tests and procedures. http://thecentralline.org/?p=2723 http://www.acep.org/Clinical---Practice-Management/ACEP-Announces-List-of-Tests-As-Part-of-Choosing-Wisely-Campaign/

  7. Recommendation #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. • Management may be guided by which one of three categories the patient belongs, • Pediatric • General Adult • Current Anticoagulation Therapy

  8. Recommendation #1 • Pediatric Patients • PECARN – Pediatric Emerg Care Applied Research Network • Validated clinical decision rule based on patient age, history, and clinical findings • Clinical Study http://www.sciencedirect.com/science/article/pii/S0140673609615580 • 2013 Adv Pediatric Emergency Medicine Assembly http://www.acep.org/uploadedFiles/ACEP/MeetingSites/PEM/Educational_Programs/7_Dayan_Head%20Trauma.pdf • Online Tool http://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm/

  9. Recommendation #1 • General Adult Patients • Several clinical decision rules, including Canadian CT Head Rule (CCHR) and New Orleans Criteria (NOC) • Based on history, risk factors, and clinical findings • Clinical Study http://jama.jamanetwork.com/article.aspx?articleid=201595 • Editorial Summary of Clinical Study http://jama.jamanetwork.com/article.aspx?articleid=201577 • 2008 ACEP Clinical Policy - Adult Mild Traumatic Brain Injury http://www.acep.org/clinicalpolicies/

  10. Recommendation #1 • Patients with Current Anticoagulation Therapy • Multiple modest studies have evaluated patients taking aspirin, clopidogrel, warfarin, and heparin • Studies of patients on newer oral anticoagulants are limited • Clinical Study #1 http://www.annemergmed.com/article/S0196-0644(12)00373-3/abstract • Editorial Commentary of Clinical Study #1 http://www.annemergmed.com/article/S0196-0644(12)00401-5/fulltext • Clinical Study #2 http://onlinelibrary.wiley.com/doi/10.1111/acem.12074/full • 2011 WA ACEP Journal Club

  11. Recommendation #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. • Catheter-associated urinary tract infection (CAUTI) is the most common hospital-acquired infection. • Clinical Study http://onlinelibrary.wiley.com/doi/10.1111/j.15532712.2009.00677.x/full • 2009 CDC Guidelines for Prevention of CAUTI http://www.cdc.gov/hicpac/pdf/cauti/cautiguideline2009final.pdf

  12. Recommendation #3 Don’t delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit. • Summary Paper http://onlinelibrary.wiley.com/doi/10.1197/j.aem.2003.07.019/abstract • Summary Paper http://www.annemergmed.com/article/S01960644(10)01202-3/fulltext • 2012 ACEP Palliative Care Information Paper http://www.acep.org/uploadedFiles/ACEP/Practice_Resources/issues_by_category/administration/Palliative_Care_IP_Final_June2012_edited.pdf

  13. Recommendation #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. • Clinical Study #1 http://www.annemergmed.com/article/S01960644(09)00270-4/fulltext • Clinical Study #2 http://aac.asm.org/content/51/11/4044.full • Review Article http://www.annemergmed.com/article/S0196-644(07)00078-9/fulltext

  14. Recommendation #5 Avoid instituting intravenous (IV) fluids before doing a trial of oral rehydration therapy in complicated emergency department cases of mild to moderate dehydration of children. • Clinical Study #1 http://archpedi.jamanetwork.com/article.aspx?articleid=485711 • Clinical Study #2 http://www.cdc.gov/hicpac/pdf/cauti/cautiguideline2009final.pdf • Clinical Review http://www.sciencedirect.com/science/article/pii/S0736467908005969

  15. Conclusion Please consider incorporating these recommendations into your practice With some thought and effort, you will continue to provide excellent care while, • reducing the use of some tests and procedures, • reducing costs, and • improving collaboration with your patients. Questions? Please, • go to www.acep.org • contact your chapter Board of Directors

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