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Friday, November 7, 2014

ACEP on the Choose Wisely Campaign

The American College of Emergency Physicians revealed a second list of five tests and procedures the council believes should be discussed to help make decisions about the most appropriate care based on a patient’s individual situation. The recommendations are part of ACEP’s participation in the American Board of Internal Medicine’s (ABIM) Choosing Wisely campaign.


The latest suggestions were developed through a multi-step process that included research and input from a panel of EPs and the ACEP Board of Directors. The following submissions should be used as guidelines to determine an appropriate treatment plan, according to ACEP’s board.


n Avoid head CTs in asymptomatic adult patients in the ED with syncope, insignificant trauma, and a normal neurological evaluation. Syncope and near-syncope are common reasons for ED visits, most of which are not serious. Tests should not be routinely ordered, and the decision to order them should be guided by information obtained from the patient’s history or physical examination.


n Avoid CT pulmonary angiography in ED patients with a low-pretest probability of pulmonary embolism and either a negative Pulmonary Embolism Rule-Out Criteria (PERC) or a negative D-dimer. Advances in medical technology have increased the ability to diagnose even small blood clots in the lung. Now, the most commonly used test is known as a CT pulmonary angiogram (CTPA), and it is readily available in most hospitals and EDs. CTPA disadvantages include patient exposure to radiation, the use of dye in the veins that can damage kidneys, and high cost.


n Avoid lumbar spine imaging in the ED for adults with atraumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition, such as vertebral infection or cancer with bony metastasis. Most of the time, low back pain is caused by conditions such as a muscle strain or a bulging disc that cannot be identified on an x-ray or CT scan.


n Avoid prescribing antibiotics in the ED for uncomplicated sinusitis. Most patients with acute sinusitis do not require antibiotic treatment because 98 percent of acute sinusitis cases are caused by a viral infection and resolve in 10-14 days without treatment.


n Avoid ordering CT of the abdomen and pelvis in young, otherwise healthy ED patients with known histories of ureterolithiasis presenting with symptoms consistent with uncomplicated kidney stones. Many ED patients who are under 50 and who have symptoms of recurrent kidney stones do not need a CT scan unless these symptoms persist or worsen, if there is a fever, or if there is a history of severe obstruction with previous stones. CT scans of patients in the ED with symptoms of a recurrent kidney stone usually do not change treatment decisions, and the cost and radiation exposure can often be avoided.


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