American College of Emergency Physicians

Five Things Physicians and Patients Should Question

Released October 14, 2013

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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.

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 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.

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 is 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. It is best to give these medications early during the ED visit, rather than later, in order to allow time for them to work optimally.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

Founded in 1968, the American College of Emergency Physicians (ACEP) has promoted the highest quality of emergency care and is the leading advocate for emergency physicians, their patients and the public. Headquartered in Dallas, Texas, ACEP has more than 32,000 members and 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies. Emergency physicians are recognized and valued for their commitment to high quality patient care, teaching, leadership, research and innovation. Emergency medicine is a valued and essential public service.

To learn more about ACEP, visit www.acep.org.

How this list was created: The American College of Emergency Physicians (ACEP) developed five Choosing Wisely® recommendations through a multi-step process that included input from ACEP members, an expert panel of emergency physicians and the ACEP Board of Directors. In 2012, ACEP appointed a task force to address cost effective emergency care. The Cost Effective Care Task Force conducted a survey that was open to all ACEP members asking for strategies to reduce cost and improve value in emergency medicine. The task force received over 200 individual suggestions, which were grouped into a set of strategies. A technical expert panel, including representatives from all aspects of emergency medicine practice, reviewed and prioritized the recommendations using a modified Delphi technique. The panel prioritized the strategies using multiple rounds of voting based on contribution to cost reduction, benefit to patients and actionability by emergency physicians. A literature review including data on cost was assembled for the highest-rated strategies. Strategies were further refined and a final list of strategies that received majority support of the panelists was created. Five of these were ultimately selected by the Board of Directors to be included in Choosing Wisely.

ACEP’s disclosure and conflict of interest policy can be found at www.acep.org.

Sources

1.

Jagoda AS, Bazarian JJ, Bruns JJ, Jr, Cantrill SV, Gean AD, Howard PK, Ghajar J, Riggio S, Wright DW, Wears RL, Bakshy A, Burgess P, Wald MM, Whitson RR; 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, Clement CM, Rowe BH, Schull MJ, Brison R, Cass D, Eisenhauer MA, McKnight RD, Bandiera G, Holroyd B, Lee JS, Dreyer J, Worthington JR, Reardon M, Greenberg G, Lesiuk H,MacPhail I, Wells GA. 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, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med. 2000 Jul 13;343(2):100–5.

Smits M, Dippel DWJ, de Haan GG, Dekker HM, Vos PE, Kool DR, Nederkoorn PJ, Hofman PA, Twijnstra A, Tanghe HL, Hunink MG. External validation of the Canadian CT head rule and theNew Orleans criteria for CT scanning in patients with minor head injury. JAMA. 2005 Sep 28;294(12):1519–25.

2.

Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. 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, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Coffin SE, Dubberke ER, Fraser V, Gerding DN, Griffin FA, Gross P, Kaye KS, Klompas M, Marschall J,Mermel LA, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS. 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, Amihod B, Orenstein P, Consolacion N, Miller MA. 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]

3.

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]. http://www.slate.com/id/2262769/.

Quest TE, Marco CA, Derse AR. Hospice and palliative medicine: new subspecialty, new opportunities. Ann Emerg Med. 2009;54:94–102.

Smith AK, McCarthy E, Weber E, Cenzer IS, Boscardin J, Fisher J, Covinsky K. 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.

4.

Baumann BM, Russo CJ, Pavlik D, Cassidy-Smith T, Brown N, Sacchetti A, Capano-Wehrle LM, Mistry RD. 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.

5.

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, Bellemare S, Wiebe N, Russell K, Klassen TP, Craig W. Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children. Cochrane Database System Rev. 2006;19(3):CD004390.