American Academy of Pediatrics – Section on Emergency Medicine and the Canadian Association of Emergency Physicians

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December 2, 2022

Do not obtain screening laboratory tests in the medical clearance process of pediatric patients who require inpatient psychiatric admission unless clinically indicated.

The incidence of mental health problems in children has increased in the last two decades, with suicide surpassing homicide as the second leading cause of death in teenagers. Most children with acute mental health issues do not have underlying medical etiologies for these symptoms. A large body of evidence, in both adults and children, has shown that routine laboratory testing without clinical indication is unnecessary and adds to health care costs. Any diagnostic testing should be based on a thorough history and physical examination. Universal requirements for routine testing should be abandoned.


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.

How The List Was Created

The American Academy of Pediatrics Section on Emergency Medicine (AAP SOEM) Committee on Quality Transformation (COQT) assembled a task force to oversee the creation of a Pediatric Emergency Medicine Choosing Wisely list. The task force first collected suggested recommendations from a diverse group of ED providers (physicians, nurses, and advanced practice providers) from six academic pediatric EDs to gather an initial list of frequently overused and/or avoidable tests and interventions. Task force members independently scored these items on an anchored rating scale based on each item’s frequency of overuse in a typical ED shift, the evidence for lack of efficacy, and the potential harm associated with overuse. The scores were discussed, and consensus was reached for the top 25 ranked items. Next, this list of 25 proposed items was sent to all COQT members in a survey format. The COQT member survey respondents selected which 10 items they believed should be included in the Choosing Wisely list. The task force then ranked the selected items based on the frequency of selection by COQT members. The five top-ranked items that were not duplicative of items on other subspecialty Choosing Wisely lists were submitted and approved by AAP SOEM leadership. The list of five final items with summary evidence was subsequently forwarded for peer review to relevant expert AAP Committee, Council, and Section leadership. The AAP Board of Directors and Executive Committee granted final approval of this list.

Sources

Thrasher TW, Rolli M, Redwood RS, et al. ‘Medical clearance’ of patients with acute mental health needs in the emergency department: a literature review and practice recommendations. WMJ. 2019;118(4):156-163

Donofrio JJ, Horeczko T, Kaji A, Santillanes G, Claudius I. Most routine laboratory testing of pediatric psychiatric patients in the emergency department is not medically necessary. Health Aff (Millwood). 2015;34(5):812-818

Chun TH. Medical clearance: time for this dinosaur to go extinct. Ann Emerg Med. 2014;63(6):676-677

Donofrio JJ, Santillanes G, McCammack BD, et al. Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance. Ann Emerg Med. 2014;63(6):666-675.e663.

Santillanes G, Donofrio JJ, Lam CN, et al. Is medical clearance necessary for pediatric psychiatric patients? J Emerg Med. 2014;46(6):800-807

Santiago LI, Tunik MG, Foltin GL, Mojica MA. Children requiring psychiatric consultation in the pediatric emergency department—epidemiology, resource utilization, and complications. Pediatr Emerg Care. 2006;22(2):85-89