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Top 5 ED Procedures to Avoid

 |  By cclark@healthleadersmedia.com  
   February 18, 2014

A health system's emergency medicine clinicians, using a methodology based on consensus, has developed a list of services that can be avoided to prevent patient harm and reduce hospital costs.

Nearly 200 emergency clinicians at six Partners Healthcare hospitals near Boston have developed a list of five overused, low-value services—an alternative to the "Choosing Wisely" campaign's list. The difference: Partners' list was built with a consensus of doctors and mid-level practitioners on the front lines of emergency room care.

"The point was not so much to critique Choosing Wisely, which hadn't started when we began this project," explains Jeremiah Schuur, MD, Vice Chair of Patient Safety and Quality at Brigham and Women's Hospital's Department of Emergency Medicine.

Rather, he says, the point was "to develop a process that's transparent and that reflects actions a specialty provider [such as an emergency doctor] can make. We wanted to make sure this wasn't just experts in a room, but reflects what practicing providers thought."

Another component of the Partners list is that these are tests or services that not only have almost no value in defined low-risk patients who seek emergency care, but "we wanted to choose items the emergency physician largely has control over… can decide to order or not order," as opposed to tests or procedures that another provider in the hospital, such as a surgeon, may want done for their patients.

For example, one item for emergency physicians on the Choosing Wisely list, developed by the American College of Emergency Physicians, urges clinicians to engage available palliative and hospice services in the emergency department, a service many hospitals lack.

The Partners' list, and the methodology by which 64 procedures were whittled down to 17, and then down to five, is published in Monday's issue of JAMA Internal Medicine. Schuur says that the process by which the Partners' group consolidated opinions of an expert panel and front line doctors is one other specialty groups could use to avoid useless and potentially harmful care, and thereby reduce hospital costs.

"We're not saying that CT scans of the head are not useful in patients with trauma, Schuur explains. "But there are a number of high quality studies that help physicians identify low risk patients in whom a CT scan does not provide useful information. Those are the patients in whom we can avoid these tests, and it's true for other tests that we describe in our top five list."

Key to making the top five was the strength of evidence of specific patient groups who would very likely benefit versus those who almost certainly would not, Schuur says. For example, one of the practices that was on the list of 17 but didn't make the cut was the practice of admitting patients who come to the emergency department with a low-risk of fainting.

While there's general agreement that such patients do not require hospital admission, Schuur says, "there's not complete agreement on how to define a low-risk patient."

The Partners' Top Five list and the American College of Emergency Physician's Top Five list for the Choosing Wisely campaign share only one low-value procedure: head CT for patients with mild traumatic head injury who are at low risk of serious skull fracture or brain bleeding.

The Partners list is as follows:

1. Do not order computed tomography (CT) of the cervical spine for patients after trauma who do not meet the National Emergency X-ray Utilization Study (NEXUS) low risk criteria or the Canadian C-Spine Rule.

2. Do not order CT to diagnose pulmonary embolism without first risk stratifying for pulmonary embolism (pretest probability and D-dimer tests if low probability).

3. Do not order magnetic resonance imaging of the lumbar spine for patients with lower back pain without high-risk features.

4. Do not order CT of the head for patients with mild traumatic head injury who do not meet New Orleans Criteria or Canadian CT Head Rule.

5. Do not order coagulation studies for patients without hemorrhage or suspected coagulopathy (e.g., with anticoagulation therapy, clinical coagulopathy).

Schuur says the Partners effort is an attempt to change a culture of medicine in the U.S. which says "we never want to miss a single diagnosis, even when knowing the diagnosis doesn't affect how the patient is cared for and may not result in any different medicine or different decision about whether to operate."

While it seems that finding a diagnosis should always be a good thing for doctors to do, "always searching for a diagnosis can lead to harm, for example in the use of CT scans, if we do them on patients who do not have fractures requiring some sort of intervention."

In an accompanying editorial, JAMA Internal Medicine editors Deborah Grady, MD, and Rita Redberg, MD of University of California San Francisco and William Mallon, MD, of the University of Southern California, said they decided to publish the Partners' article because they see it as a "response" to the American Board of Internal Medicine Foundation's Choosing Wisely campaign's top five lists cultivated by more than 50 specialty societies.

"Although many professional societies have published 'top-five' lists, most have not detailed the methods by which the list was created. In some cases, it is clear that the lists were developed without much input from frontline practitioners, using a process that was not transparent ad without clear criteria for inclusion on the list," they wrote.

They noted that the American College of Emergency Physicians initially voted to not contribute a top 5 list for Choosing Wisely out of concern that emergency room patients are different because they are often sicker than patients of other specialty groups, because their care is often controlled by other specialists, and because in the ED, malpractice is perceived as a bigger threat. In the end, ACEP changed its mind and developed its own Choosing Wisely list.

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