Bobby Redwood, M.D., M.P.H.
Wisconsin Chapter, American College of Emergency Physicians
For the past two years, national ACEP has released five practice changing recommendations each October under their Choosing Wisely Campaign. These recommendations (see below) represent ways that the emergency physician can contribute to the triple aim of efficient, equitable, and patient-centered care. Inspired by ACEP's campaign, my group began to practice these ten recommendations routinely in our rural emergency department with a consensus that we feel more career fulfillment after agreeing to follow these evidence-based, patient-centered practices.
The current Choosing Wisely recommendations are written for a national audience. Given that regional practice patterns vary widely, my question for our membership this October is this: What would Wisconsin-specific choosing wisely recommendations look-like? Are there evidence-based, best EM practices being implemented in your ED that exemplify the triple aim? Are you willing to share? Send your recommendations to WACEP@badgerbay.co. With you help, we at Wisconsin ACEP can publish our own local edition of the Choosing Wisely Campaign for the Badger State!
For your reference, ACEP's Choosing Wisely to date:
- 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.
- 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.
- Don't delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit.
- 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.*
- 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.
- Avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma and a normal neurological evaluation.
- Avoid CT pulmonary angiography in emergency department patients with a low-pretest probability of pulmonary embolism and either a negative Pulmonary Embolism Rule-Out Criteria (PERC) or a negative D-dimer.
- Avoid lumbar spine imaging in the emergency department for adults with non-traumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition (such as vertebral infection, cauda equina syndrome, or cancer with bony metastasis).
- Avoid prescribing antibiotics in the emergency department for uncomplicated sinusitis.
- Avoid ordering CT of the abdomen and pelvis in young otherwise healthy emergency department (ED) patients (age <50) with known histories of kidney stones, or ureterolithiasis, presenting with symptoms consistent with uncomplicated renal colic.
*a recent NEJM study by Talan et al has revived this as a topic of discussion