SGEM#65: Relax, Don’t Do It (Top 5 List for Emergency Medicine)

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Date: March 6, 2014

Each week I usually put my skeptical eye on a recent publication. This is an attempt to cut the knowledge translation window down from an average of 10 years to 1 year. I use the Best Evidence in Emergency Medicine (BEEM) Appraisal Tools to do a structured critical review.

However, every so often I like to take a break from the usual format. Step back and discuss a larger issue. Sort through the forest and the trees. Talk about an important emergency medicine topic. We have done this before on a number of occasions:

SGEM#15 Choosing Wisely
SGEM#20 Hit Me with your Best Shot
SGEM#35 We are Young (Social Media and Medical Education)
SGEM#49 Five Stages of Evidence Based Medicine Grief
SGEM#56 BEEM Me Up (Impact Factor in the Age of Social Media)

Today we have another great issue to discuss on the SGEM. What is even better is we have three of the co-authors of the JAMA paper. It is hot off the press and you get to hear directly from guys who did the study. I think this really demonstrates the power of social media for knowledge translation.

Guest Skeptics:

Dr. Jeremiah Schuur: Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School
Dr. Ali Raja: Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School
Dr. Arjun Venkatesh: Robert Wood Johnson Foundation Clinical Scholar and Clinical Instructor in Emergency Medicine at Yale University

Reference: JD Schuur et al. A Top-Five List for Emergency Medicine: A Pilot Project to Improve the Value of Emergency Care. JAMA Intern Med. Published online February 17, 2014. doi:10.1001/jamainternmed.2013.12688

Background: This JAMA study was partly inspired by Dr. Howard Brody’s article in the NEJM 2010. He challenged specialty societies to come up with a Top 5 List of diagnostic tests which should not be performed. Dr. Brody felt this would be a prescription for how money could be saved without impacting negatively on patient care.

Further inspiration came from the Top 5 List put together for primary care and published in JAMA Intern Med. 2011.

It has been suggested the cost of emergency medicine care has risen 240% from 2003-2011. A significant part of that cost is the diagnostic tests, treatments and hospitalizations that emergency physicians order.

Objective of the Study: Develop a Top 5 List of tests/treatments and disposition decisions that are of little value and emergency physicians can control.

Methods: Modified Delphi consensus of 283 emergency clinicians (MDs, PAs and NPs)

Results: Originally able to identified 64 low value items. This list was brought down to 17 items (7 labs, 3 meds, 4 imaging studies and 3 dispositions). From these 17 items the top 5 list was decided.

TOP 5 LIST FOR EM:

Do not order CT of the c-spine for patients after trauma who do not meet the NEXUS low-risk criteria or the Canadian C-Spine Rule
Do not order CT to diagnose PE without first risk stratifying (pretest probability and D-dimer tests if low probability)
Do not order MRI of the lumbar spine for patients with lower back pain without high-risk features.
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
Do not order coagulation studies for patients without hemorrhage or suspected coagulopathy

Discussion: The American Board of Internal Medicine (ABIM) started the project called Choosing Wisely. According to the ABIM foundation website: “Choosing Wisely is part of a multi-year effort of the ABIM Foundation to help physicians be better stewards of finite health care resources.”

ACEP joined the Chooses Wisely campaign in October 2013. Dr. Schuur was co-chair of the committee responsible for coming up with the ACEP Top 5 List.

ACEP TOP 5 LIST:

Avoid 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 IV fluids before doing a trial of oral rehydration therapy in uncomplicated emergency department cases of mild to moderate dehydration in children.

South Huron Hospital Association (SHHA) is known as “Little Hospital that Does”...Choose Wisely. Our medical staff generated its own list. This was done through discussion on five things we could do to improve patient care based on the evidence.

SHHA TOP 5 LIST:

Influenza shots for all medical staff with hospital privileges
Use Ottawa ankle and knee rules (clinical decision instruments)
No routine use of antivirals for Bell’s Palsy
No routine use of antibiotics for simple cutaneous abscesses
No routine use of proton pump inhibitors for upper GI bleeds.

Limitations to the Study: Single healthcare system (mainly academic), no cost data, and affordability projects had begun in parallel.

Authors Conclusions: “Our TEP identified clinical actions that are of low value and within the control of ED health care providers. This method can be used to identify additional actionable targets of overuse in emergency medicine.

Thank you to our guest skeptics and the co-authors of this very important paper. I challenge all the SGEM listeners to come up with their own Top 5 List of things they could do locally to choose wisely. When you do generate a list send it to me at TheSGEM@gmail.com so I can share it.

Keener Kontest: Last weeks winner was Dr. Leon Adelman from Alexandria, VA. He knew that Dr. Jokichi Takamine was the first person to isolate adrenaline/epinephrine.

Listen to this weeks episode of the SGEM for the Keener Kontest? If you know the answer send an email to THESGEM@gmail.com with “keener” in the subject line. The first person will receive a skeptical prize.

Next week I will be teaching at SweeeeeetBEEM in Stockholm, Sweden. I plan to drive a Volvo, visit the largest Ikea store in the world and listen to lots of ABBA.

Until next week, Relax, Don’t do it (order so many tests).