Choosing Wisely Campaign

Last October, ACEP joined ABIM's "Choosing Wisely" campaign.  5 measures were agreed upon.  They're pretty soft, but it's a start:

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. (see below for refresher on head CT rules)
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. 
3. Don’t delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit.
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. 
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. 

CT rules refresher:

• Canadian CT Head Rules: consider CT if ANY of the following present
• High Risk: GCS < 15 2 hours post injury, suspected open or depressed skull fracture, any sign of basilar skull fracture (hemotympanum, battle sign, racoon eyes, CSF otorrhea), >= 2 episodes of vomiting, age >= 65
• Medium Risk: Retrograde amnesia prior to event > 30 min, dangerous mechanism (MPC, ejection, fall > 3 feet or 5 stairs)
• New Orleans head CT Rules: consider CT if ANY of the following present (applicable for adults with GCS 15 and blunt head trauma within 24 hours that cause LOC, amnesia, or disorientation)
• Seizure
• Visible trauma above clavicle
• Drug or ETOH ingestion
• Headache
• Vomiting
• Age > 60
• Short-term memory loss (anterograde amnesia)

References:

1. http://www.acep.org/Clinical---Practice-Management/ACEP-Announces-List-of-Tests-As-Part-of-Choosing-Wisely-Campaign/
2. Smits M, et al. External validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head injury. JAMA. 2005 Sep 28;294(12):1519-25. PubMed PMID: 16189365.
3. Stiell IG, et al. 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. PubMed PMID: 16189364. Free Text at JAMA

Update 2/1/2015

The next 5 to make the list:

1. Avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma and a normal neurological evaluation. 
2. 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.
3. Avoid lumbar spine imaging in the emergency department for adults with atraumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition, such as vertebral infection or cancer with bony metastasis.
4. Avoid prescribing antibiotics in the emergency department for uncomplicated sinusitis. 
5. Avoid ordering CT of the abdomen and pelvis in young otherwise health emergency department patients with known histories of ureterolithiasis presenting with symptoms consistent with uncomplicated kidney stones. 

Reference: http://www.acepnow.com/article/acep-announces-new-choosing-wisely-list/