Fostering the discussion: American College of Emergency Physicians

“One thing we really like about Choosing Wisely is the prompt it gives the physician or other provider to talk to patients about what their options are,” says David Ross, DO, FACEP, Front Range Emergency Specialists, Colorado Springs, Colo. Ross has been active in American College of Emergency Physicians for several years, and is chair of ACEP’s Cost-Effective Care Task Force, which steered the College’s participation in the Choosing Wisely initiative as well as ACEP’s contribution to it.

In a hectic, fast-paced emergency room setting, holding such discussions with patients can be difficult. But when conditions allow, they can be worthwhile. For example, if there’s very little chance that a CT scan will detect anything significant in the case of a minor head injury, the ED physician can talk it over with the patient and together, they may decide to forego the scan, says Ross. If, after such a discussion, the patient simply won’t sleep well without having the scan, then maybe it’s better to proceed, he adds. “Our task force looked at ED treatments and tests [for Choosing Wisely] that we thought were relatively low-yield but high-cost, but it’s really more about fostering the discussion with the patient.”

Factors that might stand in the way of ED physicians changing their approach to conform to the spirit of Choosing Wisely include habit, time pressures in the ED, and concerns about liability, says Ross. ED members also worry that payers might use the Choosing Wisely recommendations of the various specialty societies as a means to avoid payment for claims.

“Some of our members are not particularly aware of [Choosing Wisely], and others have taken off with it,” says Ross. Several ACEP affiliates have created educational programs to help ED physicians understand the initiative and its importance. “One of our challenges is to coordinate our educational efforts,” he says. That said, ACEP was at press time preparing another set of Choosing Wisely recommendations, which it intends to publish this fall.

ACEP: Five Things Physicians and Patients Should Question

From Choosing Wisely, an initiative of the ABIM Foundation,

  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.
  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 for 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.