Five more recommendations to avoid unnecessary tests and procedures

In October at ACEP14 in Chicago, ACEP released a second list for the ABIM Foundation’s Choosing Wisely campaign. The campaign encourages medical specialty societies to create lists of five tests and procedures that may not be cost-effective in some situations and should prompt discussion with patients in order to both educate them and gain their agreement regarding avoidance of such tests and procedures. Here’s the most recent list:

1 Avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma, and a normal neurological evaluation. Syncope (passing out or fainting) or near syncope (lightheadedness or almost passing out) is a common reason for visiting an emergency department, and most of those visits are not serious. Many tests may be ordered to identify the cause of the problem. However, these tests should not be routinely ordered, and the decision to order them should be guided by information obtained from patients’ history or physical examination.

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. Advances in medical technology have increased the ability to diagnose even small blood clots in the lung. Now, the most commonly used test is known as a CT pulmonary angiogram (CTPA). It is readily available in most hospitals and emergency departments. However, disadvantages of the CTPA include patient exposure to radiation, the use of dye in the veins that can damage kidneys, and high cost.

3 Avoid lumbar spine imaging in the emergency department for adults with atraumatic back pain unless the patients have severe or progressive neurologic deficits or are suspected of having a serious underlying condition, such as vertebral infection or cancer with bony metastasis. Low back pain without trauma is a common presenting complaint in the emergency department. Most of the time, such pain is caused by conditions such as a muscle strain or a bulging disc that cannot be identified on an X-ray or CT scan.

4 Avoid prescribing antibiotics in the emergency department for uncomplicated sinusitis. Sinusitis is a common reason patients visit the emergency department. Most patients with acute sinusitis do not require antibiotic treatment because 98 percent of cases are caused by a viral infection and resolve in 10–14 days without treatment.

5 Avoid ordering CT of the abdomen and pelvis in young otherwise healthy emergency department patients with known histories of ureterolithiasis presenting with symptoms consistent with uncomplicated kidney stones. Many patients in the emergency department who are younger than 50 and who have symptoms of recurrent kidney stones do not need a CT scan unless these symptoms persist or worsen or unless there is a fever or a history of severe obstruction with previous stones. CT scans of patients in the emergency department with symptoms of a recurrent kidney stone usually don’t change treatment decisions, and the cost and radiation exposure can often be avoided in these cases.

To see ACEP’s first Choosing Wisely list—released last year at the annual conference in Seattle—as well as lists from other medical specialties, go to www.choosingwisely.org.