Author:  Luke Anderson

Editor:  Janice Yeung

 

Waste. It’s everywhere.

As frontline doctors, we have the responsibility to focus our efforts on high-value healthcare, and reject the interventions that provide negligible benefit.

Choosing Wisely Australia, in partnership with the professional colleges, has compiled a list of recommendations to decrease the provision of low-value healthcare.

Here are 5 of the Choosing Wisely recommendations to incorporate into your clinical practice.

 

1. Think twice before requesting coags

“Avoid coagulation studies in emergency department patients unless there is a clear defined specific clinical indication, such as monitoring of anticoagulants, in patients with suspected liver disease, coagulopathy, or in the assessment of snakebite envenomation.” – Australasian College for Emergency Medicine

Unless it will change management, don’t request it.

 

2. Use the PERC criteria and Well’s score to rule out pulmonary embolism

“Don’t request any diagnostic testing for suspected pulmonary embolism (PE) unless indicated by Wells Score (or Charlotte Rule) followed by PE Rule-out Criteria (in patients not pregnant). Low risk patients in whom diagnostic testing is indicated should have PE excluded by a negative D dimer, not imaging.” – The Royal Australian and New Zealand College of Radiologists

The Well’s score is well validated and easy to use. It is available on the MedCalc app which can be downloaded to your phone.

 

3. It’s viral!

“Avoid prescribing antibiotics for upper respiratory tract infection.” – Australasian Society for Infectious Diseases

 

4. Ottawa Ankle Rules

“Don’t request imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules.” – Australian Physiotherapy Association

Again, clinical examination is key. The Ottawa ankle rules have a 100% and 98% sensitivity for significant malleolar and midfoot fractures, respectively [1]. This means 100% of patients who are negative for the Ottawa ankle rules will not have a significant malleolar fracture!

 

5. Imaging low back pain

“Don’t perform imaging for patients with non-specific acute low back pain and no indicators of a serious cause for low back pain.” – The Royal Australian and New Zealand College of Radiologists

Low back pain is ubiquitous in the emergency department. Know your red flags, perform a thorough lower limb neurological exam and do your best to avoid imaging.

 

Final Thoughts

It falls upon each and every one of us to ensure the ongoing sustainability and longevity of our health care system.

By making small changes – small nudges – towards rational investigating, prescribing and procedural intervention, we can ensure future generations are able to access the same health care opportunities that we are privy to today.

As the next generation of practitioners, we can make change.

We can choose wisely.

 

Reference

  1. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993;269(9):1127-32. Abstract available from: https://jamanetwork.com/journals/jama/article-abstract/403941?redirect=true 

 

Useful links

Choosing Wisely

Well’s criteria for Pulmonary Embolism

MedCalX

 

follow Luke on Twitter @LukmanAnderson