Choosing Wisely Canada<sup>®</sup>: Five tests, procedures and treatments to question in Emergency Medicine

Cheng, Amy; Campbell, Sam; Chartier, Lucas B.; Goddard, Tom; Magee, Kirk; McEwen, Jill; Kapur, A.; Holroyd, Brian R.; Upadhye, Suneel; Couperthwaite, S.; Rowe, Brian H.

doi:10.1017/cem.2017.1

Cited by 28 publications

(22 citation statements)

References 22 publications

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“…Choosing Wisely Canada (CWC) is a campaign to help patients and healthcare professionals engage in conversations about unnecessary tests and treatments [ 1 ]. On June 2, 2015, the Canadian Association of Emergency Physicians (CAEP) established a list of five CWC recommendations that included the following recommendation: “Don’t order lumbosacral (low back) spinal imaging in patients with non-traumatic low back pain (LBP) who have no red flags/pathologic indicators.” Since then, the CAEP has updated the list to include five more CWC recommendations for emergency department (ED) physicians [ 1 , 2 ].…”

Section: Introductionmentioning

confidence: 99%

Emergency Physicians Choose Wisely When Ordering Plain Radiographs for Low Back Pain Patients

Hiranandani

Mackenzie

Wang

et al. 2018

Cureus

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ObjectivesThe Choosing Wisely Canada (CWC) Emergency Medicine group recommends avoidance of lumbosacral radiographs for patients with non-traumatic low back pain (LBP) in the absence of red flags. The objective of this study was to evaluate imaging practices of emergency physicians (EPs) in four Calgary emergency departments (EDs) and identify patient, physician, and environmental factors associated with over-ordering of radiographs for low-risk LBP patients.MethodsData was retrospectively collected from patients, ages 18–50 and Canadian Triage and Acuity Scale (CTAS) codes 2–5, who presented with non-traumatic LBP to Calgary EDs from April 1, 2014 to March 31, 2016. Patients considered high risk, specifically with partial thromboplastin time (PTT) > 40 seconds or international normalized ratio (INR) > 1.2 seconds, any consult, admission to hospital, and history of cancer, were excluded. The primary outcome was to establish the overall usage of lumbosacral radiographs. The secondary outcome was to identify factors that influenced lumbosacral spine imaging.ResultsData from 2128 low-risk patients showed that 14.8% of the patients received lumbosacral radiographs. Variation among 132 physicians in X-ray ordering ranged from 0% to 90.9%. There were site-specific differences in ordering patterns [Rockyview General Hospital (RGH) = 21.6% > South Health Campus (SHC) = 15.6% > Peter Lougheed Centre (PLC) = 13.1% > Foothills Medical Centre (FMC) = 9.7%, p < 0.001]. Canadian College of Family Physicians-Emergency Medicine (CCFP-EM) licensed physicians ordered more X-rays compared to Fellow of the Royal College of Physicians of Canada (FRCPC) licensed physicians (16.6% vs. 11.1%, p < 0.001). Older physicians and physicians with more experience ordered more X-rays than their younger and less experienced colleagues.ConclusionConsiderable variation exists in the ordering practices of Calgary EPs. Overall, EPs seem to be choosing wisely in terms of ordering plain radiographs for non-traumatic LBP.

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Section: Introductionmentioning

confidence: 99%

Emergency Physicians Choose Wisely When Ordering Plain Radiographs for Low Back Pain Patients

Hiranandani

Mackenzie

Wang

et al. 2018

Cureus

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“…This hypothesis is in agreement with the results of Tama et al (23) which showed that university hospitals had better adherence to the PECARN rule than nonuniversity ones. Another hypothesis could be the successful quality improvement campaigns led independently by the Institut National d'Excellence en Santé et en Service Sociaux (INESSS) since December 2011 (24) and Choosing Wisely Canada (25) since June 2015. These two organizations worked to raise awareness among physicians about the overuse of diagnostic tools and the dangers inherent to radiation.…”

Section: Discussionmentioning

confidence: 99%

“…These two organizations worked to raise awareness among physicians about the overuse of diagnostic tools and the dangers inherent to radiation. As an example, among many published recommendations in June 2015, the first one for Canadian emergency physicians is: "do not order a head CT in children with mTBI unless positively validated with a clinical decision rule (25)".…”

Section: Discussionmentioning

confidence: 99%

Head CT overuse in children with a mild traumatic brain injury within two Canadian emergency departments

Gariepy

Gravel

Melnick

et al. 2019

Paediatrics &Amp; Child Health

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Background: The validated Pediatric Emergency Care Applied Network (PECARN) rule helps determine the relevance of a head computerized tomography (CT) for children with mild traumatic brain injury (mTBI). We sought to estimate the potential overuse of head CT within two Canadian emergency departments (EDs). Methods: We conducted a retrospective chart review of children seen in 2016 in a paediatric Level I (site 1) and a general Level II (site 2) trauma centre. We reviewed charts to determine the appropriateness of head CT use according to the PECARN rule in a random subset of children presenting with head trauma. Simple descriptive statistics were applied. Results: One thousand five hundred and forty-six eligible patients younger than 17 years consulted during the study period. Of the 203 randomly selected cases per setting, 16 (7.9%) and 24 (12%), respectively from sites 1 and 2 had a head CT performed. Based on the PECARN rule, we estimated the overuse for the younger group (<2 years) to be below 3% for both hospitals without significant difference between them. For the older group (≥2 years), the overuse rate was higher at site 2 (9.3%, 95% confidence interval [CI]: 4.8 to 17% versus 1.2%, 95% CI: 0.2 to 6.5%, P=0.03). Conclusion: Both EDs demonstrated overuse rates below 10% although it was higher for the older group at site 2. Such low rates can potentially be explained by the university affiliation of both hospitals and by two Canadian organizations working to raise awareness among physicians about the overuse of diagnostic tools and dangers inherent to radiation.

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“…Of these, approximately 2000 visits are for head injuries. Several national and international organisations have recently highlighted the issue of unnecessary utilisation of diagnostic imaging for patients with minor head injuries, including the Choosing Wisely Canada (CWC) Campaign, the Canadian Association of Emergency Physicians and the American College of Emergency Physicians 1–3. They also recommend the use of validated clinical decision rules to determine when CT scan imaging is necessary 1 2.…”

Section: Problemmentioning

confidence: 99%

Checklist for Head Injury Management Evaluation Study (CHIMES): a quality improvement initiative to reduce imaging utilisation for head injuries in the emergency department

et al. 2020

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Over 90% of patients with head trauma seen in emergency departments (EDs) are diagnosed with minor head injuries. Over-utilisation of CT scans results in unnecessary exposure to radiation and increases healthcare utilisation. Using recommendations from the Choosing Wisely Canada (CWC) campaign and quality improvement (QI) methodology, we aimed to reduce the CT scan rate for head injuries by 10% over a 6-month period.Baseline CT scan rates were determined through a 27-month retrospective cohort review. We used stakeholder engagement and provider surveys to develop our driver diagram and Plan-Do-Study-Act (PDSA) cycles, which included (1) improving provider knowledge about the CWC campaign recommendations; (2) testing, refining and implementing a modified Canadian CT Head Rule checklist; (3) developing CWC-themed head injury–specific patient handouts; and (4) feedback on CT scan group ordering rates to providers. Our primary outcome measure was the number of CT scans performed for patients with head injuries. Process measures included the number of checklists completed and ED length of stay (LOS). Our balancing measure was return ED visits within 72 hours (with or without admission).Baseline CT scan rates prior to our interventions was 46.1%. Our QI initiative resulted in a ‘shift’ in the Statistical Process Control chart of the weekly CT scan rates, associated with the first and second PDSA cycles, resulting in a 13.9% reduction in CT rates during the initial 3 months, and a sustained reduction of 8% at 16 months (p<0.05). Mean ED LOS for all patients with head injuries decreased by 1.5 min (p=0.74). 33% of checklists were completed. 72-hour return visits did not change significantly (p=0.68).Through provider and patient education, and the creation of a user-friendly evidence-based tool, our local QI initiative was successful in achieving long-term reduction in CT rates for patients presenting to EDs with head injuries.

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Choosing Wisely Canada^®: Five tests, procedures and treatments to question in Emergency Medicine

Abstract: The CWC recommendations for emergency medicine were selected using a mixed methods approach. This top 5 list was released at the CAEP Conference in June 2015 and should form the basis for future implementation efforts.

Cited by 28 publications

References 22 publications

Emergency Physicians Choose Wisely When Ordering Plain Radiographs for Low Back Pain Patients

Emergency Physicians Choose Wisely When Ordering Plain Radiographs for Low Back Pain Patients

Head CT overuse in children with a mild traumatic brain injury within two Canadian emergency departments

Checklist for Head Injury Management Evaluation Study (CHIMES): a quality improvement initiative to reduce imaging utilisation for head injuries in the emergency department

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Choosing Wisely Canada®: Five tests, procedures and treatments to question in Emergency Medicine

Abstract: The CWC recommendations for emergency medicine were selected using a mixed methods approach. This top 5 list was released at the CAEP Conference in June 2015 and should form the basis for future implementation efforts.

Cited by 28 publications

References 22 publications

Emergency Physicians Choose Wisely When Ordering Plain Radiographs for Low Back Pain Patients

Emergency Physicians Choose Wisely When Ordering Plain Radiographs for Low Back Pain Patients

Head CT overuse in children with a mild traumatic brain injury within two Canadian emergency departments

Checklist for Head Injury Management Evaluation Study (CHIMES): a quality improvement initiative to reduce imaging utilisation for head injuries in the emergency department

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Resources

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Choosing Wisely Canada^®: Five tests, procedures and treatments to question in Emergency Medicine