Gerad Troutman, MD, an emergency physician at Lubbock’s University Medical Center (UMC), is using Choosing Wisely when symptoms of dehydration occur.
“When I first encountered our specialty’s Choosing Wisely list,” Dr Troutman said, “my first thought was how I could apply this to pre-hospital medicine?”
Choosing Wisely promotes conversations between physicians and patients based on evidence provided by dozens of national specialty societies, including the American College of Emergency Physicians (ACEP). These specialty societies help physicians "choose wisely" by identifying tests or procedures commonly used in their field whose necessity physicians and patients should question and discuss.
One suggestion from the ACEP list stood out to Dr. Troutman: "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.”
Dr. Troutman began his research and pulled data from UMC EMS system of any patient age 2-18 who had a complaint of nausea and vomiting and had an IV started in the field.
“I found that many of these patients had normal vital signs and appeared to have benign exams,” Dr. Troutman said. “It would have been appropriate to consider oral rehydration in some of these patients.”
Dr. Troutman plans to use Choosing Wisely to tweak protocols and encourage UMC’s training department to put an emphasis on abnormal vital signs and severe signs or symptoms of dehydration as the only need for an IV in these patients.
Texas College of Emergency Physicians (TCEP) is encouraging its members to use the Choosing Wisely lists. The TCEP board of directors has approved the ACEP Choosing Wisely list to mirror their own suggestions for Texas emergency physicians to consider.
The four other ACEP Choosing Wisely recommendations are:
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 patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up.
The ABIM Foundation awarded TMA and its philanthropic arm, the TMA Foundation, a grant to advance the Choosing Wisely campaign among Texas physicians. Nine Texas county medical societies, six state medical specialty societies, and the Texas Osteopathic Medical Association are participating in the program with TMA. Support for the grant program comes from the Robert Wood Johnson Foundation.
For more information, including links to all of the specialty societies’ Choosing Wisely lists, see the TMA website at www.texmed.org/choosingwisely.
Texas Medicine, May 2014