Emergency Physicians Put Head CT First on their Choosing Wisely List

Avoiding CT scans of the head in emergency department patients with minor head injuries who are at low risk based on validated decision rules came in first on the American College of Emergency Physicians (ACEP) list of questionable procedures for the American Board of Internal Medicine (ABIM) Choosing Wisely effort. The pick is hardly surprising as the issue of overuse of head CT for minor head injuries is well documented in research. Without a head CT, patients do need to wait in the ER for several hours observation, a perceived inconvenience. However, the risk from unnecessary radiation and the increased cost of the test makes avoiding it when possible a high priority. What is more notable is the ACEP simply releasing a list in the first place. This is a major step forward for the Choosing Wisely campaign, which the ACEP initially shunned over concerns that it would put ER physicians at risk for medical liability and giving payors and health systems an excuse to deny or question reimbursement for some tests and procedures. “They’re huge to bring in,’’ said Richard Baron, MD, president of the ABIM Foundation, in an interview with the Boston Globe. “More than lots of other physicians, they operate in an environment where it feels comfortable and natural to do stuff. They can have a huge impact on changing practice in an area where a huge number of Americans get health care.’’ In addition to avoiding head CT for minor head injuries, the ABIM recommended four other steps to reduce overuse of medicine. They are:

1. Avoid placing indwelling urinary catheters in the emergency department for either urine output monitoring in stable patients who can urinate on their own, or for patient or staff convenience. 
2. Don't delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit. 
3. 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. 
4. Avoid instituting intravenous IV fluids before doing a trail of oral rehydration therapy in uncomplicated emergency department cases of mild to moderate dehydration of children.