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Choosing Wisely list outlines tests to avoid in pediatric ED patients

December 1, 2022

A new Choosing Wisely list aims to help clinicians avoid unnecessary diagnostic tests for pediatric patients in emergency departments (EDs).

The list, “Five Things Physicians and Patients Should Question,” was developed by a task force comprised of members of the AAP Section on Emergency Medicine’s Committee on Quality Transformation (COQT) subcommittee and colleagues in Canada.

While recognizing there are unique considerations and options, the list includes the following recommendations:

  1. Do not obtain radiographs in children with bronchiolitis, croup, asthma or first-time wheezing.
  2. Do not obtain screening laboratory tests in the medical clearance process of pediatric patients who require inpatient psychiatric admission unless clinically indicated.
  3. Do not order laboratory testing or a CT scan of the head for pediatric patients with an unprovoked, generalized seizure or a simple febrile seizure who have returned to baseline mental status.
  4. Do not obtain abdominal radiographs for suspected constipation.
  5. Do not obtain comprehensive viral panel testing for patients who have suspected respiratory viral illness.

The list has been released in the United States and Canada, and is available at https://bit.ly/3FgqZ5t

“This list can be used by both general and pediatric emergency medicine doctors,” said Kelly Levasseur, D.O., FAAP, immediate past chair of the Section on Emergency Medicine’s COQT subcommittee. “We hope this information helps families understand why we choose to avoid certain tests for their children.”

For many patients, unnecessary testing is associated with avoidable pain, harmful radiation, prolonged length of stays in the ED and avoidable expenses.

“We know there’s a lot of overuse in emergency departments,” said Paul Mullan, M.D., M.P.H., FAAP, chair of the task force. “What we really want is for caregivers and physicians to have informed discussions about some of these diagnostic tests that aren’t perhaps always necessary. The results of these tests usually do not impact clinical management, and they come at a cost of being painful, stressful for the patient and caregivers, expensive, and the time to perform them contributes to the overcrowding problem we have in our EDs.”

Work on the list began in March 2021. The task force first collected suggestions from a diverse group of ED providers from six academic pediatric EDs across the United States. Task force members then independently scored 206 items on the initial list based on each item’s frequency of overuse in a typical ED shift, the evidence for lack of efficacy and the potential harm associated with overuse.

The top 25 items then were ranked a second time by COQT members. The final list of five recommendations with summary evidence was forwarded for peer review to relevant expert AAP committee, council and section leadership.

“It’s hard to convince people not to do things they are used to,” said Shabnam Jain, M.D., M.P.H., FAAP, one of the authors of the list. “These tests are easy for us clinicians (to order); they’re often just one click on the computer. We encourage parents and providers to think again before asking for or ordering these blood tests, viral panels, X-rays and CT scans. The current crisis of ED overcrowding underscores more than ever the need to choose wisely and avoid tests that are not evidence-based and do not improve outcomes.”

Choosing Wisely is an initiative of the ABIM Foundation, which seeks to promote conversations between clinicians and patients in choosing care that is supported by evidence, does not duplicate other tests or procedures already received, is free from harm and is truly necessary.

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