Not much fat in Australian EDs

AUSTRALIAN tertiary hospital emergency departments are well ahead of their American counterparts in policing inappropriate and wasteful tests, treatments and procedures, says a leading emergency physician.

Dr Didier Palmer, chair of the Australian College of Emergency Medicine (ACEM) quality assurance committee and director of emergency medicine at Royal Darwin Hospital, said large emergency departments (EDs) in Australia were constantly reviewing procedures to ensure quality and cost efficiency.

“I’m not sure there is much fat to cut in Australian emergency medicine”, Dr Palmer told MJA InSight. “We are driven by time factors so we are constantly asking ourselves ‘why are we doing this?’”

The American College of Emergency Physicians recently assembled a technical expert panel, including ED directors and physicians, to compile a top-five list of tests, treatments and disposition decisions that were of low value, could be standardised and could be actioned by emergency doctors and nurses.

The list, published in JAMA Internal Medicine, included not ordering computed tomography (CT) of the cervical spine for trauma patients who do not meet established criteria; not ordering CT to diagnose pulmonary embolism without first risk stratifying for pulmonary embolism; not ordering magnetic resonance imaging of the lumbar spine for patients with lower back pain without high-risk features; not ordering CT of the head for patients with mild traumatic head injury who do not meet risk criteria; and not ordering coagulation studies for patients without haemorrhage or suspected coagulopathy. (1)

The project was part of the US Choosing Wisely campaign. (2)

An accompanying editorial said the top-five list had “great potential to improve care and reduce wasteful medical spending”. (3)

Dr Palmer said that in Australia it was already recognised that the key to efficient and appropriate treatment in EDs was the early intervention of senior specialists in the process.

“There needs to be a senior doctor making decisions at the front end of the treatment”, he said.

“If it is junior doctors making those early decisions then progress can be made in inappropriate directions that may have to be remedied later. If seniors are making the early decisions it is far more efficient.

“Every single thing on the [American] list is something we’re already doing in tertiary emergency departments. We’ve looked at all of those issues.”

However, he said the situation in smaller Australian emergency departments would be different. “There is less review, less oversight, less auditing”, he said.

“What [ACEM] would like to encourage is networks of emergency medicine in which senior specialists can provide guidance to smaller departments”, he said.

“We are aiming at providing quality treatment to patients. If we can do it in a way that costs less that is a nice bonus, but not if it damages the patient.

“The really difficult thing is to do nothing. That’s where the risk lies. And that’s why the best care is delivered by senior doctors early in the treatment process.”

Dr Palmer said a more defensive culture in US practice made the top-five list project more appropriate there than in Australia.

Dr Sue Ieraci, senior staff specialist in emergency medicine at Bankstown Hospital in Sydney, said she felt that cutting waste in emergency medicine was about more than inappropriate investigation.

“When tests are done in a population with low pre-test probability, there will be more false-positives”, she told MJA InSight.

“So, in addition to the waste of time and money, there is the risk of treating for a false-positive result, which can cause harm in itself.

“We need to remember that the most important parts of diagnosis are the clinical components — history and physical examination. We have many well validated clinical tools that remove the need for further investigation or imaging.

“When patients are referred to the ED by community practitioners for a second opinion or a specific test, there is the temptation to go straight to the test, when a careful clinical re-evaluation is often what is required.”

1. JAMA Intern Med 2014; Online 17 February
2. Choosing Wisely
3. JAMA Intern Med 2014; Online 17 February