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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
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The authors of the best selling book,Leana Wen andJoshua Koosowski have already reviewed the situation in the USA, When Doctors Dont Listen,How To Avoid Misdiagnosisand Unnecessary Tests (St Martins Press).
@Mythbuster: ‘1.“Every single thing on the [American] list is something we’re already doing in tertiary emergency departments.” – no evidence provided to back up this claim’
As an ED trainee I can testify that these issues, as well as others relating to waste and inappropriate test-ordering, are frequently discussed on the floor and in education meetings. I realise that is personal experience, but it is not appropriate (or practical) to do a published study on every single thing that is discussed about our EDs. Nor is asking for evidence on every statement a fruitful way to progress a discussion. A more helpful way (if you wish to criticise a statement) might be if you could provide an argument (or evidence) why the statement might NOT be true.
I agree that EDs run by FACEMs here have more appropriate investigations and treatments than those EDs that are not.
Junior doctors need to learn, preferably not from their mistakes, rather from supervision. Investigations should be guided by history and physical examination, rather than preceding them.
The comment about ‘error-free gold standard’ was obviously tongue in cheek – we are talking medicine here. But the three major claims by the ACEM quality assurance committee chair continue to stand without any evidence to support it:
1.“Every single thing on the [American] list is something we’re already doing in tertiary emergency departments.” – no evidence provided to back up this claim
2. ‘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.’ – no evidence provided to back up this claim
3. “However he said the situation in smaller Australian emergency departments would be different. “There is less review, less oversight, less auditing”, he said.’ no evidence provided to back up this claim.
Three far-reaching claims from the ACEM chair of quality assurance based on what? In the age of evidence based medicine and interventions the data to support our claims should be natural part of our presentations, especially when coming from the chair of a quality assurance committtee. If no evidence is included by the author the substance for the claims should be provided when requested – or taken as a personal opinion only.
Mythbuster asks ”Where is the data and research to back up the claim made by the chair of the ACEM quality assurance committe that specialist and tertiary hospitals are the error-free gold standard of emergency care .” Since Dr Palmer didn;t make this claim, I suspect there is no such data. I am not aware of any human services that are error-free – let alone overloaded ones with time pressures.
Where is the data and research to back up the claim made by the chair of the ACEM quality assurance committe that specialist and tertiary hospitals are the error-free gold standard of emergency care and that mistakes or waste occur predominantly through the inexperience of junior doctors and rural hospitalist?
Or is this not an evidence-based claim but a vibe, a gut feeling, gaining traction and authority through the title of its author?
Time of presentation to time of discharge depends on a lot of factors, how sick the patients are and what investigation to perform to confirm diagnosis; how long is it going to take to get the investigation done; is it the appropriate investigation; are there harms from the investigation; can this investigation be done later as in-patient; does ED need to diagnose every patient that walks in and test each and everyone of them;is the patient safe to go out of ED, either home or to the ward?
Clinical diagnoses are lacking because not enough clinical history and examination are taken to rule out another diagnosis but in saying that appendicitis now days presents differently from individual patient to the next and surgeons too are not sure and it seems most of these patients get a CT abdomen to rule them out.
Totally agree that senior doctors first up review and plan junior doctors saves time and unnecesaary investigation BUT does the junior doctor gain self confidence for making their own decision? Are there enough senior doctors around to make early decisions?
In some hospitals, the 4 hour rule comes into consideration and patient’s safety is at risk – poorly investigated and transferred to ward with poorly stable vital signs, plan of management and they get PACED whilein the ward.
Over to the directors and managers