Choosing Wisely: Five Things Physicians and Patients Should Question in the Practice of Pediatric Emergency Medicine

The American Academy of Pediatrics (AAP), as part of the Choosing Wisely® campaign, has released an evidence-based list of five common pediatric conditions seen frequently in emergency care settings where clinicians and families can partner to safely avoid unnecessary tests.

The AAP Section of Emergency Medicine has identified several common pediatric conditions that present to emergency departments and are associated with a high rate of unnecessary diagnostic testing. Patients are commonly seen for these conditions in urgent care centers and primary care offices as well. For many patients, the unnecessary testing is associated with avoidable pain, harmful radiation, prolonged length of stays in the emergency department, and avoidable expenses. The results of these diagnostic tests can also create unwanted downstream consequences such as unnecessary therapies and further diagnostic testing when the initial test results were false positives.

“The emergency department has the ability to rapidly perform a myriad of diagnostic tests and receive results quickly,” said Paul Mullan, MD, MPH, the chair of the AAP Section of Emergency Medicine’s Choosing Wisely taskforce. “However, this comes with the danger of diagnostic over-testing.

“We hope this Choosing Wisely list will encourage clinicians to rely on their clinical skills and avoid unnecessary tests,” said Dr. Mullan, who is also a physician at Children’s Hospital of the King’s Daughters and professor of pediatrics at Eastern Virginia Medical School.

A task force went through a rigorous process of scientific evidence review and expert consensus to determine a list of clinical presentations which are frequently experiencing over-testing in the emergency department setting. The task force also included physicians working in Canada who solicited feedback from Choosing Wisely Canada and the Canadian Association of Emergency Physicians during the process of creating the list. This U.S.-Canadian collaboration has led to the first AAP Choosing Wisely list that has been simultaneously published by the Choosing Wisely organizations of two countries.

“We encourage parents and providers to think again before asking for or ordering these blood tests, viral panels, X-rays, and CT scans,” said Shabnam Jain, MD, MPH, a professor of pediatrics and emergency medicine at Emory University School of Medicine and Children’s Healthcare of Atlanta. “The current crisis of emergency department overcrowding underscores more than ever the need to choose wisely and avoid tests that are not evidence-based and do not improve outcomes.”

The Section recognizes there are unique considerations and options as it concerns children. The list is available here and includes the following recommendations:

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

The list contains additional evidence-based guidance on when these diagnostic tests might be appropriate to obtain in the ED setting. The AAP Section on Emergency Medicine (AAP SOEM) Committee on Quality Transformation (COQT) formed the list by first gathering recommendations from a diverse group of emergency department providers. Members then weighted and scored the recommendations from physicians, nurses and advanced practice providers based on frequency of inappropriate use during a typical emergency department shift, the lack of evidence for their use, and the potential for harm associated with overuse.

The list is available through the Choosing Wisely website. 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 truly necessary.
At least 80 medical specialty societies have published more than 500 recommendations of overused tests and treatments as a result of the initiative, launched in 2012.

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The American Academy of Pediatrics is an organization of 67,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well-being of infants, children, adolescents and young adults. For more information, visit www.aap.org.