Pediatric ED Patients Are Focus of New ‘Choosing Wisely’ Recommendations

November 11th, 2024

By Stacey Kusterbeck

The Choosing Wisely initiative, which aims to decrease unnecessary interventions in healthcare, has been around for more than a decade. Now a task force of pediatric emergency medicine physicians has created the first Choosing Wisely recommendations for emergency department (ED) pediatric patients.¹

“Unnecessary tests can lead to patient harm through exposure to radiation, adverse effects from medications or interventions, and the psychological impact of invasive procedures,” says Paul Mullan, MD, MPH, the chair of the task force. Mullan is the director of quality improvement and research and a pediatric emergency physician at Children’s Hospital of The King’s Daughters in Norfolk, VA. The task force offers these recommendations for ED providers:

• 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 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 guidelines have started healthy conversations among colleagues for these individual practices. This is starting to slowly change people's mindsets, and changing their clinical decision-making,” reports Mullan.

In Mullan’s experience, ED providers order unnecessary diagnostic tests for many reasons, including:

• fear of litigation;
• lack of familiarity with current guidelines or evidence-based practices;
• inadequate time for a thorough clinical evaluation, leading to over-reliance on tests;
• institutional or peer culture that may prioritize comprehensive testing;
• pressure from parents who expect thorough testing to “do something.

The problem of over-ordering diagnostic tests continues for these and other reasons. “But clinicians are steadily coming around,” says Mullan. “The publicizing of these best practice guidelines, as well as highlighting the potential harms from unnecessary practices, will hopefully motivate both provider and caregivers alike to start to question some of these age-old ways of practicing medicine.”

Mullen says that ED providers should consider the potential harm and costs associated with unnecessary diagnostic tests and treatments and engage in shared decision-making. “We hope that providers will feel confident enough to ‘safely do less’ for patients who do not have indications for certain treatments or tests,” says Mullan.

When choosing not to order a test or treatment, it’s important for ED providers to document these items, according to Mullan:

• the rationale for not performing the test or intervention (referencing guidelines or evidence as appropriate);
• a detailed clinical assessment and history that support the decision;
• plans for follow-up or alternative management strategies to monitor the patient's condition;
• discussions with patients or caregivers regarding the decision.

For example, ED providers can document the discussion with the parent of a child with febrile seizure who has returned to baseline about how the risk of radiation harm from a CT scan is significant and how the probability of finding something on the CT scan that would change management is minimal.

“Thorough documentation promotes the quality of care, supports the provider from a medicolegal standpoint, and facilitates continuity of care by informing future providers of the rationale behind decisions made,” says Mullan.

From a malpractice perspective, one of the most crucial aspects of the plaintiff attorney’s analysis is whether a diagnostic test would have ruled out or confirmed a diagnosis that was included in the emergency physician’s differential, says Anna Berent, JD, MBA, senior director of claims at MCIC Vermont, a risk retention group that provides medical professional malpractice insurance.

For example, the ED provider’s note may reference considerations for deep vein thrombosis when working up a complaint of calf pain. However, the ED chart references no venous doppler study to add to a D-dimer test. “That would constitute an issue for the defense,” says Berent.

Ideally, the ED medical record documents a physical exam and correlates that to recommended tests to rule in and out certain diagnoses. If so, the plaintiff expert who is reviewing the chart may recommend against proceeding with a lawsuit or may comment on the tenuous nature of the plaintiff’s claim.

“Certainly, there are gray areas that are filled with the provider’s professional judgment. In hindsight, those gray areas may be attacked as erroneous or incomplete,” says Berent. If it was ultimately discovered that the patient’s calf pain stemmed from an arterial thrombus in the leg, and not a venous one, a different type of diagnostic imaging study would have been warranted, for instance. “A provider’s reliance on a patient’s reported history, physical exam, and their own knowledge and experience would then guide the process for whether an arterial doppler study was indicated,” says Berent. Ideally, the ED medical record would document a lack of risk factors that would predispose the patient to an arterial thrombus (such as age, obesity, diabetes, or metabolic syndrome), with the physical exam and history supporting this conclusion.

“Plaintiff attorneys frequently like to harp on ED clinicians not ordering a diagnostic test,” says Jay Brenner, MD, FACEP, medical director of the Community ED and vice chair of research for the Department of Emergency Medicine at SUNY Upstate Medical University. Malpractice claims with this allegation often center on labs or imaging studies that are commonly ordered in an ED — but for whatever reason, the defendant did not order the test. Some of those claims are valid, such as not ordering a troponin to rule out acute coronary syndrome in a patient with risk factors and concerning symptoms. “Some of these claims are wild, however — such as impugning an ED clinician for not ordering an MRI on every patient with back pain to rule out the rare, but serious case of an epidural abscess,” says Brenner.

Evidence that the EP followed Choosing Wisely recommendations can be helpful to the defense of malpractice claims. “The recommendations are only developed after a thorough review of available evidence and can be helpful to show that the defendant provided appropriate care,” explains Jonathan M. Fanaroff, MD, JD, a professor of pediatrics at Case Western Reserve University School of Medicine in Cleveland, OH.

An alleged failure to order an indicated diagnostic test necessarily calls into question the differential diagnosis developed by the EP, says Ryan M. Shuirman, JD, an attorney in the Raleigh office of Cranfill Sumner. If the EP believes a diagnostic test is not indicated, the chart should reflect the reason why. For example, the EP’s documentation should show that the history and physical exam findings were suggestive of a more likely etiology that did not require the diagnostic test to rule out. “It is unreasonable to expect that an EP will always include a cumbersome recitation of all diagnoses on a differential and how she ruled each one out,” says Shuirman. However, it would be helpful to lawyers defending an eventual case to have thorough documentation of the decision-making on ordering of diagnostic tests. “EPs are much better at this presently than they were in the early 2000s. Perhaps this is a result of medical schools and training programs emphasizing documentation techniques that will better assist defenses down the road,” observes Shuirman.

If a malpractice lawsuit is filed, the focus is going to be on an individual patient or family — not the fact that defense medicine contributes to soaring healthcare costs. “Jurors will expect that extraordinary efforts will be made for the patient, regardless of the cost to taxpayers or society,” explains Shuirman.

Thus, many EPs are still inclined to err on the side of additional testing for an individual patient even if the risks may outweigh the benefits. Good documentation is legally protective in this situation, says Shuirman. EPs might document, for example: “Spoke to family about why a head CT, in this context, is not indicated and may not confer much benefit. We agreed to not obtain a head CT based on the history I gathered and physical exam findings. I encouraged the family to follow up with the patient’s primary care physician, and to return to the ED with any progression of symptoms or if patient does not improve.”

Without good documentation showing shared decision-making, says Shuirman, “the EP is susceptible to the argument that they benefited the health care system more abstractly, at the expense of the sick patient who is before them and asking for their help.”

Reference

1. Mullan PC, Levasseur KA, Bajaj L, et al. Recommendations for Choosing Wisely in pediatric emergency medicine: Five opportunities to improve value. Ann Emerg Med 2024 Feb 11:S0196-0644(24)00017-9. doi: 10.1016/j.annemergmed.2024.01.007. Epub ahead of print