Top Ten Pearls for Right Care in the Emergency Department

February 18, 2020

Written by Clay Smith

Spoon Feed
These are the top ten pearls to help us do the right thing for our patients in the ED. These are broader and complement Choosing Wisely for EM.

Why does this matter?
Choosing Wisely attempts to reduce overuse of certain procedures or diagnostics, but it left some of the more controversial points unsaid in many of its top 5 lists, according to the authors. The Right Care Alliance is a response. Here is what they deemed the top 10 in EM, “to identify not merely interventions that are overused but also others that need to be used more widely, if we are to achieve both better and more equitable health outcomes and financial savings.” The senior author is Jerry Hoffman, of EMA and NEXUS acclaim.

Doing the right thing
The EM Right Care Alliance group had two guiding principles. 1. There is a “quixotic search for certainty.” We can’t achieve perfection and never miss. In doing so, overtesting often harms as many patients as might be helped. 2. “Medical care is not the sole, or even most important, determinant of health outcomes.” In other words, social determinants, such as homelessness or addiction are often more important. With that, here are the top ten for EM, quoted below.

1. “Avoid further testing beyond history, physical exam, clinical gestalt and ECG in patients who are at minimal risk of an acute coronary syndrome.” Comment: There are some patients at minimal risk based on H&P + ECG alone. These authors advocate for not drawing labs or testing such patients. I say – be careful here. I use decision tools for this, like HEART.

2. “Avoid further testing beyond history, physical exam and clinical gestalt in patients who are at minimal risk of pulmonary embolus (PE).” Comment: Love me some PERC. I am all on board with this.

3. “Be judicious with the use of imaging, especially advanced imaging, in trauma patients.” Comment: Well, yeah… REACT-2, NEXUS, Canadian C-spine Rule,

4. “Avoid routine laboratory testing.” Comment: With this caveat – if you don’t know what is wrong with the patient, err on the side of doing more. Also, in cancer patients or immunocompromised patients, this is super bad advice.

5. “Consider non-medical reasons for a patient’s presentation to the ED.” Comment: Asking yourself why the patient is really back again for the 7th time this month is important. Also, asking the patient how you can best serve them today will often help you focus the workup.

6. “Tailor the intensity of care to the goals of the patient.” Comment: This is good advice. Explicitly ask your patient what is most important to them and if you have done that during their visit. You will be surprised what you learn.

7. “Employ shared decision-making (SDM) where appropriate.” Comment: My only concern with the SDM movement is when docs won’t give advice or recommendations. If my financial adviser just said to pick the funds I thought were best, what good would they be? It is OK to advise and offer your informed opinion to help the patient or family decide.

8. “When prescribing an intervention, make an effort to ensure that the patient is capable of accomplishing what is recommended.” Comment: Having an ED-based social worker can be a game-changer here.

9. “Tailor discharge instructions and follow-up recommendations to the individual patient.” Comment: It means a lot to patients when you type in a sentence or two specific to them on the discharge paperwork. Also, I like to circle in ink the most important parts. And make sure it is in their language.

10. “Be an advocate.” Comment: We are uniquely positioned to see the effects of failures in our social safety net and healthcare systems. As such, we need to speak up outside the ED for the voiceless. The authors didn’t mention it, but this also means being an advocate for our own patients. If a consultant/hospitalist/administrator/etc. won’t do the right thing – you must have the moral compass and clear understanding of what excellence demands to make sure your patient gets what they need.

Source
Bringing value, balance and humanity to the emergency department: The Right Care Top 10 for emergency medicine. Emerg Med J. 2019 Dec 24. pii: emermed-2019-209031. doi: 10.1136/emermed-2019-209031. [Epub ahead of print]

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