PEM Acute Care

Mullan, P. C., Levasseur, K. A., Bajaj, L., Nypaver, M., Chamberlain, J. M., Thull-Freedman, J., ... & Jain, S. (2024). Recommendations for choosing wisely in pediatric emergency medicine: five opportunities to improve value. Annals of emergency medicine.

Choosing wisely is an initiative that originally started in 2012 by the American Board of Internal Medicine.  It has since been adopted with broad applications across many specialties across the US.  This movement moved to Canada in 2014, with heavy influences across specialties there as well,  The premise of this movement is how we need to think more, and use evidence, before ordering tests for patient. The initiative identifies low value tests that in an ideal world would not be performed in most contexts as they are essentially useless, or in fact could be harmful.

There are more than 30 other countries that have now adopted this initiative. This article by Mullen et al was published recently and outlines several areas where we could all do better with how we think about ‘testing’.  In 2021, a group of pediatric emergency medicine (PEM) specialists within the Section of Emergency Medicine in the American Academy of Pediatrics (AAP) identified a need to create a Choosing Wisely recommendation list to highlight specific low value practices for children in the ED.  A task force was put together to look at the issue and develop a list specific to PEM. The task force included 8 members (6 from the United States and 2 from Canada) and using a three phase approach created then whittled down to a long list of 25 low value care practices.  Initially in phase 1, taskforce members queried a convenience sample of frontline clinicians at 6 of the taskforce member’s institutions requesting 5 to 10 recommendations from each clinician on low-value care practices. By independently scoring each of their suggested items across 3 domains on a 5-level anchored rating scale: perceived frequency of overuse, evidence for lack of utility, and potential harm associated with overuse, the taskforce was able to whittle down to 25 items. 

In the final phase to reduce the list, ranked recommendations underwent an external review process by several medical organizations.  The final top 5 list and corresponding references is in the table below.  It is worth the read of this article, the original 25 items are available, along with supporting references.