CHOOSING WISELY CANADA
5 things
general internists and patients should question
By the Canadian Society of Internal Medicine
1
Don’t routinely obtain neuro-imaging
studies (CT, MRI, or carotid dopplers) in the
evaluation of simple syncope in patients with
a normal neurological examination.
Although an uncommon cause for syncope, providers must
consider a neurological cause in every patient presenting
with transient loss of consciousness. In the absence of signs
or symptoms concerning for neurological causes of syncope (such as but not limited to focal neurological deficits),
the utility of neuro-imaging studies are of limited benefit.
Despite a lack of evidence for the diagnostic utility of neuroimaging in patients presenting with true syncope, providers continue to perform brain computed tomographic (CT)
scans. Thus, inappropriate use of this diagnostic imaging
modality carries high costs and subject patients to the risks
of radiation exposure.
2
Don’t place, or leave in place, urinary catheters without an acceptable indication
(such as critical illness, obstruction, palliative
care).
Use of urinary catheters without an acceptable indication of
use increases the likelihood of infection leading to greater
morbidity and health care costs. Catheter-associated bacteriuria often leads to inappropriate antimicrobial use and
secondary complications including emergence of antimicrobial-resistant organisms and infection with clostridium
difficile. A previous study showed that physicians are often
unaware of urinary catheterization among their patients.
Use of urinary catheters has found to be inappropriate in
up to 50% of cases, with urinary incontinence listed as the
most common reason for inappropriate and continued
placement of urinary catheters. Clinical practice guidelines
support the removal or avoidance of unnecessary urinary
catheters in order to reduce the risk of catheter-associated
urinary tract infections (CAUTIs).
3
Don’t transfuse red blood cells for arbitrary
hemoglobin or hematocrit thresholds in
the absence of symptoms, active coronary
disease, heart failure or stroke.
Indications for blood transfusion depend on clinical assessment and are also guided by the etiology of the anemia. No
single laboratory measurement or physiologic parameter
can predict the need for blood transfusion. Transfusions are
associated with increased morbidity and mortality in highrisk hospitalized inpatients. Adverse events range from mild
to severe, including allergic reactions, acute hemolytic reactions, anaphylaxis, transfusion related acute lung injury,
transfusion associated circulatory overload, and sepsis.
Studies of transfusion strategies among multiple patient
populations suggest that a restrictive approach is associated with improved outcomes.
4
In the inpatient setting, don’t order repeated CBC and chemistry testing in the
face of clinical and lab stability.
Repetitive inpatient blood testing occurs frequently and is
associated with adverse consequences for the hospitalized
patient such as iatrogenic anemia, and pain. A Canadian
study showed significant hemoglobin reductions as a result
of phlebotomy. Given that anemia in hospital patients is associated with increased length of stay, readmission rates
and transfusion requirements, reducing unnecessary testing may improve outcomes. Studies support the safe reduc-
* Full physician list with references is available at ChoosingWiselyCanada.org
SMA NEWS DIGEST | SUMMER 2014
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