Choosing Wisely + Pediatric Emergency Medicine
In August and September 2023 content experts from Choosing Wisely, Brad Sobolewski, the creator of PEMBlog and PEM Currents: The Pediatric Emergency Medicine Podcast, along with Spyridon Karageorgos and Andy Tagg from Don’t Forget the Bubbles along with a host of other medical professionals came together to create a series of blog articles, videos, podcast episodes, infographics and more to promote the Choosing Wisely recommendations for Pediatric Emergency Medicine. This evidence-based list of five common pediatric conditions seen frequently in emergency care settings feature opportunities for clinicians and families to partner to safely avoid unnecessary tests. Each of the recommendations has the following:
- A podcast episode with embedded players for Apple Podcasts and Spotify
- A blog article from PEMBlog
- A blog article form Don’t Forget the Bubbles
- A video or two embedded from it’s original YouTube listing
- Key References
- And information on the main subject matter experts from Choosing Wisely
We hope that these materials will serve as content that can help you disseminate knowledge related to common practices in the Emergency Department. They can serve as supplements to education, or the educational content in Quality Improvement projects. We spread the content across multiple formats in order to assure that learners can access the materials in their preferred format. Inclusion of Don’t Forget the Bubbles in the campaign is designed to spur conversations in these domains across the globe.
You are free to share any of this content on your website, in your presentations, with your colleagues, or as part of the educational interventions in quality improvement projects. Choose the format that best matches your audience! A heartfelt thanks to the taskforce members who were able to coordinate with many clinicians and organizations to make this list a reality: Paul Mulllan (chair), Kelly Levasseur, Shabnam Jain, Lalit Bajaj, James Chamberlain, Michele Nypaver, Olivia Ostrow, and Jennifer Thull-Freedman.
Here are high level links to the Choosing Wisely recommendations for Pediatric Emergency Medicine and the main link to the Choosing Wisely Toolkit
Do not obtain radiographs in children with bronchiolitis, croup, asthma, or first-time wheezing
Podcast Episode
Blog Articles
You don’t need X-Rays in a child with bronchiolitis, croup, asthma, or first time wheezing
Published August 30, 2023
Choosing Wisely – Radiographs in children with respiratory symptoms
Published August 31, 2023
Videos
Most children with respiratory illnesses don’t need X-Rays
Did you know that chest X-Rays are not recommended for most children with respiratory problems such as bronchiolitis, asthma exacerbations, croup, or first-time wheezing. Choosing Wisely recommends that doctors and all medical providers have detailed conversations with patients and their families about why X-Rays are unlikely to give new information or provide any additional reassurance. They also expose young children to unnecessary radiation. This video features Dr. Vincent Alexander who conducts a simulated discussion with a parent of a child with a respiratory illness.
A classic educational video about the dangers of Repetitive Read Syndrome
Repetitive Read Syndrome is affecting Radiologists across the globe. Symptoms include dictations including the same phrasing and suggesting clinical correlation repeatedly. We can help our Radiology colleagues by avoiding unnecessary chest X-ray orders for most children with respiratory problems such as bronchiolitis, asthma exacerbations, croup, or first-time wheezing.
References
Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474-e1502. DOI: https://doi.org/10.1542/peds.2014-2742
Trottier ED, Chan K, Allain D, Chauvin-Kimoff L. Managing an acute asthma exacerbation in children. Paediatr Child Health. 2021;26(7):438-439. DOI: 10.1093/pch/pxab058
Shah SN, Bachur RG, Simel DL, Neuman MI. Does this child have pneumonia? The rational clinical examination systematic review. JAMA. 2017;318(5):462-471. DOI: 10.1001/jama.2017.9039
Schuh S, Lalani A, Allen U, et al. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr. 2007;150(4):429-433. DOI: 10.1016/j.jpeds.2007.01.005
National Heart, Lung, and Blood Institute. Expert Panel Report 4: Guidelines for the Diagnosis and Management of Asthma; National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Bethesda, MD: National Heart, Lung, and Blood Institute; 2007:391
Expert Contributors
Michele Nypaver, MD
University of Michigan
Ann Arbor, MI, USA
michelen@med.umich.edu
Jennifer Thull-Freedman, MD
Alberta Children’s Hospital
Calgary, Alberta, Canada
Jennifer.Thull-Freedman@albertahealthservices.ca
Do not obtain screening laboratory tests in the medical clearance process of pediatric patients who require inpatient psychiatric admission unless clinically indicated
Podcast Episode
Blog Articles
You don’t need labs to medically clear a psych patient
Published September 6, 2023
Choosing Wisely – Investigations for Paediatric Patients presenting with Psychiatric Symptoms
Published September 7, 2023
Video
Do we really need labs to medically clear a pediatric psych patient?
Did you know that screening laboratory tests in the medical clearance process of pediatric patients who require inpatient psychiatric admission are not recommended unless clinically indicated? This video discusses why we don’t need labs for most children and adolescents who are being admitted to an inpatient mental health facility via an admittedly silly (but representative) conversation.
References
Thrasher TW, Rolli M, Redwood RS, et al. ‘Medical clearance’ of patients with acute mental health needs in the emergency department: a literature review and practice recommendations. WMJ. 2019;118(4):156-163
Donofrio JJ, Horeczko T, Kaji A, Santillanes G, Claudius I. Most routine laboratory testing of pediatric psychiatric patients in the emergency department is not medically necessary. Health Aff (Millwood). 2015;34(5):812-818
Chun TH. Medical clearance: time for this dinosaur to go extinct. Ann Emerg Med. 2014;63(6):676-677
Donofrio JJ, Santillanes G, McCammack BD, et al. Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance.
Ann Emerg Med. 2014;63(6):666-675.e663.
Santillanes G, Donofrio JJ, Lam CN, et al. Is medical clearance necessary for pediatric psychiatric patients? J Emerg Med. 2014;46(6):800-807
Santiago LI, Tunik MG, Foltin GL, Mojica MA. Children requiring psychiatric consultation in the pediatric emergency department—epidemiology, resource utilization, and complications. Pediatr Emerg Care. 2006;22(2):85-89
Expert Contributors
Shabnam Jain, MD, MPH
Emory University/Children’s Healthcare of Atlanta
Atlanta, GA, USA
sjain@emory.edu
Shilpa Patel, MD, MPH
Children’s National Hospital
Washington, DC, USA
SPatel@childrensnational.org
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
Podcast Episode
Blog Articles
You don’t need labs or CT scans in children who have recovered after a simple febrile or first time seizure
Published September 13, 2023
Choosing Wisely – Investigations for Seizures that have Returned to Baseline
Published September 14, 2023
Video
Children who have a febrile seizure or first time generalized seizure don’t need labs or CT scans
Did you know that lab tests and CT scans are not recommended for most children who fully recover after a simple febrile seizure or a first-time, unprovoked generalized seizure? Choosing Wisely recommends that doctors and all medical providers have detailed conversations with patients and their families about why labs and CT scans are unlikely to give new information or provide any additional reassurance. They also expose young children to painful venipuncture and unnecessary radiation. This video features Dr. Archit Sahai who conducts a simulated discussion with a parent of a child following a seizure.
References
Hirtz D, Ashwal S, Berg A, et al. Practice parameter: Evaluating a first nonfebrile seizure in children. Report of the Quality Standards Subcommittee of the American Academy of Neurology, the Child Neurology Society, and the American Epilepsy Society. Neurology. 2000; 55(5):616-623. Reaffirmed October 17, 2020
Riviello JJ Jr, Ashwal S, Hirtz D, et al; American Academy of Neurology Subcommittee; Practice Committee of the Child Neurology Society. Practice parameter: Diagnostic assessment of the child with status epilepticus (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2006;67(9):1542-1550
McKenzie KC, Hahn CD, Friedman JN; Canadian Paediatric Society, Acute Care Committee. Emergency management of the paediatric patient with convulsive status epilepticus. Paediatr Child Health. 2021;26(1):50-57
American Academy of Pediatrics, Subcommittee on Febrile Seizures. Neurodiagnostic evaluation of the children with a simple febrile seizure. Pediatrics. 2011;127(2):389-394. DOI: https://doi.org/10.1542/peds.2010-3318
Expert Contributors
Paul Mullan, MD
Children’s Hospital of the King’s Daughters
Norfolk, VA, USA
mullan20@gmail.com
Jim Chamberlain
Children’s National Hospital
Washington, DC, USA
JCHAMBER@childrensnational.org
Do not obtain abdominal radiographs for suspected constipation
Podcast Episode
Blog Articles
You don’t need X-Rays to tell if a child is constipated
Published September 20, 2023
Choosing Wisely – Radiographs in Children with Suspected Constipation
Published September 21, 2023
Video
Constipation: Do we really need X-Rays?
For most children with children with constipation an abdominal X-Ray will not assist in making the diagnosis or quantifying the exact stool burden. @WilltheThrill2 made a special video that helps to answer the question. Enjoy!
References
Freedman SB, Rodean J, Hall M, et al. Delayed diagnoses in children with constipation: multicenter retrospective cohort study. J Pediatr. 2017;186:87-94.e16. DOI: https://doi.org/10.1016/j.jpeds.2017.03.061 Pensabene L, Buonomo C, Fishman L, Chitkara D, Nurko S. Lack of utility of abdominal x-rays in the evaluation of children with constipation: Comparison of different scoring methods. J Pediatr
Gastroenterol Nutr. 2010;51(2):155-159. DOI: https://doi.org/10.1097/MPG.0b013e3181cb4309
Berger MY, Tabbers MM, Kurver MJ, Boluyt N, Benninga MA. Value of abdominal radiography, colonic transit time, and rectal ultrasound scanning in the diagnosis of idiopathic constipation in
children: a systematic review. J Pediatr. 2012;161(1):44–50.e502. DOI: https://doi.org/10.1016/j.jpeds.2011.12.045
Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children: Evidence-based recommendations from ESPGHAN and NASPGHAN.
J Pediatr Gastroenterol Nutr. 2014;58(2):258-274. DOI: https://doi.org/10.1097/mpg.0000000000000266
Kearney R, Edwards T, Braford M, Klein E. Emergency provider use of plain radiographs in the evaluation of pediatric constipation. Pediatr Emerg Care. 2019;35(9):624-629. DOI: 10.1097/ PEC.0000000000001549
Freedman SB, Thull-Freedman J, Manson D, et al. Pediatric abdominal radiograph use, constipation, and significant misdiagnoses. J Pediatr. 2014;164(1):83-88.e2
Expert Contributors
Kelly Levasseur, DO
Children’s Hospital of Michigan
Detroit, MI, USA
docklevasseur@gmail.com
Jennifer Thull-Freedman, MD
Alberta Children’s Hospital
Calgary, Alberta, Canada
Jennifer.Thull-Freedman@albertahealthservices.ca
Do not obtain comprehensive viral panel testing for patients who have suspected respiratory viral illnesses
Podcast Episode
Blog Articles
You don’t need to order comprehensive viral panels for most patients
Published September 27, 2023
Choosing Wisely – Viral Respiratory Panels in Children With Respiratory Symptoms
Published September 28, 2023
Video
Do we need comprehensive respiratory viral panels: Tips for talking with patients and families
Did you know that there are comprehensive respiratory viral panels that will test for dozens of viruses all at once? Did you know that these tests are very expensive, and that they rarely alter management? Did you know that Choosing Wisely recommends that we do not routinely obtain them for respiratory viral illnesses? Of course you did, but that doesn’t mean you shouldn’t watch this entertaining video that I made with Dr. Tanner Heckle, a Pediatric Emergency Medicine Fellow from Cincinnati Children’s which depicts a conversation between a provider and a parent of a child with a respiratory infection.
References
Gill, PJ, Richardson, SE, Ostrow O. Testing for respiratory viruses in children: to swab or not to swab. JAMA Pediatr. 2017;171(8):798-804
Noël KC, Fontela PS, Winters N, et al. The clinical utility of respiratory viral testing in hospitalized children: a meta-analysis. Hosp Pediatr. 2019;9(7):483-494
Parikh K, Hall M, Mittal V, et al. Establishing benchmarks for the hospitalized care of children with asthma, bronchiolitis, and pneumonia. Pediatrics. 2014;134(3):555-562
Innis K, Hasson D, Bodilly L, et al. Do I need proof of the culprit? Decreasing respiratory viral testing in critically ill patients. Hosp Pediatr. 2021;11(1):e1-e5
Expert Contributors
Olivia Ostrow, MD
Hospital for Sick Children
Toronto, Ontario, Canada
olivia.ostrow@sickkids.ca
Kelly Levasseur, DO
Children’s Hospital of Michigan
Detroit, MI, USA
docklevasseur@gmail.com
Lalit Bajaj, MD
Children’s Hospital of Colorado
Denver, CO, USA
Lalit.Bajaj@childrenscolorado.org