SHM's Choosing Wisely ® Final Recommendations (And My Alternatives).

(UPDATE February 2013.  Final SHM list released!  See below).  I received an email today from the Society of Hospital Medicine (SHM) asking me to fill out a survey asking for my opinion on 15 potential clinical practice recommendation candidates for the ABIM Foundation's Choosing Wisely Campaign ®. 

An initial list created by SHM committee representatives contained over 150 potential clinical elements of excessive tests or procedures whose necessity should be questioned and discussed.  This list was whittled down to just 15 proposed recommendations by a SHM subcommittee.

As a card carrying member of  The SHM, I was asked to participate in a survey on how important I felt these 15 recommendations were in my clinical practice (a 1 to 5 scale of strongly agree to strongly disagree).  The goal is to further reduce the list to a top ten list that will ultimately be used to pick the final top  five recommendations (being requested by many specialty medical  societies) for inclusion in the Choosingly Wisely Campaign ®.   

Here are the 15 potential top 5 finalists for SHM inclusion (paraphrased in my own words) on hospitalized patients.
  1. Stop placing urinary catheters for incontinence or convenience or monitoring output in non critical care patients. 
  2. Stop ordering repetitive CBC and chemistry panels with clinical and lab stability.
  3. Stop prescribing GI prophylaxis in medical patients without clear indication or a high risk of GI complication.
  4. Stop ordering so much telemetry.  Just stop it.
  5. Stop ordering routine CXR/EKG for asymptomatic pre operative evaluations.  
  6. Don't order hypercoagulable tests on patients on active anticoagulation or acute clot
  7. Stop transfusing blood based on arbitrary numbers in the absence of symptoms.
  8. Don't treat asymptomatic bacteriuria and stop ordering urine cultures in patients without symptoms of UTI.
  9. Don't use TPN when tube feeds can be ordered instead.
  10. Don't use antibiotics routinely to treat asthma or acute bronchitis.
  11. Stop placing PICC lines in patients expected to stay less than 48 hours and not required for discharge.
  12. Stop ordering serial chest xrays in COPD, CHF or pneumonia patients outside of the ICU who are clinically not improving or deteriorating.
  13. Stop placing unnecessary IVC filters.
  14. Don't order cardiac nuc med studies for low risk patients with atypical chest pain
  15. Improve communication of end of life care wishes and goals of care at the outpatient and inpatient level.
These are the 15 finalists for SHM's contribution to the ABIM Foundation's Choosing Wisely Campaign ®.  This list, I suppose, will use SHM membership survey results to get the top ten and ultimately the final five recommendations.  

After 10 years of clinical practice, I can say, categorically, without hesitation, that I think the most bang for our buck would be achieved if we chose the following five as SHM's final recommendations from this list.  (in this order)
  1. Improve communication of end of life wishes.  In other words, either become a great palliative care doctor or get a great palliative care team in your hospital.   Implementing this key recommendation alone would do more to eliminate unnecessary tests and procedures than all the other 14 combined.  
  2. Stop ordering all those unnecessary CBC and chemistry panels. Remember, too many lab draws can kill patients.  
  3. Stop placing unnecessary urinary catheters of convenience.  They are not a benign procedure.  
  4. Stop ordering so much telemetry.  What a waste of time, resources and patient satisfaction.
  5.   Stop transfusing blood at arbitrary lab values.  They come with some pretty scare but rare complications.  
UPDATE FEBRUARY 2013:  What were the winners?  Here is the file detailing the the final decisions made by the Society of Hospital Medicine.   Looks like most hospitalists agree with me.
  1. Stop with the convenience catheters already.
  2. Stop prescribing soo much stress ulcer prophylaxis
  3. Quit transfusing so much blood
  4. Enough with ordering so much telemetry
  5. Stop ordering so many CBC and electrolyte panels.
Please enjoy this original Happy Hospitalist crude medical ecard, part of an entire collection on Pinterest.

"The telemetry I ordered on you is expensive, annoying, unnecessary and has all the nurses talking about how stupid I am for ordering it.  Let's do it."

The telemetry I ordered on you is expensive, annoying, unnecessary and has all the nurses talking about how stupid I am for ordering it.  Let's do it doctor ecard humor photo.

Now, since you're still reading, you're probably asking yourself what are the top five recommendations by The Happy Hosptialist  for reducing unnecessary tests or procedures that failed to make it through the rigors of the SHM subcommittee?  Any practicing hospitalist knows these are the real ways to reduce unnecessary expenses
  1. Eliminate observation care.  Every practicing hospitalist knows observation is the most widely abused Medicare benefit out there.  Patients abuse it.  Doctors abuse it.  Families going on weekend vacations abuse it.  Either patients need to be admitted to the hospital or they don't.   Observation status has turned into a back door method to codify the too old  to go home social admit.  Medicare has turned hospitals into nursing homes with their observation status..  You want to reduce unnecessary costs?  Let's start by eliminating observation status.
  2. Figure out a way to force doctors to read the chart.   Not a day goes by where doctors may be too lazy to read the recommendations and the orders of other physicians who have rounded on the patient already.  Sometimes it is so blatantly obvious it scares me to think I might someday be a patient being cared for by blind (by choice) doctors.  For example, if the hospitalist ordered the TSH,  B12 level and ANA yesterday, getting a second or third value before the week is over offers nothing of patient value.  It does however increase costs and indicates doctors don't read the chart.  Just stop it.  Read the chart. You'll save a lot more than ordering duplicate orders.  Perhaps, someday, with ObamaCare in the wings,  hospitals will start charging doctors for their duplicate orders.
  3. Mandate video recording for physician directed informed consent.  If physicians were required to provide detailed informed consent in an ethical fashion, on video,  I would suspect a vast number of patient labs, tests, interventions, surgeries and procedures would never happen.  Physicians have a tendency to offer their expertise in the moment without thinking of the downstream consequences of their actions.    Just imagine how many physicians would back out of offering their medically necessary care if they knew they were required to provide consent, on tape, for all the family and lawyers to see when badness starts rolling with the wind.  Physicians who provide adequate informed consent would applaud this requirement as a mandatory necessity for first doing no harm.  If physicians  are ethical in their actions, they have nothing to worry about.
  4. Mandate check list rounding.  We have the 5Ps of nursing to improve the patient experience.    It's time hospitals provided physicians with the tools to implement bed side checklists on rounds to address  many important, but under appreciated cost centers in hospitals  We order things and forget about it (like urinary catheters, telemetry and daily labs).  Why there isn't a national standard yet for checklists in the hospital  is beyond me.  Checklists work in the ICU.  I beg for check lists on the wards.
  5. Automate an IV to PO pharmacy process.  Unless physicians remember to check the daily medication  profile of their patients (which many physicians won't), patients will continue to receive unnecessary intravenous medications that could have been converted to pill form days prior or discontinued all together.   I think this issue is vastly under appreciated as a cost center, but one that has the potential for hospitals to save millions of dollars a year.  Hospitals should hire a pharmacist or two that does this all day long and that stays in close communication with the hospitalists and other physicians.  It's WIN-WIN-WIN for doctors, patients and hospitals.  
There you have it.  You have SHMs recommendations and Happy's too. What are yours?

You can read more about the Choosing Wisely Campaign ® here.

Some of this post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk. 

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