Paediatrics
Don’t routinely order a head computed tomography (Head CT) to assess for shunt failure in children with this condition.
Hydrocephalus
It should not be assumed that a head CT is always needed in an evaluation for shunt failure. Children have an increased risk of cancer with exposure to higher cumulative radiation doses. Consider using head ultrasonography when there is an open fontanel. A rapid sequence MRI is less expensive than a formal MRI and comparable in cost to a CT scan. Sedation is not needed because the rapid sequence MRI is quick, which further reduces the costs and medical risks of sedation.
A CT scan can be used for emergencies and if the child has implanted metal or a device that is not compatible with an MRI.
Don’t order creatine kinase or creatine kinase-myocardial band (CK-MB) in patients suspected with this diagnosis
Acute coronary syndrome (ACS) or Acute myocardial infarction. (MI)
According to published guidelines, cardiac troponin is the lab test of choice to diagnose acute coronary syndrome or acute myocardial infarction. Troponin is highly sensitive for acute myocardial infarction and more specific than CK-MB; CK-MB yields no incremental diagnostic value even in patients with chronic kidney disease. Guidelines also support the use of cardiac troponin over CK-MB for diagnosing reinfarction.
Don’t repeat A1C testing in stable patients within how many months of a previous result.
Three (3) months.
The lifespan of an A1C is approximately 90 to 120 days, and the full effects of a patient’s change in behavior, diet, or newly adjusted medications will not be fully appreciated until all previous A1C in circulation are replaced (~90 days).
Therefore, testing at time intervals earlier than three months may not allow enough time to pass to reach the expected target by the clinician.
Testing at six-month intervals may be considered when glycemic targets are consistently achieved.
Consider evaluating rotator cuff tears with _________ before ordering an MRI.
Ultrasound
Rotator cuff tears are one of the most common causes of shoulder pain. Determining rotator cuff integrity is pivotal in deciding between surgical and nonsurgical management.
A combination of clinical history, physical examination, and imaging studies is needed to confirm the diagnosis.
Given its comparable diagnostic accuracy, low cost, and convenience, high-frequency ultrasound may be considered prior to MRI, based on clinical determination via medical history, physical examination, and review of relevant imaging, for the evaluation of rotator cuff tears.
Don’t combine _______ with _________ to treat pain in older adults; reevaluate routinely for deprescribing during chronic use.
Opioids with benzodiazepines or gabapentinoids.
Coprescribing of benzodiazepines or gabapentinoids (e.g., gabapentin, pregabalin) with opioids is increasingly used in the multimodal treatment of acute and chronic pain, despite limited evidence to support the effectiveness of this practice.
Population studies have demonstrated that these combinations are associated with an increased risk of serious adverse outcomes such as excessive sedation, overdose events, and death.
Don’t routinely order electroencephalography (EEG) on neurologically healthy children who have this episode.
Simple febrile seizures.
Febrile seizures are the most commonly occurring seizures in the first 60 months of life. Caregiver anxiety can often lead to requests for neurodiagnostic testing. Attention should be directed at finding the cause of fever and treating it. Electroencephalography tests are costly and can increase caregiver and child anxiety without changing the outcome or course of treatment.
Don’t obtain radiographs in children with the following pulmonary symptoms
Bronchiolitis, croup, asthma, or first-time wheezing.
Respiratory illnesses are among the most common reasons for pediatric emergency department visits, with wheezing being a frequently encountered clinical finding. For children presenting with first-time wheezing or with typical findings of asthma, bronchiolitis, or croup, radiographs rarely yield important positive findings and expose patients to radiation, increased cost of care, and prolonged emergency department length of stay.
National and international guidelines emphasize the value of the history and physical examination in making an accurate diagnosis and excluding serious underlying pathology. Radiography performed in the absence of significant findings has been associated with the overuse of antibiotics. Radiographs should not be routinely obtained in these situations unless findings such as significant hypoxia, focal abnormalities, prolonged course of illness, or severe distress are present.
If wheezing is occurring without a clear atopic etiology or upper respiratory tract infection symptoms (e.g., rhinorrhea, nasal congestion, fever), appropriate diagnostic imaging should be considered on a case-by-case basis.
Don’t prescribe neuropathic pain agents for patients with...
Painless neuropathy.
Diabetic peripheral neuropathy is a progressive condition that may be painful or painless. Neuropathic pain agents (e.g., anticonvulsants, antidepressants) have been studied to reduce painful symptoms in those with neuropathy; however, they have no effect on painless neuropathy and their many side effects can cause unnecessary harm (e.g., unwanted drug interactions, increased fall risk).
Don’t order ankle or midfoot x-rays for patients older than six years without positive criteria of which rule
The Ottawa ankle rules.
Both children and adults commonly present to health care settings in outpatient clinics, urgent care clinics, and hospital emergency rooms with ankle and foot injuries. Multiple randomized controlled studies and meta-analyses have shown the high sensitivity of the Ottawa Ankle Rules to rule out fractures when criteria are not met, and thus avoid the need for imaging in the acute setting.
Unnecessary imaging increases health care costs, patient wait times, and radiation exposure. It should be noted that there is much less data for application of the Ottawa Ankle Rules for children under the age of six years, due to fewer ankle and midfoot injuries in this patient population, as well as difficulty of children in this age group to walk independently.
Don’t prescribe this type of "pain medication" for older adults without considering the potential risks and harms related to serotonergic excess, seizures, falls, and drug-drug interactions.
Tramadol
A recent national study reported that older adults account for 33% of tramadol-associated emergency department visits and half of subsequent hospitalizations, suggesting that greater scrutiny of tramadol’s safety in this population is warranted. Tramadol’s adverse effects (e.g., sedation) and the potential for serotonin syndrome and hyponatremia are well recognized by clinicians.
However, tramadol-induced seizures and hypoglycemia are particularly harmful to older adults and may further elevate the risk of falls and fractures.
The risk of tramadol’s clinically relevant adverse effects is heightened among patients with decreased renal function.
Don’t obtain abdominal radiographs for suspected these common complaints in children; they can be diagnosed clinically.
Constipation.
Functional constipation and nonspecific, generalized abdominal pain are common presenting complaints for children in emergency departments. Constipation is a clinical diagnosis and does not require testing, yet many of these children receive an abdominal radiograph
Don’t maintain a peripheral capillary oxygen saturation of higher than ______ when using supplemental oxygen
*except for carbon monoxide poisoning, cluster headaches, sickle cell crisis, or pneumothorax.
96%
Ideal oxygen saturation levels for patients getting supplemental oxygen therapy is at or below 96%. The overuse of supplemental oxygen has been shown to increase mortality in numerous studies of patients with a variety of critical illnesses, including cardiac arrest, stroke, and trauma, as well as after emergency surgery.
Higher oxygen levels may be needed for those with certain medical conditions such as carbon monoxide poisoning or special types of headaches such as cluster headaches, sickle cell crisis, or pneumothorax.
*An important caveat to this recommendation is the higher incidence of occult hypoxemia, defined as an arterial oxygen saturation of less than 88% with a pulse oximetry measurement of 92% to 96%, in Black patients compared with White patients.
Don’t order these expensive tests unless the patient is suspected of having a connective tissue disease.
Antinuclear antibody (ANA) and extractable nuclear antigen (eg: SS-A, Scl-70, anti-smith)
Testing for antinuclear antibody (ANA) and extractable nuclear antigen (ENA) should be avoided in the investigation of widespread pain or fatigue alone.
Instead, testing should be performed only in patients suspected to have a diagnosis of a connective tissue disease (e.g., lupus, rheumatoid arthritis).
ANA positivity can be as high as 20% in patients with nonrheumatic conditions and healthy individuals.
For this reason, proper pretest probability is important, and false-positive results may lead to further unnecessary testing. Repeat testing is also not recommended unless the clinical picture changes significantly.
Don’t cast or perform ___________ for isolated, nondisplaced or nonangulated distal radius buckle fractures that do not involve the physis and which have an intact cortex in children.
Follow-up x-rays
Distal radius buckle fractures are one of the most common wrist fractures in children. These fractures are inherently stable and have an excellent prognosis. Radius buckle fractures can be safely treated with a Velcro removable wrist splint for three to four weeks, as long as the following conditions are met: 1) cortex is intact, 2) there are no fracture lines extending to the physis on any view, 3) there is no angulation or displacement of the fracture, 4) there are two or three inflection points seen in the cortex on either view that best represents the fracture, and 5) the parent can do a symptom check with instructions.
Treating in a cast and repeating x-rays increases health care costs and radiation exposure for the patient. Parent satisfaction is also increased when these fractures are treated with a brace.
Don’t use _______ concomitantly with ________ in patients with dementia.
Anticholinergic medications with cholinesterase inhibitors
Pharmacologic actions of anticholinergics and cholinesterase inhibitors oppose each other. Concomitant use of anticholinergics with cholinesterase inhibitors reduces the effectiveness of antidementia drugs, the benefits of which are modest at best; concomitant use increases the risk of adverse effects of anticholinergics and may also increase the rate of functional and cognitive decline. Patients with dementia are sensitive to cognitive impairment induced by medications with anticholinergic properties. In general, it has been recognized that anticholinergics adversely affect cognition in older patients and even more so with concomitant dementia diagnosis.
Don’t obtain comprehensive viral panel testing for patients who have suspected symptoms of these
Respiratory viral illnesses.
The diagnosis of a viral illness is made clinically and usually does not require confirmatory testing. There is a lack of consistent evidence to demonstrate the impact of comprehensive viral panel (i.e., panels simultaneously testing for 8 to 20+ viruses) results on clinical outcomes or management, especially in emergency department settings. Hence, most national and international clinical practice guidelines do not recommend their routine use.
Testing for specific viruses might be indicated if the results of the testing may alter treatment plans (e.g., antivirals for influenza) or public health recommendations (e.g., isolation for SARS-CoV-2).
Don’t order daily chest radiography in hospitalized patients unless
There are specific clinical indications.
Patients in intensive care units have historically had daily chest x-rays as part of routine management. Evidence suggests that this does not lead to change in management, unless there are specific clinical indications to obtain a chest x-ray.
The use of routine daily chest x-rays leads to unnecessary test utilization, unwarranted exposure to radiation, and downstream testing.
Don’t use __________ as initial screening for adrenal hyperfunction (Cushing syndrome); instead consider superior strategies provided in the justification.
serum cortisol levels
Serum cortisol levels do not provide high-end diagnostic accuracy or sensitivity when used as an initial diagnostic test. Late-night salivary cortisol samples employing an approved collection device, 24-hour urine-free cortisol, or a 1-mg overnight dexamethasone suppression test should be used as an initial test.
These tests have a high diagnostic accuracy for Cushing syndrome. Multiple screening tests may need to be performed based on the variability of hypercortisolism in Cushing syndrome.
Two measurements of abnormal cortisol levels with these tests are recommended for an initial diagnosis; further workup should be referred to an endocrinologist to make the final diagnosis.
Don’t use _______ for individuals with a hemiplegic arm that place the arm in a flexor pattern for extended periods of time.
Slings
Standard shoulder slings immobilize the upper extremity in a flexor pattern (i.e., a position of elbow flexion, and shoulder adduction and internal rotation). Utilizing a sling that places a person’s hemiplegic arm in this position for extended periods of time increases the risk of contractures and pain, and limits active use of the extremity, thereby decreasing opportunities for neuroplastic changes that support an organic increase in function.
Education should be provided to clients and caregivers on safe positioning of the hemiplegic arm during activity and at rest.
Don’t recommend these "class of medications" in older adults without first considering safer alternatives or non-drug measures.
Highly anticholinergic medications
Older adults are more sensitive to adverse events associated with anticholinergics, including confusion, dry mouth, blurry vision, constipation, urinary retention, decreased perspiration, and excess sedation. Anticholinergics have also been associated with increased risk of dementia. These medications are especially problematic for people with existing cognitive impairment, and bladder anticholinergics should be used judiciously for these patients.
It is important to inquire about over-the-counter antihistamine use and help patients select safer alternatives for sleep and seasonal allergies.
Don’t order hair analyses for “environmental toxins” in children with behavioral or developmental disorders, including this known condition
Autism
The analysis of hair for a broad array of elements and chemicals as a way to diagnose the cause of childhood diseases such as autistic spectrum disorder has no scientific basis. Such assays may not be reliable.
Routinely assess activity levels and recommend appropriate physical activity to your patients of this age
All age groups
Leading an active lifestyle has wide-ranging health benefits for people of all ages. Specifically, studies have shown a decrease in all-cause mortality associated with increasing levels of energy expenditure (i.e., kcal per week).
It has also been shown to decrease risk of coronary artery disease, diabetes, hypertension, many types of cancers, and a host of other medical conditions with strong, consistent epidemiologic evidence and moderately strong supporting evidence from clinical trials.
Benefits on bone health and mental health have also been demonstrated.
Don’t routinely prescribe ___________ prophylaxis to all hospitalized patients.
Venous thromboembolism (VTE) Prophylaxis
Instead, use an evidence-based risk stratification system to determine whether a patient needs it.
If the patient does warrant prophylaxis, use a bleeding risk assessment to determine whether mechanical prophylaxis is more appropriate than pharmacologic prophylaxis
Don’t obtain __________ following trauma in a patient who is awake and alert without considering the use of clinical decision-making tools for cervical spine clearance.
Imaging of the cervical spine
Consideration should be given to avoid unnecessary radiation exposure when appropriate. For instance, clinical decision-making tools incorporate three or more variables from history, physical examination, or simple clinical tests to guide patient management.
Results from the National Emergency X-Radiography Utilization Study (NEXUS) and the Pediatric Emergency Care Applied Research Network (PECARN) provide a high negative predictive value for significant cervical spine injuries in pediatric patients.
Low-risk criteria from NEXUS include: no posterior midline cervical spine tenderness, no evidence of intoxication, normal level of consciousness, no focal neurological deficit, and no painful distracting injuries.
PECARN developed a model that was highly sensitive for a normal cervical spine in the absence of: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, conditions predisposing to cervical spine injury, high-risk motor vehicle crash, and diving.
In comparison to NEXUS, the PECARN model takes into account mechanism of injury and specific extent and location of other associated injuries.
Don’t provide this "type of training interventions" that do not directly link to functional mobility.
Ambulation or gait training interventions
Occupational therapy practice requires consideration of contextual factors that affect a person’s ability to participate in meaningful occupations.
Gait training and ambulation interventions do not necessarily consider the context of performing everyday activities. One must address functional mobility by considering the context to implement effective, evidence-based interventions that are personally meaningful to the individual.