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There is controversy about how to manage requests by patients or surrogates for treatments that clinicians believe should not be administered. This multisociety statement provides recommendations to prevent and manage intractable disagreements about the use of such treatments in intensive care units. The recommendations were developed using an iterative consensus process, including expert committee development and peer review by designated committees of each of the participating professional societies (American Thoracic Society, American Association for Critical Care Nurses, American College of Chest Physicians, European Society for Intensive Care Medicine, and Society of Critical Care). The committee recommends: (1) Institutions should implement strategies to prevent intractable treatment conflicts, including proactive communication and early involvement of expert consultants. (2) The term \"potentially inappropriate\" should be used, rather than futile, to describe treatments that have at least some chance of accomplishing the effect sought by the patient, but clinicians believe that competing ethical considerations justify not providing them. Clinicians should explain and advocate for the treatment plan they believe is appropriate. Conflicts regarding potentially inappropriate treatments that remain intractable despite intensive communication and negotiation should be managed by a fair process of conflict resolution; this process should include hospital review, attempts to find a willing provider at another institution, and opportunity for external review of decisions. When time pressures make it infeasible to complete all steps of the conflict-resolution process and clinicians have a high degree of certainty that the requested treatment is outside accepted practice, they should seek procedural oversight to the extent allowed by the clinical situation and need not provide the requested treatment. (3) Use of the term \"futile\" should be restricted to the rare situations in which surrogates request interventions that simply cannot accomplish their intended physiologic goal. Clinicians should not provide futile interventions. (4) The medical profession should lead public engagement efforts and advocate for policies and legislation about when life-prolonging technologies should not be used. The multisociety statement on responding to requests for potentially inappropriate treatments in intensive care units provides guidance for clinicians to prevent and manage disputes in patients with advanced critical illness.

To evaluate the impact of changes to urine testing orderables in computerized physician order entry (CPOE) system on urine culturing practices. Retrospective before-and-after study. A 1,250-bed academic tertiary-care referral center. Hospitalized adults who had ≥1 urine culture performed during their stay. The intervention (implemented in April 2017) consisted of notifications to providers, changes to order sets, and inclusion of the new urine culture reflex tests in commonly used order sets. We compared the urine culture rates before the intervention (January 2015 to April 2016) and after the intervention (May 2016 to August 2017), adjusting for temporal trends. During the study period, 18,954 inpatients (median age, 62 years; 68.8% white and 52.3% female) had 24,569 urine cultures ordered. Overall, 6,662 urine cultures (27%) were positive. The urine culturing rate decreased significantly in the postintervention period for any specimen type (38.1 per 1,000 patient days preintervention vs 20.9 per 1,000 patient days postintervention; P < .001), clean catch (30.0 vs 18.7; P < .001) and catheterized urine (7.8 vs 1.9; P < .001). Using an interrupted time series model, urine culture rates decreased for all specimen types (P < .05). Our intervention of changes to order sets and inclusion of the new urine culture reflex tests resulted in a 45% reduction in the urine cultures ordered. CPOE system format plays a vital role in reducing the burden of unnecessary urine cultures and should be implemented in combination with other efforts.

ABSTRACT BACKGROUND Ongoing efforts to increase colorectal cancer (CRC) screening rates have raised concerns that these exams may be overused, thereby subjecting patients to unnecessary risks and wasting healthcare resources. OBJECTIVE Our aim was to measure overuse of screening and surveillance colonoscopies among average-risk adults, and to identify correlates of overuse. DESIGN, SETTING, AND PARTICIPANTS Our approach was a retrospective cohort study using electronic health record data for patients 50–65 years old with no personal history of CRC or colorectal adenomas with an incident CRC screening colonoscopy from 2001 to 2010 within a multispecialty physician group practice. MAIN OUTCOME MEASURES We measured time to next screening or surveillance colonoscopy and predictors of overuse (exam performed more than one year earlier than guideline recommended intervals) of colonoscopies. KEY RESULTS We identified 1,429 adults who had an incident colonoscopy between 2001 and 2010, and they underwent an additional 871 screening or surveillance colonoscopies during a median follow-up of 6 years. Most follow-up screening colonoscopies (88 %) and many surveillance colonoscopies (49 %) repeated during the study represented overuse. Time to next colonoscopy after incident screening varied by exam findings (no polyp: median 6.9 years, interquartile range [IQR]: 5.1–10.0; hyperplastic polyp: 5.7 years, IQR: 4.9–9.7; low-risk adenoma: 5.1 years, IQR: 3.3–6.3; high-risk adenoma: 2.9 years, IQR: 2.0–3.4, p  < 0.001). In logistic regression models of colonoscopy overuse, an endoscopist recommendation for early follow-up was strongly associated with overuse of screening colonoscopy (OR 6.27, 95 % CI: 3.15–12.50) and surveillance colonoscopy (OR 13.47, 95 % CI 6.61-27.46). In a multilevel logistic regression model, variation in the overuse of screening colonoscopy was significantly associated with the endoscopist performing the previous exam. CONCLUSIONS Overuse of screening and surveillance exams are common and should be monitored by healthcare systems. Variations in endoscopist recommendations represent targets for interventions to reduce overuse.

There is a noticeable increase in the unnecessary ordering of Magnetic Resonance Imaging (MRI) of the knee in older patients. This quality improvement study assessed the frequency of unnecessary pre-consultation knee MRIs and investigated the effect on the outcome of the patients' consultation with the orthopedic surgeon. 650 medical charts of patients aged 55 years or older referred to an orthopedic clinic with knee complaints were reviewed. Patients arriving with a pre-consultation MRI were identified, and the usefulness of the MRI was evaluated using the appropriateness criteria developed to support this study. Of the 650 patient charts reviewed, 225 patients presented with a pre-consultation MRI, 76% of which were not useful for the orthopedic surgeon. The ordered knee MRI scans were considered not useful because they were requested for confirmed meniscal tear for patients ≥55 years, suspected degenerative disorder and ligament/tendon injury, or for patients with severe osteoarthritis without locking or extension. These MRI scans were done despite the absence of signs of effusion, tenderness, soft tissue swelling, decreased range of motion, or difficulty of weight-bearing, a lack of persistent knee joint pain at the time of assessment, or with no x-ray before ordering MRI. Half of the patients with a pre-consult MRI did not present with plain radiographs of their knee, however, 35% of those still required an x-ray to be ordered at the time of the surgical consult. A logistic regression analysis on post-consult disposition found that patients with pre-consult MRI were less likely to be considered for total knee arthroplasty (TKA) (OR 0.424, CI 0.258-0.698, p = 0.001). Patients assessed by an advanced practice physiotherapist prior to referral for surgical consult were 4.47 more likely to have TKA (CI 2.844-7.039, p< 0.000). Most of the pre-consult knee MRIs were deemed as unnecessary for the orthopedic surgeon's clinical decision-making. This study highlights the potential benefits of following a comprehensive model of care within the referral process to reduce the unnecessary high orders of pre-consult MRI scans.

The prevalence and incidence of inflammatory bowel disease (IBD) in North America is among the highest in the world and imparts substantial direct and indirect medical costs. The Choosing Wisely Campaign was launched in wide variety of medical specialties and disciplines to reduce unnecessary or harmful tests or treatment interventions. The Choosing Wisely list for IBD was developed by the Canadian IBD Network for Research and Growth in Quality Improvement (CINERGI) in collaboration with Crohn's and Colitis Canada (CCC) and the Canadian Association of Gastroenterology (CAG). Using a modified Delphi process, 5 recommendations were selected from an initial list of 30 statements at a face-to-face consensus meeting. The 5 things physicians and patients should question: (1) Don't use steroids (e.g., prednisone) for maintenance therapy in IBD; (2) Don't use opioids long-term to manage abdominal pain in inflammatory bowel disease (IBD); (3) Don't unnecessarily prolong the course of intravenous corticosteroids in patients with acute severe ulcerative colitis (UC) in the absence of clinical response; (4) Don't initiate or escalate long-term medical therapies for the treatment of IBD based only on symptoms; and (5) Don't use abdominal computed tomography (CT) scan to assess IBD in the acute setting unless there is suspicion of a complication (obstruction, perforation, abscess) or a non-IBD etiology for abdominal symptoms. The Choosing Wisely recommendations will foster patient-physician discussions to optimize IBD therapy, reduce adverse effects from testing and treatment, and reduce medical expenditure.

Transthoracic echocardiograms (TTEs) have limited value in guiding management of normotensive patients with acute pulmonary embolism (PE). Nevertheless, TTEs are frequently ordered inappropriately. This quality improvement project aimed to decrease inappropriate TTE orders by 30% over 6 months in patients with PE admitted to general internal medicine at a community hospital. Two interventions were implemented using successive plan-do-study-act (PDSA) cycles: educational sessions for physicians and the distribution of TTE-ordering algorithms for triaging of TTE appropriateness. Four audits on TTE orders for inpatients with PE were conducted throughout the project: a pre-intervention audit (pre-audit; March to August 2020), a post-intervention 1 audit (post-I1; August to September 2022), a post-intervention 2 audit (post-I2; December 2022 to February 2023) and a post-intervention audit (post-audit; March to August 2023). The primary outcome measure was the proportion of inappropriate to appropriate TTE orders during the pre-intervention and post-intervention periods. During the pre-audit, post-I1, post-I2 and post-audit periods, 89, 23, 20 and 158 patients, respectively, were admitted with PEs. 37, 10, 3 and 14 patients in each of these periods, respectively, received a TTE for PE-related reasons and were therefore included in the audits. 42%, 43%, 15% and 24% of patients, respectively, received a TTE for PE-related reasons. 89%, 50%, 67% and 79% of those TTEs, respectively, were inappropriate. There was a transient decrease in inappropriate to appropriate TTE orders ratio after the first intervention (p<0.005). Inappropriate investigations lead to additional healthcare costs and delays in patient care. This quality improvement project highlights an ongoing need to increase awareness surrounding TTE indications to improve appropriate utilisation. Next steps include further PDSA cycles with additional interventions to continue to try and decrease inappropriate TTE orders in the community hospital setting.

Lower limb cellulitis is a frequently encountered condition in the acute hospital setting, yet many patients with only mild lower limb cellulitis undergo unnecessary collection of blood cultures and X-ray imaging. This leads to increased healthcare costs and prolongation of the length of hospitalisation.A retrospective review of electronic medical records was performed to determine the frequency of blood cultures and lower limb X-rays performed for patients with lower limb cellulitis presenting to the Department of Emergency Medicine and admitted to the Department of Internal Medicine, in a national tertiary hospital.Quality improvement methods were implemented to increase accessibility to and awareness of lower limb cellulitis management guidance among clinical staff, to empower appropriate and rationalised decision-making in the management of patients with lower limb cellulitis. The percentage of patient encounters with blood cultures performed subsequently improved from a baseline median of 73.3% to a post-intervention median of 52.3%, with direct healthcare cost savings and additional ancillary beneficial effects for patients and healthcare staff. However, no reduction in the frequency of imaging performed was observed, for which the opportunity arises for further root-cause analyses and intervention.Encouraging small changes in individual clinicians’ routine daily clinical practice through quality improvement initiatives results in significant impacts when multiplied across healthcare staff and departments. Initiatives implemented need to be accessible, realistic and pragmatic to maximise real-world on the ground effects and facilitate a sustained impact.

Most quality improvement efforts in surgery have focused on the technical quality of care provided, rather than whether the care was indicated, or could have been provided with a safer procedure. Because risk is inherent in any procedure, reducing the number of unnecessary operations is an important issue in patient safety. In the case of lumbar spine surgery, several lines of evidence suggest that, in at least some locations, there may be excessively high surgery rates. This evidence comes from international comparisons of surgical rates; study of small area variations within countries; increasing surgical rates in the absence of new indications; comparisons of surgical outcomes between geographic areas with high or low surgical rates; expert opinion; the preferences of well-informed patients; and increasing rates of repeat surgery. From a population perspective, reducing unnecessary surgery may have a greater impact on complication rates than improving the technical quality of surgery that is performed. Evidence suggests this may be true for coronary bypass surgery in the US and hysterectomy rates in Canada. Though similar studies have not been done for spine surgery, wide geographic variations in surgical rates suggest that this could be the case for spine surgery as well. We suggest that monitoring geographic variations in surgery rates may become an important aspect of quality improvement, and that rates of repeat surgery may bear special attention. Patient registries can help in this regard, if they are very complete and rigorously maintained. They can provide data on surgical rates; offer post-marketing surveillance for new surgical devices and techniques; and help to identify patient subgroups that may benefit most from certain procedures.

Abstract Objectives To determine non–American Society for Clinical Pathology pathology- and laboratory-related Choosing Wisely recommendations that drive effective test utilization in the laboratory. Methods Data were collected via a two-part web-based survey distributed to a broad sample of pathologists and laboratory professionals from a variety of institutions. Results Pathologists’ most relevant recommendation: “Do not transfuse more units of blood than absolutely necessary”; highest priority: “Do not transfuse more than the minimum number of RBC units necessary to relieve symptoms of anemia or to return a patient to a safe hemoglobin range (7-8 g/dL in stable, noncardiac inpatients).” Laboratory professionals’ most relevant recommendation: “Avoid testing for a Clostridium difficile infection in the absence of diarrhea”; highest priority: “Do not routinely transfuse stable, asymptomatic hospitalized patients with a hemoglobin level greater than 7 to 8 g/dL.” Conclusions Most of the highest priority, most relevant recommendations among those surveyed concerned utilization of blood products and transfusion management.