Recommendations for choosing wisely in paediatric emergency medicine: five opportunities to improve value

Paul C Mullan, Kelly A Levasseur, Lalit Bajaj, Michele Nypaver, James M Chamberlain, Jennifer Thull-Freedman, Olivia Ostrow, Shabnam Jain,

Unnecessary diagnostic tests and treatments in children cared for in EDs do not benefit patients, increase costs and may result in harm. To address this low-value care, a taskforce of paediatric emergency medicine (PEM) physicians was formed to create the first PEM Choosing Wisely recommendations. Using a systematic, iterative process, the taskforce collected suggested items from an interprofessional group of 33 ED clinicians from six academic paediatric EDs. An initial review of 219 suggested items yielded 72 unique items. Taskforce members independently scored each item for its extent of overuse, strength of evidence and potential for harm. The 25 highest rated items were sent in an electronic survey to all 89 members of the American Academy of Paediatrics PEM Committee on Quality Transformation (AAP COQT) to select their top 10 recommendations. The AAP COQT survey had a 63% response rate. The five most selected items were circulated to over 100 stakeholder and specialty groups (within the AAP, CW Canada, and CW USA organisations) for review, iterative feedback and approval. The final five items were simultaneously published by Choosing Wisely United States and Choosing Wisely Canada on 1 December 2022. All recommendations focused on decreasing diagnostic testing related to respiratory conditions, medical clearance for psychiatric conditions, seizures, constipation and viral respiratory tract infections. A multinational PEM taskforce developed the first Choosing Wisely recommendation list for paediatric patients in the ED setting. Future activities will include dissemination efforts and interventions to improve the quality and value of care specific to recommendations.

Reproduced with permission.

Anti-inflammatories as adjunct treatment for cellulitis: a systematic review and meta-analysis

Laura Hamill, Gerben Keijzers, Scott Robertson, Chiara Ventre, Nuri Song, Paul Glasziou, Anna Mae Scott, Justin Clark, Krishan Yadav

Objectives: Existing guideline recommendations suggest considering corticosteroids for adjunct treatment of cellulitis, but this is based on a single trial with low certainty of evidence. The objective was to determine if anti-inflammatory medication (non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids) as adjunct cellulitis treatment improves clinical response and cure.

Methods: Systematic review and meta-analysis including randomised controlled trials of patients with cellulitis treated with antibiotics irrespective of age, gender, severity and setting, and an intervention of anti-inflammatories (NSAIDs or corticosteroids) versus placebo or no intervention. Medline (PubMed), Embase (via Elsevier) and Cochrane CENTRAL were searched from inception to 1 August 2023. Data extraction was conducted independently in pairs. Risk of bias was assessed using the Cochrane Risk of Bias Tool V.2. Data were pooled using a random effects model. Primary outcomes are time to clinical response and cure.

Results: Five studies (n = 331) were included, all were adults. Three trials reported time to clinical response. There was a benefit with use of an oral NSAID as adjunct therapy at day 3 (risk ratio 1.81, 95% CI 1.42 to 2.31, I² = 0%). There was no difference between groups at day 5 (risk ratio 1.19, 95% CI 0.62 to 2.26), although heterogeneity was high (I² = 96%). Clinical cure was reported by three trials, and there was no difference between groups at all timepoints up to 22 days. Statistical heterogeneity was moderate to low. Adverse events (n = 3 trials) were infrequent.

Conclusions: For patients with cellulitis, the best available data suggest that oral NSAIDs as adjunct therapy to antibiotics may lead to improved early clinical response, although this is not sustained beyond 4 days. There is insufficient data to comment on the role of corticosteroids for clinical response. These results must be interpreted with caution due to the small number of included studies.

Reproduced with permission.

Diagnostic performance of a clinical ultrasound-based algorithm for acute heart failure in patients presenting to the emergency department with dyspnoea

Nicolas L’Hermitte, Thibaut Markarian, Laura Grau-Mercier, Fabien Coisy, Laurent Muller, Laysa Saadi, Pierre-Géraud Claret, Hugo Krebs, Xavier Bobbia

Objective: To study the diagnostic performance of an ultrasound-based algorithm that includes the deceleration time (DT) of early mitral filling to establish a diagnosis of acute heart failure (AHF) in patients who come to an ED because of dyspnoea.

Methods: Prospective analysis in a convenience sample of patients who came to a hospital ED with acute dyspnoea. The algorithm included ultrasound findings and four echocardiographic findings as follows: mitral annular plane systolic excursion, Doppler mitral flow velocity, tissue Doppler imaging measure of the lateral annulus and the DT of early mitral filling. The definitive diagnosis was made by two physicians blinded to each other’s diagnosis and the ultrasound findings.

Results: A total of 166 adult patients with a mean (SD) age of 76 (13) years were included; 79 (48%) were female. AHF was the definitive diagnosis in 62 patients (37%). Diagnostic agreement was good between the two physicians (κ=0.71). The algorithm classified all the patients, and there were no undetermined diagnoses. Diagnostic performance indicators for the ultrasound-based algorithm integrating early DT findings were as follows: area under the receiver operating characteristic curve, 0.91 (95% CI 0.86 to 0.96); sensitivity, 87% (95% CI 76% to 94%); specificity, 95% (95% CI 89% to 98%); positive likelihood ratio, 18.1 (95% CI 7.7 to 42.8); and negative likelihood ratio, 0.14 (95% CI 0.07 to 0.26).

Conclusions: The ultrasound-based algorithm integrating the DT of early mitral filling performs well for diagnosing AHF in emergency patients with dyspnoea. The inclusion of early DT allows all patients to be diagnosed.

Reproduced with permission.