Hospital medicine

Five Things Physicians and Patients Should Question


Released June 2, 2015

1

Don’t place or leave in place a urinary catheter without reassessment.

The use of urinary catheters among hospitalized patients is common. Urinary catheter use is associated with preventable harm such as, catheter-associated urinary tract infection, sepsis, and delirium. Guidelines support routine assessment of the indications for urinary catheters and minimizing their duration of use. Appropriate indications include acute urinary obstruction, critical illness and end-of-life care. Strategies that reduce inappropriate use of urinary catheters have been shown to reduce health care associated infections.

2

Don’t prescribe antibiotics for asymptomatic bacteriuria (ASB) in non-pregnant patients.

The inappropriate treatment of ASB represents a leading misuse of antimicrobial therapeutics. Clinicians should avoid the use of antibiotics given the lack of treatment benefits, risk of potential harm such as Clostridium difficile infections and the emergence of antimicrobial resistant organisms. The majority of hospitalized patients with ASB do not require antibiotics with the exception of pregnant women, and patients undergoing invasive urologic surgical procedures. In all other situations, antimicrobial therapy should be targeted to those who have symptoms of urinary tract infections in the presence of bacteriuria.

3

Don’t use benzodiazepines and other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium.

Insomnia, agitation, and delirium commonly occur among elderly inpatients, and hospital providers frequently prescribe pharmacological sleep aids or sedatives. However, studies in older adults have shown that benzodiazepines and other sedative-hypnotics significantly increase the risk of morbidity (such as falls, delirium and hip fractures) and mortality. Use of these drugs should be avoided as first line treatment for the indications of insomnia, agitation, or delirium. Instead, other non-pharmacological alternatives should be considered first.

4

Don’t routinely obtain neuro-imaging studies (CT, MRI scans, or carotid Doppler ultrasonography) in the evaluation of simple syncope in patients with a normal neurological examination.

Syncope is common and has been defined as transient loss of consciousness, associated with inability to maintain postural tone and with immediate, spontaneous and complete recovery. Patients presenting with transient loss of consciousness due to neurological causes (such as seizures and stroke) are infrequent and must be differentiated from true syncope. While neurological disorders can occasionally result in transient loss of consciousness, the utility of neuro-imaging studies are of limited benefit in the absence of signs or symptoms concerning for neurological pathologies.

5

Don’t routinely obtain head computed tomography (CT) scans, in hospitalized patients with delirium in the absence of risk factors.

Delirium is a common problem among hospitalized patients. In the absence of risk factors for intracranial causes of delirium (such as recent head trauma or fall, new focal neurological findings, and sudden or unexplained prolonged decreased level of consciousness), routine head CT scans are of low diagnostic yield. Guidelines suggest a step-wise approach to the management of new delirium in hospitalized patients and consideration of head CT only in patients with select risk factors.


How the list was created

The Canadian Society for Hospital Medicine (CSHM) established its Choosing Wisely Canada (CWC) Top 5 recommendations by creating a CWC subcommittee within its Quality Improvement (QI) Committee. The subcommittee members represent a diverse group of hospitalists from across Canada, practicing in a variety of settings. A draft list of 16 recommendations was solicited from the broader CSHM membership via email and society website. Members were asked to consider relevance to hospital medicine, frequency of occurrence and potential for harm. The QI Committee vetted each recommendation and conducted a literature review to determine the strength of the supporting evidence. Recommendations lacking in evidence were removed from the list. All CSHM members were invited to rank the remaining 12 items using an anonymous electronic web-based survey tool. The top 9 recommendations with the highest scores were selected for a second round of voting in which the scores from the first round of voting were revealed to participants. The top 5 recommendations with the highest degree of agreement were selected and submitted to the Board of Directors for approval as the final list.


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1

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2

Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar 1;52(5):e103-20.

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3

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Gillis CM, Poyant JO, Degrado JR, Ye L, Anger KE, Owens RL. Inpatient pharmacological sleep aid utilization is common at a tertiary medical center. J Hosp Med. 2014 Oct;9(10):652-7.

4

Alboni P, Brignole M, Menozzi C, Raviele A, Del Rosso A, Dinelli M, et al. Diagnostic value of history in patients with syncope with or without heart disease. J Am Coll Cardiol. 2001 Jun 1;37(7):1921-8.

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5

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Michaud L, Büla C, Berney A, Camus V, Voellinger R, Stiefel F, et al. Delirium: guidelines for general hospitals. J Psychosom Res. 2007 Mar;62(3):371-83.

Pompei P, Foreman M, Rudberg MA, Inouye SK, Braund V, Cassel CK. Delirium in hospitalized older persons: outcomes and predictors. J Am Geriatr Soc. 1994 Aug;42(8):809-15.

Theisen-Toupal J, Breu AC, Mattison ML, Arnaout R. Diagnostic yield of head computed tomography for the hospitalized medical patient with delirium. J Hosp Med. 2014 Aug;9(8):497-501.

Vijayakrishnan R, Ramasubramanian A, Dhand S. Utility of Head CT Scan for Acute Inpatient Delirium. Hosp Top. 2015 Jan-Mar;93(1):9-12.