Scott Halpern, MD, PhD, MBE, leads the ATS’s Choosing Wisely Task Force.

Preliminary guidelines for critical care and pulmonary medicine, which focus on seven commonly used tests or procedures whose necessity should be questioned and discussed, will be unveiled for the first time in public during the ATS and ABIM joint symposium, “Choosing Wisely” (©ABIM Foundation Symposium): Top Ways to Reduce Low Value Care in Pulmonary and Critical Care Medicine,” from 8:15 to 10:45 a.m. Monday in Room 107 A-B (100 Level) Pennsylvania Convention Center.

The lists will be winnowed down to five guidelines in critical care and pulmonary medicine, respectively, which will be announced in October.

The ABIM produced the critical care guidelines in collaboration with the Critical Care Societies Collaborative—the ATS, American Association of Critical-Care Nurses, Society of Critical Care Medicine, and American College of Chest Physicians—and the pulmonary guidelines were developed with ATS and ACCP.

“Choosing Wisely is designed to have physicians take the high ground in reining in the costs of their practices versus leaving that in the hands of external policymakers,” said Scott Halpern, MD, PhD, MBE, who is leading the ATS’s Choosing Wisely Task Force. “There are a lot of diagnostic tests and therapies for which available evidence suggests a lack of effectiveness, and physicians are in the best position to determine exactly which practices in their own specialties fit that bill.”

Choosing Wisely Top 7 List in Critical Care Medicine

1. Don’t order diagnostic tests at regular intervals (e.g., daily), but rather in response to specific clinical questions.
2. Don’t transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 mg/dL.
3. Don’t use parenteral nutrition in adequately nourished critically ill patients within the first seven days of an ICU stay.
4. Don’t deeply sedate mechanically ventilated patients without specific indications, and do attempt to lighten sedation daily.
5. Don’t continue life support for patients at high risk for death or impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.
6. Do not initiate or continue antimicrobial agents without specifying an evidence-based duration or endpoint and reassessing daily whether to narrow the spectrum of coverage based on cultures and clinical response.
7. Do not place or maintain arterial and central venous catheters in critically ill patients without specific indications.

Choosing Wisely Top 7 List in Pulmonary Medicine

1. Do not perform CT surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines.
2. For patients recently discharged on supplemental home oxygen following hospitalization for an acute illness, do not renew the prescription without assessing the patient for ongoing hypoxemia.
3. Do not routinely administer IV steroids for patients hospitalized for acute exacerbations of asthma and COPD.
4. Do not perform CT screening for lung cancer among patients at low risk for lung cancer.
5. Do not perform chest x-rays in patients without pulmonary symptoms as part of routine examinations.
6. Do not routinely offer pharmacologic treatment with advanced vasoactive agents approved only for the management of pulmonary arterial hypertension to patients with pulmonary hypertension resulting from left heart disease or hypoxemic lung diseases (Groups II or III pulmonary hypertension).
7. Do not perform chest computed tomography (CT angiography) to evaluate for possible pulmonary embolism in patients with a low clinical probability and negative results of a highly sensitive D-dimer assay.