Choosing Wisely Trinidad and Tobago: Top 5 Recommendations for Emergency Medicine

Abstract

Objective: To identify the top five Choosing Wisely recommendations for the Trinidad and Tobago Emergency Medicine Association (TTEMA) Methods: A modified Delphi process was used. An initial list of 27 recommendations was compiled from all Choosing Wisely Emergency Medicine recommendations from existing international campaigns. This was distributed to an expert panel from the TTEMA. To generate the final list of five, each panel member voted on each recommendation based on: action-ability, effectiveness, safety, economic burden, and frequency of use. Results: The top five recommendations were: 1) Avoid instituting intravenous (IV) fluids before doing a trial of oral rehydration therapy in uncomplicated emergency department cases of mild to moderate dehydration in children; 2) Don’t order CT head scans in adult patients with simple syncope in the absence of high-risk predictors; 3) Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule; 4) Don’t order CT pulmonary angiograms or VQ scans in patients with suspected pulmonary embolism until risk stratification with decision rule has been applied and when indicated, D-dimer biomarker results are obtained; and 5) Avoid coagulation studies in emergency department patients unless there is a clearly defined specific clinical indication, such as for monitoring of anticoagulants, in patients with suspected severe liver disease, coagulopathy, or in the assessment of snakebite envenomation. Conclusion: This is the first Choosing Wisely initiative in the Caribbean. Next steps include creating awareness, developing working groups for each recommendation and strategies for implementation.