Australasian College for Emergency Medicine
Recommendations from the Australasian College for Emergency Medicine on CT scans for head injury and renal colic, end-of-life care in emergency departments, cervical spine (neck) imaging and coagulation studies. ACEM is the not-for-profit organisation responsible for training emergency physicians and advancing professional standards in emergency medicine in Australia and New Zealand.
2.
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*.
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*.
Abnormal coagulation test results in conditions such as acute coronary syndrome can usually be predicted by history, and they rarely affect patient management. Routine coagulation studies in the emergency department therefore represent a substantial added cost, with no benefit to patients. Coagulation studies should be performed based on a history of warfarin or heparin use, or a history of severe liver disease.
Please refer to the joint ACEM/Royal Australian College of Pathologists Guideline on Pathology Testing in the Emergency Department, for further guidance on appropriate pathology test requesting in emergency departments.
* Point of care testing (POCT) devices are unreliable in assessment of snakebite envenomation.
Supporting evidence
- Schwartz D. Utility of routine coagulation studies in emergency department patients with suspected acute coronary syndromes. Isr Med Assoc J. 2005;7(8):502-6.
- Martin D, Beardsell I. Is routine coagulation testing necessary in patients presenting to the emergency department with chest pain? Emerg Med J. 2012;29(3):184-7.
- Hodgson D, Burdett-Smith P. Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary: Routine coagulation testing in adult patients with epistaxis. Emerg Med J 2011;28(7):633-4.
- Segall J, Dzik WH. Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence based review. Transfusion. 2005; 45(9): 1413-25.
- Darcy MD, Kanterman RY, Kleinhoffer MA, Vesely TM, Picus D, Hicks ME, and Pilgram TK. Evaluation of coagulation tests as predictors of angiographic bleeding complications. Radiology. 1996; 198 (3): 741-4.
- Murphy E, MacGlone S, McGroarty. A novel approach to improving sample ordering in an emergency department. BMJ Qual Improv Report 2015;4.
- Geoffrey K Isbister, Simon G A Brown, Colin B Page, David L McCoubrie, Shaun L Greene and Nicholas A Buckley. 2013. Snakebite in Australia: a practical approach to diagnosis and treatment. Med J Aust 2013; 199 (11): 763-768.
- NSW Ministry of Health. 2014. Snakebite and Spiderbite Clinical Management Guidelines. 3rd edition. www0.health.nsw.gov.au/policies/gl/2014/pdf/GL2014_005.pdf
How this list was made
A Choosing Wisely Working Group of 9 emergency physicians identified an initial list of 10 potential items. All ACEM members were able to provide feedback on these items and suggest other issues for consideration. This feedback informed Working Group refinement of the initial list into 8 recommendations. Evidence reviews were then completed for each recommendation. These evidence reviews, frequency of use in ED, risks/benefit to patient and cost were used as criteria for Working Group member voting in order to determine the final 6 recommendations. These recommendations have been endorsed by ACEM's Council of Advocacy, Practice and Partnerships.
Following identification of two common recommendations with the Royal Australian and New Zealand College of Radiologists, it was agreed by both Colleges to jointly present these items.
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1
Avoid requesting computed tomography (CT) imaging of kidneys, ureters and bladder (KUB) in otherwise healthy emergency department patients, age <50 years, with a known history of kidney stones, presenting with symptoms and signs consistent with uncomplicated renal colic.
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2
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*.
- 3 Avoid blood cultures in patients who are not systemically septic, have a clear source of infection and in whom a direct specimen for culture (e.g. urine, wound swab, sputum, cerebrospinal fluid, or joint aspirate) is possible.
- 4 For emergency department patients approaching end-of-life, ensure clinicians, patients and families have a common understanding of the goals of care.
- 5 Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule.
- 6 Don’t request computed tomography (CT) head scans in patients with a head injury, unless indicated by a validated clinical decision rule.