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.
Blood cultures taken in an emergency department do not add more information that would aid clinical management; they also represent a significant cost. The rate of false positives in blood cultures has been reported as approximately 50% and other, more direct, tests have been shown to have a markedly higher yield – i.e. a diagnostic procedure that often results in a definitive diagnosis.
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.
- Cham G, Yan S, Heng BH, Seow E. Predicting positive blood cultures in patients presenting with pneumonia at an ED in Singapore. Ann Acad Med Singapore. 2009;38(6): 508-17.
- Kennedy M, Bates DW, Wright SB, Ruiz R, Wolfe RE, Shapiro NI. Do emergency department blood cultures change practice in patients with pneumonia? Ann Emerg Med. 2005; 46(5):393-400.
- Shah SS, Dugan MH, Bell LM, Grundmeier RW, Florin TA, Hines EM, and Metlay JP. Blood cultures in the Emergency Department Evaluation of Childhood Pneumonia. Pediat Inf Dis J. 2011; 30(6): 475-9.
- Makam AN, Auerbach AD, Steinman MA. Blood culture use in the ED in patients hospitalised for community-acquired pneumonia. JAMA Intern Med. 2014; 174(5):803.
- Kelly AM. Clinical impact of blood cultures taken in the emergency department. J Acc Emerg Med 1998; 15(4):254-6.
- Mountain D, Bailey PM, O'Brien D, Jelinek GA. Blood cultures ordered in the adult emergency department are rarely useful. Eur J Emerg Med. 2006; 13(2): 76-9.
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.
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.
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.