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Armstrong Institute for Patient Safety and Quality

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Choosing Wisely® Initiatives

In 2013, the Johns Hopkins School of Medicine Dean Paul Rothman and Vice Dean Roy Ziegelstein asked each training program director to identify at least one commonly used unnecessary or wasteful medical test or procedure in their specialty area and work with residents and fellows to reduce or eliminate utilization. As a result, these residency and fellowship programs have emphasized the responsibility that our institution has to reduce health care expenditures by implementing specific interventions to eliminate unnecessary tests, treatments and procedures.

Specialty AreaTest or Procedure
Adult Infectious Disease

Reduce unnecessary ordering of hepatitis C (HCV) viral loads and genotypes for inpatients

Allergy and ImmunologyExtensive tests for urticaria
AnesthesiaBlood lactate in the operating room
Child and Adolescent PsychiatryReduce the ordering of routing urinalysis for patients admitted to the child psychiatry inpatient unit
Child NeurologyCT scans for patients with epilepsy
Clinical NeurophysiologyEEG for patients with headaches
DermatologyAsx skin tag removal
DermatopathologyReducing the use of special stains for microorganisms on formalin-fixed paraffin-embedded tissue:
  1. When cultures (which are more sensitive than special stains) have also been submitted, and
  2. When clinicians preorder or request bug stains prior to or independent of a Dermpath interpretation suggesting infection.
Emergency MedicineReducing unnecessary coagulation testing
Endocrinology

Avoidance of costly use of fractionated vitamin D when total vitamin D level can be used

Genetic MedicineUrine amino acids
Geriatrics

Eliminate use of aspirin and statins for primary prevention in older adults (>75 years, or with life expectancy <5 years)

Gynecology and ObstetricsUmbilical artery doppler
Hand SurgeryEliminate unnecessary antibiotic use in hand surgery
Medicine
  • Carotid Doppler in patients with syncope
  • Treatment of asymptomatic bacteriuria
  • Ordering ABO
Johns Hopkins Bayview Medical Center Department of MedicineTelemetry monitoring
NeonatologyDuration of nitric oxide
Neurodevelopmental DisabilitiesSerum pyruvate
Neurology and Clinical NeurophysiologyParaneoplastic Ab testing
NeurosurgeryUnnecessary postoperative physical and occupational therapy
NeurotologyEliminating routing labs and routine CT scans for unilateral sudden hearing loss
Nuclear MedicinePET/CT for cancer screening in healthy individuals
OphthalmologyTopical antibiotics following intravitreal injection
Orthopedic SurgeryRoutine post operative CBS/BMP
OtolaryngologyImaging in patients with suspected rhinosinusitis
Pain MedicineDecrease MRI for patients with back pain
Pathology and MedicineSerum folate test
Pediatric AnesthesiaRoutine use of ondansetron for nausea and vomiting in children less than one year of age
Pediatric CardiologyEKGs on all outpatient consults
Pediatric Critical CareConsolidate lab ordering
Pediatric Emergency DepartmentCultures following incision and drainage
Pediatric NephrologyBone radiographs in patients with renal transplant
Pediatric NeurologyHead CTs for patients with seizures
Pediatric Radiology
  • Radiographs and head CT replaced by a screening MRI. If findings are stable, no more imaging is required. If there has been a change, then shunt survey is ordered.
  • Valium and child life have replaced general anesthesia for some children undergoing MRI
  • MRI following inadequate ultrasound study instead of CT for suspected appendicitis
Pediatric Rehabilitation

Use of DEXA scans in high-risk children with brain injury and CP

Pediatric Urology

Do not routinely order DMSA renal scan for children who present with urinary tract infection or low-grade vesicoureteral reflux with normal renal ultrasound

PediatricsBronchodilators in children with bronchiolitis
Physical Medicine and RehabilitationReducing GI prophylaxis
Plastic SurgeryCT for patients with facial cellulitis
Physical Medicine and Rehabilitation and Pediatric RehabilitationAppropriate use of urine cultures in treating urinary tract infections
Radiation OncologyReduce the number of palliative patients who receive multifraction palliative regimens to treat bone metastasis
RadiologyCombined use of upper GI and small bowel follow through fluoroscopic exams
Spinal Cord InjuryAppropriate use of urine cultures in treating urinary tract infections
Surgery and Surgical Critical Care
  • Reduce CT for suspected Pulmonary Embolism
  • Blood transfusion for patients with hemoglobin >7
Transfusion MedicineUnnecessary and possibly detrimental transfusions