Background: Patients presenting to the Emergency Department (ED) may be subjected to unnecessary bloodwork. This leads to excessive work for front-line nurses, physicians and laboratory staff, contributing to increased ED length of stay (LOS), patient discomfort, and health care costs. Aim Statement: By January 1, 2020, we will reduce the number of targeted blood tests (AST, GGT, aPTT and CK) by 40% in the Mount Sinai ED, as measured by the percent per 1000 ED visits of AST to ALT, GGT to ALT, aPTT to INR and CK to troponin. Measures & Design: This was a prospective time series quality improvement study. Using the Model for Improvement, we engaged front-line ED staff, as well as stakeholders from Consultant, Laboratory and Information Services. Data was analyzed using run chart rules. Intervention: a) Removed rarely used tests from electronic nursing order sets b) Uncoupled order panels c) Developed six presentation-based medical directives with appropriate blood testing. d) Staff education Family of measures Outcomes: percent of targeted uncoupled test per 1000 ED visits for each of AST to ALT, GGT to ALT, aPTT to INR, and CK to troponin; Total number of blood tests ordered per 1000 ED visits Process: number of “separate and hold” tubes; number of blood tubes used in the ED; proportion of staff attending education Balancing: volume of blood drawn; LOS Evaluation/Results: Outcome: Estimated relative reduction in proportion of all uncoupled tests per 1000 ED visits by: • 33% AST/ALT • 52% GGT/ALT • 50% CK/troponin •18% aPTT/INR Total number of lab tests per 1000 ED visits decreased by 7.7% (5742 to 5331). Evidence of special cause variation on all outcomes. Process measures: 1. 100% reduction in weekly “Separate and Hold” tubes (56 to 0). 2. Monthly total of blood tubes used in the ED decreased by 2.8% (11620 to 11300) 3. Attendance pending. Balancing measures: Monthly average volume of blood drawn decreased by 1.4L(2%) from 50.4L to 49.0L; LOS pending Discussion/Impact: A multi-pronged intervention resulted in a decrease in blood testing in the ED. We achieved the sub-aim of reducing targeted blood tests and are on track to achieve the overall aim of total lab reduction in the ED by April 2020. Final interventions to be implemented in the coming months include changes to the ED paper record and replacement of the paper add-on order process with an electronic ordering tool. Complete data will be available by April 2020. This intervention is scalable and has the potential to reduce costs and preventable harm to patients.

Background: Curbing unnecessary laboratory testing represents a significant opportunity for cost reduction in the Canadian health care system. A Choosing Wisely report cited a 31% decline in the number of tests ordered in a Canadian emergency department (ED) after implementation of recommendations. The international normalized ratio (INR) remains frequently ordered in emergency departments without an appropriate indication. Aim Statement: We aimed to reduce the number of INR tests completed in the St. Joseph's Healthcare Hamilton Emergency Department by 50% by April 30, 2019. Measures & Design: We conducted the study in an urban, academic ED employing the Epic electronic health record (EHR). We tailored interventions according to the Hierarchy of Effectiveness to address root causes revealed by analysis of our baseline ordering behaviour. Interventions included provider education around evidence-based ordering indications and removal of the INR from our “chest pain” bloodwork panel. Our outcome measure was the weekly number of INR tests completed per ED visit. Process measures included the proportion of INR tests ordered for inappropriate indications on monthly audits of 20 charts where an INR was completed. Balancing measures included average ED length of stay for patients receiving INR testing. Evaluation/Results: We collected outcome, process, and balancing measures through the EHR and analyzed this data using statistical process control charts. Over the nine-month study period, we decreased weekly INR tests from 248.4 to 115.0, a reduction of 56% which met criteria for special cause variation. This amounts to a cost savings of $43,008 per year. ED length of stay for patients receiving INR testing did not change significantly. Discussion/Impact: Our interventions were successful in realising our 50% target reduction in INR tests without an increase in ED length of stay from repeat venipuncture. This result is in keeping with similar efforts in other Canadian EDs. Our interventions could likely be spread to other settings where an INR is included as part of a “chest pain” panel. This may represent a substantial cost reduction opportunity on a national scale. Further work is needed in order to assess long term sustainability, which can be supported by employing high effectiveness mechanisms such as automation of optimal behaviour.

Background: The Choosing Wisely campaign aims to reduce unnecessary testing. Over testing for urinary tract infections and concomitant overtreatment of asymptomatic bacteriuria is a target of this campaign, aiming to decrease healthcare costs and the risks of side effects such as Clostridium difficile infection, adverse reactions, and antimicrobial resistance. During the study baseline (2017), 95 urine cultures (UC) were sent for every 1000 ED visits (9.5%). Of these, fewer than 20% were positive. Aim Statement: The aim of this improvement initiative was to reduce UC testing in the ED, by 50%, from a baseline average of nearly 100 cultures per 1000 ED patients visits, to 50 cultures per 1000 visits, by May 31st, 2018. Measures & Design: This was an interrupted time series study, analyzed using Statistical Process Control (SPC) methodology. Root cause analysis was performed using an Ishikawa diagram. A Pareto chart was completed via multi-voting. A Driver Diagram was developed using the highest ranked items from the Pareto chart to identify locally relevant and feasible interventions. Interventions 1) Medical directives were modified; Routine paired sending of UC with urinalysis by nurses was removed. 2) Physician Education and implementation of a clinical decision aid (CDA); A CDA was created using PDSA methodology, using an iterative approach from development through implementation. Outcome measure: rate of Urine Cultures sent per 1000 ED patient visits Process measure: percent of positive cultures Balancing measures: rate of 14-day ED return visits and hospital admission for patients diagnosed with UTI/Urosepsis/Pyelonephritis. Evalution/Results: At the study's conclusion, there was a decrease in UC rate, from 95 per 1000 ED visits, to 59 per 1000 ED visits (RR 38%, AR 3.6%) There was evidence of special cause variation on the SPC chart. Positive cultures increased from 19% to 34%. There was no increase in the rate of ED 14-day return visits or hospital admission for patients with a diagnosis of UTI, urosepsis or pyelonephritis. Discussion/Impact: The study interventions of uncoupling routine sending of UA and UC, and physician education and use of a clinical decision aid, effectively decreased the rate of UC testing during the study period. A reduction in inappropriate UC testing is important to limit avoidable patient morbidity and reduce unnecessary health care spending. Further studies are indicated to target interventions on patient subgroups and to reduce unnecessary antibiotic prescriptions.

Introduction: Recent reports suggest that up to 30% of medical interventions provide no benefit to patients. In a response to ED over-crowding, guidelines commonly exist to guide blood test ordering in patients waiting to see a physician. In many cases, this increases the use of tests without benefiting patients. We describe a quality improvement project designed to reduce the number of laboratory tests considered routine for waiting patients. Methods: A multidisciplinary group reviewed existing symptom-prompted nursing blood test guidelines for serum electrolytes and glucose, renal function tests, liver tests, lipase, toxicological tests and beta Human Chorionic gonadotrophin levels. Order sets were revised with tests eliminated from the routine panels that were not felt to routinely contribute to patient care. The new guidelines were communicated to nursing staff in a series of educational sessions, and the revised guidelines were posted at nursing stations. Physician ordering practice was not changed. A pre-post evaluation compared the period 1 December 2014, - 30 November 2015 with 1 December 2015 - 30 November 2016. Clinical outcomes and patient wait times were not evaluated. Results: The use of tests in these categories decreased 32% between the two periods, at a net saving of $210, 246c. The largest savings came from total protein (73% decrease), Creatine kinase (68%), chloride (64%), glucose (49%), and albumin (47%). Sodium/Potassium testing decreased by only 13%. The only increase in test ordering recorded was AST (3% increase). Conclusion: Simply changing symptom driven order sets resulted in significant savings to the system. In the era of Choosing wisely regular review of lab order sets is indicated. Further study is needed to assess the effect of these changes on patient flow and on clinical outcome.

Introduction: To help mitigated risks associated with red blood cell transfusions, CWC guidelines recommend practicing restrictively. Transfusion Medicine recommends using a Hgb threshold of 70 g/L, and ordering a single unit at a time (with reassessment after). The purpose of this study is to investigate Emergency Department (ED) compliance with these more restrictive thresholds among hemodynamically stable patients. Methods: A retrospective analysis was performed on data from all emergency visits to 4 adult urban ED sites from July 1 2014 to July 1 2016. We excluded unstable patients (CTAS1, temperature >38°C, HR >100 bpm, RR >20 rpm, systolic BP <90 mmHg, and O2 sat <85%) and certain others (patients without a Hgb level, patients who left without being seen, and orders cancelled via patient discharge). After applying exclusion factors, we examined transfusions ordered. Appropriateness was assessed using the stratified Choosing Wisely Canada Guidelines for Transfusion. As an adjunct, IV iron therapy data was also analyzed for the same period between July 1 2014 and July 1 2016, excluding patients who did not have a Hgb level. Results: We identified 1329 eligible patients (54% female), with a mean age of 68 and average first hemoglobin of 72 g/L. Across all groups, 16% of patients received only 1 unit of blood. 19% of transfused patients had a hemoglobin less than 60 g/L, 45% had a Hgb <70 g/L, 32% had a Hgb 70-80 g/L, 14% had a Hgb 81-90 g/L, and 8% had a Hgb >90 g/L. Over the same two-year period, 178 patients received IV iron. The average Hgb for those patients was 82 g/L. Conclusion: A retrospective analysis documents a significant likelihood of pRBC over-transfusion among Emergency Department physicians and an underutilization of IV iron therapy for certain hemodynamically stable and anemic patients. The development of audit and feedback methods, and creation of a clinical pathway may help address the rate of over-transfusion.

Introduction: Within Alberta, 30% of patients presenting to emergency with minor traumatic brain injury (mTBI) will receive a CT scan before being sent home, regardless of whether it was clinically indicated. Choosing Wisely (CW) Canada recommends using validated clinical decision support to determine whether a CT scan is necessary for patients presenting with a mTBI. In order to provide patients with information on the risks and benefits of CT scans in mTBI and to encourage discussions between patients and their doctor, the Emergency StrategicClinical Network (ESCN) designed a patient focused information visualization on CT scans for head injuries. Methods: The ESCN, Physician Learning Program and CW Alberta partnered with the Mount Royal University Department of Information Design to develop a patient information visualization (infographic) intervention. Students spent a semester developing these infographics on Choosing Wisely recommendations, which were then presented to stakeholders. A student was then selected to develop a final design. Refinement of the design took place in consultation with clinical experts and tested in two patient focus groups. The final design was evaluated against the International Patient Decision Aid Standards checklist. The infographic was posted in 2 local emergency department waiting rooms. A survey was administered to any patients in the waiting room when volunteers were available. The survey was designed to evaluate whether the tool influenced patient beliefs about the risks and benefits of CT scans, and their willingness to engage in a discussion with their doctor. Results: In a 26 day period, 90 patients consented and completed the survey. Before reading the infographic, 33% of patients thought that after a head injury a CT was always a good idea and 63% thought it was sometimes a good idea. 82% and 91% of patients stated the poster helped them understand the indications and risks of CT imaging for mTBI. After viewing the poster, only 15% of patients felt that a CT was always a good idea after a mTBI. Conclusion: The mTBI patient infographic significantly changed patient perceptions regarding the need for CT scans in the setting of mTBI. This study demonstrates that targeted patient education materials can help support CW recommendations.

Introduction: Included in the first list of recommendations from the Choosing Wisely Canada (CW) Emergency Medicine (EM) group was to avoid ordering lumbosacral radiographs for patients with non-traumatic low back pain (LBP) in the absence of red flags. It has been suggested that these lumbosacral radiographs lead to unnecessary ionizing radiation and increase emergency department (ED) wait times without improving patient outcomes. This study evaluates lumbosacral imaging practices of emergency physicians (EPs) in four urban EDs. Methods: Data was retrospectively collected from patients, ages 18-60 and CTAS codes 2-5, who presented with non-traumatic LBP from April 1, 2014 to March 31, 2016 to four urban EDs. The time frame included both pre- and post-CW recommendation. Patients considered high risk, specifically with PTT >40 s or INR >1.2 s, neurology/neurosurgery/spine consults, admission to hospital, and history of cancer, were excluded. The primary outcome was to establish lumbosacral radiograph usage rates for non-traumatic LBP. The secondary outcome was to identify factors that influenced lumbosacral spine imaging. Factors analyzed included patient age, patient sex, ED wait times, physician age, physician experience, and physician sex. Statistical significance was determined by chi-squared analysis. Results: The data from 3140 low-risk patients showed that 16.5% of the patients received lumbosacral radiographs. Physician variation in X-ray ordering was 0% to 85.7% (IQR 4.6 to 25%). There was a significant difference between the X-rays ordered at each site (site 1 (23.1%)>site 2 (17.2%)>site 3 (14.9%)>site 4 (11.3%), p<0.001). CCFP-EM licensed physicians (17.9%) ordered more X-rays compared to licensed physicians (13.7%, p<0.001). Time of presentation, physician sex, and patient sex did not affect the imaging practices. There was a trend towards decreased ordering of X-rays (17.6% vs. 15.1%, p=0.06) post-CW recommendation. Conclusion: Considerable variation exists in the ordering practices of Calgary EPs; however, on average they are choosing wisely in terms of ordering imaging for non-traumatic LBP.

Introduction: Computerized tomography for pulmonary embolism (CTPE) has come under increased scrutiny with recommendations for evidence-based use found on Choosing Wisely lists in both Canada and the US. However practice variation in ordering patterns and diagnostic yield have not been well-reported for the Canadian context. Our objective was to investigate practice variation in CTPE ordering and rule-in rates within a large group of specialty-trained emergency physicians. Methods: We undertook an analysis of a computerized physician order entry database from four tertiary care EDs covering a 12-month period from August 1, 2016 to July 30, 2016 with 31 419 visits for potential pulmonary embolism (PE) as determined by a previously validated algorithm based on presenting complaints. CTPE utilization and diagnostic yield were determined for 149 physicians who ordered at least 10 studies over that time period. Outcomes of interest included CT utilization as determined by electronic order entry and a confirmed diagnosis of PE based on ICD-10 coding of the emergency visit. Descriptive statistics using medians, IQR and 95% confidence intervals are reported. This study is approved through REB14-0650 and is a component of a larger cluster RCT to improve CTPE utilization. Results: During the study period 2670 CTPE studies were ordered for potential PE patients representing 8.5% of the total with relevant complaints. We observed a 10-fold variation in CTPE ordering among physicians with rates as low as 2.7% and as high as 25%. The median rate of CTPE ordering for potential PE was 8.8% with an IQR of 6.0% to 11.7%. A total of 4146 CTPE studies were ordered during the study period with physicians ordering an average of 28 CTPE studies each; range 10-90. In terms of diagnostic yield, 591/4146 studies, or 14.3% (95% CI 13.2-15.3%) were associated with a diagnosis of PE. Diagnostic yield per physician ranged from 0 to 50%, with a median of 13.5% and an IQR of 7.6% to 21.4%. Conclusion: In this large, robust administrative dataset from four Canadian urban EDs, threshold for CTPE ordering varies widely among physicians as does diagnostic yield. Efforts to improve appropriate utilization are justified with an eye to reducing unnecessary radiation, costs and incidental findings.

Introduction: Head injuries are a commonly encountered presentation in emergency departments (ED) and the Choosing Wisely Canada (CWC) campaign was released in June 2015 in an attempt to decrease imaging utilization for patients with minor head injuries. The impact of the CWC campaign on imaging utilization for head injuries has not been explored in the ED setting. In our study, we describe the characteristics of patients with head injuries presenting to a tertiary care academic ED and the impact of the CWC campaign on CT head utilization. Methods: This retrospective cohort study used linked databases from the province of Ontario, Canada to assess emergency department visits with a primary diagnosis of head injury made between June 1, 2014 and Aug 31, 2016 at the University Health Network in Toronto, Canada. We examined the number of visits during the study period, the proportion of patients that had a CT head performed before and after the release of the CWC campaign, as well as mode of arrival, and disposition. Results: There were 4,322 qualifying visits at our site during the study period. The median presenting age was 44.12 years (IQR 27.83,67.45), the median GCS was 15 (IQR 15,15) and the majority of patients presenting had intermediate acuity (CTAS 3). Overall, 43.17% of patients arrived via ambulance, 49.24 % of patients received a CT head and 10.46% of patients were admitted. Compared to patients presenting before the CWC campaign release, there was no significant difference in the rate of CT heads after the CWC (50.41% vs 47.68%, P=0.07). There were also no significant differences between the two groups in mode of arrival (ambulance vs ambulatory) (42.94% vs 43.48%, P=0.72) or admission rates (9.85% vs 11.26%, P=0.15). However, more patients belonged to the high acuity groups (CTAS 1 or 2) in the post CWC campaign release group (12.98% vs 8.11% P<0.001). Conclusion: Visits for head injuries make up a significant proportion of total ED visits and approximately half of these patients receive CT imaging in the ED. The CWC campaign did not seem to impact imaging utilization for head injuries in the 14 months following its launch. Further efforts, including local quality improvement initiatives, are likely needed to increase adherence to its recommendation and reduce imaging utilization for head injuries.

Introduction: Computed tomography (CT) has increasingly been used as a standard initial investigation for patients presenting to the Emergency Department (ED) with suspected nephrolithiasis. Compared to ultrasound, CT has increased system-level costs, ionizing radiation exposure and frequently does not alter management. For these reasons, Choosing Wisely (CW) recommends avoiding CT imaging of otherwise healthy patients younger than age 50 years presenting with symptoms of uncomplicated renal colic that have a known history of nephrolithiasis or ureterolithiasis. We aimed to evaluate the degree of utilization of CT imaging for this subgroup of patients in a tertiary care centre ED. Methods: A retrospective chart review was performed for all patients younger than 50 years who visited Sunnybrook Health Sciences Centre ED for six months between December 2015 and May 2016 with renal colic symptoms and a history of nephrolithiasis. Demographic data, relevant past medical history, clinical presentation, lab values, urology consultation, ED treatments administered, diagnostic imaging orders and dispositions were recorded for each eligible patient. Results: Out of 130 reviewed patient charts, 73 patients were identified with a previous history of nephrolithiasis and a presentation consistent with uncomplicated renal colic. 54 patients received ultrasound, KUB x-ray, or no imaging. The other 19 (26.0%) of these patients received an abdominal/pelvic CT with an indication of looking for renal or ureteral stones. Of the patients that received CT, none demonstrated significant findings warranting hospital admission or leading to identifiable changes in ED management. Five (26.3%) of these 19 patients had received a total of three to four CTs for renal colic during past Sunnybrook ED visits, while one had previously received 13 CTs. Conclusion: CT scans are often used as an initial diagnostic modality for suspected renal colic despite a Choosing Wisely recommendation to restrict the use of CT scans in a target population and infrequent changes in management after obtaining a CT. These findings highlight the need for quality improvement strategies to decrease CT utilization in this patient population with suspected renal colic.

Introduction: We previously reported that a targeted knowledge translation (KT) intervention was associated with a trend towards increased awareness and knowledge of the Choosing Wisely Canada (CWC) emergency medicine (EM) recommendations. We wished to assess if the intervention changed physician practice, specifically looking at the imperative “do not order lumbar XRs for non-traumatic low back pain unless red flags exist”. Methods: A departmental KT initiative was implemented in April 2016 and consisted of a 1-hour seminar reviewing the CWC-EM recommendations, access to a video cast, departmental posters, and a before and after awareness survey. The effectiveness of our intervention was assessed by analyzing the frequency of lumbar XR imaging conducted for low back pain before and after the introduction of our intervention at a tertiary teaching hospital emergency department. All patient visits for the complaint of low back pain were included. The rates of XR imaging from June 2014 to September 2014 for the pre-intervention period and June 2016 to September 2016 for the post-intervention period were collected and analyzed using Fisher exact tests. A sample size of 683 was required to detect a 5% change with an alpha of 0.05 and a power of 80%. Results: Baseline characteristics of patients were similar for the pre- and post-intervention periods. There was a total of 781 patient visits for low back pain in June to September 2014 and 672 in June to September 2016. The XR imaging rate for low back pain increased from 12% (95% CI 9.9-14.5) to 16.2% (95% CI 13.6-19.2) following the intervention (p=0.023). Conclusion: We previously demonstrated a trend towards increased awareness and knowledge of the CWC EM recommendations following a knowledge translation initiative. Baseline XR imaging rates for low back pain were lower than what has been reported. We observed that our intervention was associated with an increased frequency of imaging for low back pain. This may be due to a contrarian effect. We feel this calls into question the role of knowledge translation initiatives where physician practice already closely adheres to pre-established recommendations.

Introduction: Choosing Wisely is an innovative approach to address physician and patient attitudes towards low value medical tests; however, a knowledge translation (KT) gap exists. We aimed to quantify the baseline familiarity of emergency medicine (EM) physicians with the Choosing Wisely Canada (CWC) EM recommendations. We then assessed whether a structured KT initiative affected knowledge and awareness. Methods: Physicians working in urban (tertiary teaching hospital, Saint John, NB) and rural (community teaching hospital, Waterville, NB) emergency departments were asked to participate in a survey assessing awareness and knowledge of the first five CWC EM recommendations before an educational intervention. The intervention consisted of a 1-hour seminar reviewing the recommendations, access to a video cast and departmental posters. Knowledge was assessed by asking respondents to identify 80% or more of the recommendations correctly. Physicians were surveyed again at a 6-month follow up period. The Fisher exact test was used for statistical analyses. A sample size of 36 was required to detect a 30% change with an alpha of 0.05 and a power of 80%. Results: At the urban site, 16 of 25 (64%) physicians responded to the pre- and 14 of 26 (53.8%) responded to the post-intervention survey. Awareness of the EM recommendations did not increase significantly (81.3% pre; 95% CI 56.2-94.2 vs. 92.9% post; 66.4-99.9; p=0.60). There was a weak trend towards improved knowledge with 62.5% (38.5-81.6) of physicians responding correctly initially, and 85.7% (58.8-97.2; p=0.23) after the intervention. At the rural site, 8 of 11 (72.7%) physicians responded to the pre- and post-intervention survey. There was a trend towards improved awareness, (25% pre; 6.3-59.9 vs. 75% post; 40.1-93.7; p=0.13), with 50% (21.5-78.5) responding correctly pre, and 87.5% (50.8-99.9; p=0.28) after the intervention. Conclusion: We have described the current awareness and knowledge of the CWC EM recommendations. Limited by our small sample size, we report a trend towards increased awareness and knowledge at 6 months following our KT initiative in a rural setting where there was a low baseline awareness. At the urban site where baseline knowledge was high, changes seen were less significant. Further work will look at the effectiveness of our initiative on physician practice.

The American College of Physicians in its ethics manual endorsed the idea that physicians ought to improve their ability to provide care to their patients more parsimoniously. This elicited a critical backlash; critics essentially claimed that what was being endorsed was a renamed form of rationing. In a recent article, Tilburt and Cassel argued that parsimonious care and rationing are ethically distinct practices. In this essay I critically assess that claim. I argue that in practice there is considerable overlap between what they term parsimonious care and what they define as rationing. The same is true of the Choosing Wisely campaign endorsed by the American Board of Internal Medicine. In both cases, if the goal is to control healthcare costs by reducing the use of marginally beneficial care that is not cost effective, then a public conversation about the justness of specific choices is essential.

Introduction: Individual and institutional disparities in CT imaging rates for patients with head injuries have long been recognized, leading to the development of well-validated clinical decision rules designed to standardize clinical practice. To assess their impact on current practice, we sought to evaluate variation in CT imaging by emergency physicians for patients presenting with head injury across the province of Alberta. Methods: A unique data warehouse merging administrative, clinical, and imaging platforms for 11 Alberta emergency departments (EDs) was created. Unique identifiers were obtained for all emergency physicians who were included in this analysis if they evaluated in excess of ten ED patients presenting with a chief complaint of “head injury”. Patients with high triage acuity (CTAS 1) were excluded, as were patients who were admitted to hospital. Descriptive statistics were employed to describe variation between physicians and sites for a 24 month period from 2013-2015. Results: 311 emergency physicians treating 20,797 patient encounters for head injury were included. Overall a total of 8,245 head injury patients (40%) received one or more CT scans. Physician variation across the 11 sites ranged from 4% -100% of head injury patients receiving a CT. Within sites CT ordering between physicians varied from 9-fold (4% - 36%) at the lowest variation site, to more than 20-fold (4% - 90%) at the highest variation site. After removing the 5% lowest and highest ordering physicians, variation in ordering continued to range from 10% - 72%. No trends were observed across the two years examined. Conclusion: This is the largest study to date examining physician level variation in CT ordering practices for ED head injury patients. We have identified marked persistent practice variation despite the presence of well-validated clinical decision rules and a relatively low risk medicolegal environment. Variable risk tolerance and limited use of validated clinical decision rules are likely contributors making this area an ideal focus for targeted interventions to improve imaging appropriateness and reduce practice variation.

Introduction: Standardized tools for disseminating knowledge summaries of low value or unnecessary care (e.g., testing, procedures and treatments) are limited, but needed to equip clinicians for discussions with patients about care decisions. The objective of this study is to assess the acceptability of a tool developed by our emergency department (ED) team to communicate the evidence supporting the Choosing Wisely Canada© (CWC) and other similar recommendations. Methods: A consensus process was used by team members to develop a tool that highlights three areas: Facts, Gaps, and Acts. The Facts portion highlights the current state of knowledge and illustrates the strength of the evidence supporting guideline recommendations. The Gaps section identifies variation in current clinical practice. The Acts section includes larger CWC goals, as well as specific next steps for a demonstration project. Each section contains one key message for clinicians, ensuring the tool is easy to use. Results: A test case has been developed for avoiding chest radiographs in patients with an exacerbation of documented asthma. The Facts section reviewed current guidelines for asthma care. The Gaps section collated evidence from a systematic review and primary research. The Acts section recapitulates the CWC recommendations. In order to assess acceptability feedback cycle will be completed using surveys of 50 patients and 50 clinicians. Conclusion: While generating the Facts, Gaps, and Acts tool for a CWC recommendation represents a translational activity, evidence of effectiveness is needed prior to widespread implementation. We report the rational and development of a novel tool to engage clinicians and patients in conversations about unnecessary care in the ED.