Recommendations

royal-college-of-anaesthetists-logo
surgeons

1. Day surgery should be considered the default for most surgical procedures (except complex procedures). Variation in the use of day surgery for specific operations should be measured and this information should be available to patients.

Evidence/guidance

2. Patients do not need to come into hospital the day before surgery if they have had the appropriate preoperative assessment and preparation.

Evidence/guidance

3. Most patients do not need routine preoperative tests before minor or intermediate surgery. There are national guidelines to determine who needs preoperative tests.

Evidence/guidance

4. All patients considering an operation should have shared decision making consultations to discuss their individual chance of benefit or harm and to identify their personal preference. Patients choosing surgery who are at a high risk of dying (predicted 30 day mortality >1%) should be identified by their age, type of surgery and additional medical conditions.

Shared decision aids to use with patients

Evidence/guidance

5. For many patients the chance of harm after an operation may be reduced if they improve fitness, stop smoking, reduce alcohol intake and in some cases reduce weight in the weeks or months before their surgery.

Shared decision aid to use with patients

Evidence/guidance

royal-college-of-emergency-medicine-logo

1. Connecting an intoxicated (alcohol) patient up to a drip and providing intravenous fluids will not help them feel better or allow discharge from hospital any quicker.

Evidence/Guidance

 

2. Children with small fractures on one side of the wrist, ‘buckle fractures’ do not usually need a plaster cast. They can be treated with a removable splint and written information. There is usually no need to put a plaster cast on, or follow these children up in fracture clinic as they will get better just as quickly without this.

Evidence/Guidance

 

3. Small fractures of the base of the fifth metatarsal, a bone on the outside of the foot, do not usually need to put into a plaster cast as they will heal just as quickly in a removable boot.

Evidence/Guidance

4. Some injuries, such as hip and shoulder dislocations, can be treated with sedation in the emergency department rather than undergoing a general anaesthetic in the operating theatre.

 

5. Tap water is just as effective for cleaning wounds as sterile saline.

Evidence/Guidance

royal-college-of-general-practitioners-_-rcgp

1. When patients are particularly frail or in their last year of life, unless there is a clear preference otherwise by the patient or advocate, discuss with the patient and family/carers the option of decreasing the number of medicines to only those used for control of symptoms.

Evidence/guidance

2. Being alert to the possibility of dementia in patients at risk, with further assessment on an individual basis is good practice, but routinely screening for dementia using structured tools has not been recommended by the UK National Screening Council. It risks false positive diagnoses and has no proven benefit. 

Evidence/guidance

3. When considering risk modifying treatment in primary prevention, for example treatment for blood pressure, cholesterol or bone density, share the option to have treatment or not before prescribing. Decision aids exist to support this process for doctors and patients. 

Shared decision aids to use with patients

4. Treating Stage 1 (mild) hypertension in people without any other cardiovascular risk factors may have only small potential benefit for an individual. Consider total cardiovascular risk before initiating drug treatment.

Shared decision aid to use with patients

Evidence/guidance

5. Ultrasound has very limited value in making a diagnosis of polycystic ovarian syndrome:

Polycystic ovaries do not have to be present to make the diagnosis, and the finding of polycystic ovaries does not alone establish the diagnosis.

Symptoms and a hormonal profile* will usually be enough to establish a diagnosis.
*NICE recommends: Testosterone/SHBG/LH/FSH/Prolactin/TSH

Evidence/guidance

6. Once a patient being treated with a statin has reached their target level of cholesterol, there is no need to keep measuring it.

The only liver function test which needs monitoring on statins is the ALT or AST at 3 months and 1 year. If it is normal at 1 year, it does not require ongoing monitoring.

Shared decision aid to use with patients

Evidence/guidance

the-royal-college-of-obstetricians-and-gynaecologists

1. Medicines like aspirin, heparin or progesterone should not be used in a bid to maintaining a pregnancy in a woman who has had unexplained and recurrent miscarriages.

Evidence/guidance

2. Aspirin is not recommended as a way of reducing the chances of pregnant women developing blood clots (thromboprophylaxis).

 

3. Unless the mother has diabetes, ultrasound scans should not be used to check if a baby is bigger than normal for its gestational age (macrosomia).

Evidence/guidance

4. A simple ovarian cyst less than 5cm in diameter in a woman who has not gone through the menopause does not need to be followed up; nor is there any need for a blood test to check levels of the protein CA-125.

Evidence/guidance

5. Electronic monitoring of a baby’s heart should not be offered routinely during labour unless the mother is at a higher risk of complications than normal.

Evidence/guidance

royal-college-of-ophthalmologists

1. Do not review uncomplicated cataract cases on day one post-op

Shared decision making aid to use with patients

Evidence/guidance


2. If a child is under 12 months old and has a blocked nasolacrimal duct, do not try to unblock.


3. Do not carry out laser retinopexy for asymptomatic lattice degeneration/atrophic retinal holes.

Evidence/guidance


4. If conjunctivitis is thought to be viral, there is no need to send samples to the laboratory or to treat with antibiotics.

Evidence/guidance


5. The initial episode of unilateral anterior uveitis does not usually need further investigation

royal-college-of-pediatrics-and-child-health

1. Helmet therapy is not effective in the treatment of positional plagiocephaly in children, other treatment options should be considered and discussed with your patient.

 

2. Polyethylene Glycol should be used in preference to Lactulose in the treatment of chronic constipation in children. 

Evidence/guidance

3. Buccal midazolam or lorazepam should be in the treatment of prolonged seizures in young people and children, as these are the most effective treatments, in preference to rectal and intravenous diazepam.

Evidence/guidance

4. Bronchodilators should not be used in the treatment of mild or moderate presentations of acute bronchiolitis in children without any underlying conditions.

Evidence/guidance

royal-college-of-pathologists

1. Unless a patient is at increased risk of prostate cancer because of race or family history, PSA testing does not necessarily lead to a longer life.

Shared decision making aid to use with patients

Evidence/guidance

 

2. Calcium testing is used when there are symptoms of kidney stones, bone disease or nerve-related disorders; but it is not necessary to test less than three months after the previous test except in acute conditions, during major surgery or in critically ill patients when tests should not be made more often than every 48 hours.

 

3. Only consider transfusing platelets for patients with chemotherapy-induced thrombocytopenia where the platelet count is < 10 x 109/L except when the patient has clinical significant bleeding or will be undergoing a procedure with a high risk of bleeding.

 

4. Use restrictive thresholds for patients needing red cell transfusions and give only one unit at a time except when the patient has active bleeding.

Evidence/guidance

5. Only transfuse O Rh D negative red cells to O Rh D negative patients and in emergencies for females of childbearing potential with unknown blood group.

royal-college-of-psychiatrists

1. In the treatment of depression, if an antidepressant has been prescribed within the therapeutic range for two months with little or no response, it should be reviewed and changed or another medication added, which will work in parallel with the initial drug that was prescribed.
Shared decision making aid to use with patients

2. When adults with schizophrenia are introduced to treatment with long-term anti-psychotic medication, the benefits and harm of taking oral medication compared to long-acting depot injections should be discussed with all relevant parties.

Evidence/guidance

3. Women who are planning a pregnancy or may be pregnant should not be prescribed valproate for mental disorders except where there is treatment resistance and/or very high risk clinical situations.

Evidence/guidance

4. When a diagnosis of psychosis is made, CT or MRI head scans should only be used for specific indications where there are signs or symptoms suggestive of neurological problems.

Evidence/guidance

rcr

1. In advanced cancer, the use of chemotherapy that is unlikely to be beneficial and may cause harm should be minimised

 

2. In cases of a minor head injury, imaging is not likely to be useful

Evidence/guidance

 

3. Back pain which is uncomplicated, that is not associated with ‘red flags’ or radicolupathy usually does not require imaging

Evidence/guidance

 

4. Where there is suspicion of a pulmonary embolus, imaging should be guided by clinical scoring systems.

Evidence/guidance

 

5. After treatment for cancer, the use of routine scanning should only be used where this is beneficial to the patient.

faculty-of-intensive-care-medicine

1. Life support for patients at high risk of death or severely impaired functional recovery should not be offered. A discussion with patients and their families should focus on the goals of comfort care.

Shared decision aids to use with patients

Evidence/guidance

  • Choosing Wisely US: Critical Care Societies Collaborative – Critical Care

2. Tests and investigations should only be done in response to answering a specific question rather than routinely.

Evidence/guidance

3. Blood transfusions should only be given when the haemoglobin is less than 70 g/L. Blood transfusions may occur above this level where the patient is haemodynamically unstable or actively bleeding.

Evidence/guidance

4. Patients who are mechanically ventilated may not need to be deeply sedated, and where possible daily trials to lighten sedation should be done.

Evidence/guidance

faculty-of-sexual-and-reproductive-health

1. If a woman has abnormal vaginal discharge that is likely to be caused by thrush (also known as candida) or Bacterial vaginosis (BV) and she is at low risk of having a sexually transmitted infection, a vaginal swab is not usually necessary.

Evidence/guidance

2. A woman who is thought to be having recurrent thrush should have an examination of the skin around her vagina to exclude other conditions such as lack of vaginal estrogen, allergies or other skin conditions rather than be given another course of thrush treatment.

Evidence/guidance

3. If a woman over the age of 45 years with typical symptoms of menopause, such as hot flushes and sweats and if her periods have become irregular, much lighter or have stopped, further bloods tests to check hormone levels are not usually necessary.

Evidence/guidance

4. Women who have a copper intrauterine device (IUD) or the hormonal intrauterine system (IUS) fitted only need to seek professional advice when they cannot feel the threads which hang from the device. Women should be taught how to feel for these threads.