"It's about stewardship. We want to increase appropriateness. I don't want to say we're playing wordsmithing games, but this is an important way to frame the issue. We're not taking away patients' nebulizers, We're improving the appropriate use of respiratory therapies."
Eliminating unnecessary care can also reduce the chance of harm, he adds. Repeating calcium level tests may lead to unnecessary augmentation of calcium with IV, which carries risks such as allergic reactions, lower blood pressure and arrhythmia.
"And there is some harm associated with the use of nebulizers," Moriates says. "They can cause arrhythmias, although that's rare." The bigger argument for moving patients more quickly from nebulizers to inhalers in the hospital is to use their inpatient stay to teach them how to use inhalers correctly.
"Studies have shown that patients don't know how to use their inhalers. We send them out of the hospital without knowing, and if we did a better job teaching them they would be less likely to bounce right back to the hospital (as a readmission.)" And that can easily be defined as a potential harm and a cost.
Other projects to reduce unnecessary, potentially harmful care are in the works, Moriates says. These include four projects now listed in the Society of Hospital Medicine's Choosing Wisely Top 5, including moving to a "restrictive" transfusion strategy, avoiding repetitive blood draws when patients' lab work and clinical picture are stable, and not prescribing preventive medications to medical inpatients to prevent stress ulcers unless they're at high risk for GI complications.