Palliative Care | Choosing Wisely Italia

When organizing a local palliative care network, don’t omit the activation of II° level home care involving medical staff (doctors and nurses) with specialised training palliative care and team management.

ACP

Avoid the habitual use of inhaled corticalsteroids in upper respiratory tract infections in children.

In absence of medical indications do not prescribe formula or liquids other than breast milk to newborns in the first weeks of life.

Do not prescribe antibiotics for viral acute respiratory tract diseases (ear infections, sinusitis, pharyngitis, bronchitis)

Do not prescrive chest x-ray for diagnosis and follow-up of uncomplicated pneumonia in children

Do not prescribe drugs (Histamine receptor antagonists, proton pump inhibitors and prokinetics) in physiological gastroesophageal reflux (GER), which does not impair growth and is not associated with suspected signs or symptoms of GER disease . Inform and support parents.

ADI

Don’t follow “elimination” or fasting diets. These are specific nutritional approaches for some pathologies and only physicians can recommend them.

Avoid contacting professionals who are not experts in the diagnosis and treatment of eating disorders, only specialized or competent health care teams belonging to different disciplines can take care of these serious pathologies in a multidisciplinary way.

Do not encourage the extensive and indiscriminate use of vitamin and mineral supplements as preventive elements for cancer and cardiovascular disease.

Obese people of any age are not to be blamed. The stigma of obesity worsens the condition of those who are affected.

Do not follow Occidental style diets with high environmental impact. Only healthy diets such as the Mediterranean diet can guarantee the physical health of individuals and of the planet. (Green recommendation)

AICPR

Don’t perform routine chest X-ray in patients entering rehabilitation programme after cardiac surgery

Don’t perform Computed Tomography for coronary calcium score in patients at high cardioascular risk

Don’t perfom Holter electrocardiographic monitoring in patients suffering from syncope, near syncope o dizziness, in whom a non arrhytmic origin has been documented

Don’t routinely prescribe proton pump inhibitors (PPI) for gastrointestinal bleeding profilaxis in patient with single drug antiplatelet therapy in absence of additional risk factors

Avoid routine use of Infective endocarditis profilaxis in mild to moderate native valve disease

AIFI

Do not use continuous passive mobilization (CPM) devices for postsurgical treatment of knee ligament reconstructions or uncomplicated hip or knee arthroplasties.

Do not use mechanical or manual traction, as single treatment or in combination with other treatments, in patients with low back pain, in presence or absence of radicular pain.

Do not use specific exercises of selective strengthening of the vastus medialis obliquus (VMO) in patellofemoral pain syndrome.

Do not use ultrasound therapy for rotator cuff tendinopathy, ankle sprains and low back pain.

Do not teach or have patients with acute or chronic respiratory diseases practice diaphragmatic breathing.

AIGO

Prescribe fecal occult blood test (FOBT) only for screening of colorectal cancer.

Don’t perform surveillance colonoscopy for colon polyps after a valid exam, with intervals that vary from those indicated by the responsible gastroenterologist or after histologic evaluation of the polyp.

Don’t repeat esofagogastroduodenoscopy (EGDS) for a patient that has been diagnosed with a gastroesophageal reflux disease, with or without hiatal hernia, in absence of new symptoms.

Once the diagnosis is established, don’t prescribe systematic abdominal ultrasound checkup in asymptomatic patients with epathic angiomas < 30 mm in diameter.

Don’t prescribe proton pump inhibitors (PPI) during steroid therapy or for long periods with patients that exhibit dyspeptic symptoms.

AIGO

Do not request surveillance investigations for patients with pancreatic cysts who are poor surgical candidates, irrespective of cysts nature and characteristics

Do not request esophagogastroduodenoscopy in patients with recent onset of upper gastrointestinal symptoms younger than 50 years, without alarm features

Do not request surveillance colonoscopy for asymptomatic colonic diverticular disease without changes in symptoms

Do not perform food intolerance tests except for those scientifically validated

Do not prescribe proton pump inhibitors to patients with liver cirrhosis, outside of established indications

AIGO

Do not prescribe endoscopic examination when low-waste, less invasive alternatives endorsed by evidence-based clinical guidelines are available.

Do not take mucosal biopsies when the histopathological results would not change the patient management.

Do not plan most elective endoscopic procedures on an inpatient basis if they can be performed safely without hospitalization, to avoid overnight hospital stays.

Do not use single use endoscopes regularly as they should be reserved for highly selected patients, on a case-by-case basis (immunocompromised patients or those with multidrug-resistant bacteria).

Do not abuse of periprocedural and intraprocedural medication and prefer their use only when strictly indicated (e.g. avoid inadequate antibiotic prophylaxis and saline fluid intravenous solution)

AIMN

Don’t use brain SPECT (Single photon emission computed tomography) with DAT (dopamine transporter) radiopharmaceuticals in the differential diagnosis of degenerative Parkinsonisms or to convince a patient with Parkinson’s disease that he/she is really affected with that disease.

Don’t use 18F-FDG (Fluorodeoxyglucose) PET-CT as a “screening” test for cancer in healthy subjects.

Don’t perform PET/CT with [18F]FDG (Fluorodeoxyglucose) in suspected peripheral osteomyelitis and in differential diagnosing between acute and chronic infection.

Don’t perform lymphoscintigraphy and radioguided biopsy of the sentinel node in patients affected by cutaneous melanoma thinner than 0.75 mm, with no ulceration and mitotic rate <1/mm2

Don’t treat with radioiodine low-risk differentiated thyroid carcinomas (namely “microcarcinomas” or carcinomas <1 cm, in the absence of unfavorable prognostic factors), after total thyroidectomy

AIRO

Do not define a treatment program that includes radiation therapy without the involvement of the radiation oncologist from the beginning (usually, at time of the tumour first diagnosis) in the definition of the program.

Do not recommend the use of “special” techniques or radiation therapy machines without having previously obtained the recommendation by a radiation oncologist.

Do not neglect to offer radiotherapy delivered with hypofractionated schedules when the scientific evidence is already available.

Do not use, to the extent possible, prolonged radiation therapy for palliative treatments in frail patients with a short life expectancy

Limit the use of diagnostic procedures in case of low-risk prostate and breast cancer. Avoid the use of serum biomarkers in early stage breast cancer.

AIURO

Don’t use the bladder catheterization if not expressly recommended. If necessary, follow the guidelines as far as the choice of the devices, the insertion procedure, the management, the early removal and patient education are concerned.

Don’t practice bladder catheterization with 2-ways latex catheters; caliber of less than 22 ch for men and 20 ch for women; in patients with suspected or confirmed diagnosis of macrohematuria.

Don’t carry out the assessment of pain without using standardized scales in the immediate post-operative period.

Unless there is any complication, don’t renew the dressing of the surgical site in the first 48 hours after surgery.

Don’t renew the advanced dressings placed on complicated and/or infected surgical site with different timing than indicated by the guidelines and the product specifications.

AMD

Don’t use the ‘sliding scale insulin therapy’ for the treatment of hyperglycemia in hospitalized patients.

Don’t prescribe routine glucose self-monitoring to Type 2 diabetes patients who are being treated with drugs that do not cause hypoglycemia.

Don’t prescribe screenings for diabetes complications that are not in accordance with the national guidelines.

Don’t treat diabetes patients indiscriminately with antiplatelet drugs.

Don’t perform routine measurement of C-peptide in diabetes patients.

AME

Do not routinely request / perform thyroid ultrasound in subjects without signs and / or symptoms of thyroid disease and not belonging to risk groups for thyroid cancer and limit the indication and execution of fine needle aspirations on low-risk nodules.

Avoid excess bone density testing: intervals less than two years are rarely necessary.

Use of free testosterone testing is not recommended for hypogonadism or hyperandrogenism diagnosis.

Do not prescribe the dosage of FT3 (free triiodothyronine) for the initial evaluation of the functional state of the thyroid and in the periodic control of hypothyroidism in therapy.

Thyroid nodules patients should not be treated with L-thyroxine except in selected cases.

AMGE

Don’t prescribe a medication without conducting a drug regimen review (medication reconciliation)

Don’t routinely prescribe lipid-lowering medications in people aged 80 years and over especially for primary prevention of cardiovascular disease; don’t use statins in elderly patients with severe frailty

Don’t use antimicrobials to treat asymptomatic bacteriuria in older adults

Don’t let older adults lie in bed all day during their hospital stay unless they’re terminally ill or they’ve got a specific medical advice

ANDRIA

Don’t clamp the umbilical cord before 1 minute in neonates that do not need immediate resuscitation manouvres.

Don’t use continous cardiotocography (CTG) during labour of women at low risk for hypoxia.

Don’t routinely require general blood tests, general coagulation tests or tests for trombophylia to prescribe hormonal contraceptive medications.

Don’t require a pelvic exam or other physical exam to prescribe oral contraceptive medications.

Don’t schedule elective, non medically indicated inductions of labour or Cesarean deliveries before 39 weeks 0 days gestational age.

ANIARTI

Don’t replace regularly the mechanical ventilator circuits to reduce the risk of VAP (Ventilator Associated Pneumonia)

Don’t routinely use personal protective equipment (gowns, masks, hats, gloves, ….) for the access of family members in ICU. (Green recommendation)

Don’t perform endotracheal aspirations at regular intervals but according to early indicators of retention of bronchial secretions.

Don’t replace peripheral venous catheters at regular intervals but based on clinical evaluation.

Don’t maintain routine preoperative fasting since the midnight preceding the elective surgery.

ANIMO

Don’t mince and disguise medications in foods to administer them to patients with dysphagia and/or via NG-tube (nasogastric tube) or PEG (Percutaneous Endoscopic Gastrostomy) if not specifically indicated.

Don’t make regular use of restraint as a falls risk management tool.

Don’t resort to bladder catheterization for managing incontinence or performing simple diagnostic tests.

Don’t leave in place any type of venous catheter (central; peripheral; short, medium or long term) if the problem for which it was set is no longer present.

Don’t follow the mobilization protocols and those for the treatment of pressure sores as “standard” protocols in the dying patient.

ANIPIO

Do not use gloves as an alternative to hand hygiene with alcohol solution for performing non-biological care work, especially in the presence of a patient with multi-drug resistant organisms (MDRO). (Green recommendation)

Do not use antiseptic products routinely in addition to or in place of normal detergent in the pre-operative bath/shower.

Do not apply standard and additional precautions when assisting a patient with an “alert” multi-drug resistant organism without first evaluating the type of “alert” multi-drug resistant organism involved.

Do not maintain precautionary isolation upon symptom resolution in patients with Clostridium difficile diarrhoea.

Do not replace surgical dressings before 48 hours have elapsed from the operation.

ANIPIO

Do not use double pair of non-sterile gloves in patient care.

Do not use disposable adhesive surgical sheets with the intent of reducing surgical site infections (Surgical Site Infections – SSI)

For the management of vascular access, in particular for washing and closing operations (Flushing and locking) don’t use syringes with direct filling from the IV fluid solution bottle, but prefer the use of pre-filled syringes.

Do not consider only surgical clinics, operating rooms and interventional x-ray as the only option for the implantation of peripherally Inserted Central Catheter (PICC) and peripheral venous catheters (Midline) but, preferably, to favour the implant procedure at the patient’s bedside.

For patients in isolation rooms, do not place isolation supplies, equipment and medical devices of no immediate use at the bedside.

ANMCO

Do not request inductive ischemia testing (stress test and other inductive ischemia tests) as a routine check-up in asymptomatic patients who have undergone surgical or percutaneous revascularization within 2 years from the procedure.

Do not request a Holter ECG in patients with palpitations or syncope less than once a week.

Do not request annual follow-up echocardiography in patients with known mild-to-moderate valvular disease in the absence of new symptoms or clinical events and in patients with known mild left ventricular dysfunction in the absence of new symptoms or clinical events.

Do not request routine coronary angiography in all patients with heart failure with reduced systolic function, asymptomatic for angina pectoris, and without signs of inducible ischemia, with low pretest probability of coronary artery disease or in the absence of known anatomy favorable to further revascularization.

Do not request stress testing for inducible ischemia.

ANMDO

Don’t replace hand hygiene with the use of non-sterile disposable gloves. Use alcohol-based product as a first choice for hand hygiene routine. (Green recommendation)

Never administer antibiotics for perioperative prophylaxis before 60 minutes prior to surgical incision*; the ideal time is upon induction of anesthesia.

Never administer antibiotics for perioperative prophylaxis beyond 24 hours after surgery. Antibiotic prophylaxis should be limited to the perioperative period. The choice to continue prophylaxis beyond the first 24 postoperative hours is not justified.

Do not open the doors of the operating room during the surgical activity, except where necessary for the passage of patients, staff and equipment.

Do not forget to indicate in the patient health documentation (discharge letter or document for transfer to another healthcare facility) any positivity to alert microorganisms *

AOGOI

Don’t proceed to the early clamping (before 1 minute after birth) of the umbilical cord.

Don’t perform routine episiotomy apart from when there are clear clinical indications.

Don’t proceed to induction of labour before 39 weeks of gestation if appropriate maternal or fetal indications are lacking.

Don’t schedule routine repeated cesarean section (CS) in all the pregnant women with a previous cesarean section.

Don’t force to fasting and don’t forbid fluid intake during labour.

CIPOMO-Green Oncology

Don’t prescribe antibiotics to prevent infectious complications from neutropenia in cancer patients treated with standard dose chemotherapy.

Don’t routinely prescribe serum cancer markers during the diagnostic or staging procedures in cancer care.

Don’t routinely use cancer-directed therapy for solid tumor patients with low performance status (3 or 4) or progressive after 2-3 therapeutic lines, but prioritize palliative care.

Don’t perform laboratory tests (including biochemical profile), imaging (chest x-rays, liver and pelvic ultrasound, PET, CT and radionuclide bone scans) or serum cancer markers for asymptomatic patients after surgery for breast cancer, in the absence of clinical signs.

Don’t prescribe neither chemotherapy nor radiotherapy in the treatment of ductal carcinoma in situ of the breast.

CNF

Don’t recommend enteral nutrition (PEG, percutaneous endoscopic gastrostomy or naso-gastric feeding tube) in patients with advanced dementia; instead offer oral assisted feeding.

Don’t use antipsychotics as the first choice to treat behavioral symptoms of dementia, avoiding prescription before careful evaluation and removal of precipitating factors.

Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia.

Don’t recommend brain ¹⁸F-FDG PET (positron emission tomography) in the diagnostic investigation of dementia when clinical and neuropsychological assessment, laboratory tests and basic neuroimaging adequately support diagnosis.

Don’t recommend Amyloid PET (positron emission tomography) in asymptomatic individuals without cognitive impairment, even in the presence of a familiarity for dementia, and in subjects reporting deficits not confirmed by the neuropsychological evaluation.

CNF

In the anamnestic reconstruction of a possible transient loss of consciousness, do not fail to clarify whether the characteristics of the suspension of consciousness actually occurred and to draw up a list of all drugs in use.

In the clinical evaluation of the patient who has presented a transient loss of consciousness, do not leave out the measurement of blood pressure in the supine and standing position (horizontal and upright position) in order to exclude a condition of persistent orthostatic hypotension.

Do not perform an electroencephalogram (EEG) to patients who have experienced only transient loss of consciousness and have normal neurological examination and no history of epileptic symptoms.

Do not perform supra-aortic trunks ultrasound to patients who have experienced transient loss of consciousness in the absence of other neurological symptoms and with normal neurological examination. Adapted from the American Academy of Neurology.

Do not perform computed tomography (CT) or nuclear magnetic resonance imaging (MRI) of the brain to patients who have experienced transient loss of consciousness in the absence of other neurological symptoms and have normal neurological examination. Adapted from the American College of Physicians

COMLAS

Don’t promote the culture of “informed consent” as a mere bureaucratic and professional self-help tool.

Don’t prescribe clinical and instrumental tests aimed at the assessment of any disability otherwise already clinically proven.

Don’t encourage the use of defensive medicine practices.

Don’t draw advice and expertise without joining forensic criteriology* or lacking thorough technical and scientific analysis of clinical problems.

Don’t draw biased opinion in terms of health professional responsibilities, which may lead to false expectations in the assisted

CReI

Do not request the dosage of anti-CCP antibodies (cyclic citrullinated peptide) simply based on the presence of arthralgia.

Do not request the dosage of ANCA (antibodies against the cytoplasm of neutrophils) only in the presence of a clinical suspicion of connectivitis, without adequate and documented evaluation or evident clinical suspect of a vasculitis.

Do not request the dosage of ENA (Extractable Nuclear Antigens) / ENA profile in patients with Raynaud’s phenomenon before having performed a capillaroscopy.

Do not request a standard radiograph for diagnostic purposes in the clinical suspicion of an early-stage arthritis.

Do not request the dosage of ANA (anti-nucleic autoantibody) and rheumatoid factor dosage to a child when there is the presence of arthralgia, without any clinical objectivity.

FADOI

Do not prescribe “gastroprotection” for stress ulcer prophylaxis in medical patients unless there is a high risk of bleeding.

In the absence of urinary symptoms, do not screen for bacteriuria and in any case do not treat with antibiotics bacteriuria in elderly subjects whether they live in the community or in residential facilities.

Do not recommend PEG (Percutaneous Endoscopic Gastrostomy) in advanced dementia; instead, prefer assisted oral feeding.

Do not perform repetitive laboratory tests when patients show clinical and laboratory stability.

Use a restrictive strategy for transfusions of red blood cells (RBCs) (hemoglobin threshold 7-8 g/dl) in patients with anemia in the absence of acute coronary syndrome, current major bleeding or critical conditions and in patients with chronic anemia.

FADOI

Do not use benzodiazepines in elderly patients as a first choice for insomnia, agitation, delirium.

Do not delay palliative cares in the dying patients.

Do not routinely prescribe lipid lowering drugs in patients with a limited life expectancy.

Do not use non-steroid anti-inflammatory drugs (NSAID) in subjects with arterial hypertension, heart failure, renal insufficiency from any cause, including diabetes.

Do not perform PET/CT for cancer screening in healthy subjects.

FederSpecializzandi

Don’t recommend a test, a treatment or a procedure that will not change the patient clinical course; do not hesitate to ask your tutor for clarification if you believe that those tests, treatment or procedures are not necessary and always opt for less invasive options.

Don’t hesitate to ask to be appropriately evaluated during your learning process.

Don’t test new skills and procedures directly on patients, especially if not trained nor tutored.

Before and during the residency, don’t neglect to stay informed and know your contract and your rights as well as the national and local residency contract. Not knowing your rights could make you a danger to your patients!

Don’t focus only on clinical skills, work also on your soft skills.

FIMP

Do not prescribe any drug (nebulized and/or by systemic route) for treatment of Bronchiolitis.

Do not diagnose Urinary Tract Infection based on urine cultures alone

Do not treat a fever systemically unless there are symptoms of discomfort. If you decide to treat it, use an appropriate dose avoiding combined/alternate use of paracetamol and ibuprofen

Do not use oral corticosteroids for fever management

Do not use topical nasal therapy through Nebulizers with drugs not specifically approved for this route of administration

FNOPI

Don’t perform preoperative hair removal with a razor blade in anticipation of surgery (AICO).

Don’t incorrectly use collection devices for ostomy with convex plate. (AIOSS).

Don’t incorrectly use chemicals for clearing the stomatal complex. (AIOSS)

Don’t use abrasive disinfectants on intact skin in the elderly, who are bedridden and with fragile and/or damaged skin. (AIUC)

Don’t use bladder training (repeated closure of the catheter) before urinary catheter removal. (AIURO – ANIMO)

FNOPI ped

Don’t run the newborn hearing screening at birth but at least after 48 hours of life in a 1st level birth center.

Don’t replace devices without assessing the skin integrity.

Don’t reheat several times artificial or breast milk before feeding it to the baby.

Don’t heat the milk to inappropriate temperatures to prevent nutrient decomposition and store it properly.

Don’t use physical restraint as a first choice during painful procedures in children

ISDE

Air: do not consume fuels of “fossil” origin (coal, oil, gas). Whenever possible, use renewable energy (solar, photovoltaic, wind, geothermal, energy-saving buildings) and reduce the use of private vehicles in the city by encouraging the use of: bicycles, public transport, shared private vehicles, pedestrian mobility. Limit travel by plane as much as possible by favoring the use of the train, not necessarily at High Speed. Try to oppose against the fashion of cruise tourism.

Water: Do not drink bottled water, but whenever possible favor tap water, which is safe and controlled.

Biodiversity. Antibiotics: only when indispensable! For common respiratory infections (colds, rhinosinusitis, cough/bronchitis, flu syndromes) and bacteria in the urine without symptoms, do not prescribe antibiotics, because generally they are useless, and expose patient and family to risks, both present and future. The rule is to avoid them, leaving to doctors’ autonomy the assessment of any exception.

Ionizing Radiation: X-rays should not be carried out unless a specific clinical indication.

Nutrition: Limit the foods of animal origin and industrial production. Give preference to fruits, vegetables, whole cereals and legumes, better if fresh, from your local area, and cultivated according to current season and in a biological way.

ISDE

Do not focus on illness: don’t forget primary prevention and health empowerment.

Do not prescribe periodic examinations without a specific diagnostic hypothesis.

Do not prescribe drugs first in many chronic illness but advise lyfestiles modifications.

Do not routinely prescribe metered-dose inhalers but dry powder inhalers.

Do not use printed medical prescriptions but transmit prescriptions electronically.

ITACARE-P

Do not perform an ischemia induction test in the follow-up of chronic coronary syndromes in the stable and asymptomatic patient.

Do not prescribe Vitamin K Antagonists if the patient has no contraindication to the use of direct oral anticoagulants (DOACs).

Do not systematically request an ECG-Holter in patients with sporadic palpitation if structural heart disease has already been excluded.

Do not routinely check a carotid stenosis of less than 50% every year with Color Doppler Ultrasound.

Do not prescribe benzodiazepines and Serotonergic Antidepressants (SSRIs) after an acute cardiovascular event without planning for a follow-up review.

Italian College of the Directors of Vascular Surgery

Do not request a Duplex scan as a first level test for lower limb arterial disease, in patients that are asymptomatic or with mild claudication. Measure instead the Ankle Brachial Index (ABI).

Do not perform Duplex scan or Chest CT scan as first level tests for patients that, according to Wells or Geneva score, have a low probability of Deep Venous Thrombosis (DVT). D-dimer determination has a high sensitivity as a first level test.

Do not request a Duplex scan of the carotid arteries for vertigo, tinnitus, headache, neck pain, unless there are neurologic signs.

Do not perform open or endovascular treatment of lower limb lesions unless there is disabling claudication, critical limb ischemia or diabetic foot.

Do not stent a stenotic renal artery unless there is refractory hypertension or declining renal function.

LIMPE-DISMOV

Do not use brain scintigraphic examinations such as brain SPECT (Single Photon Emission Tomography) with dopamine transporter marker (DAT-SCAN) or myocardial examination with Metaiodobenzylguanidine (MIBG) as well as positron emission brain tomography (PET) with any radionuclide, for diagnostic confirmation of Parkinson’s disease or to evaluate its progression.

Do not use drugs that may worsen the symptoms of Parkinson’s disease, such as anti-dopaminergic, alphalitic and anticholinergic drugs, without consulting your neurologist.

Do not delay prescribing levodopa if appropriate, and instead, do not use drugs for the complicated phase of the disease prematurely.

Do not abruptly discontinue/modify Parkinson’s disease therapy.

Do not underestimate the importance of multidisciplinary and non-pharmacological approaches.

SIAAIC

Don’t perform allergy tests for drugs (including anhestetics) and/or foods when there are not clinical history and symptoms suggestive of hypersensitivity reactions.

Don’t perform the so-called “food intolerance tests” (apart from those which are validated for suspect celiac disease or lactose enzymatic intolerance)

Don’t perform serological allergy tests (i.e.: total IgE, specific IgE, ISAC) as first-line tests or as “screening” assays.

Don’t treat patients sensitized to allergens or aptens if there is not a clear correlation between exposure to that specific allergen/apten and symptoms suggestive of allergic reaction. This recommendation is particularly strong for allergen immunotherapy and elimination diets.

Don’t diagnose asthma without having performed lung function tests (including bronchodilating test and/or bronchial challenge).

SIAARTI

Do not perform routine blood tests on patients undergoing surgery (or anaesthetic evaluation).

Do not perform blood tests routinely and daily in patients admitted to Intensive Care, but only on the basis of specific clinical questions.

Do not perform blood transfusions for arbitrary Hb values > 70 g/l but evaluate the clinical need of each individual patient (bleeding, hemodynamic stability, comorbidity).

Do not exceed 24 hours of antibiotic prophylaxis after surgery, the duration of prophylaxis should be as short as possible.

Don’t wait until the pain is at its peak intensity to start treatment, but actively prevent it by setting up an appropriate basic therapy for as long as necessary.

SIAARTI

Don’t use inhaled anesthetic agents with high global warming potential, such as desflurane and nitrous oxide.

Don’t use high fresh gas flows; prefer low flows and the minimum effective oxygen concentration.

Don’t choose unsustainable anaesthetic techniques, materials/devices or behaviours.

Don’t use disposable materials unless strictly necessary, and do not neglect proper separate waste collection.

Every anaesthetist-intensivist must not forget to be, with the support of scientific societies, a protagonist and promoter of sustainable practices in the operating theatre and intensive care unit.

SIAIP

Avoid contraindicating routinely vaccination in case of allergies.

Avoid performing routine allergy testing in children with acute urticaria.

Avoid prescribing mucolytics in children with bronchial asthma.

Avoid prescribing routine immunological tests in children with recurrent respiratory infections.

Avoid ruling out a food from the diet only for the positivity of skin prick tests and/or specific serum IgE.

SIAMS

Do not measure serum free testosterone in the suspicion of male hypogonadism.

Do not prescribe nutraceuticals in all male patients with sperm abnormalities.

Do not prescribe phosphodiesterase-5 inhibitors (PDE5i) in men with erectile dysfunction (ED) without an adequate diagnostic work-up.

Do not perform genetic tests and assessment of sperm DNA fragmentation in all male patients with sperm abnormalities.

Do not use phytoestrogens for menopausal-related sexual symptoms.

SIBIoC

Don’t perform serum protein electrophoresis nor search of urinary Bence-Jones protein as laboratory test before contrast media administration.

Don’t ask for AST, LDH, total CK, CK-MB or myoglobin for the diagnosis of acute myocardial infarction.

Don’t perform the determination of urine glucose for the monitoring of diabetes mellitus.

Don’t ask for the determination of serum biomarkers like CEA, CA-125, HE4, CA-15.3, a-fetoprotein or CA-19.9 for the diagnosis of neoplastic disease in asymptomatic individuals.

Don’t ask for the measurement of pancreatic enzymes in people who have no suspicion of acute pancreatic disease and, in the case of suspected acute pancreatitis, don’t ask the associated measure of amylase and lipase.

SICP

Don’t exclude nor postpone the oral or parenteral administration of opioids for the palliative treatment of dyspnoea in patients affected by chronic incurable illness with a limited life expectancy.

Don’t initiate or prolong artificial nutrition (enteral or parenteral) in late stage cancer patients with a life expectancy of less than a few weeks and a Performance Status <50.

Don’t combine drugs for which there is no documented evidence of compatibility and chemical and physical stability in devices for the continuous subcutaneous or intravenous infusion of medications (e.g. Elastomers).

Do not postpone the start of a shared care planning with the patient, when the evolution of the disease makes it important to understand the expectations and desires of the sick person regarding possible choices at the end of life.

SICuPP

The foreskin should not be forcibly retracted if physiologic phimosis is present

An oral dose of vitamin K is not recommended in term newborns who received an intramuscular shot at birth

Do not routinely prescribe antiseptic medication in the umbilical cord care

Fear of febrile seizure should not lead to vaccination hesitancy in healthy children

Do not prescribe systemic fluoride but rather promote oral hygiene and age-related use of toothpaste

SIdCO

DON’T routinely PRESCRIBE antibiotic in patients undergoing dental extractions

DON’T DELAY dental care due to pregnancy

DON’T EXTRACT impacted third lower molars WITHOUT a valid clinical indication

DON’T routinely DISCONTINUE antiplatelet agents in oral surgical procedures and DON’T REPLACE them with low molecular weight heparins

DON’T REQUIRE dental radiography exams WITHOUT a valid working diagnosis, clearly stated in the clinical prescription

SIFACT

Don’t use costly drugs when low-cost generics with the same composition are available and try to convey a correct information to citizens on this point.

Don’t propose any type of palliative chemotherapy in the end-of-life setting.

Don’t prescribe MF-59 adjuvated influenza vaccine in elderly people.

Don’t prefer bioresorbable coronary stents over traditional drug-eluting stents.

Don’t use bevacizumab for its various oncologic indications.

SIGU

Don’t perform genetic testing for mutations analysis in the 5,10-Methylene TetraHydrofolate Reductase (MTHFR) gene

Don’t perform genetic tests directly to consumers, purchased on websites, pharmacies, gyms, beauty institutions, without a doctor’s prescription.

Don’t perform genetic tests for monogenic diseases without specific indication both in the physiological procreation or by assisted reproduction technology (ART).

Don’t perform HLA genotyping in the presence of established diagnosis of celiac disease or for screening purpose.

Don’t perform screening tests of polymorphisms of factor V (Leiden) and Factor II (G20210A) in unselected patients, like all patients with only one episodes of venous thrombosis, in healthy subjects or in pregnant women with no specific anamnestic signs or before to start a treatment with oral contraceptives.

SIGU

Do not perform genetic testing for polymorphisms in genes involved in detoxification processes for the diagnosis of Multiple Chemical Sensitivity (MCS)

Do not perform genetic testing for Y chromosome microdeletions as a screening test for all male patients with reproductive problems

Do not include Glucose 6 Phosphate Dehydrogenase (G6PD) in the tests required for Medically Assisted Reproduction (MAP)

Do not perform prenatal testing that can be performed on circulating fetal free fetal DNA (cfDNA) by non-invasive prenatal testing (NIPT) without first informing women about the limitations and accuracy of the different prenatal investigations that can be performed

Do not perform test investigating genes associated with food metabolism and food intolerances (genetic testing for nutrition) to define a dietary path

SIMG

Don’t routinely prescribe imaging for low back pain without warning signs or symptoms (Red Flags)

Don’t routinely prescribe antibiotics for acute upper airway infections. Assess the opportunity in patients at risk of lower respiratory tract infection or in case of clinical worsening after a few days

Don’t routinely prescribe Proton Pump Inhibitors (PPI) in patients without risk factors for ulcer disease. In gastroesophageal reflux disease prescribe the lowest dose that can control symptoms and educate the patient to desirable withdrawal periods.

Don’t prescribe therapies with anti-inflammatory drugs (NSAIDs) without initial and periodical assessment in each patient of the actual clinical indications and of the side effects risk at that time.

Don’t routinely prescribe benzodiazepines or Z -drugs in elderly patients in case of insomnia as first choice treatment. Physicians should always recommend intermittent use of these drugs.In case of chronic use, evaluate both the indications and the possible occurrence of side effects

SIMPIOS

Don’t examine or assist a patient without having first done an accurate hand hygiene, that has to be repeated at the end of the examination.

Don’t utilize reusable medical instrumentations that have not been adequately re-processed.

Don’t perform an urino-culture if without symptoms.

Don’t use fluoroquinolone antibiotics in empiric therapies, even if for severe infections, but use antibiotics with less impact on antibiotic resistance phenomenon and with less side effects.

Don’t prescribe antibiotic therapy to patients colonized by multi-resistant antibiotics microorganisms without signs of infection.

SIMRI

Do not perform chest X-ray in a child with suspected non-severe community-acquired pneumonia or with uncomplicated acute asthma.

Do not use salmeterol in children with acute asthma.

Do not perform CT scans in children in the absence of strict clinical indications.

Do not prescribe antihistamines for preventing asthma in children.

Asthma should not be diagnosed without performing spirometry.

SIN-Nephrology

Do not perform creatinine clearance tests in situations where it is impossible to ensure an accurate urine collection, or when it is not necessary to measure urinary creatinine excretion. In such cases, it is preferable to assess renal function by calculating the eGFR (the volume of the filtrate).

Do not perform computerized tomography (CT) for the diagnosis of renal stones. It is initially preferable to use ultrasound.

Only opt for chronic dialysis after a decision-making process has been conducted jointly with patients, their families, and their family physicians.

Do not administer erythropoiesis stimulating agents (ESA) to patients with chronic kidney disease (CKD) and spontaneous hemoglobin levels between 10 and 11 g/dL with no symptoms of anemization. The same applies to patients who have not been tested for blood ferritin levels and transferrin saturation, at least.

Avoid the use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients suffering from hypertension, cardiac insufficiency or chronic kidney disease – whatever their cause (including diabetes).

SINePe

Urine culture should not be carried out either routinely or in the absence of the typical symptoms of a urinary tract infection; bag urine collection should be avoided

In the case of low-grade or asymptomatic proteinuria, it is not necessary to perform blood tests or complex instrumental exams. In these cases, medical history, physical exam and urine tests (two separate tests performed at least a week apart) are sufficient. The appropriate diagnostic approach for proteinuria should be followed, if proteinuria persists.

The indiscriminate use of albumin in children with a first episode of nephrotic syndrome is not recommended.

When asymptomatic microhaematuria is detected in a random urine sample, biohumoral or instrumental exams are not necessary.

Children under 6 years of age with primary monosymptomatic enuresis do not need to be seen by a specialist, undergo laboratory (with the exception of urinary dipstick) or instrumental testing or start pharmacological treatment.

SIP

Discourage pediatric patients attending the Emergency Room with mild symptoms suggestive of COVID-19 or if they are contacts of SARS-CoV-2 positive patients in the absence of symptoms and do not delay access to Health Services if children and adolescents present with any clinical condition indicative of possible serious illness (whether or not related to presumed COVID-19 infection).

Do not administer drug therapy other than symptomatic drugs in pediatric and adolescent cases of COVID-19 for which hospitalization is not required.

Do not modify, reduce, or discontinue usual therapies without a specific clinical indication in children and adolescents with chronic disease and COVID-19.

Do not postpone routine immunization or modify usual pediatric preventive and treatment measures in both the territory and hospital during the circulation of SARS-CoV-2.

Avoid as much as possible the closure of educational services and schools by carefully assessing the need for it with the competent authorities, in order to protect the psychophysical health and promote the development of children and adolescents.

SIP

Do not substitute careful hand hygiene for just wearing gloves. (Green recommendation)

Do not neglect careful disinfection of the baby’s skin with alcohol-based antiseptic solutions and that of the newborn with chlorhexidine or iodophore before any surgical procedure

Do not perform peri-operative antibiotic prophylaxis when it is not necessary

Do not administer antibiotic for peri-operative prophylaxis before 60 minutes prior to surgical incision and do not continue it postoperatively unless specifically indicated

Do not overlook the risk of patient colonization by multi-resistant microorganisms

SIPeM

Don’t use non-interactive lectures as the main teaching method. Privilege the use of interactive methods instead.

Don’t address topics about clinical or organization choices without considering their ethical, social and inter-professional aspects, patient’s expectations and values, and the most appropriate teaching setting (hospital, primary care).

Avoid non-structured oral exams, and don’t use only cognitive tools of technical knowledge in the assessment of practical skills.

Don’t let learners perform procedures directly on patients, without having practiced them in an appropriate simulated model, and without proper tutorial supervision.

Don’t use only cognitive tests with a prevalent biological focus in the selection of candidates for the access to undergraduate and postgraduate medical and health sciences schools.

SIPMeL

Don’t routinely request creatin kinase-MB (CK-MB), total creatin kinase (CK), aspartato transaminase (AST), lactic-dehydrogenase (LDH) e myoglobin diagnosing Acute Coronary Syndromes (ACS).

Don’t perform the determination of urine glucose for the monitoring of diabetes mellitus.

Don’t routinely request preoperative laboratory tests in low-risk patients (for minor surgery and for intermediate surgery in ASA 1, ASA 2 patients).

Don’t request serum protein electrophoresis nor search urinary Bence-Jones protein as laboratory test before contrast media administration.

Don’t request the determination of serum biomarkers like CEA, CA-125, HE4, CA-15.3, -fetoprotein or CA-19.9 for the diagnosis of neoplastic disease in asymptomatic patients.

SIPMeL

Do not screen asymptomatic subjects. Do not request an extended panel of thyroid function tests in suspected thyroid function impairment; limit to TSH or TSH Reflex in all cases where it is not contraindicated. Do not require FT3 determination for monitoring levothyroxine therapy in patients with hypothyroidism.

Do not require anti-Thyroperoxidase (AbTPO) and anti-Thyroglobulin (AbTg) antibodies together in suspected autoimmune thyroiditis, only AbTPO.

Do not measure serum cortisol and plasma corticotropin (ACTH) at random times during the day as first-line tests in suspected Cushing’s syndrome.

Do not require urinary vanillymandelic acid and plasma and/or urinary catecholamines for diagnosis of pheochromocytoma-paraganglioma.

Do not use the determination of 25OH vitamin D (25OH-D) as a routine or screening test to determine the status of hypovitaminosis without a specific clinical indication.

SIPMeL

In the case of autoimmune thyrotoxicosis / hyperthyroidism, anti-TPO and anti-Tg antibodies should not be sought; search instead for anti-TSHR antibodies (TRAb). Do not request anti-TPO (anti-thyroid peroxidase) and anti-Tg (anti-thyroglobulin) antibody tests in the monitoring of autoimmune thyroid disease.

Do not order the HEp-2 indirect immunofluorescence test for ANA (antibodies to cellular antigens) as a screening test in patients with suspected autoimmune myositis.

When myasthenia gravis is suspected, specific autoantibodies (AChR, MuSK, Lrp4) should not be searched as a profile, but the initial test is represented only by anti-AchR antibodies.

Do not search for IgA class antibodies to deamidated gliadin peptide (DGP) to screen for celiac disease in the general population.

In the case of suspected late-onset autoimmune diabetes (LADA) or gestational diabetes mellitus, the search for anti-insular cell antibodies (ICA) and anti-insulin antibodies (IAA) should not be performed.

SIPMeL

Don’t request amylase in addition to lipase if acute pancreatitis is suspected.

Don’t request erythrocyte sedimentation rate to screen asymptomatic patients or as a general test to look for inflammatory states in patients with undiagnosed conditions.

Don’t request blood ammonium measurement for diagnosis or management of hepatic encephalopathy (HE) in patients with chronic hepatopathy.

Don’t measure procalcitonin outside of evidence-based protocols defined by professional Societies or at the health organization/regional/national level.

Don’t request uric acid as part of routine assessment of cardiovascular risk, obesity or diabetes.

SIPMeL

Do not perform routine laboratory tests or screenings without a clear clinical question and within an inappropriate retesting interval.

Do not acquire reagents, instrumentation, and/or laboratory supplies without considering their environmental impact, while maintaining diagnostic efficiency.

Do not use the paper report when a dematerialized report or electronic health record is available.

Do not engage in automatic or unconscious behaviors that lead to the waste of reagents, the use of non-essential single-use plastics, improper waste management, or energy waste, in compliance with the laboratory’s Quality System.

Do not overlook advocacy for “Green Laboratory” initiatives, a key element in raising awareness among institutions, companies, citizens, and patients toward a sustainable healthcare system. The laboratory must not limit itself to communicating internally its choices, awareness initiatives, results, and sustainability goals, but must also address patients, institutions, suppliers, and the broader community.

SIPPS

Don’t prescribe blood exams in children with acute pharyngitis.

Don’t administer antibiotics in children with acute pharyngitis unless microbiologic confirmation of streptococcal infection has been carried out.

If throat culture is performed, susceptibility tests on isolates should not be executed in children with acute pharyngitis.

Don’t shorten antibiotic course in children with acute pharyngitis and microbiologic confirmation of streptococcal infection.

Don’t administer steroids to children with acute pharyngitis.

SIRM

Don’t perform magnetic resonance imaging (MRI) of the spine within the first six weeks in patients with low back pain in the absence of warning signs or symptoms (red flags).

Don’t perform routine magnetic resonance imaging (MRI) of the knee in the event of acute pain from trauma or chronic pain.

Don’t perform magnetic resonance imaging (MRI) for non-traumatic headache in the absence of warning clinical signs.

Don’t perform preoperative chest x-rays in the absence of clinical signs or symptoms which indicate diseases that could affect the outcome of the surgery.

Don’t perform routine radiology of the skull in minor head injury.

SIRM

In children, do not prescribe or perform routine X-rays of the contralateral limb in trauma.

In infants and children with epilepsy do not perform routine CT of the skull and brain.

In infants and children younger than 6 years of age with suspected sinusitis, do not perform X-rays of the sinuses.

In children less than 3 years of age, do not perform X-rays of the nasal bones if a fracture is suspected.

In infants and children with torticollis without trauma, do not perform X-rays of the cervical spine.

SISM

Don’t settle for receiving a teaching limited to a mere mnemonic exercise that does not employ active learning processes, require to center the teaching on the semeiological examination and on the rational that underlies every diagnostic and therapeutic process.

Don’t observe the patient only from the biological point of view but consider also the subjective component of the disease, the level of health literacy and the familial and social context in which the patient is inserted.

Don’t perform any diagnostic or therapeutic procedure without having previously collected the medical history and information on possible allergies or pre-existing diseases of the patient.

Don’t neglect to gather informations not only about the benefits, but also about the contraindications or side effects of the diagnostic or therapeutic procedures.

Before entering in the room and starting the examination, don’t forget to ask the doctor/tutor informations about the patient’s state of health and don’t engage in diagnostic procedures without previously obtaining informed consent from the patient.

SItI

Don’t replace hand hygiene with the use of non-sterile disposable gloves. Use alcohol-based product as a first choice for hand hygiene routine. (Green recommendation)

Never administer antibiotics for perioperative prophylaxis before 60 minutes prior to surgical incision*; the ideal time is upon induction of anesthesia.

Do not open the doors of the operating room during the surgical activity, except where necessary for the passage of patients, staff and equipment.

Do not forget to indicate in the patient health documentation (discharge letter or document for transfer to another healthcare facility) any positivity to alert microorganisms *

SICP #1

ACP

Avoid the habitual use of inhaled corticalsteroids in upper respiratory tract infections in children.

In absence of medical indications do not prescribe formula or liquids other than breast milk to newborns in the first weeks of life.

Do not prescribe antibiotics for viral acute respiratory tract diseases (ear infections, sinusitis, pharyngitis, bronchitis)

Do not prescrive chest x-ray for diagnosis and follow-up of uncomplicated pneumonia in children

ADI

Don’t follow “elimination” or fasting diets. These are specific nutritional approaches for some pathologies and only physicians can recommend them.

Do not encourage the extensive and indiscriminate use of vitamin and mineral supplements as preventive elements for cancer and cardiovascular disease.

Obese people of any age are not to be blamed. The stigma of obesity worsens the condition of those who are affected.

AICPR

Don’t perform routine chest X-ray in patients entering rehabilitation programme after cardiac surgery

Don’t perform Computed Tomography for coronary calcium score in patients at high cardioascular risk

Don’t perfom Holter electrocardiographic monitoring in patients suffering from syncope, near syncope o dizziness, in whom a non arrhytmic origin has been documented

Don’t routinely prescribe proton pump inhibitors (PPI) for gastrointestinal bleeding profilaxis in patient with single drug antiplatelet therapy in absence of additional risk factors

Avoid routine use of Infective endocarditis profilaxis in mild to moderate native valve disease

AIFI

Do not use continuous passive mobilization (CPM) devices for postsurgical treatment of knee ligament reconstructions or uncomplicated hip or knee arthroplasties.

Do not use mechanical or manual traction, as single treatment or in combination with other treatments, in patients with low back pain, in presence or absence of radicular pain.

Do not use specific exercises of selective strengthening of the vastus medialis obliquus (VMO) in patellofemoral pain syndrome.

Do not use ultrasound therapy for rotator cuff tendinopathy, ankle sprains and low back pain.

Do not teach or have patients with acute or chronic respiratory diseases practice diaphragmatic breathing.

AIGO

Prescribe fecal occult blood test (FOBT) only for screening of colorectal cancer.

Don’t repeat esofagogastroduodenoscopy (EGDS) for a patient that has been diagnosed with a gastroesophageal reflux disease, with or without hiatal hernia, in absence of new symptoms.

Once the diagnosis is established, don’t prescribe systematic abdominal ultrasound checkup in asymptomatic patients with epathic angiomas < 30 mm in diameter.

Don’t prescribe proton pump inhibitors (PPI) during steroid therapy or for long periods with patients that exhibit dyspeptic symptoms.

AIGO

Do not request surveillance investigations for patients with pancreatic cysts who are poor surgical candidates, irrespective of cysts nature and characteristics

Do not request esophagogastroduodenoscopy in patients with recent onset of upper gastrointestinal symptoms younger than 50 years, without alarm features

Do not request surveillance colonoscopy for asymptomatic colonic diverticular disease without changes in symptoms

Do not perform food intolerance tests except for those scientifically validated

Do not prescribe proton pump inhibitors to patients with liver cirrhosis, outside of established indications

AIGO

Do not prescribe endoscopic examination when low-waste, less invasive alternatives endorsed by evidence-based clinical guidelines are available.

Do not take mucosal biopsies when the histopathological results would not change the patient management.

Do not plan most elective endoscopic procedures on an inpatient basis if they can be performed safely without hospitalization, to avoid overnight hospital stays.

Do not use single use endoscopes regularly as they should be reserved for highly selected patients, on a case-by-case basis (immunocompromised patients or those with multidrug-resistant bacteria).

Do not abuse of periprocedural and intraprocedural medication and prefer their use only when strictly indicated (e.g. avoid inadequate antibiotic prophylaxis and saline fluid intravenous solution)

AIMN

Don’t use 18F-FDG (Fluorodeoxyglucose) PET-CT as a “screening” test for cancer in healthy subjects.

Don’t perform PET/CT with [18F]FDG (Fluorodeoxyglucose) in suspected peripheral osteomyelitis and in differential diagnosing between acute and chronic infection.

Don’t perform lymphoscintigraphy and radioguided biopsy of the sentinel node in patients affected by cutaneous melanoma thinner than 0.75 mm, with no ulceration and mitotic rate <1/mm2

AIRO

Do not recommend the use of “special” techniques or radiation therapy machines without having previously obtained the recommendation by a radiation oncologist.

Do not neglect to offer radiotherapy delivered with hypofractionated schedules when the scientific evidence is already available.

Do not use, to the extent possible, prolonged radiation therapy for palliative treatments in frail patients with a short life expectancy

Limit the use of diagnostic procedures in case of low-risk prostate and breast cancer. Avoid the use of serum biomarkers in early stage breast cancer.

AIURO

Don’t practice bladder catheterization with 2-ways latex catheters; caliber of less than 22 ch for men and 20 ch for women; in patients with suspected or confirmed diagnosis of macrohematuria.

Don’t carry out the assessment of pain without using standardized scales in the immediate post-operative period.

Unless there is any complication, don’t renew the dressing of the surgical site in the first 48 hours after surgery.

Don’t renew the advanced dressings placed on complicated and/or infected surgical site with different timing than indicated by the guidelines and the product specifications.

AMD

Don’t use the ‘sliding scale insulin therapy’ for the treatment of hyperglycemia in hospitalized patients.

Don’t prescribe routine glucose self-monitoring to Type 2 diabetes patients who are being treated with drugs that do not cause hypoglycemia.

Don’t prescribe screenings for diabetes complications that are not in accordance with the national guidelines.

Don’t treat diabetes patients indiscriminately with antiplatelet drugs.

Don’t perform routine measurement of C-peptide in diabetes patients.

AME

Avoid excess bone density testing: intervals less than two years are rarely necessary.

Use of free testosterone testing is not recommended for hypogonadism or hyperandrogenism diagnosis.

Do not prescribe the dosage of FT3 (free triiodothyronine) for the initial evaluation of the functional state of the thyroid and in the periodic control of hypothyroidism in therapy.

Thyroid nodules patients should not be treated with L-thyroxine except in selected cases.

AMGE

Don’t prescribe a medication without conducting a drug regimen review (medication reconciliation)

Don’t use antimicrobials to treat asymptomatic bacteriuria in older adults

Don’t let older adults lie in bed all day during their hospital stay unless they’re terminally ill or they’ve got a specific medical advice

ANDRIA

Don’t clamp the umbilical cord before 1 minute in neonates that do not need immediate resuscitation manouvres.

Don’t use continous cardiotocography (CTG) during labour of women at low risk for hypoxia.

Don’t routinely require general blood tests, general coagulation tests or tests for trombophylia to prescribe hormonal contraceptive medications.

Don’t require a pelvic exam or other physical exam to prescribe oral contraceptive medications.

Don’t schedule elective, non medically indicated inductions of labour or Cesarean deliveries before 39 weeks 0 days gestational age.

ANIARTI

Don’t replace regularly the mechanical ventilator circuits to reduce the risk of VAP (Ventilator Associated Pneumonia)

Don’t routinely use personal protective equipment (gowns, masks, hats, gloves, ….) for the access of family members in ICU. (Green recommendation)

Don’t perform endotracheal aspirations at regular intervals but according to early indicators of retention of bronchial secretions.

Don’t replace peripheral venous catheters at regular intervals but based on clinical evaluation.

Don’t maintain routine preoperative fasting since the midnight preceding the elective surgery.

ANIMO

Don’t make regular use of restraint as a falls risk management tool.

Don’t resort to bladder catheterization for managing incontinence or performing simple diagnostic tests.

Don’t leave in place any type of venous catheter (central; peripheral; short, medium or long term) if the problem for which it was set is no longer present.

Don’t follow the mobilization protocols and those for the treatment of pressure sores as “standard” protocols in the dying patient.

ANIPIO

Do not use antiseptic products routinely in addition to or in place of normal detergent in the pre-operative bath/shower.

Do not maintain precautionary isolation upon symptom resolution in patients with Clostridium difficile diarrhoea.

Do not replace surgical dressings before 48 hours have elapsed from the operation.

ANIPIO

Do not use double pair of non-sterile gloves in patient care.

Do not use disposable adhesive surgical sheets with the intent of reducing surgical site infections (Surgical Site Infections – SSI)

For patients in isolation rooms, do not place isolation supplies, equipment and medical devices of no immediate use at the bedside.

ANMCO

Do not request a Holter ECG in patients with palpitations or syncope less than once a week.

Do not request stress testing for inducible ischemia.

ANMDO

Don’t replace hand hygiene with the use of non-sterile disposable gloves. Use alcohol-based product as a first choice for hand hygiene routine. (Green recommendation)

Never administer antibiotics for perioperative prophylaxis before 60 minutes prior to surgical incision*; the ideal time is upon induction of anesthesia.

Do not open the doors of the operating room during the surgical activity, except where necessary for the passage of patients, staff and equipment.

Do not forget to indicate in the patient health documentation (discharge letter or document for transfer to another healthcare facility) any positivity to alert microorganisms *

AOGOI

Don’t proceed to the early clamping (before 1 minute after birth) of the umbilical cord.

Don’t perform routine episiotomy apart from when there are clear clinical indications.

Don’t proceed to induction of labour before 39 weeks of gestation if appropriate maternal or fetal indications are lacking.

Don’t schedule routine repeated cesarean section (CS) in all the pregnant women with a previous cesarean section.

Don’t force to fasting and don’t forbid fluid intake during labour.

CIPOMO-Green Oncology

Don’t prescribe antibiotics to prevent infectious complications from neutropenia in cancer patients treated with standard dose chemotherapy.

Don’t routinely prescribe serum cancer markers during the diagnostic or staging procedures in cancer care.

Don’t routinely use cancer-directed therapy for solid tumor patients with low performance status (3 or 4) or progressive after 2-3 therapeutic lines, but prioritize palliative care.

Don’t prescribe neither chemotherapy nor radiotherapy in the treatment of ductal carcinoma in situ of the breast.

CNF

Don’t recommend enteral nutrition (PEG, percutaneous endoscopic gastrostomy or naso-gastric feeding tube) in patients with advanced dementia; instead offer oral assisted feeding.

Don’t use antipsychotics as the first choice to treat behavioral symptoms of dementia, avoiding prescription before careful evaluation and removal of precipitating factors.

Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia.

CNF

Do not perform an electroencephalogram (EEG) to patients who have experienced only transient loss of consciousness and have normal neurological examination and no history of epileptic symptoms.

COMLAS

Don’t promote the culture of “informed consent” as a mere bureaucratic and professional self-help tool.

Don’t prescribe clinical and instrumental tests aimed at the assessment of any disability otherwise already clinically proven.

Don’t encourage the use of defensive medicine practices.

Don’t draw advice and expertise without joining forensic criteriology* or lacking thorough technical and scientific analysis of clinical problems.

Don’t draw biased opinion in terms of health professional responsibilities, which may lead to false expectations in the assisted

CReI

Do not request the dosage of anti-CCP antibodies (cyclic citrullinated peptide) simply based on the presence of arthralgia.

Do not request the dosage of ENA (Extractable Nuclear Antigens) / ENA profile in patients with Raynaud’s phenomenon before having performed a capillaroscopy.

Do not request a standard radiograph for diagnostic purposes in the clinical suspicion of an early-stage arthritis.

Do not request the dosage of ANA (anti-nucleic autoantibody) and rheumatoid factor dosage to a child when there is the presence of arthralgia, without any clinical objectivity.

FADOI

Do not prescribe “gastroprotection” for stress ulcer prophylaxis in medical patients unless there is a high risk of bleeding.

Do not recommend PEG (Percutaneous Endoscopic Gastrostomy) in advanced dementia; instead, prefer assisted oral feeding.

Do not perform repetitive laboratory tests when patients show clinical and laboratory stability.

FADOI

Do not use benzodiazepines in elderly patients as a first choice for insomnia, agitation, delirium.

Do not delay palliative cares in the dying patients.

Do not routinely prescribe lipid lowering drugs in patients with a limited life expectancy.

Do not use non-steroid anti-inflammatory drugs (NSAID) in subjects with arterial hypertension, heart failure, renal insufficiency from any cause, including diabetes.

Do not perform PET/CT for cancer screening in healthy subjects.

FederSpecializzandi

Don’t hesitate to ask to be appropriately evaluated during your learning process.

Don’t test new skills and procedures directly on patients, especially if not trained nor tutored.

Don’t focus only on clinical skills, work also on your soft skills.

FIMP

Do not prescribe any drug (nebulized and/or by systemic route) for treatment of Bronchiolitis.

Do not diagnose Urinary Tract Infection based on urine cultures alone

Do not treat a fever systemically unless there are symptoms of discomfort. If you decide to treat it, use an appropriate dose avoiding combined/alternate use of paracetamol and ibuprofen

Do not use oral corticosteroids for fever management

Do not use topical nasal therapy through Nebulizers with drugs not specifically approved for this route of administration

FNOPI

Don’t perform preoperative hair removal with a razor blade in anticipation of surgery (AICO).

Don’t incorrectly use collection devices for ostomy with convex plate. (AIOSS).

Don’t incorrectly use chemicals for clearing the stomatal complex. (AIOSS)

Don’t use abrasive disinfectants on intact skin in the elderly, who are bedridden and with fragile and/or damaged skin. (AIUC)

Don’t use bladder training (repeated closure of the catheter) before urinary catheter removal. (AIURO – ANIMO)

FNOPI ped

Don’t run the newborn hearing screening at birth but at least after 48 hours of life in a 1st level birth center.

Don’t replace devices without assessing the skin integrity.

Don’t reheat several times artificial or breast milk before feeding it to the baby.

Don’t heat the milk to inappropriate temperatures to prevent nutrient decomposition and store it properly.

Don’t use physical restraint as a first choice during painful procedures in children

ISDE

Water: Do not drink bottled water, but whenever possible favor tap water, which is safe and controlled.

Ionizing Radiation: X-rays should not be carried out unless a specific clinical indication.

ISDE

Do not focus on illness: don’t forget primary prevention and health empowerment.

Do not prescribe periodic examinations without a specific diagnostic hypothesis.

Do not prescribe drugs first in many chronic illness but advise lyfestiles modifications.

Do not routinely prescribe metered-dose inhalers but dry powder inhalers.

Do not use printed medical prescriptions but transmit prescriptions electronically.

ITACARE-P

Do not perform an ischemia induction test in the follow-up of chronic coronary syndromes in the stable and asymptomatic patient.

Do not prescribe Vitamin K Antagonists if the patient has no contraindication to the use of direct oral anticoagulants (DOACs).

Do not systematically request an ECG-Holter in patients with sporadic palpitation if structural heart disease has already been excluded.

Do not routinely check a carotid stenosis of less than 50% every year with Color Doppler Ultrasound.

Do not prescribe benzodiazepines and Serotonergic Antidepressants (SSRIs) after an acute cardiovascular event without planning for a follow-up review.

Italian College of the Directors of Vascular Surgery

Do not request a Duplex scan as a first level test for lower limb arterial disease, in patients that are asymptomatic or with mild claudication. Measure instead the Ankle Brachial Index (ABI).

Do not request a Duplex scan of the carotid arteries for vertigo, tinnitus, headache, neck pain, unless there are neurologic signs.

Do not perform open or endovascular treatment of lower limb lesions unless there is disabling claudication, critical limb ischemia or diabetic foot.

Do not stent a stenotic renal artery unless there is refractory hypertension or declining renal function.

LIMPE-DISMOV

Do not use drugs that may worsen the symptoms of Parkinson’s disease, such as anti-dopaminergic, alphalitic and anticholinergic drugs, without consulting your neurologist.

Do not delay prescribing levodopa if appropriate, and instead, do not use drugs for the complicated phase of the disease prematurely.

Do not abruptly discontinue/modify Parkinson’s disease therapy.

Do not underestimate the importance of multidisciplinary and non-pharmacological approaches.

SIAAIC

Don’t perform allergy tests for drugs (including anhestetics) and/or foods when there are not clinical history and symptoms suggestive of hypersensitivity reactions.

Don’t perform the so-called “food intolerance tests” (apart from those which are validated for suspect celiac disease or lactose enzymatic intolerance)

Don’t perform serological allergy tests (i.e.: total IgE, specific IgE, ISAC) as first-line tests or as “screening” assays.

Don’t diagnose asthma without having performed lung function tests (including bronchodilating test and/or bronchial challenge).

SIAARTI

Do not perform routine blood tests on patients undergoing surgery (or anaesthetic evaluation).

Do not perform blood tests routinely and daily in patients admitted to Intensive Care, but only on the basis of specific clinical questions.

Do not perform blood transfusions for arbitrary Hb values > 70 g/l but evaluate the clinical need of each individual patient (bleeding, hemodynamic stability, comorbidity).

Do not exceed 24 hours of antibiotic prophylaxis after surgery, the duration of prophylaxis should be as short as possible.

Don’t wait until the pain is at its peak intensity to start treatment, but actively prevent it by setting up an appropriate basic therapy for as long as necessary.

SIAARTI

Don’t use inhaled anesthetic agents with high global warming potential, such as desflurane and nitrous oxide.

Don’t use high fresh gas flows; prefer low flows and the minimum effective oxygen concentration.

Don’t choose unsustainable anaesthetic techniques, materials/devices or behaviours.

Don’t use disposable materials unless strictly necessary, and do not neglect proper separate waste collection.

Every anaesthetist-intensivist must not forget to be, with the support of scientific societies, a protagonist and promoter of sustainable practices in the operating theatre and intensive care unit.

SIAIP

Avoid contraindicating routinely vaccination in case of allergies.

Avoid performing routine allergy testing in children with acute urticaria.

Avoid prescribing mucolytics in children with bronchial asthma.

Avoid prescribing routine immunological tests in children with recurrent respiratory infections.

Avoid ruling out a food from the diet only for the positivity of skin prick tests and/or specific serum IgE.

SIAMS

Do not measure serum free testosterone in the suspicion of male hypogonadism.

Do not prescribe nutraceuticals in all male patients with sperm abnormalities.

Do not prescribe phosphodiesterase-5 inhibitors (PDE5i) in men with erectile dysfunction (ED) without an adequate diagnostic work-up.

Do not perform genetic tests and assessment of sperm DNA fragmentation in all male patients with sperm abnormalities.

Do not use phytoestrogens for menopausal-related sexual symptoms.

SIBIoC

Don’t perform serum protein electrophoresis nor search of urinary Bence-Jones protein as laboratory test before contrast media administration.

Don’t ask for AST, LDH, total CK, CK-MB or myoglobin for the diagnosis of acute myocardial infarction.

Don’t perform the determination of urine glucose for the monitoring of diabetes mellitus.

Don’t ask for the determination of serum biomarkers like CEA, CA-125, HE4, CA-15.3, a-fetoprotein or CA-19.9 for the diagnosis of neoplastic disease in asymptomatic individuals.

SICuPP

The foreskin should not be forcibly retracted if physiologic phimosis is present

An oral dose of vitamin K is not recommended in term newborns who received an intramuscular shot at birth

Do not routinely prescribe antiseptic medication in the umbilical cord care

Fear of febrile seizure should not lead to vaccination hesitancy in healthy children

Do not prescribe systemic fluoride but rather promote oral hygiene and age-related use of toothpaste

SIdCO

DON’T routinely PRESCRIBE antibiotic in patients undergoing dental extractions

DON’T DELAY dental care due to pregnancy

DON’T EXTRACT impacted third lower molars WITHOUT a valid clinical indication

DON’T routinely DISCONTINUE antiplatelet agents in oral surgical procedures and DON’T REPLACE them with low molecular weight heparins

DON’T REQUIRE dental radiography exams WITHOUT a valid working diagnosis, clearly stated in the clinical prescription

SIFACT

Don’t use costly drugs when low-cost generics with the same composition are available and try to convey a correct information to citizens on this point.

Don’t propose any type of palliative chemotherapy in the end-of-life setting.

Don’t prescribe MF-59 adjuvated influenza vaccine in elderly people.

Don’t prefer bioresorbable coronary stents over traditional drug-eluting stents.

Don’t use bevacizumab for its various oncologic indications.

SIGU

Don’t perform genetic testing for mutations analysis in the 5,10-Methylene TetraHydrofolate Reductase (MTHFR) gene

Don’t perform genetic tests directly to consumers, purchased on websites, pharmacies, gyms, beauty institutions, without a doctor’s prescription.

Don’t perform genetic tests for monogenic diseases without specific indication both in the physiological procreation or by assisted reproduction technology (ART).

Don’t perform HLA genotyping in the presence of established diagnosis of celiac disease or for screening purpose.

SIGU

Do not perform genetic testing for polymorphisms in genes involved in detoxification processes for the diagnosis of Multiple Chemical Sensitivity (MCS)

Do not perform genetic testing for Y chromosome microdeletions as a screening test for all male patients with reproductive problems

Do not include Glucose 6 Phosphate Dehydrogenase (G6PD) in the tests required for Medically Assisted Reproduction (MAP)

Do not perform test investigating genes associated with food metabolism and food intolerances (genetic testing for nutrition) to define a dietary path

SIMG

Don’t routinely prescribe imaging for low back pain without warning signs or symptoms (Red Flags)

SIMPIOS

Don’t examine or assist a patient without having first done an accurate hand hygiene, that has to be repeated at the end of the examination.

Don’t utilize reusable medical instrumentations that have not been adequately re-processed.

Don’t perform an urino-culture if without symptoms.

Don’t use fluoroquinolone antibiotics in empiric therapies, even if for severe infections, but use antibiotics with less impact on antibiotic resistance phenomenon and with less side effects.

Don’t prescribe antibiotic therapy to patients colonized by multi-resistant antibiotics microorganisms without signs of infection.

SIMRI

Do not perform chest X-ray in a child with suspected non-severe community-acquired pneumonia or with uncomplicated acute asthma.

Do not use salmeterol in children with acute asthma.

Do not perform CT scans in children in the absence of strict clinical indications.

Do not prescribe antihistamines for preventing asthma in children.

Asthma should not be diagnosed without performing spirometry.

SIN-Nephrology

Do not perform computerized tomography (CT) for the diagnosis of renal stones. It is initially preferable to use ultrasound.

Only opt for chronic dialysis after a decision-making process has been conducted jointly with patients, their families, and their family physicians.

Avoid the use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients suffering from hypertension, cardiac insufficiency or chronic kidney disease – whatever their cause (including diabetes).

SINePe

Urine culture should not be carried out either routinely or in the absence of the typical symptoms of a urinary tract infection; bag urine collection should be avoided

The indiscriminate use of albumin in children with a first episode of nephrotic syndrome is not recommended.

When asymptomatic microhaematuria is detected in a random urine sample, biohumoral or instrumental exams are not necessary.

SIP

Do not administer drug therapy other than symptomatic drugs in pediatric and adolescent cases of COVID-19 for which hospitalization is not required.

Do not modify, reduce, or discontinue usual therapies without a specific clinical indication in children and adolescents with chronic disease and COVID-19.

Do not postpone routine immunization or modify usual pediatric preventive and treatment measures in both the territory and hospital during the circulation of SARS-CoV-2.

SIP

Do not substitute careful hand hygiene for just wearing gloves. (Green recommendation)

Do not neglect careful disinfection of the baby’s skin with alcohol-based antiseptic solutions and that of the newborn with chlorhexidine or iodophore before any surgical procedure

Do not perform peri-operative antibiotic prophylaxis when it is not necessary

Do not administer antibiotic for peri-operative prophylaxis before 60 minutes prior to surgical incision and do not continue it postoperatively unless specifically indicated

Do not overlook the risk of patient colonization by multi-resistant microorganisms

SIPeM

Don’t use non-interactive lectures as the main teaching method. Privilege the use of interactive methods instead.

Avoid non-structured oral exams, and don’t use only cognitive tools of technical knowledge in the assessment of practical skills.

Don’t let learners perform procedures directly on patients, without having practiced them in an appropriate simulated model, and without proper tutorial supervision.

Don’t use only cognitive tests with a prevalent biological focus in the selection of candidates for the access to undergraduate and postgraduate medical and health sciences schools.

SIPMeL

Don’t routinely request creatin kinase-MB (CK-MB), total creatin kinase (CK), aspartato transaminase (AST), lactic-dehydrogenase (LDH) e myoglobin diagnosing Acute Coronary Syndromes (ACS).

Don’t perform the determination of urine glucose for the monitoring of diabetes mellitus.

Don’t routinely request preoperative laboratory tests in low-risk patients (for minor surgery and for intermediate surgery in ASA 1, ASA 2 patients).

Don’t request serum protein electrophoresis nor search urinary Bence-Jones protein as laboratory test before contrast media administration.

Don’t request the determination of serum biomarkers like CEA, CA-125, HE4, CA-15.3, -fetoprotein or CA-19.9 for the diagnosis of neoplastic disease in asymptomatic patients.

SIPMeL

Do not require anti-Thyroperoxidase (AbTPO) and anti-Thyroglobulin (AbTg) antibodies together in suspected autoimmune thyroiditis, only AbTPO.

Do not measure serum cortisol and plasma corticotropin (ACTH) at random times during the day as first-line tests in suspected Cushing’s syndrome.

Do not require urinary vanillymandelic acid and plasma and/or urinary catecholamines for diagnosis of pheochromocytoma-paraganglioma.

Do not use the determination of 25OH vitamin D (25OH-D) as a routine or screening test to determine the status of hypovitaminosis without a specific clinical indication.

SIPMeL

Do not order the HEp-2 indirect immunofluorescence test for ANA (antibodies to cellular antigens) as a screening test in patients with suspected autoimmune myositis.

When myasthenia gravis is suspected, specific autoantibodies (AChR, MuSK, Lrp4) should not be searched as a profile, but the initial test is represented only by anti-AchR antibodies.

Do not search for IgA class antibodies to deamidated gliadin peptide (DGP) to screen for celiac disease in the general population.

SIPMeL

Don’t request amylase in addition to lipase if acute pancreatitis is suspected.

Don’t request erythrocyte sedimentation rate to screen asymptomatic patients or as a general test to look for inflammatory states in patients with undiagnosed conditions.

Don’t request blood ammonium measurement for diagnosis or management of hepatic encephalopathy (HE) in patients with chronic hepatopathy.

Don’t measure procalcitonin outside of evidence-based protocols defined by professional Societies or at the health organization/regional/national level.

Don’t request uric acid as part of routine assessment of cardiovascular risk, obesity or diabetes.

SIPMeL

Do not perform routine laboratory tests or screenings without a clear clinical question and within an inappropriate retesting interval.

Do not acquire reagents, instrumentation, and/or laboratory supplies without considering their environmental impact, while maintaining diagnostic efficiency.

Do not use the paper report when a dematerialized report or electronic health record is available.

SIPPS

Don’t prescribe blood exams in children with acute pharyngitis.

Don’t administer antibiotics in children with acute pharyngitis unless microbiologic confirmation of streptococcal infection has been carried out.

If throat culture is performed, susceptibility tests on isolates should not be executed in children with acute pharyngitis.

Don’t shorten antibiotic course in children with acute pharyngitis and microbiologic confirmation of streptococcal infection.

Don’t administer steroids to children with acute pharyngitis.

SIRM

Don’t perform magnetic resonance imaging (MRI) of the spine within the first six weeks in patients with low back pain in the absence of warning signs or symptoms (red flags).

Don’t perform routine magnetic resonance imaging (MRI) of the knee in the event of acute pain from trauma or chronic pain.

Don’t perform magnetic resonance imaging (MRI) for non-traumatic headache in the absence of warning clinical signs.

Don’t perform preoperative chest x-rays in the absence of clinical signs or symptoms which indicate diseases that could affect the outcome of the surgery.

Don’t perform routine radiology of the skull in minor head injury.

SIRM

In children, do not prescribe or perform routine X-rays of the contralateral limb in trauma.

In infants and children with epilepsy do not perform routine CT of the skull and brain.

In infants and children younger than 6 years of age with suspected sinusitis, do not perform X-rays of the sinuses.

In children less than 3 years of age, do not perform X-rays of the nasal bones if a fracture is suspected.

In infants and children with torticollis without trauma, do not perform X-rays of the cervical spine.

SISM

Don’t perform any diagnostic or therapeutic procedure without having previously collected the medical history and information on possible allergies or pre-existing diseases of the patient.

Don’t neglect to gather informations not only about the benefits, but also about the contraindications or side effects of the diagnostic or therapeutic procedures.

SItI

Don’t replace hand hygiene with the use of non-sterile disposable gloves. Use alcohol-based product as a first choice for hand hygiene routine. (Green recommendation)

Never administer antibiotics for perioperative prophylaxis before 60 minutes prior to surgical incision*; the ideal time is upon induction of anesthesia.

Do not open the doors of the operating room during the surgical activity, except where necessary for the passage of patients, staff and equipment.

Do not forget to indicate in the patient health documentation (discharge letter or document for transfer to another healthcare facility) any positivity to alert microorganisms *

Don’t initiate or prolong artificial nutrition (enteral or parenteral) in late stage cancer patients with a life expectancy of less than a few weeks and a Performance Status <50.

ACP

Avoid the habitual use of inhaled corticalsteroids in upper respiratory tract infections in children.

In absence of medical indications do not prescribe formula or liquids other than breast milk to newborns in the first weeks of life.

Do not prescribe antibiotics for viral acute respiratory tract diseases (ear infections, sinusitis, pharyngitis, bronchitis)

Do not prescrive chest x-ray for diagnosis and follow-up of uncomplicated pneumonia in children

ADI

Don’t follow “elimination” or fasting diets. These are specific nutritional approaches for some pathologies and only physicians can recommend them.

Do not encourage the extensive and indiscriminate use of vitamin and mineral supplements as preventive elements for cancer and cardiovascular disease.

Obese people of any age are not to be blamed. The stigma of obesity worsens the condition of those who are affected.

AICPR

Don’t perform routine chest X-ray in patients entering rehabilitation programme after cardiac surgery

Don’t perform Computed Tomography for coronary calcium score in patients at high cardioascular risk