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Choosing Wisely in Critical Care

Ten Things Clinicians and Patients Should Question

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The Society of Critical Care Medicine, in collaboration with the  American Board of Internal Medicine's (ABIM) Choosing Wisely Campaign, an initiative of the ABIM Foundation, released in 2020 a new list of five things clinicians and patients should question in critical care. This guidance is in addition to the first five Choosing Wisely Campaign items released in 2015. 

2015 Choosing Wisely Recommendations 

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Read the Article in Critical Care Medicine


1. Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.

Many diagnostic studies (including chest radiographs, arterial blood gases, blood chemistries and counts and electrocardiograms) are ordered at regular intervals (e.g., daily). Compared with a practice of ordering tests only to help answer clinical questions, or when doing so will affect management, the routine ordering of tests increases health care costs, does not benefit patients and may in fact harm them. Potential harms include anemia due to unnecessary phlebotomy, which may necessitate risky and costly transfusion, and the aggressive work-up of incidental and non-pathological results found on routine studies.

2. Don’t transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 g/dL.

Most red blood cell transfusions in the ICU are for benign anemia rather than acute bleeding that causes hemodynamic compromise. For all patient populations in which it has been studied, transfusing red blood cells at a threshold of 7 g/dL is associated with similar or improved survival, fewer complications and reduced costs compared to higher transfusion triggers. More aggressive transfusion may also limit the availability of a scarce resource. It is possible that different thresholds may be appropriate in patients with acute coronary syndromes, although most observational studies suggest harms of aggressive transfusion even among such patients.


3. Don't use parenteral nutrition in adequately nourished critically ill patients within the first seven days of an ICU stay.

For patients who are adequately nourished prior to ICU admission, parenteral nutrition initiated within the first seven days of an ICU stay has been associated with harm, or at best no benefit, in terms of survival and length of stay in the ICU. Early parenteral nutrition is also associated with unnecessary costs. These findings are true even among patients who cannot tolerate enteral nutrition. Evidence is mixed regarding the effects of early parenteral nutrition on nosocomial infections. For patients who are severely malnourished directly prior to their ICU admission, there may be benefits to earlier parenteral nutrition.


4. Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.

Many mechanically ventilated ICU patients are deeply sedated as a routine practice despite evidence that using less sedation reduces the duration of mechanical ventilation and ICU and hospital length of stay. Several protocol-based approaches can safely limit deep sedation, including the explicit titration of sedation to the lightest effective level, the preferential administration of analgesic medications prior to initiating anxiolytics and the performance of daily interruptions of sedation in appropriately selected patients receiving continuous sedative infusions. Although combining these approaches may not improve outcomes compared to one approach alone, each has been shown to improve patient outcomes compared with approaches that provide deeper sedation for ventilated patients.


5. Don’t continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.

Patients and their families often value the avoidance of prolonged dependence on life support. However, many of these patients receive aggressive life-sustaining therapies, in part due to clinicians’ failures to elicit patients’ values and goals, and to provide patient-centered recommendations. Routinely engaging high-risk patients and their surrogate decision makers in discussions about the option of forgoing life-sustaining therapies may promote patients’ and families’ values, improve the quality of dying and reduce family distress and bereavement. Even among patients pursuing life-sustaining therapy, initiating palliative care simultaneously with ongoing disease-focused therapy may be beneficial.

2020 Choosing Wisely Recommendations

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Read the Article in Critical Care Medicine


1. Don’t retain catheters and drains in place without a clear indication.

Patients in intensive care units typically require insertion of catheters and drains for fluid and medication delivery, pressure and flow monitoring, and fluid and gas evacuation. The majority of hospital-acquired infections and unintended safety events are associated with such devices. Daily assessment of need for invasive devices should be an essential element of critical care workflow, to reduce time of exposure by identifying the earliest opportunity for their discontinuation.

2. Don’t delay progress toward liberation from mechanical ventilation.

Although mechanical ventilation is frequently lifesaving, it is also associated with numerous complications. Discontinuation of mechanical ventilation support is frequently the rate-limiting step in ICU discharge. Current guidelines recommend removing patients from mechanical ventilation support as soon possible, utilizing mechanical ventilation liberation and sedation interruption protocols in concert with structured multidisciplinary rounds.

3. Don’t continue antibiotic therapy without evidence of need.

In addition to employing microbe-directed therapy, a core principle of antibiotic stewardship is limiting antimicrobial therapy to the shortest effective duration. As a general rule, antimicrobials should be discontinued when the condition for which they were prescribed has been adequately treated, as one strategy to ensure access to effective antimicrobials at a time when increased antimicrobial resistance represents a global health care challenge.

4. Don’t delay mobilizing ICU patients.

Patients can develop significant muscle weakness and atrophy (including the diaphragm) during their ICU stay due to immobilization. However, multidisciplinary facilitated early mobilization has been shown to be safe in the ICU setting. Numerous patient-centered, clinically meaningful outcomes are supported by early mobilization of critically ill patients.

5. Don’t provide care that is discordant with the patient’s goals and values.

The condition of ICU patients is often uncertain and dynamic, which generates stress for ICU families and the care staff. Accordingly, eliciting and documenting desired care preferences helps ensure the provision of goal-concordant care. Patients, families and providers may participate as partners in shared decision-making to ensure that goals and values align with care that is offered and provided.
Choosing Wisely KEG

Choosing Wisely KEG

SCCM Members: The Choosing Wisely KEG is aimed at improving awareness of the Choosing Wisely® campaign. Members will exchange ideas on how to avoid unnecessary tests and treatments and discuss how they have been able to implement initiatives at their institutions.

 


 

How to Succeed in Implementing Less is More

This presentation from the Society of Critical Care Medicine's 50th Critical Care Congress offers education on how to implement the Choosing Wisely campaign. 

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Choosing Wisely Resources

Are We Choosing Wisely in Critical Care?
"Are We Choosing Wisely in Critical Care?" was published in the April/May 2018 issue of Critical Connections.
SCCM Pod-388 Choosing Wisely in Critical Care
Ranjit Deshpande, MD, and Ruth M. Kleinpell, PhD, RN, ACNP, FCCM, discuss the results of the Choosing Wisely national survey from the Critical Care Societies Collaborative (Kleinpell R, et al. Crit Care Med. 2019;47:331-336).
SCCM Pod-433 Choosing Wisely for Critical Care: The Next Five
Five new recommendations to reduce waste and enhance value in the practice of critical care address invasive devices, proactive liberation from mechanical ventilation, antibiotic stewardship, early mobilization, and providing goal-concordant care.