Choosing Wisely in Critical Care

2015 Choosing Wisely Recommendations 

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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 delay providing nutrition, preferring enteral over parenteral, to critically ill patients during the first 24–36 hours of a critical illness.

Two large multicenter trials compared early (within 24-36 hours of ICU admission) enteral nutrition with parenteral nutrition and clinical outcomes related to mortality (30-day, ICU, hospital and 90-day), length of stay (ICU and hospital), and infections (pneumonia and bacteremia) were not significantly different. Based on more recent, higher quality data, parenteral nutrition should not be avoided regardless of nutrition risk.

 

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.

2021 Choosing Wisely Recommendations

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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.