Choosing Wisely's five top "no-no's" in critical care - PulmCCM
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Jan 292014
 
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Choosing Wisely is an initiative of the American Board of Internal Medicine (ABIM) with the stated goal of “promoting conversations between physicians and patients by helping patients choose care that is supported by evidence, not duplicative, free from harm, and truly necessary.” Sounds good, huh?

Politically, ABIM’s Choosing Wisely seeks to demonstrate to policymakers responsible self-governance by us physicians in response to rising health care costs. ABIM asked each specialty to identify 5 common practices whose elimination would reduce costs without harming care (and might improve it). Because patients often perceive “more care = better care” (and its converse), Consumer Reports were also enlisted to sell Choosing Wisely to the public as positive and patient-centered — certainly not rationing by death-panelist bureaucrats who if you gave them half a chance, would let the government take over Medicare.

Last year, PulmCCM reported on the Choosing Wisely “5 Don’ts” for pulmonology. Recently, representatives from the Critical Care Societies Collaborative (the American College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine, and the American Association of Critical-Care Nurses) emerged from their own proverbial smoke-filled room to announce the Choosing Wisely admonitions for physicians practicing critical care medicine.

After considering 58 items, committee members Scott D. Halpern (Chair), Deborah Becker, J. Randall Curtis, Robert Fowler, Robert Hyzy, Jeremy M. Kahn, Lewis Kaplan, Nishi Rawat, Curtis Sessler, and Hannah Wunsch shared their final 5 recommendations for practicing intensivists. PulmCCM took the liberty of paraphrasing the Choosing Wisely recommendations for critical care into a much ruder, more proscriptive tone than the committee’s original wording, just because it’s more fun that way. Here they are (in our words):

#1. Stop ordering chest films and blood work every day on every patient without thinking about why. With occasional exceptions, you’re generating a pile of expensive, useless data, and then chasing the abnormal results with additional tests that have their own risks and expense. You’re also making patients anemic — absurdly, to the point of transfusing them back the blood you needlessly removed.

#2. Speaking of transfusing patients blood, stop doing that too, unless their hemoglobin falls below 7 g/dL, or they are hemodynamically unstable or bleeding. (Even people with acute coronary syndrome might be harmed by aggressive blood transfusion.)

#3. Whoa, easy on the TPN there, Iron Chef! This patient just got here. Giving parenteral nutrition within 7 days of ICU entry to adequately nourished patients is harmful or (at best) unnecessary, even for patients unable to tolerate any enteral nutrition. Go on, take your big milky bag over to that severely malnourished and gastroparetic patient in bed 7.

#4. Did I just hear you say, “Snow this guy, I’m on call tonight?” Nurse, please disregard Dr. Sleepypants and step away slowly from the Versed drip. Unnecessary deep sedation prolongs mechanical ventilation, hospital and ICU stays, and has been uncool since 1999. You can use a sedation-limiting protocol, daily sedation interruptions, give analgesics before anxiolytics, or all of the above — we’re not fascists here. Just reduce sedation to the absolute minimum necessary for mechanically ventilated patients.

#5. As recent headlines have shown, some families (and politicians) will choose to artificially prolong life, or a barely-believable facsimile thereof, well past the point most physicians would ever consider for themselves or their own loved ones. But all patients and families deserve to know that palliative options exist to relieve suffering at the end of life. I know — you have 2 other crashing patients, you don’t have time to “go there” emotionally with the family right now (and yes, that other doctor should have already). This part is hard, I get it. So I dialed palliative care’s number in for you. All I’m asking you to do is push the green button. It doesn’t mean you or the family are “giving up” — it does show you want to ensure the patient’s values are honored, and suffering minimized, whatever may happen next medically.

All snark aside, for the record I’ve violated all these directives, as I suspect every intensivist has at some point. But I’m getting better (or at least trying). Practice patterns change slowly, and local cultural factors are often thick brick walls to any single physician’s efforts, no matter how earnest or well-informed. It’s only through collectivist projects like Choosing Wisely that physician behavior will ever change meaningfully for the better (faster than in geological time, I mean). Some may hallucinate an authoritarian agenda hiding behind these 5 innocuous pieces of advice — and yes, I’m sure more will be coming as we all get used to the nudging. But to those who disagree with the process, or its product — on the basis of the evidence, or for any other defensible reason — please speak your mind. I for one would like to hear what you have to say.

Choosing Wisely website, Critical Care Societies Collaborative – “Critical Care: Five Things Physicians and Patients Should Question

PulmCCM’s take on the Choosing Wisely pulmonology recommendations

Choosing Wisely for Pulmonology

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  5 Responses to “Choosing Wisely’s five top “no-no’s” in critical care”

  1. This is very nice. For those interested in these topics, please keep an eye on my blogs http://www.medicalevidence.blogspot.com and http://www.statusiatrogenicus.blogspot.com

    For reference also, my colleagues and I wrote the seminal monograph on laboratory testing in the ICU (see: http://www.ncbi.nlm.nih.gov/pubmed/17900480 ) seven years ago.

    On the Medical Evidence Blog, I have chronicled both ESAs (Erythropoetin Stimulating Agents) and transfusions and have opined that I could be rationed to 12 units of PRBCs per year and not harm a single patient, especially if I were to live by #5, which is limitation of care in “futile” cases – here “futile” means care which is inconsistent with patients’ goals if those goals are properly informed by REALISTIC estimations of patient outcomes.

    In my hospital system, I have staunchly refused surgeons’ inclination to “start TPN per intensivist” – TPN is rarely indicated, and we should not be complicit in its administration. See the SCCM guidelines for further information, and stick to it.

    The “Less is More” movement is in its infancy, but there is no greater reward than to raise an infant to adolescense and sit back and enjoy the rewards. The only problem for me is that when we all get with the program, I will have precious little to blog and rant about….

    • The problem of course, is that although it is appropriate to consider limiting wasteful care, such as may often happen in these circumstances, the very title of the discussion, i.e. “no-no’s”, leaves the impression that doing otherwise is always wrong. And then, the “regulators” will call you out whenever you break “the rule”, since “the rule” was created by us.

  2. Maybe so but these do seem pretty reasonable and chances are if you agree you will not be ‘breaking the rule’ very often and probably with good reason … a pain to document every time you deviate but i’ll pay that price if overall care gets better …. all in all a good thing I think

  3. No No is a title designed to get your attention. It worked. If you have a real reason to do daily lab and CXRs, then, by all means, do it. Just think before you default to habit. I recently reviewed a chart at a major hospital here in San Antonio in which the patient was in the ICU for over 120 days and received daily CXRs and almost daily ABGS during the entire stay, The daily CXRs followed her to the floor for an additional 2 weeks. From my review, the CXRs and ABGs rarely if ever changed the clinical management of this patient. Being on a ventilator or having a tracheostomy is not an indication for daily studies any more than having stable chronic renal disease is an indication for a daily renal panel.

    We are mature experienced physicians and should act accordingly.

  4. […] Ripper this week is taken out by PulmCCM.org as they highlight Choosing Wisely’s five top “no-no’s” in critical care – we do these things every day to patients thinking we are doing the right thing or […]

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