Part of the reason why I love critical care includes all the sexy high adrenaline stuff we do to keep people alive. Some of the not so sexy stuff is trying to save money as well as resources to provide good value for our hospital systems and the country as a whole if we’re being honest with ourselves. The first choosing wisely initiative was a list of five recommendations which included the opinions of people from the American Association of critical care nurses, the American College of Chest physicians, the American thoracic society, and the society of critical care medicine. This was published in 2014.

Given that today is 14 February of 2021 these five first recommendations have been deeply ingrained into our minds. We adhere to these recommendations because many of us were trained with these recommendations in mind. Links to the first set of recommendations are down in the citation but these recommendations include (in my own words):

1. A recommendation to not order diagnostic test daily. What they want you to do and I completely agree with this, is to only order tests to figure out certain clinical questions. It seems to me here like they were taking a dig at daily chest x-rays, daily blood gases, and other tests.
2. The second recommendation is to avoid transfusing patients with red blood cells if they are hemodynamically stable as well as non-bleeding if their hemoglobin is greater than seven. Seems as if some clinicians still haven’t gotten this memo, but here we are.
3. The third recommendation is to not provide patients parenteral nutrition within the first seven days of being in the intensive care unit if they were adequately nourish prior to this. I have discussed this in some of my contacts on social media before as well as in my nutrition lectures. I definitely agree with the statement especially given that parenteral nutrition is so expensive.
4. You really don’t want to snow your patients. The fourth recommendation is to not snow your patients, or how they say “deeply sedate” without an indication to do cell and without attempts to lighten the sedation daily.
5. Please take the time to talk to patients and families about comfort measures. We all know that we get patients to come in through the ED, outside hospital or from the floor in whom our aggressive measures are only going to lead to further pain but not improve their mortality or their quality of life.

I have to say I’m quite a fan of these five measures and I think that the authors did a fantastic job. Now for 2021 there are five new recommendations for choosing wisely in critical care.

1. The first recommendation is a reminder that we should not keep in Foley catheters, Central lines, as well as drains in their place without a clear indication. The reason for this is that these lead to hospital acquired infections as well as unintended safety events. The sooner you can get them out the better. Here, the authors clearly have a point but sometimes I must admit that I struggle with getting rid of central lines in some patients were quite marginal. I guess there I could defend that I have a clear indication. I know that this is something that hospital administrators are watching closely as I frequently get asked by my fantastic nursing staff if the central line and Foley catheter could go. I personally like the Foley catheter because I pay very close attention to the patient’s urine output and, during the deresuscitation phase, I often give patient significant amounts of diuretics.
2. Extubate patients as soon as possible. They have a more eloquent way of saying this by stating “don’t delay liberation from mechanical ventilation”. This is where the spontaneous breathing trials as well as spontaneous awakening trials are so valuable and I’d greatly appreciate the respiratory therapist and nurses who together help these things take place and therefore help us liberate people from mechanical ventilation sooner.
3. I should definitely have a conversation with some of my infections disease colleagues with regards to number three which states “don’t continue antibiotic therapy without evidence of need”. This one’s kind of hard because of the fear of litigation by not starting an antibiotic or by discontinuing it perhaps too early. We obviously want to be great stewards of antibiotics but the fluctuations in white blood cell counts are extremely important to some clinicians while others of us know that there are fluctuations in this lab result regularly.
4. I am a big fan of number four which states that we should not delay mobilizing I see you patients. Obviously we know that our patients, while they are critically ill, could develop weakness and atrophy of their muscles. A good relationship with our physical therapist as well as occupational therapist could help mobilize patients earlier and therefore mitigate this to some degree.
5. The last recommendation states that we should not “provide care that is discordant with the patient’s goals and values”. I personally try to discuss goals of care with all my patients and their families amongst arrival to the intensive care unit. These types of discussions helped decrease ICU admissions and overall hospitalizations near the end of life. Although I must admit that once they’re in the ICU, it’s hard for the families to change their mind. This is something that could be more appropriately addressed in the outpatient setting with the primary care physician or other physicians who take care of the patient.

All in all, I strongly agree with the recommendations made by this group. I am sharing this today to help spread the word of the practices that we should be taking in our respective intensive care units. Click here to head back to my main page for other posts.

Citation
Zimmerman JJ, Harmon LA, Smithburger PL, Chaykosky D, Heffner AC, Hravnak M, Kane JM, Kayser JB, Lane-Fall MB, Matos RI, Mauricio RV, Murphy DJ, Nurok M, Reddy AJ, Ringle E, Seferian EG, Smalls-Mantey NM, To KB, Kaplan LJ. Choosing Wisely For Critical Care: The Next Five. Crit Care Med. 2021 Jan 28. doi: 10.1097/CCM.0000000000004876. Epub ahead of print. PMID: 33555779.
Link to Article and FULL FREE PDF

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