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Are We Choosing Wisely in Critical Care?

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Lewis J. Kaplan, MD, FCCM

In 2014, the Society of Critical Care Medicine (SCCM), as a member of the Critical Care Societies Collaborative (CCSC), joined the ranks of a host of professional organizations outlining five diagnostic, therapeutic, or care approaches that might not support providing high-value care in the way they are routinely used (Figure 1).1 The umbrella movement is called Choosing Wisely and was initially developed by the American Board of Internal Medicine Foundation. Dozens of organizations have participated to date, some with more than one iteration of their recommendations that are targeted to affect practice. Perhaps more importantly, the campaign was designed to spark conversation between patients and clinicians in terms of the most appropriate care to benefit individual patients.

In keeping with the concept of elements of care to avoid, the recommendations are phrased in the negative (i.e., “Do not . . .”). Accordingly, one might be erroneously tempted to equate avoiding the profiled low-value elements as being synonymous with providing highvalue care. High-value care, however, embraces many other dimensions to improve care quality while controlling or reducing costs.
Perhaps unsurprisingly, elements deemed to be of low value generally fell outside the recommending specialty’s services. The most common recommendations involved avoiding a wide variety of diagnostic imaging, recommendations supported by the American College of Radiology, one of which appears on the CCSC list as well.2 While avoiding low value—and what may be perceived as unnecessary care—may reduce overall cost, the intention of the program was to foster robust communication about care. In this way, Choosing Wisely dovetails with patient- and family-centered care, which is a specific focus of SCCM and is interwoven in programs addressing post-intensive care syndrome, such as the THRIVE initiative.
Are the initial five recommendations in Figure 1 still relevant? A recent analysis by the CCSC, driven in large part by SCCM’s immediate Past President Ruth M. Kleinpell, CCRN, PhD, FCCM, offers resounding affirmation of not only relevance, but awareness and implementation. Reductions in frontal radiographs in particular, but also laboratory profiles and red blood cell transfusion for non-hemorrhaging anemia management, appear to be the most common recommendations that have been implemented. SCCM’s ICU Liberation guidelines and ABCDEF Bundle have similarly impacted management of analgesia and sedation approaches for those requiring invasive mechanical ventilation, in concert with the Choosing Wisely recommendations. Finally, the last recommendation appears to be increasingly deployed, with the tremendous increase in partnering with palliative care medicine experts as members of the multiprofessional team on daily rounds or in response to specific triggers for consultation addressing change in life circumstance, as well as end-of-life issues.
The concept that in-hospital care readily supports garnering vast amounts of data to help guide management is recognized worldwide. Choosing Wisely initiatives are found in England, Australia, Switzerland, Italy, Germany, Japan, and the Netherlands, as well as the United States. In England, such an approach is identified as aiming to reduce the “harms of too much medicine.”3 Since the desire is to trigger discussions about the risks and benefits of diagnostic or therapeutic interventions, as well as approaches to care, is there a group of best practices that could inform a practice, a facility, or a healthcare system as to how best to embrace such recommendations?
Culture change from “More is better” to “Appropriately targeted is better” may underpin the success of implementing change and benefit from having champions.4 Embedding decision support into the electronic health record helps reinforce adherence to care pathways and remind clinicians to carefully consider each order. Streamlining order sets to include desired practices, such as sedation reduction or interruption, can be built for routine use instead of relying on individual order entry. Such a plan readily accommodates changing care providers, such as trainees who regularly switch rotations. The use of a bedside checklist during rounds (mine is attached to the rounding workstation-on-wheels) is a low-cost strategy to daily assess a variety of care elements, as well as all five Choosing Wisely recommendations. Moreover, incorporating such recommendations into didactic sessions, problem-based learning, and the like serve to introduce the concept and the specifics early in healthcare education.
Finally, planned iterative evaluation of the recommendations, including consideration for adding additional relevant recommendations by professional organizations such as CCSC, helps ensure that what is recommended remains relevant to current practice.5 Plans are underway to assess how well each of these recommendations works and to share them with you to deploy at your institutions as you wisely choose to deliver the Right Care, Right Now™.

1. Halpern SD, Becker D, Curtis JR, et al; Choosing Wisely Taskforce; American Thoracic Society; American Association of Critical-Care Nurses; Society of Critical Care Medicine. An official American Thoracic Society/American Association of Critical-Care Nurses/American College of Chest Physicians/Society of Critical Care Medicine policy statement: the Choosing Wisely® top 5 list in critical care medicine. Am J Respir Crit Care Med. 2014 Oct 1;190(7):818-826.
2. Morden NE, Colla CH, Sequist TD, Rosenthal MB. Choosing wisely—the politics and economics of labeling low-value services. N Engl J Med. 2014 Feb 13;370(7):589-592.
3. Admon AJ, Cooke CR. Will Choosing Wisely® improve quality and lower costs of care for patients with critical illness? Ann Am Thorac Soc. 2014 Jun;11(5):823-827.
4. Malhotra A, Maughan D, Ansell J, et al. Choosing wisely in the UK: the Academy of Royal Colleges’ initiative to reduce the harms of too much medicine.BMJ. 2015 May 12;350:h2308.

5. Angus DC, Deutschmann CS, Hall JB, Wilson KC, Munro CL, Hill NS. Choosing Wisely® in critical care: maximizing value in the intensive care unit. Am J Crit Care. 2014 Nov;23(6):444-446.