Jerry J. Zimmerman, MD, PhD, FCCM
President Barack Obama stated in 2009 that the biggest threat to our nation’s balance sheet, by a wide margin, is the skyrocketing cost of healthcare. It is a sobering fact that in 2013 the United States ranked first in healthcare cost per capita and last in healthcare quality.1 It has been estimated that healthcare waste accounts for 34% of total healthcare spending—$910 billion (6% of the gross domestic product).2,3 Such overuse waste is a very real, underappreciated safety issue that has been associated with patient physical, emotional, and financial harm.2 Closer to home, the intensive care unit (ICU) is a resource-intense environment where new drugs, expensive technologies, and specialized clinical care all contribute to dramatic healthcare expenditures. It is known that intensivists’ daily charges vary widely, with no correlation between this spending and their patients’ outcomes.4 Providing high-value care, specifically high-quality care at the most reasonable cost, should be a primary tenet for every critical care practitioner. It is what all of us would expect for our families and ourselves.
The Society of Critical Care Medicine’s (SCCM) mission statement is to provide the highest-quality care for all critically ill and injured patients. In a broader view, the word quality might be replaced with the word value, which encompasses the concepts of both quality improvement and cost reduction. Value is not an abstract ideal and does not merely represent cost reduction. Value is important to all healthcare stakeholders—patients, providers, payers, and suppliers—and ideally should define the framework for performance improvement.5
In this issue of Critical Connections, Lewis J. Kaplan, MD, FCCM, in his discussion of the Choosing Wisely initiative developed by the American Board of Internal Medicine Foundation, addresses two primary practices that decrease value in the ICU, namely allocation of ICU beds to patients who will not benefit compared to use of a ward bed, and provision of excessive critical care resources to patients who are appropriately admitted to the ICU.6 Choosing Wisely is endorsed by SCCM and the Critical Care Societies Collaborative as a practical, common-sense, grassroots approach to enhancing value in the ICU.
In addition to implementing Choosing Wisely principles, another approach to limit provision of excessive critical care resources begins with the recognition that the biggest waste in medicine is waiting, which results in delaying and detouring continuous advancement of care. Critical care practitioners in particular excel at adding therapies during the life-and-death struggle of resuscitation but are much more reluctant to potentially disturb the status quo once their patient has stabilized. However, serial scheduled assessment and titrated weaning (withdrawal of support), when it is safe to do so, will reduce waiting and enhance value in the ICU.
SCCM’s ICU Liberation initiative (www.iculiberation.org) and the evidence-based ABCDEF Bundle include an unspoken engine of weaning.7 Bundle element B encourages both daily spontaneous awakening trials and daily spontaneous breathing trials. A spontaneous awakening trial is one strategy to systematically wean sedative administration.8 An alternative approach involves a nurse-driven protocol to continuously wean sedation that typically includes serial assessments of agitation, anxiety, and comfort using validated tools. Both approaches can decrease the burden of psychotropic drugs, permitting a more awake and interactive patient. At the same time, always prioritizing the treatment of pain (bundle element A) while reducing sedation decreases the risk for transition to delirium (addressed in bundle element D), which is associated with multiple adverse events related to excessive waiting, including prolonged ICU stay and increased ICU costs. The second aspect of bundle element B encourages daily spontaneous breathing trials (or extubation readiness testing).9 Spontaneous breathing trials frequently identify patients who were not otherwise recognized as ready for extubation.
Often the rate-limiting steps in discharge from the expensive ICU environment are discontinuation from mechanical ventilation support and tracheal extubation. Liberation from mechanical ventilation is also associated with decreases in laboratory testing, ventilator-associated events, and risks of anemia and hospital-acquired infection.10,11 Bundle element C challenges clinicians to thoughtfully consider the drug class options when sedation is needed beyond that provided by adequate analgesia. In particular, avoidance of benzodiazepines and diphenhydramine may reduce the risk of transition to delirium and associated additional cost and time for treatment of this neurologic dysfunction adverse event.12, 13 Progressive early mobilization (bundle element E) provides positive feedback to the patient and reduces the risk of immobilization-mediated catabolism of lean muscle, including the diaphragm, decreasing the risk of prolonged physical rehabilitation.14 Although bundle element F, engaging and empowering the family in the care plan, might seem remote from weaning, in fact, family-centered nonpharmacologic interventions to reduce pain, anxiety, and agitation provide a holistic alternative to more sedation. SCCM’s Patient-Centered Outcomes Research – ICU program chronicled multiple ways families can support their loved one during critical illness.15
Higher compliance with the ABCDEF Bundle was reported to be independently associated with improved survival and more days free of delirium and coma, after adjusting for age, illness severity, and need for mechanical ventilation.16 Other biologically plausible but as yet unconfirmed benefits are likely to include decreased patient exposure to all psychotropic drug classes; decreased risk of ventilator-associated events, ventilator-associated pneumonia, and ventilator-associated lung injury; decreased risk of central line-associated bloodstream infections; decreased risk of anemia and need for erythrocyte transfusions; decreased ICU costs; and increased family satisfaction.
Routine application of the ABCDEF Bundle should be considered as the framework for delivery of usual care in the ICU. Dissemination of the ICU Liberation care model has the potential to reduce waiting and enhance value for all critically ill patients. And there are other common intensive care interventions that would likely benefit from more proactive downward titration, such as supplemental oxygen,17–19 intravenous fluid administration,20,21and antimicrobials.22–24 In addition, promoting a learning healthcare environment in ICUs can facilitate discovery of new evidence to support best practices that address both enhancing quality and reducing cost.25 In this model, perfected on the hematology-oncology ward, clinical care, clinical research, and quality improvement are so intertwined and integrated that they are practically inseparable—each activity informs and promotes the other. Increasing critical care practitioner cost awareness may turn out to be another important strategy for improving value of care in the ICU setting.26
Lastly, the SCCM Burnout Summit in December 2017 ascertained that promoting value in the ICU begins with individual critical care practitioners and their knowledge and practice of personal wellness. Likely as a consequence of chronic stress in the ICU, critical care healthcare providers are at very high risk for transition to burnout syndrome (BOS).27 Aspects of BOS such as exhaustion, cynicism, ineffectiveness, depression, and posttraumatic stress disorder may further manifest as job dissatisfaction, poor work performance, medical errors, absenteeism, and turnover. These latter consequences of BOS represent major contributors to low-value care in the ICU.28 Multiple organizational and individual interventions have been proposed to prevent and treat BOS. Practicing wellness should represent a core value for everyone who works in the ICU, as it constitutes a foundational approach to preventing BOS and accordingly is the starting point for enhancing value in the ICU.29
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