Critical care nurses are accustomed to working in compliance with numerous types of directives that specify the who, what, when, where, and why of some dimension of their responsibilities. Our practice is frequently directed by documents such as unit, department, or hospital policies and procedures; local, regional, or national protocols; standards; guidelines; algorithms, and the like, which, under optimal circumstances, are derived from exhaustive review and analysis of current research and relevant health care literature that enables construction of a valid and reliable foundation of evidence upon which to base those directives. The continual evolution of new, refined, and updated versions of documents such as these promulgates what can feel like a never-ending profusion of sets of expectations from various stewards of our professional practice that, at times, can seem overwhelming. It is not very often that those same professional societies that develop and disseminate these codified sets of behaviors issue a directive to stop doing something that we have been practicing for quite some time. When such an infrequent stop order is issued, it is noteworthy to pause and consider what has now been relegated to the cease-and-desist category of practice for critical care providers.
Five Things to Stop Doing in the Intensive Care Unit to Limit Waste
In January 2014, at the Society of Critical Care Medicine’s Critical Care Congress, a list of 5 critical care practices were identified as practices clinicians should question. Characterized as the “Five Don’ts in Critical Care,”1 these 5 practices were selected by the Critical Care Societies Collaborative (CCSC), a partnership of the 4 major US health care professional organizations whose 150000 collective members provide health care services for the critically ill and injured: the American Association of Critical-Care Nurses, the American College of Chest Physicians, the American Thoracic Society, and the Society of Critical Care Medicine.2
The critical care list is just one of many comparable lists generated by professional health care societies in conjunction with the American Board of Internal Medicine’s Choosing Wisely initiative, which promotes dialogue between patients and physicians aimed at assisting patients to use care that is truly necessary, substantiated by valid research evidence, free from harm, and not repetitive of diagnostic or therapeutic procedures previously completed.3 Some 60 different national medical specialty organizations, including the CCSC, have now issued their respective lists of tests, procedures, or treatments that need to be considered more thoughtfully by providers and their patients in order to “choose wisely”4 and contribute to eliminating unnecessary costs, procedures, and wasteful expenditure of health care resources.
The CCSC’s list of 5 Don’ts appears in the Table together with a summary of the rationale surrounding its inclusion and the research evidence upon which it is based.5
The list was generated by a 10-member task-force of representatives from all 4 societies, who initially contributed 58 items for consideration, critiqued those against 5 criteria (evidence, prevalence, cost, relevance, innovation), whittled the list to 16, then to 9 and—following numerous iterative reviews—down to the final list of 5 items that was endorsed by all 4 societies. (For a more detailed description of how this list was created, visit www.choosingwisely.org/doctor-patient-lists/critical-care-societies-collaborative-critical-care.) The list covers a broad range of practices recommended for restraint, including orders for daily bloodwork, electrocardiograms, or chest radiographs; use of blood transfusions in hemodynamically stable patients; early use of parental nutrition; deep sedation of patients receiving mechanical ventilation; and extended use of aggressive life support measures without offering the alternative of palliative care.
What Other Practices Would You Add to This List?
My purpose for bringing this information to your attention is 3-fold:
To reinforce its mention and relevance to you as critical care staff nurses, clinical nurse specialists, and nurse managers, who interact and collaborate daily with our colleagues in medicine and other health care professions to plan and manage patient care that may include these measures.
To reinforce its mention and relevance to acute care nurse practitioners who both collaborate with members of the health care team and may order these procedures.
To solicit your suggestions for other critical care practices that have little or no evidence for their efficacy or where greater clinical scrutiny needs to be exercised or specific clinical criteria or indications need to be met before those measures are implemented. If the CCSC began their work from nearly 60 areas recommended for consideration, there must be other practice areas that warrant our attention. Please let us know what your observations, analysis, and/or literature review may expose as another practice area that deserves a discriminating investigation. Be our Critical Care Nurse reporter and e-mail your proposed new Critical Care Practice Don’t, your rationale for adding that practice to this list, and full citations to literature that supports your rationale to firstname.lastname@example.org. Let us hear from you so we can continue this dialogue, provide more tailored patient care, and cut waste of critical care resources.