Over the last couple of years, 4 US critical care societies put together a literature-scouring taskforce as part of the Choosing Wisely campaign. After a lengthy process they came up with 5 cost-effective, tradition-questioning recommendations:
1. Do not order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions;
Avoid anaemia (and so transfusions). Avoid ultimately inconsequential incidental findings demand further work-up.
2. Do not transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with an Hb concentration greater than 7 g/dl;
A threshold of 7 mg/dl results in better survival, fewer complications, and reduced costs. And preserves a precious resource. But unelucidated subgroups may exist.
3. Do not use parenteral nutrition in adequately nourished critically ill patients within the first 7 days of an ICU stay;
If not malnourished prior to admission, early PN (even in those not tolerating EN) is possibly harmful and costs more.
4. Do not deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation;
Protocol-based approaches can safely limit unnecessary deep sedation – eg lightest effective dose; analgesic before sedative; daily sedation holds.
5. Do not continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort
Routinely engage high-risk patients and their next of kin or advocate in discussions about limiting the level of aggression of treatment. Promotes patient’s/family’s values, improves the quality of death, and reduces family distress. Initiating palliative care pathways/team may be beneficial even where death is not necessarily expected.
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Whether or not these would be your top five the ambition is laudable and these 5 recommendations, originally published in January, have generally withstood criticism over the last 9 months, and ‘savings’ are being made.
