Another test? More sedation? The “technological imperative”?
A national survey of acute and critical care nurses finds that measures to reduce unnecessary testing and treatments are increasingly being integrated into clinical practice, even though few respondents are aware of the campaign behind the specific recommendations. The study - co-authored by professor Clareen Wiencek, who directs the School of Nursing's advanced practice programs and teaches a host of palliative care courses - appears in the November issue of the American Journal of Critical Care.
The Choosing Wisely initiative was established by the ABIM Foundation in 2012, and encouraged professional medical societies to develop lists of medical tests, treatments and procedures that are commonly used but whose necessity should be questioned. A multidisciplinary Critical Care Societies Collaborative work group conducted the survey to assess awareness and use of five ICU-specific recommendations that it developed as part of the Choosing Wisely initiative.
These ICU-specific recommendations were implemented by members of the four main associations whose members care for critically ill patients in the United States: American Association of Critical-Care Nurses, the American College of Chest Physicians, the American Thoracic Society, and the Society of Critical Care Medicine - to incorporate them into practice.
“Because nurses consistently oversee patient care at the bedside, they can play a significant role in ensuring that organizations and individual units are aware of, and work to implement, the Choosing Wisely critical care recommendations,” explained Wiencek. “The Choosing Wisely critical care list was the first developed in partnership with a nursing professional society (AACN), which is important and noteworthy because it reflects the multiprofessional nature of critical care."
A total of 1,651 responses were received from AACN-member nurses, including 200 respondents who identified themselves as advanced practice nurses.
Overall, fewer than 40 percent of respondents reported being familiar with the Choosing Wisely campaign, with more APRNs (64 percent) than registered nurses (36 percent) reporting awareness of CCSC’s critical care recommendations. About 38 percent reported that the CCSC recommendations had been implemented in their practice settings, to varying degrees and in different ways:
- Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions (50.2 percent)
- Don’t transfuse red blood cells in hemodynamically stable, non-bleeding critically ill patients with a hemoglobin concentration greater than 7 mg/dL (85.5 percent)
- Don’t use parenteral nutrition in adequately nourished critically ill patients within the first seven days of a stay in an intensive care unit (47.3 percent)
- Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation (80.5 percent)
- Don’t 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 (67.1 percent)
The work group also used the open-ended comment section to identify recurring themes and specific strategies to raise awareness and address barriers to implementation.
The list, including more detailed explanations and supporting references, is online at ChoosingWisely.org. A downloadable PDF, suitable for use in staff meetings and posting, is also available.
To access the article and full-text PDF, visit the AJCC website at hwww.ajcconline.org
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