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[ICU Management & Practice]: 明智选择:另外5项推荐意见
2021年06月10日 指南导读, 进展交流 暂无评论

Choosing Wisely: The Next Five Recommendations

In 2010, Howard Brody, a medical ethicist and family physician, authored "Medicine's Ethical Responsibility for Healthcare Reform - The Top Five List". His list challenged medical societies to identify five interventions in healthcare that were overused, and that did not provide patient benefit. Following the same logic, the American Board of Internal Medicine (ABIM) soon launched its "Choosing Wisely" campaign that also championed the avoidance of wasteful interventions and to instead focus on value-added, evidence-based care. Over 70 medical societies, including the Critical Care Societies Collaborative (CCSC), participate in the Choosing Wisely campaign. Initially, the CCSS outlined the top five Choosing Wisely recommendations for critical care practices to reduce waste while caring for the critically ill. These included:

  • Do not order diagnostic tests at regular intervals but only in response to specific clinical questions. 
  • Do not transfuse RBC in haemodynamically stable, nonbleeding ICU patients with a haemoglobin concentration > 7 g/dL.
  • Do not use parenteral nutrition in adequately nourished critically ill patients within the first seven days of their ICU stay.
  • Do not deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation. 
  • Do not continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families alternative care options that focused entirely on comfort. 

These five practices were further evaluated, and it was suggested that there might be additional opportunities to align new evidence-based recommendations. Hence, the Society of Critical Care Medicine (SCCM) established a task force to determine the Next Five Choosing Wisely recommendations for Critical Care. The taskforce included 17 SCCM members who represented the community, military and academic centres. Three domains were deemed important when assessing literature: patient safety and quality of care, strength of evidence to support the recommendation and potential improvement in patient outcomes. 

Thirteen new recommendations were initially discussed, and subsequently, five top-ranking statements were finalised. These include:

  • Do not keep catheters, tubes or drains in without a clear indication. 
  • Do not delay mechanical ventilator weaning unless there is clinical evidence of need. 
  • Do not give prolonged, broad-spectrum antibiotic courses in the absence of ongoing culture data or symptoms. 
  • Do not delay early mobility in ICU patients. 
  • Do not provide care that does not align with the documented patient's and family's goals, values and preferences for healthcare.

These are important recommendations that should be considered when treating critically ill patients. The Choosing Wisely campaign focuses on the delivery, safety and cost of care and recognises the fact that wasteful practices do not offer additional value. Both the initial recommendations and the Next Five Choosing Wisely recommendations are designed to reduce waste and improve outcomes in the critically ill and injured.

Source: Critical Care Medicine

References:

Zimmerman J et al. (2021) Choosing Wisely For Critical Care: The Next Five. Critical Care Medicine, 49(3):472-481. doi: 10.1097/CCM.0000000000004876 

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