Society of Critical Care Medicine

Five Things Physicians and Patients Should Question

Released January 29, 2021

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    Don’t retain catheters and drains in place without a clear indication.

    Patients in intensive care units typically require insertion of catheters and drains for fluid and medication delivery, pressure and flow monitoring, and fluid and gas evacuation. The majority of hospital-acquired infections and unintended safety events are associated with such devices. Daily assessment of need for invasive devices should be an essential element of critical care workflow, to reduce time of exposure by identifying the earliest opportunity for their discontinuation.

  2. 2

    Don’t delay progress towards liberation from mechanical ventilation.

    Although mechanical ventilation is frequently lifesaving, it is also associated with numerous complications. Discontinuation of mechanical ventilation support is frequently the rate limiting step in ICU discharge. Current guidelines recommend removing patients from mechanical ventilation support as soon possible, utilizing mechanical ventilation liberation and sedation interruption protocols in concert with structured multidisciplinary rounds.

  3. 3

    Don’t continue antibiotic therapy without evidence of need.

    In addition to employing microbe-directed therapy, a core principle of antibiotic stewardship is limiting antimicrobial therapy to the shortest effective duration. As a general rule, antimicrobials should be discontinued when the condition for which they were prescribed has been adequately treated, as one strategy to ensure access to effective antimicrobials, at a time when increased antimicrobial resistance represents a global health care challenge.

  4. 4

    Don’t delay mobilizing ICU patients.

    Patients can develop significant muscle weakness and atrophy (including the diaphragm) during their ICU stay due to immobilization. However, multidisciplinary facilitated early mobilization has been shown to be safe in the ICU setting. Numerous, patient-centered, clinically meaningful outcomes are supported by early mobilization of critically ill patients.

  5. 5

    Don’t provide care that is discordant with the patient’s goals and values.

    The condition of ICU patients is often uncertain and dynamic, which generates stress for ICU families and the care staff. Accordingly, eliciting and documenting desired care preferences helps ensure the provision of goal-concordant care. Patients, families and providers may participate as partners in shared decision-making to ensure that goals and values align with care that is offered and provided.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

The Society of Critical Care Medicine (SCCM) is the largest non-profit medical organization dedicated to promoting excellence and consistency in the practice of critical care. With members in more than 100 countries, SCCM is the only organization that represents all professional components of the critical care team. The Society offers a variety of activities that ensure excellence in patient care, education, research and advocacy. Its mission is to secure the highest quality care for all critically ill and injured patients.

How This List Was Created

A diversified, multiprofessional task force of 17 critical care quality and clinical experts was formed with an aim to identify five new Choosing Wisely for Critical Care recommendations. The task force included practicing clinicians representing community, military and academic centers. A priori three domains were deemed important: 1) patient safety and quality of care; 2) strength of evidence to support the recommendation; and 3) potential improvement in patient outcomes. Using a modified Delphi consensus building methodology and a quantitative survey analysis, eight novel recommendations were identified and deemed representative of wasteful critical care practices. Following a quantitative survey of the SCCM membership and review by the SCCM Council, the five highest ranked recommendations established SCCM’s next five Choosing Wisely for critical care were approved. The five recommendations address invasive devices, proactive liberation from mechanical ventilation, antibiotic stewardship, early mobilization, and providing goal-concordant care.

Sources

  1. Bell T, O’Grady NP. Prevention of Central Line-Associated Bloodstream Infections. Infect Dis Clin North Am. 2017;31(3):551-559. doi:10.1016/j.idc.2017.05.007

    Hooten TM, Bradley, SF, Cardenas DD, et al. Diagnosis, prevention and treatment of catheter associated urinary tract infection in adults; 2009 International Clinical Practice Guidelines.

  2. Devlin, JW., Skrobik Y., Gelinas, C. et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU, Critical Care Medicine: September 2018 – Volume 46 – Issue 9 – p e825-e873 doi: 10.1097/CCM.0000000000003299

  3. CDC. Core Elements of Hospital Antibiotics Stewardship Program Atlanta, GA: US Department of Health and Human Services, CDC, 2019.

  4. Pohlman, MC, Schweickert, WD & Pohlman, AS, et al. (2010). Feasibility of Physical and Occupational Therapy beginning from initiation of mechanical ventilator. Critical Care Medicine;38:2089-2094.

  5. Deptola, AZ & Riggs, J. (2019). In patient Goals-of-Care conversations reduce ICU transfers in high risk patients. American Journal of Hospital Palliative Care; 36(7): 583-586.