Choosing Wisely Canada 5 things NOT to do in the ICU

Transcription

1 Choosing Wisely Canada 5 things NOT to do in the ICU Andre Amaral, MD on behalf of the CWC Critical Care Task Force Assistant Professor Interdepartmental Division of Critical Care Medicine University of Toronto Sunnybrook Health Sciences Centre

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3 Choosing Wisely Canada is a campaign to help clinicians and patients engage in conversations about unnecessary tests and treatments and make smart and effective choices to ensure high-quality care.

4 What is unique about CWC? Clinician led Bottom up approach Focused on common clinical conditions Simple Remarkably rapid uptake

5 Campaign approach Clinicians Societies develop lists Disseminate through multiple channels Patients Develop patient materials Disseminate broadly through multiple channels Media Coordinated approach toward media Multiple voices, a common message Stakeholders Work through health care stakeholder organizations to implement and support adoption

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7 Online resources Clinician website: Patient website: Twitter: Facebook:

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9 Methodology Task force from Canadian Critical Care Society Canadian Association of Critical Care Nurses Canadian Society of Respiratory Therapists Representatives from pharmacy, physiotherapy and dietitian

10 Methodology and YOUR opinion! During this presentation we will survey you via SMS and your participation in this survey infers you agree to have results included in the CWC Critical Care Recommendations once ready for publication

11 TASK FORCE MEMBERS Halfkenny-Zellas, C Bazinet, K O Callaghan, N Huberdeau, C Morgan, B Buttazzoni, L Wickson, P Newman, A Downar, J Amaral, A Martin, C Mahan, N McCall, M Zygun, D Cheng, D Granton, J Martin, J Kanji, S Muscedere, J Dhanani, S Fowler, R Fox-Robichaud, A Ménard, C Toma, A

12 1. ITEM GENERATION 1. CCCS Google-groups list 2. Members of the task force

13 Treatments 1. Parenteral nutrition 2. RBC Transfusion 3. Antimicrobials for septic shock 4. Duration of empiric antibiotics 5. HES for resuscitation 6. ino for ARDS 7. Glucose control 8. EPO for critically ill patients without CKD 9. Early goal directed therapy 10. Broad-spectrum antimicrobials 11. Steroids for sepsis 12. Steroids for spinal cord injuries 13. Steroids for patients with TBI 14. Omega-3 fish oils for ARDS/ALI 15. Hyperventilation in TBI 16. Continuous sedation 17. Bronchoscopy for atelectasis 18. End-of-life care 19. Sleep preservation 20. Targeted temperature control post cardiac arrest Procedures 21. NIV for ALI 22. Holding feeds for OR 23. PACs to guide hemodynamic management 24. Craniectomy for TBI 25. Line insertion under US 26. Early mobility 27. Physical and pharmacological restraints Tests 28. Routine CXR 29. Routine blood work 30. BAL for the diagnosis of VAP 31. Follow-up CT scans in CVAs 32. Delirium screening Other 33. Consideration for organ donation 34. Goals of care discussion 35. Physician Assistants in ICU 36. C-spine clearance after trauma 37. Establishing daily goals 38. Family participation in daily rounds

14 2. ITEM SELECTION Task force members prioritized 10 items from this list For the 10 selected items, task force members wrote a DON T statement and brief summary focused on: Existing evidence Extent of overutilization Potential cost-impact

15 2. ITEM SELECTION 1. Don t routinely hold feeds in intubated patients for OR 2. Don t use hydroxyethyl starches in the critically ill 3. Don t limit interactions between the patients and their family 4. Don t routinely keep critically ill patients under bed rest 5. Don t maintain mechanically ventilated patients deeply sedated 6. Don t prolong mechanical ventilation without attempting an SBT 7. Don t transfer a patient out without discussing goals of care 8. Don t withdraw life support before discussing organ donation 9. Don t initiate life support therapies for terminally ill patients 10. Don t order routine chest X-rays, unless to inform a specific decision 11. Don t routinely transfuse PRBC in patients with a Hb > 70 g/l

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19 3. ITEM SELECTION (2ND ROUND) Task force members ranked items on: Evidence Prevalence Relevance Ease of implementation Prevention of harm Innovation Cost savings

20 Evidence Prevalence Relevance Ease of Prevention Innovation Cost Average of harm savings (no costs) CXR Sedation Transfusion Early Mobility GOC Discussion SBT Family Interaction HES LST for terminal illness Enteral nutrition Organ Donation

21 Evidence Prevalence Relevance Ease of Prevention Innovation Cost Average of harm savings (no costs) CXR Sedation Transfusion Early Mobility GOC Discussion SBT Family Interaction HES LST for terminal illness Enteral nutrition Organ Donation

22 Evidence Prevalence Relevance Ease of Prevention Innovation Cost Average of harm savings (no costs) CXR Sedation Transfusion Early Mobility GOC Discussion SBT Family Interaction HES LST for terminal illness Enteral nutrition Organ Donation

23 Evidence Prevalence Relevance Ease of Prevention Innovation Cost Average of harm savings (no costs) CXR Sedation Transfusion Early Mobility GOC Discussion SBT Family Interaction HES LST for terminal illness Enteral nutrition Organ Donation

24 #1 DON T LIMIT INTERACTIONS BETWEEN THE PATIENT AND THEIR FAMILY Access for families on rounds, visitation and resuscitation Stickney J Pediatr 2014, Wyskiel Families, systems and health 2015, Oczkowski J Intens Care 2015 Highly valued by families Stelson Am J Crit Care 2016 In the US: 80% units restrict visitation Liu Crit Care 2013

25 #2 DON T PROLONG MECHANICAL VENTILATION BY PRACTICES FACILITATING IMMOBILITY, OVER-USE OF SEDATIVES AND DELAYED ASSESSMENT OF ABILITY TO LIBERATE FROM VENTILATION 58% of patients in Canada did not receive a sedation interruption Burry Can J Anaesth 2014 Adherence to SBTs in US: 9-55% Robertson CCM 2008 Mobility not performed in 60-80% of eligible days in Canada Fan, Amaral. Unpublished data

26 #3 DON T TRANSFER A PATIENT WITH END-STAGE OR TERMINAL ILLNESS OUT OF THE ICU WITHOUT A DISCUSSION ABOUT GOALS OF CARE Overutilization of ICU beds for patients that may not benefit (6.7% in the US) Huyhn, JAMA Int Med 2013 Physicians don t always elicit the preferences of dying patients Downar CCM 2015 Ward physicians may defer conversations to a clinician with ICU experience Jones CCM 2014

27 #4 DON T ORDER ROUTINE CHEST RADIOGRAPHS FOR CRITICALLY ILL PATIENTS, EXCEPT TO ANSWER A SPECIFIC CLINICAL QUESTION RCTs and observational studies find that routine CXRs do not improve outcomes compared with an ondemand CXR strategy Oba Radiology 2010 Meta-analysis of eliminating daily routine CXRs: no affect on mortality (OR 0.92) no effect on ICU LOS (difference = 0.19 days) no effect on ventilator days (difference = 0.33 days) Ganapathy Crit Care 2012

28 #5 DON T ROUTINELY TRANSFUSE RED BLOOD CELLS IN HEMODYNAMICALLY STABLE ICU PATIENTS WITH A HEMOGLOBIN CONCENTRATION GREATER THAN 70 G/L* *A threshold of 80 g/l may be considered for patients undergoing cardiac or orthopedic surgery and those with active cardiovascular disease Unnecessary transfusion of RBCs is more harmful than helpful Carson JAMA 2016 In certain populations, the restrictive arm tested Hb of 80g/L (cardiac surgery, orthopedics, active CV disease)

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32 THANK YOU!