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 most respondents are not aware of the campaign behind the specific recommendations.
A multidisciplinary Critical Care Societies Collaborative (CCSC) work group conducted the survey to assess awareness and use of five ICU-specific recommendations that CCSC developed as part of the Choosing Wisely initiative. The results, "Choosing Wisely in Critical Care: A National Survey of Critical Care Nurses," are published in the November issue of American Journal of Critical Care (AJCC).
The ABIM Foundation established the Choosing Wisely initiative in 2012, encouraging professional medical societies to develop lists of medical tests, treatments and procedures that are commonly used but whose necessity should be questioned.
CCSC responded by developing a list of five ICU-specific recommendations and encouraging individual CCSC members to incorporate them into practice. The CCSC is a partnership among the four main associations whose members care for critically ill patients in the United States. Its members are the American Association of Critical-Care Nurses (AACN), the American College of Chest Physicians, the American Thoracic Society and the Society of Critical Care Medicine.
As part of CCSC's work with Choosing Wisely, AACN became the first nursing organization to actively contribute to the development of a list of recommendations.
Co-author Clareen Wiencek, PhD, RN, ACNP, is an AACN past president and associate professor of nursing and director of advanced practice, University of Virginia School of Nursing, Charlottesville. She represented AACN on the CCSC workgroup.
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 multi-professional nature of critical care. 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."
Clareen Wiencek, co-author
The workgroup added six questions specific to Choosing Wisely to a national survey of all 150,000+ members of the CCSC organizations. A total of 1,651 responses were received from nurses who reported membership in AACN, including 200 respondents who identified themselves as advanced practice nurses (APRNs).
Overall, less than 40% reported being familiar with the Choosing Wisely campaign, with more APRNs (64%) than registered nurses (36%) reporting awareness of CCSC's critical care recommendations.
In addition, about 38% 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%)
- 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%)
- 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%)
- Don't deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation. (80.5%)
- 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%)
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.
Wiencek, C.A., et al. (2019) Choosing Wisely in Critical Care: A National Survey of Critical Care Nurses. American Journal of Critical Care. doi.org/10.4037/ajcc2019241.