5 Critical Care Practices Come Under Scrutiny

The American Association of Critical-Care Nurses has released a list of five common critical care practices that it says clinicians should reconsider. The practices persist only "because we're covering our butts," insists one nursing leader.

By now you've probably heard of the American Board of Internal Medicine Foundation's Choosing Wisely campaign to reduce unnecessary or non-evidence-based care.

Now the American Association of Critical-Care Nurses has released a list of its own Choosing Wisely guidelines—five common critical care practices that clinicians should reconsider because they might not help patients, and in some cases, might harm them. The AACN worked on the recommendations as part of the Critical Care Societies Collaborative (CCSC), which also includes the American College of Chest Physicians, the American Thoracic Society, and the Society of Critical Care Medicine.

Some of the recommendations should come as no surprise. For instance, one says critical care professionals shouldn't "order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions." Others are more controversial, such as the recommendation that life support shouldn't necessarily be continued for certain patients.

The five recommendations are part of the Choosing Wisely campaign that encourages patient-provider dialogue about choosing necessary care. They are:

1. Don't order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.
2. Don't transfuse red blood cells in hemodynamically stable, non-bleeding critically ill patients with a hemoglobin concentration greater than 7 mg/dL.
3. Don't use parenteral nutrition in adequately nourished critically ill patients within the first seven days of a stay in an intensive care unit.
4. Don't deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.
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.

Deborah Becker, PhD, ACNP, BC, CCNS, one of the members of the CCSC task force that developed the recommendations, says rethinking these practices will help to reduce costs, especially repetitive costs for procedures that are only being done "because we're covering our butts."

In addition, the recommendations can also be a catalyst for a change in provider mentality, says Becker, who is a Practice Associate Professor of Nursing at the University of Pennsylvania School of Nursing; assistant dean for Innovations in Simulation; and the Adult Gerontology Acute Care program director.

"It's really beyond coming up with a list of five things… [it's about] making it patient-centered care instead of provider-centered care," she says.

Perhaps this mentality shift can be best illustrated with the list's recommendation for talking with patients and families about continuing life support. "What this really recommends is pulling in the patients into these discussions, the patients and their families," she says. "This is something that nurses always encouraged… It has to be a joint decision."

Once new recommendations like these are made, working critical care professionals must actually act on them. Becker says large academic institutions are always evaluating and reevaluating care based on the most current clinical evidence, whereas smaller, community hospitals might have more trouble rethinking common care practices. In some organizations, the culture might be more autocratic, and nurses might be expected to simply implement care that physicians order without questioning it.

But Becker says nurse leaders can use these new recommendations to open up a dialogue with physicians by showing the list to members of the medical team and asking them what they think about it.

"I think the nurse leader has to have conversations with the medical team," Becker says. "This will help the physicians and nurses work together collaboratively."

Nurse leaders should encourage their staff nurses to do the same, empowering them to perhaps ask for rationales behind certain orders, speak up when they participate in rounds, or question care that they don't agree with, depending on the culture of the hospital and unit.

"The nurse leader has an obligation to really make this known to the staff nurses that these societies are backing this, and we really want to consider these items," Becker says. "Talking with them about how to initiate the conversations with the providers is important."

Ultimately, the recommendations are just that: recommendations. But they challenge routine, by-the-numbers care and should prompt physicians and nurses to ask themselves, "Am I just doing this because it's written on an order sheet?" Becker says.