Choosing Wisely Canada5 things NOT to do in the ICUAndre Amaral, MDon behalf of the CWC Critical Care Task ForceAssistant ProfessorInterdepartmental Division of Critical Care MedicineUniversity of TorontoSunnybrook Health Sciences Centre

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.

What is unique about CWC?

• Clinician led

• Bottom up approach

• Focused on common clinical conditions

• Simple

• Remarkably rapid uptake

Campaign approach

• Societies develop lists

• Disseminate through multiple channelsClinicians

• Develop patient materials

• Disseminate broadly through multiple channelsPatients

• Coordinated approach toward media

• Multiple voices, a common messageMedia

• Work through health care stakeholder organizations to implement and support adoptionStakeholders

Online resources

• Clinician website: – www.ChoosingWiselyCanda.org– www.ChoisirAvecSoin.org

• Patient website:– www.ChoosingWisely.ca– www.ChoisirAvecSoin.ca

• Twitter: – www.twitter.com/ChooseWiselyCA (@ChooseWiselyCA)– www.twitter.com/ChoisirAvecSoin (@ChoisirAvecSoin)

• Facebook: – www.facebook.com/ChoosingWiselyCanada– www.facebook.com/ChoisirAvecSoin

Methodology

• Task force from– Canadian Critical Care Society

– Canadian Association of Critical Care Nurses

– Canadian Society of Respiratory Therapists

– Representatives from pharmacy, physiotherapyand dietitian

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

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

1. ITEM GENERATION

1. CCCS Google-groups list

2. Members of the task force

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

• Task force members prioritized 10 items fromthis list

• For the 10 selected items, task force memberswrote a “DON’T” statement and briefsummary focused on:

– Existing evidence

– Extent of overutilization

– Potential cost-impact

2. ITEM SELECTION

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

Task force members ranked items on:

• Evidence

• Prevalence

• Relevance

• Ease of implementation

• Prevention of harm

• Innovation

• Cost savings

3. ITEM SELECTION (2ND ROUND)

Evidence Prevalence Relevance Ease of Prevention of harm

Innovation Cost savings

Average (no costs)

CXR 4.61 4.11 4.72 4.33 3.83 3.56 4.35 4.19

Sedation 4.67 4.06 4.83 3.5 4.5 3.53 4 4.18

Transfusion 4.83 3.94 4.44 4.17 4.44 3.17 4.22 4.17

Early Mobility 4.22 4.56 4.56 3.28 4.17 4.11 3.83 4.15

GOC Discussion

3.5 4.28 4.67 3.56 4.11 3.83 3.94 3.99

SBT 4.39 3.94 4.67 3.72 4.06 3.11 3.89 3.98

Family Interaction

3.83 4.28 4.33 3.72 3.72 3.89 2.89 3.96

HES 4.78 2.89 3.83 4.5 4.5 2.56 3.56 3.84

LST for terminal illness

3.72 4.06 4.44 2.56 4.06 3.61 4.44 3.74

Enteral nutrition

3.22 3.83 4.39 4.11 3.22 3.17 2.39 3.66

Organ Donation

3.17 3.61 4.67 3.06 2.94 3.17 3.17 3.44

Evidence Prevalence Relevance Ease of Prevention of harm

Innovation Cost savings

Average (no costs)

CXR 4.61 4.11 4.72 4.33 3.83 3.56 4.35 4.19

Sedation 4.67 4.06 4.83 3.5 4.5 3.53 4 4.18

Transfusion 4.83 3.94 4.44 4.17 4.44 3.17 4.22 4.17

Early Mobility 4.22 4.56 4.56 3.28 4.17 4.11 3.83 4.15

GOC Discussion

3.5 4.28 4.67 3.56 4.11 3.83 3.94 3.99

SBT 4.39 3.94 4.67 3.72 4.06 3.11 3.89 3.98

Family Interaction

3.83 4.28 4.33 3.72 3.72 3.89 2.89 3.96

HES 4.78 2.89 3.83 4.5 4.5 2.56 3.56 3.84

LST for terminal illness

3.72 4.06 4.44 2.56 4.06 3.61 4.44 3.74

Enteral nutrition

3.22 3.83 4.39 4.11 3.22 3.17 2.39 3.66

Organ Donation

3.17 3.61 4.67 3.06 2.94 3.17 3.17 3.44

Evidence Prevalence Relevance Ease of Prevention of harm

Innovation Cost savings

Average (no costs)

CXR 4.61 4.11 4.72 4.33 3.83 3.56 4.35 4.19

Sedation 4.67 4.06 4.83 3.5 4.5 3.53 4 4.18

Transfusion 4.83 3.94 4.44 4.17 4.44 3.17 4.22 4.17

Early Mobility 4.22 4.56 4.56 3.28 4.17 4.11 3.83 4.15

GOC Discussion

3.5 4.28 4.67 3.56 4.11 3.83 3.94 3.99

SBT 4.39 3.94 4.67 3.72 4.06 3.11 3.89 3.98

Family Interaction

3.83 4.28 4.33 3.72 3.72 3.89 2.89 3.96

HES 4.78 2.89 3.83 4.5 4.5 2.56 3.56 3.84

LST for terminal illness

3.72 4.06 4.44 2.56 4.06 3.61 4.44 3.74

Enteral nutrition

3.22 3.83 4.39 4.11 3.22 3.17 2.39 3.66

Organ Donation

3.17 3.61 4.67 3.06 2.94 3.17 3.17 3.44

Evidence Prevalence Relevance Ease of Prevention of harm

Innovation Cost savings

Average (no costs)

CXR 4.61 4.11 4.72 4.33 3.83 3.56 4.35 4.19

Sedation 4.67 4.06 4.83 3.5 4.5 3.53 4 4.18

Transfusion 4.83 3.94 4.44 4.17 4.44 3.17 4.22 4.17

Early Mobility 4.22 4.56 4.56 3.28 4.17 4.11 3.83 4.15

GOC Discussion

3.5 4.28 4.67 3.56 4.11 3.83 3.94 3.99

SBT 4.39 3.94 4.67 3.72 4.06 3.11 3.89 3.98

Family Interaction

3.83 4.28 4.33 3.72 3.72 3.89 2.89 3.96

HES 4.78 2.89 3.83 4.5 4.5 2.56 3.56 3.84

LST for terminal illness

3.72 4.06 4.44 2.56 4.06 3.61 4.44 3.74

Enteral nutrition

3.22 3.83 4.39 4.11 3.22 3.17 2.39 3.66

Organ Donation

3.17 3.61 4.67 3.06 2.94 3.17 3.17 3.44

• Access for families on rounds, visitationand 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

#1 DON’T LIMIT INTERACTIONS BETWEEN THE PATIENT AND THEIR FAMILY

• 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

#2 DON’T PROLONG MECHANICAL VENTILATION BY PRACTICES FACILITATING IMMOBILITY, OVER-USE OF

SEDATIVES AND DELAYED ASSESSMENT OF ABILITY TO LIBERATE FROM VENTILATION

• Overutilization of ICU beds for patients thatmay 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

#3 DON’T TRANSFER A PATIENT WITH END-STAGE OR TERMINAL ILLNESS OUT OF THE ICU WITHOUT A

DISCUSSION ABOUT GOALS OF CARE

• RCTs and observational studies find that routine CXRs do not improve outcomes compared with an on-demand 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

#4 DON’T ORDER ROUTINE CHEST RADIOGRAPHS FOR CRITICALLY ILL PATIENTS, EXCEPT TO ANSWER A

SPECIFIC CLINICAL QUESTION

*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 Hbof 80g/L (cardiac surgery, orthopedics, active CV disease)

#5 DON’T ROUTINELY TRANSFUSE RED BLOOD CELLS IN HEMODYNAMICALLY STABLE ICU PATIENTS WITH A

HEMOGLOBIN CONCENTRATION GREATER THAN 70 G/L*

andrecarlos.amaral@sunnybrook.ca

THANK YOU!