Reducing Unnecessary Testing in the Intensive Care Unit by Choosing Wisely

Abstract

Overuse of laboratory and X-ray testing is common in the intensive care unit (ICU). This review highlights focused strategies for critical care clinicians as outlined by the Critical Care Societies Collaborative (CCSC) as part of the American Board of Internal Medicine Foundation's Choosing Wisely^® campaign. The campaign aims to promote the use of judicious testing and decrease unnecessary treatment measures in the ICU. The CCSC outlines five specific recommendations for reducing unnecessary testing in the ICU. First, reduce the use of daily or regular interval diagnostic testing. Second, do not transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 mg/dl. Third, do not use parenteral nutrition in adequately nourished critically ill patients within the first 7 days of ICU stay. Fourth, do not deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation. Finally, do not continue life support for patients at high risk of death without offering patients and their families the alternative of comfort focused care. A number of strategies can be used to reduce unnecessary testing in the ICU, including educational campaigns, audit and feedback, and implementing prompts in the electronic ordering system to allow only acceptable indications when ordering routine testing. Greater awareness of the lack of outcome benefit and associated costs can prompt clinicians to be more mindful of ordering tests and procedures in order to reduce unnecessary testing in the ICU.

Keywords: Choosing Wisely; X-ray testing; intensive care units; laboratory testing.

Figure 1.

Critical Care Society Collaborative’s Choosing Wisely^® list for critical care. ICU: intensive care unit. Adapted from the Critical Care Societies Collaborative [6].

Figure 2.

Reports by 432 critical care physicians on implementation efforts targeting the Choosing Wisely^® critical care recommendations. ICU: intensive care unit; RBC: red blood cell. Adapted from the Society of Critical Care Medicine [11].

Figure 3.

Reports by 432 critical care physicians on how the Choosing Wisely^® critical care recommendations had been implemented in clinical practice. Adapted from the Society of Critical Care Medicine [11].