Dr Fernando Zampieri MD PhD published a thought provoking article in ICU management and practice. This takes an example of use of CRP in diagnosing ventilator associated pneumonia and various clinician biases. In the end, there is an exhaustive list of things which we do today which are not proven to be beneficial.
In 2014, Choosing wisely campaign released following five practices commonly used in ICUs which were of questionable benefit to the patients.
- Ordering daily scheduled tests (daily labs or daily xrays)
- Transfusing PRBC in patients who have hemoglobin above 7gm/dl and who are hemodynamically stable.
- Using total parenteral nutrition in first 7 days of ICU stay.
- Deeply sedating mechanically ventilated patients.
- Continuing life support treatment for patients expected to have high risk of death and poor functional recovery.
It will be very tough to implement the last recommendation depending on your country, culture and its laws.
When applying these recommendations, it is important to consider that intensive care patients are very complex; therefore, the applicability of these principles must be assessed on an individual basis and, where necessary, modified appropriately.
Need of hour is not to follow blindly the for or against recommendation as this may not apply to the individual patient you are treating, but to go over this list and decide which one you can avoid.
There are several I can add to the list-
- Chasing electrolyte normalcy- to 2,3,4 (Magnesium of 2, phosphate of 3 and potassium of 4). We do not know if attaining a hard number to these actually help the patient.
- Maintenance fluids (almost all patients in ICU get some sort of continuous IVF which invariably leads to positive fluid balance over few days of ICU stay)
- Putting socks on all patients (this is USA specific, do not know why but all patients get socks from hospital, yellow colored).
- Using yellow gowns and non sterile gloves in patients with MRSA and C diff. (Lastest cochrane review and earlier JAMA study has debunked the efficacy).
Here is the list –
| Practice | Comment | Cognitive bias involved | Suggestion Reference | |
| ICU STRUCTURE | ||||
| ICUs built in improvised spaces with old-fashioned architecture | There is no place for old-fashioned window- less ballroom ICUs in modern practice. Natural light deprivation is a real issue. | Conservatism; default effect. | New ICUs should be designed to improve patients and staff wellbeing. This includes windows, places to interact with staff (cafeterias), proper resting rooms, family meeting rooms, etc. | Caruso 2014; Mroczek 2005 |
| Keep families outside the ICU | Family engagement may reduce delirium and improve outcomes. | Conservatism; default effect; hostile attribution bias. | Adopt liberal visitation policy while coping with staff´s own demand for privacy. | Soares 2017 |
| Keep pets outside the ICU | There are few plausible reasons to keep pets outside the ICU. There are many potential benefits for patients and staff. | Conservatism; default effect;
“not invented here” bias. |
Adopt a more liberal pet visitation policy Hosey 2018 in ICUs. | |
| Ignore staff´s own health | Burnout is endemic in practitioners. Ignoring staff burnout can harm staff and patients. | Identifiable victim effect; Ostrich effect. | Recognise the problem. Attempt to treat Ricou 2018 burnout as an organisational problem and not an individual issue. | |
| DAILY CARE | ||||
| Daily chest x-rays | Increases radiation exposure. May worsen several biases due to poor method sensi- tivity/specificity. | Conservatism; default effect. | Switch to on-demand methods such as Resnick 2017 ultrasound (if available) or more selective x-ray prescription. | |
| Daily full set of labs | May produce noise without clear benefit. May increase need for transfusions. | Conservatism; default effect; bandwagon effect. | Adopt a minimal daily set of tests; add Zimmerman 1997 tests as indicated. | |
| Widespread contact precautions | May be useful for Gram-positive bacteria but data lacking for multidrug-resistant Gram-negative. Widespread use can increase adverse events at patient level. | Conservatism; default effect; continued influence effect. | Join randomised controlled trials on Furuya 2018 contact precautions. Consider local study. | |
| Aggressive antibiotic use after infection suspicions in stable patients | For stable ICU patients, a wait-and-see approach may result in better outcomes than an aggressive strategy. | Conservatism; default effect; continued influence effect; Semmelweis reflex. | Adopt more conservative triggers to start Melsen 2013 antibiotics in stable patients. | |
| Long pre-established courses of antibiotics | Shorter courses of antibiotics are probably safe, reduce costs and antibiotic exposure. | Conservatism; default effect; Bandwagon effect; Semmelweis reflex. | Consider strategies to reduce length of Klompas 2017; Sawyer antibiotic courses 2015 | |
| Alveolar recruitment for
ARDS |
Increased mortality in large RCT. | “Not invented here” bias; Semmelweis reflex. | Apply evidence as it stands. Cavalcanti 2017 | |
| Aggressive hypothermia protocols | Failed to improve outcomes in most scenarios. | Semmelweis reflex. | Consider switching to normothermia Shaefi 2016 protocols. | |
| Aggressive glycaemic control protocols | Associated with more adverse events, no benefit for clear majority of patients. | Semmelweis reflex. | Adopt more liberal glycaemic control. Finfer 2009 | |
| Early aggressive nutrition protocols | While no clear harm can be attributed, it may derive attention from more pressing problems. | Semmelweis reflex. | Adopt timely introduction of nutrition to Casaer 2011 the most severely ill patients. | |
| Proton pump inhibitors prophylaxis for upper gastrointestinal bleeding | May not be useful and may increase complications. | Conservatism; Semmelweis reflex. | Probably not necessary. Large RCT recently completed Krag 2016 | |
| Early goal therapy for sepsis | Large bulk of evidence suggesting it may increase costs due to more ICU admissions without clear mortality benefit. | Semmelweis reflex. | Focus on early diagnosis and source PRISM Investigators 2017 control in septic patients (preferably outside the ICU). | |
| Use fluid bolus to treat every conceivable abnormality (oliguria, hypotension, tachycardia, reduction in consciousness levels, etc.) | Fluid creep is a major issue. Fluids should be considered drugs with very low therapeutic range. | Law of the instrument (“Give a small boy a hammer, and he will find that everything he encounters needs pounding”, Maslow 1966); conservatism; Semmelweis reflex. | Reduce fluid creep starting with maintenance fluids and reducing unnecessary dilutions. Adopt early negative fluid balance whenever possible. Van Regenmortel 2018 | |
| Attempt to correct physi- ological abnormalities | Physiology can be bent to fit one´s desire for adequacy. There is no single or correct physiological parameter in critically ill patients. | Conservatism; default effect; continued influence effect. | Aim for physiological targets only in the Reade 2009; 2013 absence of hard evidence. | |
Please post your comments about things which we do in ICUs which have no value.