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Choosing Wisely for Critical Care
12 Plays4 years ago
In this episode of Critical Matters, we will explore the Choosing Wisely for Critical Care. These are evidenced-based best practices to avoid waste and promote value in the practice of critical care medicine.
We are fortunate to have with us today three of the authors of the recently published guidelines for critical care medicine – Choosing Wisely for Critical Care: The Next Five. Our guests are Jerry Zimmerman, Pamela Smithburger, and Anita Reddy. Jerry Zimmerman is a physician from the Department of Pediatrics, Seattle Children’s Hospital, Harborview Medical Center, University of Washington School of Medicine, in Seattle. Pamela Smithburger is a doctor in clinical pharmacy from the University Of Pittsburgh School Of Pharmacy, in Pittsburgh. Anita Reddy is a physician from the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Cleveland Clinic, in Cleveland.
Additional Resources:
Choosing Wisely For Critical Care: The NEXT Five. Critical Care Medicine 2021: https://bit.ly/3hQFkbx
Medicine’s Ethical Responsibility for Health Care Reform- The Top Five List: https://bit.ly/36nDhGI
The Choosing Wisely Website – ABIM: https://bit.ly/3hLdsWt
Society of Critical Care Medicine – Choosing Wisely Website: https://bit.ly/3yG4TTN
Society of Critical Care Medicine – Knowledge and Education Group (KEG): https://bit.ly/36tKvJb
Books Mentioned in this Episode:
Pediatric Critical Care Medicine 6th Edition by Jerry Zimmerman Alexandre T. Rotta: https://amzn.to/3ADJk82
One Hundred Years of Solitude by Gabriel Garcia Marquez: https://amzn.to/3ARKJYS
Love in the Times of Cholera by Gabriel Garcia Marquez: https://amzn.to/3jXWsyL
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
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And now your host, Dr. Sergio Zanotti.
Healthcare Spending and Wasteful Interventions
00:00:32
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Healthcare costs in the United States represent about 18% of the gross domestic product.
00:00:38
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For every dollar spent in healthcare, an estimated 25 to 30 cents is spent on waste and tests, procedures, or interventions with little evidence to support their value.
00:00:49
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Overuse of medical interventions is not only a cost problem, but also poses important safety threats to our patients.
Evidence-Based Practices to Reduce Waste
00:00:56
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In today's episode of the podcast, we will explore the choosing wisely for critical care.
00:01:01
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These are evidence-based best practices to avoid waste and promote value in the practice of critical care medicine.
00:01:08
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We are fortunate to have with us today three of the authors of the recently published Choosing Wisely Guidelines for the Critical Care Medicine, Choosing Wisely for Critical Care, The Next Five.
00:01:18
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Our guests are Jerry Simmerman, a critical care physician from the Department of Pediatrics, Seattle Children's Hospital, Harborview Medical Center, University of Washington School of Medicine in Seattle.
Guests and Choosing Wisely History
00:01:30
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Pamela Smithberger, a doctor in clinical pharmacy from the University of Pittsburgh School of Pharmacy in Pittsburgh, and Anita Reddy, a critical care physician from the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine at the Cleveland Clinic in Cleveland.
00:01:44
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Jerry, Pam, and Anita, welcome to the podcast, and thanks for taking the time to discuss this important topic with us.
00:01:51
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Thank you for having us.
00:01:54
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Absolutely.
00:01:55
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I would like to start with a brief history of the Choosing Wisely campaign.
00:01:59
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And Anita, maybe you could take us through that.
00:02:02
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I would be happy to.
00:02:04
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So Choosing Wisely started back in 2010 when Howard Brody wrote an article in the New England Journal of Medicine where he challenged the medical specialty societies in the United States to identify five tests or treatments that are overused and don't provide any meaningful benefit to patient care.
00:02:25
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The American Board of Internal Medicine pivoted off of that and set up the Choosing Wisely campaign to promote these conversations between clinicians and their patients and encourage them to choose care that is supported by the literature and the evidence and was not duplicative, care that wasn't harming them, and pick tests and procedures that are truly necessary.
00:02:51
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Then the campaign suggested that societies, both nationally and internationally, identify certain tests or procedures where the necessity would be questioned and discussed.
00:03:02
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And as a result of this effort, they've been able to involve over 80 national societies who have provided over 550 recommendations on tests and procedures that are potentially unnecessary.
00:03:15
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And there's been a lot of effort
00:03:18
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with ABIM and the Choosing Wisely campaign to create webinars, newsletters, and even patient-facing materials.
00:03:24
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It's a very successful, broad campaign.
00:03:29
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Excellent.
00:03:30
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And today we're talking about the next five, which is really the second come around of these recommendations for critical care.
Critical Care Societies Collaborative's Top Five
00:03:38
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But before we dive into the next five, Pam, could you just give us a little bit of insight into the original Choosing Wisely and critical care?
00:03:46
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and where they are?
00:03:49
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Absolutely.
00:03:50
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So the original top five for critical care was developed through participation of all organizations within the Critical Care Societies Collaborative in 2014.
00:04:00
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The Critical Care Societies Collaborative, just as a little bit of background, is a consortium that represents the four professional societies most involved with providing care to the critically ill
00:04:10
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And they include the American Associations of Critical Care Nurses, American College of Chest Physicians, American Thoracic Society, and the Society of Critical Care Medicine.
00:04:19
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And this collaborative represents about 150,000 members and has a broad stakeholder range.
00:04:26
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So the original list was developed by a task force composed of representatives from each of those organizations.
00:04:33
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These recommendations were focused on tests or therapies that were largely under clinicians' control and evaluated based on predefined criteria, such as the strength of evidence, prevalence, aggregate cost, relevance, and innovation.
00:04:50
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In short, the task force reviewed the literature and identified 58 candidate items and used Delphi methodology to reach a consensus and choose the final five that was believed to be most appropriate of that list.
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That list was then submitted to each society's executive committee who sought out external feedback.
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The feedback was received and a final consensus was reached.
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And then finally, in February of 2013, each society endorsed that original list and it was published in January of 2014.
00:05:23
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The original five initials choosing wisely for critical care were, number one, don't order diagnostic tests at regular intervals, such as every day, but rather in response to specific clinical questions.
00:05:38
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The second was don't transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than seven.
00:05:47
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The third was do not use parenteral nutrition in adequately nourished critically ill patients within the first seven days of an ICU stay.
00:05:56
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The fourth was don't deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.
00:06:05
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And finally, the fifth was don't continue life support for patients at high risk for death or severely impaired functional recovery.
00:06:13
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Without offering patients and their families the alternative of care, focus entirely on comfort.
00:06:19
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The fact that this list was a collaborative effort from four professional societies really supports the credibility of this list and the effort.
00:06:27
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That really is a high-level summary of the first initial Choosing Wisely for Critical Care list.
Relevance and Revisiting Best Practices
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believe that we all agree that these five are still very relevant and important, but as the years has gone by, obviously the idea is to kind of revisit, reevaluate and make sure that we continue to push forward with identifying best practices that would eliminate waste and improve patient care.
00:06:56
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So Jerry, if you could maybe walk us through the methodology of how we landed on these next five, what was the process that was followed for choosing the next five?
00:07:08
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Absolutely.
00:07:08
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So I became interested in this whole subject when I was researching for my presidential address in 2018.
00:07:24
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My focus of that talk was practicing less is more to improve value in the critical care that we deliver.
00:07:32
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And value in its simplest terms is the ratio of quality
00:07:37
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divided by cost and certainly the choosing wisely principles really address this idea of waste and decreasing the cost of care that we delivered.
00:07:52
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Anyway, the SCCM council appointed a task force that contains 17 members as well as two council liaison.
00:08:03
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And I would say from the start, this was deliberately a diverse group in terms of the members themselves
Choosing Wisely Next Recommendations
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and the institutions which they represented.
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At the onset of this process, each of the members in this task force or committee was charged with identifying their own personal examples
00:08:33
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based on their experience, based on their expertise of waste in their practice and to find supporting references for the benefit of eliminating that waste.
00:08:50
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Each council of the members of the task force was also
00:08:58
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asked to review an existing practice guideline that was relevant to the choosing wisely of principle.
00:09:08
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In choosing these potentially new choosing wisely elements, people were asked to consider within this potential recommendation, how it affected patient safety, as well as the quality of care.
00:09:26
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what exactly was the strength of evidence to support a potential new recommendation and did it have, was there any evidence of improvement in patient outcomes?
00:09:41
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So initially everyone did their literature reviews and individually generated a practice statements for the next five choosing wisely.
00:09:53
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there was a discussion consensus building and ultimately we ended up with 13 new items with additional meetings.
00:10:05
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This list was narrowed from 13 down to eight.
00:10:12
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Again, in large part based on the strength of the evidence and the potential impact that the item might have on patient care.
00:10:24
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Next, a survey was developed and this survey was sent out to the entire SCCM membership and SCCM members were asked to rank these eight items from most to least important.
00:10:47
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And ultimately this was used to reduce the eight recommendations down
00:10:54
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five based on how important the, uh, SCCM members, uh, bought each item was.
00:11:02
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These, uh, five were, uh, reviewed, uh, by the task force of members.
00:11:09
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Uh, and then the, uh, SCCM executive committee and council, uh, also reviewed, uh, these new items.
00:11:18
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Following that, there was significant activity around simplifying the language that was utilized to explain each of the new items.
00:11:31
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And ultimately, the next five choosing wisely for critical care was reviewed and approved by the American Board of Internal Medicine.
00:11:44
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Excellent.
00:11:44
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And I would like to ask Pam as chair of the committee, a couple of questions regarding the evolution of these recommendations like Jerry shared.
00:11:54
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It started with 13, whittled down to eight, then to five.
00:11:58
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And specifically, you mentioned Pam in the original choosing wisely the importance of multi-society approach, but also a very salient aspect of this process that Jerry shared.
00:12:11
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was consulting really a large number of SCCM members.
00:12:16
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So ultimately, this is about containing cost from the perspective of the clinicians and the practitioners and not from some entity that is regulating that.
00:12:25
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If you could comment on that aspect first.
00:12:28
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Absolutely.
00:12:29
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And that's such a wonderful question and point to make.
00:12:32
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One of the, I think, strengths and
00:12:35
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Dare I say beauty of SBCM is the vast number of stakeholders and professions that are represented and all equally looked at with membership in different committees and task force.
00:12:48
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And when we were initially creating the task force to work on the next five, we deliberately chose individuals with roles that represented a wide breadth of critical care professions that were
00:13:05
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important in engaging and caring for our critically ill patients, but also from a variety of practice settings.
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We wanted to ensure that we included physicians from the community setting as well as academic medical centers and our pharmacists, our nurses, our advanced practice providers, our respiratory therapists, physical therapists, and individuals from different specialties such as emergency medicine, anesthesia, surgery,
00:13:35
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to make sure that our recommendations really did cover the breadth of our organization.
00:13:42
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And while FCCM led this initiative, I think that the fact that we specifically had a broad inclusion in stakeholders and that each of the individuals on the task force then also went back to their respective sections to gain further insight really helped to make
00:14:04
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the next five very applicable to critical care as a whole.
00:14:10
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Excellent.
00:14:10
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The second question I have for you regards the verbiage, and I know Jerry talked about simplifying language, but something that I presume is very deliberate, and I think it's worth sharing with the audience, is the use of do not for every single one of the best practices.
00:14:28
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Right.
00:14:29
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And that was very deliberate.
00:14:31
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And
00:14:32
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the big thing is choosing wisely.
00:14:34
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So things that we want to choose things we should do, and these are things we should not.
00:14:38
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So
Key Recommendations for ICU Care
00:14:39
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when we, you know, when we go through the next five lists, you'll see that they were specifically phrased as easily remembered, easily shared items that clinicians could put into practice of things not to do.
00:14:55
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So we're choosing to do things wisely and specifically choosing not to do these things.
00:15:01
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And
00:15:02
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As we'll discuss, when you look at the flow of the five recommendations, they really are phrased simply and to the point with not a lot of fluff, so to speak, in the recommendations to make them very targeted.
00:15:19
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Excellent.
00:15:19
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I would like to move on.
00:15:21
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And, Anita, maybe the next step would be for you to give us an overview of the five, next five final selection.
00:15:28
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So just share with us what are the five recommendations.
00:15:31
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and then we can dive deeper into each one of them.
00:15:35
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Yes.
00:15:35
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So the five recommendations that we have for the Choosing Wisely Next Five for critical care are, number one, do not retain catheters and drains in place without a clear indication.
00:15:49
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Recommendation number two, do not delay liberation from mechanical ventilation.
00:15:55
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Recommendation number three,
00:15:57
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do not continue antibiotic therapy without evidence of need.
00:16:03
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Recommendation number four, do not delay mobilizing ICU patients.
00:16:08
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And finally, recommendation number five, do not provide care that is discordant with the patient's goals and values.
00:16:19
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Excellent.
00:16:20
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So I believe that what I would like to do now is maybe a dive deeper into each one of these
00:16:27
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and have one of you explain a little bit more for each one of these recommendations.
00:16:33
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What's a little bit of the rationale, the evidence, and some maybe practice tips that would be useful as we evaluate each one of these five best practices individually.
00:16:43
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So I would like to start with recommendation one, do not retain catheters and drains in place without a clear indication.
00:16:50
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Jerry, could you give us your insights on this one?
00:16:52
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Sure.
00:16:54
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This recommendation, interestingly, reflects a similar choosing wisely recommendation made by the Society of Healthcare Epidemiology of America or the SHEA organization.
00:17:13
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And their choosing wisely recommendation reads, avoid invasive devices,
00:17:21
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such as central venous catheters, endotracheal tubes and urinary catheter.
00:17:27
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But if they are required, use them no longer than necessary because they pose a major risk to infection.
00:17:37
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I think all of us in the critical care environment are aware of the risks of any invasive devices.
00:17:49
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Uh, and as example, uh, uh, uh, central line associated bloodstream infections and, uh, uh, urinary catheter related, uh, infection have, uh, bundles, uh, associated with their use, uh, that are very important in reducing hospital acquired, uh, uh, or associated infection with these devices, but
00:18:17
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One of the most important for both of these examples is don't need the device, get rid of it because you can't be charged with a hospital acquired infection.
00:18:27
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If the device is not present.
00:18:32
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Surgeons are well aware of the post surgery drains that they insert that they should come out of the patient as soon as possible as they pose a
00:18:46
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a type of immunosuppression if you wish bypassing some epithelial barrier as long as they remain in place.
00:19:01
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So reduction of hospital acquired infection is the motor major driving force for this first next five choosing wisely for your element.
00:19:15
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And an important aspect that you did mention is really expanding this beyond central lines and Foley catheters, which are the usual target of efforts in ICU.
00:19:24
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So really thinking of every foreign body and making a deliberate practice of evaluating, do I need this today?
00:19:31
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Can it come out?
00:19:33
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Correct.
00:19:34
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Excellent.
00:19:36
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The second recommendation, do not delay liberation from mechanical ventilation.
Spontaneous Trials and ICU Liberation Bundle
00:19:41
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Anita, could you give us your thoughts on this one?
00:19:44
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Sure.
00:19:45
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So in terms of liberation from mechanical ventilation, there has been extensive literature showing that liberation is very important to reducing ICU length of stay.
00:19:57
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And this is achieved by reducing sedation burden, as well as delirium and improving mobility.
00:20:06
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As part of Society of Critical Care Medicine's ICU Liberation A-F bundle, daily spontaneous awakening trials
00:20:15
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as well as daily spontaneous breathing trials are very important to ventilator liberation as long as there are no contraindications.
00:20:25
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And in fact, in some patients, liberation attempts can occur multiple times a day to help facilitate liberation from ventilation.
00:20:36
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Additionally, I'll just mention that a multidisciplinary approach is highly recommended
00:20:43
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when developing processes related to SATs, SBTs, and ventilator liberation locally in each unit.
00:20:52
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And an important aspect of this and some of the other recommendations that we'll see later is that they really fall within the aim and the goals of our A to F bundles that a lot of ICUs are working on and also the SECM, which is ICU Liberation Campaign, have promoted and pushed forward.
00:21:14
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For this, the third recommendation says do not continue antibiotic therapy without evidence of need.
00:21:20
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Pam, could you give us your thoughts on this aspect?
Antibiotic Stewardship Programs
00:21:25
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Absolutely.
00:21:26
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And as a pharmacist, this recommendation is very near and dear to my heart.
00:21:31
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Not that the others aren't, of course.
00:21:33
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But for this, we know there's a growing body of evidence that demonstrates that hospital-based programs that are dedicated to improving antibiotic use
00:21:42
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which we commonly refer to as antibiotic stewardship program, can both optimize the treatment of infections and reduce adverse offense associated with antibiotic use.
00:21:52
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We know these programs help clinicians improve quality of care and patient safety through increased infection cure rates and reduced rate of treatment failures, and also increasing the frequency of correct prescribing for therapy and prophylaxis.
00:22:08
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These antibiotic stewardship programs also reduce rates of
00:22:14
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antibiotic resistance and have benefits while saving hospitals money.
00:22:18
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So there's multiple aspects of this recommendation.
00:22:22
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And we also recognize that there is an urgent need to improve antibiotic use in hospitals and the benefits of antibiotic stewardship in programs.
00:22:32
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And that in 2014, the CDC recommended that all acute care hospitals implement antibiotic stewardship programs.
00:22:38
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So really this recommendation is a part of that.
00:22:43
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and illustrate the intent and need to limit the duration to the shortest effective course of antibiotics and minimize exposure to help reduce exposure and are primary principles of this antibiotic stewardship.
00:22:59
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And these measures really maintain efficacy, reduce related adverse events and cost as a whole.
00:23:06
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Absolutely.
00:23:07
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And I think I want to
00:23:08
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the problems that we have in the ICU is that we're very facile to starting broad spectrum antibiotics.
00:23:15
Speaker
We're not as good at stopping them, right?
00:23:18
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And it does seem that obviously the participation of our pharmacy colleagues in the ICU has been really a game changer, not only in this aspect, but in so many aspects in the ICU.
00:23:31
Speaker
But there's also a growing innovation such as the use of
00:23:37
Speaker
procalcitonin, MRSA, PCRs that have also added to our ability to really be more rational about the use of antibiotics.
00:23:45
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Any comments on that, Pam?
00:23:48
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And that's such a great point.
00:23:49
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I mean, I think as data's mounting for, you know, different strategies, such as you mentioned, it just makes being good stewards of antibiotics hopefully easier across the board.
00:24:02
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But it's always difficult just to keep in mind, though, with everything that's going on, you know,
00:24:06
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the different varied pieces of care for our ICU patients.
00:24:09
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And I know sometimes it's difficult to think about narrowing to say even just unison or ampicillin as a whole based on sensitivities because the patient quote unquote is in the ICU and oh goodness, they're so sick.
00:24:25
Speaker
So I think relying on these technologies and the evidence that's emerging
00:24:31
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to help us guide therapy and minimize and discontinue antibiotics is really crucial as we move forward.
Mobilization Benefits in ICU
00:24:38
Speaker
Great.
00:24:39
Speaker
Recommendation four, do not delay mobilizing ICU patients, at least in my practice, has been probably one of the things that is most different than when I was in training.
00:24:51
Speaker
I can't imagine that we would ever think of moving or walking somebody on a ventilator when I was a fellow, but clearly
00:24:59
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as we move forward, this is something that more and more people are pushing for.
00:25:03
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Jerry, could you give us your thoughts and considerations on recommendation number four?
00:25:09
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Yeah.
00:25:12
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This recommendation is also in line with a very similar recommendation within ICU liberation.
00:25:23
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So it's nice to see that connection.
00:25:27
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I think a lot of critical care providers may not realize that even without corticosteroids, even without neuromuscular blocking agents, just being immobilized is a major risk factor for a catabolism of a lean body muscle.
00:25:50
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And this is through activation of the stress response and activation of a
00:25:56
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family of genes called atrogenes which basically code for proteases that release amino acids from a lean body muscle for synthesis of acute phase reactions expanding the immune system and of course also leukemia genesis so
00:26:21
Speaker
mobilizing the patient will modulate that stress response in a positive way.
00:26:31
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Mobilization does not mean that every patient is necessarily going to be doing laps around the intensive care unit, but anything instead of letting the patient lie still in bed.
00:26:47
Speaker
So it may be
00:26:48
Speaker
passive range of motion, active range of motion, getting the patient to a sitting position in the bed, allowing the patient to stand next to the bed, gradually allowing the patient to walk to a cardiac chair, for example, or use a commode.
00:27:08
Speaker
And then even potentially walking around the intensive care unit with help from
00:27:18
Speaker
uh the team this act of participating in any kind of mobilization is beneficial I would say the evidence is not perfect but it is growing exponentially that patients just feel better about themselves they are more confident and ultimately uh this seems maybe counterintuitive but they require less sedation
00:27:45
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in the studies that have examined this.
00:27:47
Speaker
They are on the mechanical ventilator fewer days, perhaps because there is a less total body catabolism, including the diaphragm.
00:27:59
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So they require fewer days in the intensive care unit.
00:28:03
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As I said, less sedation.
00:28:05
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The secondary effect of this is a lower risk of delirium.
00:28:11
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So for all of these reasons, as
00:28:16
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As soon as it is safe to do so, the patient should be initiated on a mobilization program and advanced with physical therapy, occupational therapy, and input from other members of the ICU.
00:28:39
Speaker
And one of the very interesting developments over the last several years has been the recognition
00:28:44
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of what our patients go through once they survive critical illness.
00:28:48
Speaker
So the post ICU care syndrome, and clearly items like this recommendation number four on mobilization are super important upstream in terms of determining long-term outcomes for our patients.
00:29:03
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So I think it's something that we can't emphasize enough.
00:29:09
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Recommendation number five,
00:29:11
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do not provide care that is discordant with the patient's goal and values.
Aligning ICU Care with Patient Goals
00:29:16
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This perhaps is the one that hits right in the bullseyes of waste.
00:29:22
Speaker
There's multiple studies that have shown that the amount of money that is spent at the end of life and the amount of money that is spent on care that's discordant with what patients really want is really mind-blowing.
00:29:36
Speaker
So, Anita, could you give us some thoughts on recommendation number five?
00:29:40
Speaker
Definitely.
00:29:42
Speaker
So we feel that there's a need to elicit and document care wishes so that care, especially in the intensive care unit, when a patient's critically ill, aligns with that patient's goals and values.
00:29:57
Speaker
Certainly early discussions, even in the outpatient setting, especially for patients who have multiple health problems or advanced
00:30:09
Speaker
illnesses such as malignant or metastatic cancer ensure that concordant care is provided.
00:30:17
Speaker
And you can imagine in the ICU when surrogate decision makers are under a lot of stress, not only because their family member or friend is going through a lot in the ICU, but they have this pressure to make decisions.
00:30:34
Speaker
But if goals and values are discussed and documented ahead of time,
00:30:39
Speaker
that can assist the surrogate decision makers in making appropriate decisions for a patient's care.
00:30:50
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The other item is to just make sure that throughout the hospital stay, that engaging families and patients in the care plan and having them participate in decision making helps ensure that the care plan is aligned
00:31:08
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with the patient's goals and values.
00:31:14
Speaker
Jerry, I would like to ask you in your capacity as an intensivist of little patients to comment on these seem to be universal regardless of it to pediatric or an adult ICU, regardless of the type of ICU, but are there any particular aspects of Recommendation 5 that are nuanced or unique to pediatrics?
00:31:39
Speaker
Thanks for asking that because I agree with you.
00:31:44
Speaker
I think the principles are universal and in line with this idea of a family care conference to establish the goals and values of the patient.
00:32:00
Speaker
It's just as important for children who are critically ill, perhaps near the end of their life,
00:32:07
Speaker
as it is as it is for adults.
00:32:10
Speaker
So establishing what the realistic goals for this patient might be with the family is a crucial discussion and you know sometimes this even leads to interventions like discontinuing care at the patient's home
00:32:34
Speaker
and mobilizing a team to be able to make this happen.
00:32:40
Speaker
Patients and families are always worried about pain and certainly that is easy to address in the ICU in most cases and patients and families can be assured that everybody is focused on that.
00:33:00
Speaker
In addition,
00:33:01
Speaker
It is possible that the care providers might learn about goals that they would never have thought of had this conference not occurred.
00:33:12
Speaker
And I think the multidisciplinary care team is very agile at making some of these requests happen.
00:33:22
Speaker
For example, a common one is allowing multiple family members
00:33:30
Speaker
be in the room of somebody who is very critically ill or injured to provide support.
00:33:39
Speaker
So, yes, this element of NEXT 5, choosing wisely for critical care, is critically important for kids as it is for adults.
00:33:51
Speaker
And I think an important aspect also as we will summarize these five recommendations is that eliminating waste
00:33:59
Speaker
is also about creating value.
Reiteration of Key Recommendations
00:34:01
Speaker
And these are high value items for our patients, like these discussions and what all these best practices really entail or what's happening at the bedside.
00:34:13
Speaker
So to remind our audience, the five recommendations are number one, do not retain catheters and drains in place without a clear indication.
00:34:22
Speaker
Number two, do not delay liberation from mechanical ventilation.
00:34:27
Speaker
Number three,
00:34:28
Speaker
do not continue antibiotic therapy without evidence of need.
00:34:32
Speaker
Number four, do not delay mobilizing ICU patients.
00:34:37
Speaker
And number five, do not provide care that is discordant with the patient's goals and values.
00:34:43
Speaker
I would like to get thoughts from each one of you on what is next for the next five.
00:34:48
Speaker
How do we make these stick and become real at the bedside for our patients?
00:34:55
Speaker
And I'll start with Pam.
00:34:59
Speaker
I think really when we think about implementing these, and Anita definitely can speak to this and the great work that her keg's doing, we need to think about what works in our individual unit and not one size fits all.
00:35:15
Speaker
I've primarily worked in the same MICU since I've completed training, but I know a lot of my colleagues and friends across the country, their unit works very differently.
00:35:25
Speaker
thinking realistically of how to implement these, how to think of them on a daily basis for each and every patient really is unit specific and needs to be done at the local level.
00:35:35
Speaker
So taking education and things that societies and organizations are developing and then drilling down to what would work and what would be successful.
00:35:43
Speaker
How would things best be accepted and implemented with the workflow that goes on for each individual unit?
00:35:53
Speaker
So I really think that
00:35:55
Speaker
thinking through that first prior to initiating the next five choosing list, or even thinking of what would work first.
00:36:07
Speaker
What could be the first win when implementing them?
00:36:09
Speaker
Instead of going for all five, maybe pick a few that are either would be the biggest benefit for your unit and your patients, or that would be the easiest to implement to really get the ball rolling.
00:36:22
Speaker
And I think that it speaks to
00:36:24
Speaker
to that team building effect of really applying these in a way that makes sense to your ICU, to your team, to the expertise that you have there and to your needs.
00:36:34
Speaker
I think that's a great, great advice.
00:36:36
Speaker
Anita, before you tell us your thoughts on what's next, could you tell our audience what a keg is?
00:36:42
Speaker
Sure, absolutely.
Implementation and Collaboration in Critical Care
00:36:44
Speaker
So we are very fortunate within the Society of Critical Care Medicine to have a number of different knowledge education groups.
00:36:53
Speaker
These groups help pull together individuals who have interest in a certain topic, such as choosing wisely.
00:37:01
Speaker
Our choosing wisely keg has been meeting for, I think about two years now, actually, this might be our anniversary in July, to bring people who have similar interests together, talk about topics in choosing wisely, know what the recommendations are in critical care, and
00:37:23
Speaker
share best practices across our institutions.
00:37:27
Speaker
So it's been a very eye-opening experience, I think a very collaborative experience, and we hope to use this keg as a sounding board as well as a stepping stone for further work in terms of increasing awareness in addition to possibly research as well, which we'll talk about in a minute also.
00:37:49
Speaker
Excellent.
00:37:51
Speaker
And tell us a little bit of your thoughts of how to make these real at the bedside.
00:37:56
Speaker
I completely echo what Pam just mentioned in terms of you do have to implement locally based on how things are set up in each unit.
00:38:08
Speaker
You can't expect that every ICU works the same way.
00:38:14
Speaker
What we've found success in at the Cleveland Clinic is to share the why.
00:38:18
Speaker
Why are we doing this?
00:38:20
Speaker
How does it help my patient?
00:38:21
Speaker
How does it help my patient's outcomes?
00:38:24
Speaker
And we also ensure that there's a multidisciplinary or multi-professional approach to implementation.
00:38:32
Speaker
As you heard us talk through these next five recommendations, you see that these items touch multiple members of the team.
00:38:43
Speaker
And so we need to make sure we continue to take that team approach.
00:38:47
Speaker
The other thing that we've been successful with at the clinic is to utilize tools in the electronic medical record to increase awareness.
00:38:58
Speaker
For example, we have a tool within our EMR to show us how long a central line has been in place or a urinary catheter has been in place, as well as a reminder as to how long antibiotics have been prescribed.
00:39:14
Speaker
So these are all tools that we use within the EMR to make sure that we're choosing wisely.
00:39:22
Speaker
Excellent.
00:39:23
Speaker
Jerry, you obviously have not only experience in leadership at the site level in your ICU, but also as a past president of SCCM have thought about this in a broader context.
00:39:35
Speaker
What are your thoughts in terms of making these real and taking the ideas to the bedside?
Promoting Choosing Wisely Initiatives
00:39:44
Speaker
Well, first of all, I cannot speak for the council myself, but I would hope that, and this is already in process, as I understand it, that there will be a marketing campaign for the next five choosing wisely for critical care.
00:40:06
Speaker
to encourage people, I guess, number one, not to forget the first five, but to take a serious look at the second five.
00:40:16
Speaker
And as Pam and Anita have said, look at ways of implementing these good ideas to improve value, reduce waste at work at their institution.
00:40:31
Speaker
I think there's always the potential for an annual award for institutions that initiate things like choosing wisely as quality improvement projects and the success stories around that effort.
00:40:56
Speaker
One of the things that the Society of Critical Care Medicine does very, very well
00:41:01
Speaker
are these collaboratives where hospitals will come together, for example, to learn about something in an interactive way with experts providing lectures on various topics related to the overall program under consideration.
00:41:27
Speaker
and basically ways of doing successful quality improvement.
00:41:31
Speaker
And this certainly the choosing wisely, an issue that certainly would fit in this sort of realm.
00:41:41
Speaker
So it is possible, but that could also happen.
00:41:47
Speaker
I think this is a good opportunity perhaps for the choosing wisely CAG to get more
00:41:55
Speaker
or continue to be involved in choosing wisely, perhaps designing a survey in terms of how are these new recommendations being implemented?
00:42:09
Speaker
What are the success stories?
00:42:12
Speaker
What are the challenges or barriers and potential ways to overcome them?
00:42:18
Speaker
so that these new Choosing Wisely elements can gain wider recognition and hopefully implementation across intensive care units in the United States and internationally as well.
Personal Beliefs and Book Recommendations
00:42:37
Speaker
Excellent.
00:42:38
Speaker
And really a lot of very insightful thoughts from all of you with the experience that you've had with creating
00:42:46
Speaker
this document and going through this process, really we're fortunate to hear it from you and hoping that we can continue to promote these and push forward.
00:42:56
Speaker
We'll have plenty of links on the show notes of the podcast.
00:42:59
Speaker
We usually close the podcast with some questions that are unrelated to the clinical topic.
00:43:05
Speaker
So if that's okay with you, we could go to that portion.
00:43:07
Speaker
Sure.
00:43:10
Speaker
And I'll start with Anita.
00:43:14
Speaker
What would you want every intensivist to know who's listening to us today?
00:43:19
Speaker
Could be a quote or a fact.
00:43:22
Speaker
So actually, I'm not going to change the topic.
00:43:25
Speaker
I am a strong proponent of choosing wisely.
00:43:30
Speaker
And I'll go back to Jerry's comments earlier about less is more.
00:43:35
Speaker
And I can share with you a little bit about the historical context of this phrase.
00:43:42
Speaker
So this phrase of less is more is actually associated with a designer and architect Ludwig Mize VanderRoe, and I apologize if I've mispronounced his name, but he's one of the founders of modern architecture.
00:43:58
Speaker
And he advocated for a minimalist approach to modernist design.
00:44:04
Speaker
And I think one of the things he was trying to convey is the value of simplicity.
00:44:09
Speaker
And I think we can translate this to medicine
00:44:12
Speaker
as Jerry has mentioned when he was president of the society, that this value of simplicity, the value is not created by doing more, which sometimes in medicine we feel compelled to do.
00:44:28
Speaker
Let's do everything we can, but that doesn't always mean more tests, more labs, more interventions.
00:44:36
Speaker
I think what we need to focus on is value.
00:44:41
Speaker
Is what we're doing actually going to provide a value for the patient?
00:44:45
Speaker
Is it going to change the patient's outcome?
00:44:48
Speaker
And so more is not more, actually less is more.
00:44:53
Speaker
So that's something I want to make sure intensivists think about and practice when they're taking care of critically ill patients.
00:45:02
Speaker
Absolutely.
00:45:03
Speaker
I think this is obviously a very important lesson for us on a daily basis in the ICU and outside.
00:45:09
Speaker
And definitely a lot of times less is more and something that we should be thinking of actively.
00:45:16
Speaker
Pam, is there something that you believe to be true in medicine or in life that most other people either don't believe or behave like they don't believe it?
00:45:27
Speaker
That is, that's a really tough question.
00:45:32
Speaker
I think, well, one thing that I, I know personally, sometimes I lose sight of, so I can't speak
00:45:38
Speaker
you know, for others, but I know it's something I struggle with that I try to remind myself on a daily basis is that many times we don't know what other people are struggling with or dealing with based on their background or things that are happening to them.
00:45:52
Speaker
So it's really important just to be kind all the time to everyone.
00:45:58
Speaker
And I think this is also very important when we talk about some of the choosing wisely items that we've discussed, whether that's talking with colleagues, talking with family members,
00:46:08
Speaker
We might not know where they're coming from, what happened to them that day.
00:46:12
Speaker
So giving grace and being kind goes a long way, even at the end of a very long and trying day, having that conversation with the family, having goals of care discussion, and really taking into consideration family's perspective and what they bring with them to the meeting.
00:46:33
Speaker
I think
00:46:34
Speaker
is something that I struggle with and is something that I feel very passionate about and try to remember.
00:46:39
Speaker
So I would say a truth in life and in medicine is to be kind and to not take advantage or not to take lightly what other people are bringing into a conversation because we really don't know, you know, what just happened to them right before they stepped into it.
00:46:57
Speaker
So that would be one thing that, you know, I try every day to live.
00:47:01
Speaker
And I think it's an excellent point.
00:47:03
Speaker
And like most things in life, if it's common in ourselves, it's common in other people, right?
00:47:10
Speaker
So many things that we kind of view from our unique perspective are very common elsewhere.
00:47:15
Speaker
And I think, Pam, what you talked to is like that empathetic concern, right?
00:47:19
Speaker
We always assume that the patient's family is being difficult or the colleagues behaving in a way that we wouldn't agree, but we never take the time to really ask, why could that be?
00:47:29
Speaker
What's going on in their life that I don't know?
00:47:32
Speaker
And perhaps if I knew that or if I was going through that same situation, I would be behaving exactly the same.
00:47:37
Speaker
So that empathetic concern and that kindness, we have to bring that every day for every interaction.
00:47:44
Speaker
And sometimes we forget.
00:47:45
Speaker
So I think it's a great point.
00:47:46
Speaker
Thanks for sharing that.
00:47:48
Speaker
Absolutely.
00:47:49
Speaker
Thank you.
00:47:49
Speaker
Great question.
00:47:51
Speaker
And last, I would like to finish with some books.
00:47:54
Speaker
So, Jerry, could you mention some books, a book or books that have influenced you the most or that you have gifted most often to others?
00:48:04
Speaker
Well, I would be dishonest, but this is a huge conflict of interest.
00:48:09
Speaker
But the book closest to me is a textbook, Pediatric Critical Care, that I have been editor along with Brad Furman for six editions.
00:48:23
Speaker
So this is like a lifetime work over 30 years.
00:48:30
Speaker
I think Brad has said on more than one occasion, maybe this is gonna be our most important contributions during our life.
00:48:37
Speaker
So it is certainly the book I know the most about and have gifted that often to others.
00:48:44
Speaker
But aside from that, I also just wanna put on the top of my list, Anything by Gabriel Garcia Marquez,
00:48:57
Speaker
This is probably the antithesis of a textbook in pediatric critical care medicine just for a completely beautiful writing and inspiration in a different way than mathematics and science.
00:49:18
Speaker
I would go with Gabriel Garcia Marquez.
00:49:23
Speaker
I believe I've
00:49:24
Speaker
I've read everything that this author has ever written, never been disappointed, and would highly recommend it to anyone.
00:49:36
Speaker
Excellent.
00:49:36
Speaker
And I will look at some of those books as well.
00:49:39
Speaker
Is there any book in particular from Gabriel Garcia Marquez that comes to mind immediately?
00:49:45
Speaker
Oh, the most famous one is A Hundred Years of Solitude.
00:49:51
Speaker
The other that are very well known are loved in the time of cholera.
00:49:56
Speaker
We could paraphrase that nowadays.
00:49:58
Speaker
Somebody should do a follow up to this and the title would be loved in the time of COVID.
00:50:05
Speaker
And what are the consequences of isolation over a long period of time?
00:50:12
Speaker
General In His Labyrinth is another one that's very popular.
00:50:17
Speaker
They are all very good and have this sort of quality of history of South America, particularly Columbia, where he's from.
00:50:29
Speaker
And also this sort of real, unreal aspect of writing.
00:50:41
Speaker
What actually happened and what is a sort of fantasy or even mysticism
00:50:47
Speaker
um isabel allende takes the same idea and and takes it even further but i would say just uh i i will sit down and read a paragraph and just say wow why can't i write something like that because it is so beautiful and i think you'll find that uh i think you'll find that regardless of which of the books uh that he's written that you pick up to read absolutely and i'm a big fan
00:51:16
Speaker
of him and the magic realism kind of group or authors in South America.
00:51:24
Speaker
But also I think it speaks to what Pam was saying, right?
00:51:27
Speaker
Fiction is a great tool to develop our empathy because through fiction, we see, I mean, different points of view, we see different views in life.
00:51:38
Speaker
And like they say, I mean, fiction is the only truth.
00:51:40
Speaker
So a great, I think, muscle to exercise
00:51:44
Speaker
when we're not dealing with critical care.
00:51:45
Speaker
So we will link some of these books on the show notes as well.
Conclusion and Call to Action
00:51:49
Speaker
Well, I wanna thank Jerry, Pam and Anita first for the wonderful work that you've all done, giving your generous time to really push Choosing Wisely forward to get these next five accomplished, published and to disseminate your knowledge.
00:52:05
Speaker
Also wanna really thank you for your generosity with your time today
00:52:12
Speaker
and sharing your expertise and knowledge with the audience of the podcast.
00:52:16
Speaker
And look forward to talking more with you about these and other topics in critical care.
00:52:23
Speaker
Thank you so much.
00:52:26
Speaker
Thank you for the opportunity.
00:52:28
Speaker
Yeah.
00:52:28
Speaker
Thank you so much for giving us an audience on this topic that we feel passionately about.
00:52:34
Speaker
Thank you.
00:52:37
Speaker
Thank you for listening to Critical Matters, a sound podcast.
00:52:41
Speaker
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00:52:47
Speaker
Sound's transforming the way critical care is provided in hospitals across the country.
00:52:51
Speaker
To learn more, visit www.soundphysicians.com.