Laird Harrison

January 13, 2014

SAN FRANCISCO — Four critical care provider groups have announced a list of measures to limit wasteful procedures in the intensive care unit (ICU) in an attempt to control spiraling healthcare costs.

"It should be clear to everyone in the audience that rationing is unavoidable," said committee chair Scott Halpern, MD, assistant professor of internal medicine at the University of Pennsylvania in Philadelphia. "You cannot reconcile boundless needs to bounded funds."

Dr. Halpern presented the list here at the Society of Critical Care Medicine 43rd Critical Care Congress.

The work — developed by the American Association of Critical-Care Nurses, the American College of Chest Physicians, the American Thoracic Society, and the Society of Critical Care Medicine — provides specific guidelines on restraining the use of tests, transfusions, parental nutrition, sedation, and life support.

This list is one of many being rolled out by professional societies as part of the Choosing Wisely initiative of the ABIM Foundation, a health policy group founded by the American Board of Internal Medicine.

In issuing the list, the societies are acknowledging that physicians "serve 2 masters": individual patients and the general population, Dr. Halpern explained.

Rationing is unavoidable. You cannot reconcile boundless needs to bounded funds.

Some physicians have argued that there is no conflict between these 2 missions, and have tried to distance themselves from anything that implies rationing. But that position creates unreasonable expectations about how much care the healthcare system can deliver, and doesn't acknowledge the choices that physicians are already facing, Dr. Halpern noted.

"We ration stuff in the ICU every day," he said. "We ration our time. You have to make decisions about who needs your time the most and how your time can best be allocated. And deciding who gets beds in the ICU and who gets kicked out is a form of rationing."

The Choosing Wisely campaign acknowledges this reality with a specific list of 5 "don'ts" that could reduce costs.

Table: Five Don'ts in Critical Care

Don't order diagnostic tests at regular intervals, such as every day; rather, order them in response to specific clinical questions.
Don't transfuse red blood cells in hemodynamically stable, nonbleeding ICU patients with a hemoglobin concentration greater than 7 mg/dL.
Don't use parenteral nutrition in adequately nourished critically ill patients in the first 7 days of an ICU stay.
Don't deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.
Don't continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families care focused entirely on comfort.


The list was chosen from 58 items nominated by committee members representing the 4 critical care organizations. The committee gradually refined the list, incorporating feedback from the societies' leaderships as they went along.

Committee members carefully researched published literature to support these guidelines, said committee member Hannah Wunsch, MD, assistant professor of anesthesiology at Columbia University in New York City.

They based the list on how often the concerns arise and how much money the guidelines might save. "We don't have a lot of great economic data for a lot of the things we do in the ICU," she explained.

The committee also considered how relevant each item is to the practice of critical care providers, and whether new innovations could be brought to bear in cost savings.

After the presentation, most of those who came forward praised the committee for its work. But one meeting delegate questioned the call to reduce the use of life support. "The concern is that some of the literature in the neurosciences shows how much difficulty there is in early diagnosis," he said.

Dr. Wunsch noted that the guideline puts the emphasis on family discussion.

Another meeting delegate noted that "maybe it's because I'm not from the United States, but it seems to me this list is premised on the idea that patients and families, at the end of the day, can have whatever care they want."

The list may well be specific to the realities of practicing medicine in the United States, Dr. Wunsch acknowledged.

Dr. Halpern reports receiving grant funding from the Greenwall Foundation and the Moore Foundation. Dr. Wunsch has disclosed no relevant financial relationships.

Society of Critical Care Medicine (SCCM) 43rd Critical Care Congress. Presented January 11, 2014.


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