McCarthy: "Choosing Wisely", how we can save modern medicine

[x_text]Today we are pleased to have Dr. Paul McCarthy,  Assistant Professor of Medicine at the University of Maryland and a staple in the Shock Trauma ECLS program. Today Dr. McCarthy will be speaking on the cost of healthcare and how physicians are contributing to the problem. This is as succinct a summary of the recent Choosing Wisely® campaign as you will find. Over the next 40 minutes he will outline some major steps that will right the ship of modern medicine and perhaps stop American ICUs from hemorrhaging money!![/x_text]

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Clinical Pearls

(Summary assisted by Dr. Sofian Al-Khatib)

Routine or Daily Labs

• Phlebotomy →  anemia + ↑ unneeded transfusions 
• Pre-test Probability are usually low, with most values requiring an additional blood draw to “confirm”
• Adds to healthcare costs (~ 11% of ICU costs) and does not improve outcomes
  • Eliminating “routine” labs can save approx. 20 cbc’s and chemistry/week and $$$$

Routine or Daily Chest X-ray’s

• Rarely Problems are found
  • 2% of findings are clinically relevant and these often do not change management
• Harm is possible
  • Loss of line/ETT, radiation, increased risk to infection, agitation
• Use non-invasive methods such as ultrasound:
  • Eval: Effusions, Pneumothorax, Parenchymal disease, ET tube placement and Diaphragm movement

RBC Transfusions

• TRICC study
  • No difference in 30 day mortality for restrictive (7) vs liberal (10) hemoglobin levels.
  • DO NOT transfuse hemodynamically stable, nonbleeding patients with a hgb > 7g/dL
• Adverse outcomes of Transfusions:
  • Volume overload, infection risk, TRIM, TACO, TRALI, cost
• Recommendation by American Association of Blood Banks:
  • DO NOT transfuse hgb >10g/dL

Parenteral Nutrition

• DO NOT administer parenteral nutrition in adequately nourished critical ill patients until 7 days into stay
• Adverse outcomes:
  • Requires central line access, lab monitoring, errors in Rx, overfeeding, hyperglycemia, infection risk, volume overload, cost
• Nutrition studies showed no benefit of early PN [source][meta-analysis]

Avoid Deep Sedation in Mechanical Vented Patient

• Prolonged Mechanical Ventilation:
  • ↑ neuro-testing, ↑ LOS, ↑ delerium, ↑ infections,  ↑ tracheostomies
• Nearly all ventilated patients receive more sedation at night (source)
• Daily sedation holidays decrease duration of mechanical ventilation and ICU length of stays (source)
  • Sedation holidays +  SBT = better outcomes

End of Life Care and Comfort Measures

• Life support measures include but not limited too:
  • Hydration, tube feeding, parenteral nutrition, CPR, defibrillation, dialysis, mechanical ventilation, pacemakers, vasopressors, and cardiac assist devices.
• Majority of patients do want prolonged dependence on life support
  • Of all seriously ill patients that receive aggressive care in ICU →  1 in 5 die
• Goals:
  • End-of-life discussions, realistic expectations + prognosis, palliative care consults early!

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