By Briana Witherspoon, DNP, ACNP, and Karen March, MN, RN, CCRN
In 2012, the American Board of Internal Medicine (ABIM) Foundation partnered with Consumer Reports to create Choosing Wisely®, an initiative focused on reducing the number of unnecessary tests and procedures performed during a hospital admission or clinic appointment. The overall goal of Choosing Wisely® is to encourage dialogue between patients, families and healthcare staff to ensure that patients are receiving care that is not only evidenced-based but also a necessary component of their plan of care. As part of the campaign, national and international healthcare organizations asked their members to identify tests or procedures commonly used in their respective fields of practice whose necessity should be questioned and discussed. Since the initial launch, Choosing Wisely® has grown exponentially. Today, 19 countries and more than 80 specialty societies are participating in the initiative, including nursing organizations such as the American Academy of Nursing, American Association of Critical Care Nurses and the American Association of Neuroscience Nurses. Collectively, over 500 recommendations and 1,300 journal articles have been published.
In 2014, the American Association of Critical Care Nurses partnered with three other critical care societies as part of the Critical Care Societies Collaborative to create a list of routine critical care practices that should be questioned and could even be considered harmful in some instances. The recommendations are:
1. Don’t order diagnostic tests at regular intervals, but instead in response to a specific clinical question.
2. Don’t transfuse red blood cells in hemodynamically stable, non-bleeding patients who have a hemoglobin concentration greater than 7 g/dL.
3. Don’t initiate parenteral nutrition in an adequately nourished critically ill patient during the first seven days of their ICU admission.
4. Don’t deeply sedate mechanically ventilated patients without a specific indication and daily attempts to lighten and wean sedation.
5. Don’t continue life support for patients at high risk for death or severely impaired functional recovery without offering a comfort care focused option.
In addition to the aforementioned recommendations, the American Academy of Nursing developed a list of “20 Things Nurses and Patients Should Question.” Those that are applicable to neurocritical care include:
1. Don’t let older adults lie in bed or only get up to a chair during their hospital stay.
2. Don’t use physical restraints with an older hospitalized patient.
3. Don’t wake the patient for routine care unless the patient’s condition or care specially requires it.
4. Don’t place or maintain a urinary catheter in a patient unless there is a specific indication to do so.
5. Don’t administer PRN sedative, antipsychotic or hypnotic medications to prevent and/or treat delirium without first assessing for, removing and treating the underlying cause of delirium and using non-pharmacologic delirium prevention and treatment approaches.
6. Don’t assume a diagnosis of dementia in an older adult who presents with altered mental status and/or symptoms of confusion without assessing for delirium or delirium superimposed on dementia using a brief, sensitive, validated assessment tool.
7. Don’t administer diazepam for muscle spasm following spine surgery in the elderly.
8. Don’t order formal swallow evaluations in stroke patients unless they fail their initial swallow screen.
As a constant presence at the bedside, nurses can have an enormous influence on patient care. Patients and their families often turn to nurses to ask their thoughts and opinions on treatments and healthcare decisions. Ideally, if nurses are familiar with Choosing Wisely®, they will feel empowered to help patients understand the recommendations, assist patients in asking questions and feel confident discussing recommendations with prescribing providers in order to ensure patients are receiving necessary and evidence based care.
Advanced Practice Registered Nurses (APRNs) can participate in the Choosing Wisely® initiative by serving as a source of continuity of care for patients in the ICU, especially in larger academic medical centers where residents rotate from one service to another. Some APRN staffing models include 24-hour coverage, making it possible for them to help significantly decrease the use of unnecessary testing. In 2015, Vanderbilt University Medical Center launched an APRN led Choosing Wisely® initiative that successfully increased clinician awareness and better ordering practices. Due to the success of the initiative, the Advanced Practice Nursing Collaborative was created to enable advanced practice teams at other institutions to participate in implementing a Choosing Wisely® initiative of their own.
In conclusion, it is our responsibility as nurses to further disseminate Choosing Wisely® resources and help educate our peers and colleagues. Both APRNs and staff nurses can promote awareness and serve as champions to reinforce the goals of improved ordering practices and decreasing unnecessary tests. This can be done formally through presentations, flyers, email communications, or informally by simply encouraging daily discussions in multidisciplinary rounds.
To learn more about the Choosing Wisely® initiative, please visit http://www.choosingwisely.org/
To learn more about the Advanced Practice Nursing Collaborative, please visit https://ww2.mc.vanderbilt.edu/nursingoap/49500
#Leading Insights #BrianaWitherspoon #KarenMarch #June2018