Oct 19, 2020
By Basil Evan

Dos and don’ts in the ICU: are you choosing wisely?

istockphoto.com/fangxianuoWhen we ask questions, we help identify potential problems before they occur. And by doing so, we promote the development of innovative solutions that prevent problems before they happen.

Takeaway messages

  • “Do” ask questions. Questions help facilitate dialogue about the “don’ts.”
  • Routine/common practices are not always supported by the evidence.
  • Choosing wisely means choosing care that is truly necessary.

Why we must choose wisely

In the climactic scene in 1989’s Indiana Jones and the Last Crusade, a 700-year-old knight gives the warning, “You must choose, but choose wisely.” The villain does not know what to choose and allows his co-conspirator to make their choice, but they choose poorly. The hero, meanwhile, considers the options, reflects upon the evidence, and chooses wisely.

As nurses, we too face choices and make decisions. Our critical care environment is advancing: new evidence-based recommendations are changing the choices we make, the care we provide, and the way we do things in the intensive care unit (ICU). Most nurses would agree that a typical day (if there is such a thing as a typical day in the ICU) can begin one way and end another, depending on the questions we choose to ask ourselves, our teams, and our patients.

Choosing Wisely Canada (CWC) is the national voice for reducing unnecessary tests and treatments in health care. It was launched in 2014 and is now part of a global movement that spans more than 25 countries across five continents. Over the years, numerous professional societies have developed recommendations for a variety of clinical specialties, including general nursing, critical care, and COVID-19.

Nursing: Critical Care, Five Things Nurses and Patients Should Question is the latest list of recommendations from CWC. It focuses on nursing practice in the ICU and was developed by the Canadian Nurses Association (CNA) in partnership with the Canadian Association of Critical Care Nurses (CACCN).

Making the list

Choosing Wisely Canada (CWC) is the national voice for reducing unnecessary tests and treatments in health care.

CNA and CACCN established this list of recommendations by convening an 11-member working group. The group consisted of critical care nursing experts from across Canada, representing a broad range of geographical regions and practice settings. The group reviewed existing recommendations, brought forward new evidence-based items, and appraised, refined, and adapted the list until it reached a consensus. The list underwent extensive consultation and internal review before receiving full endorsement by CNA in March 2020.

Dos and don’ts

The ICU is a fast-paced environment where every second counts. When a patient begins to deteriorate, we do what the patient needs done at that moment. As a result, we frequently choose to “treat first and ask questions later.” On the other hand, when critically ill patients are managed by routine/common practices, we sometimes resist the urge to ask questions and adopt the maxim, “If it ain’t broke, don’t fix it.”

Be that as it may, we eventually do ask questions. And the conversations we promote between clinicians and patients help us choose the care that is truly necessary, supported by evidence and shown to improve patient outcomes. When we ask questions, we help identify potential problems before they occur. And by doing so, we promote the development of innovative solutions that prevent problems before they happen. Have you identified any “don’ts” (unnecessary tests, treatments, or procedures) that could expose patients to harm? Perhaps the better question is, “Have you considered any of the five ‘don’ts’ below?”

  1. Don’t insert or leave in place a urinary catheter without an acceptable indication.
  2. Don’t administer benzodiazepines to treat symptoms of delirium.
  3. Don’t use physical restraints with critically ill patients as the first choice to prevent self-extubation or removal of lines or tubes.
  4. Don’t repeatedly attempt intravenous access during a life-threatening event when intraosseous access is available.
  5. Don’t prolong use of central venous or peripherally inserted central catheters without daily reassessment.

Each of the five items in the list is supported by several references.

There is a fine line between common practices for patients with legitimate indications, and common practices for patients without legitimate indications. “Choosing wisely” means acknowledging the difference.

Application to practice

Critical care nurses understand the importance of systematic head-to-toe assessments in the ICU. We also recognize the significance of daily, hourly, and minute-by-minute reassessments to ensure effective patient management. A cultural shift toward “less is more” is happening, and strategies that emphasize non-invasive/non-pharmacologic interventions are paramount to our success. But how can we apply these new recommendations to our practice?

First, let’s take a closer look at two of these five recommendations. Both #1 and #5 involve invasive lines, the dangers associated with their prolonged use, and the importance of daily assessments/reassessments to ensure their medical necessity. When left in too long, urinary catheters can lead to catheter-associated urinary tract infections (CAUTI), and central venous/peripherally inserted central catheters can lead to central line-associated bloodstream infections (CLABSI). When these infections occur, they negatively affect patient outcomes.

Next, let’s explore how and when to apply these recommendations. Daily rounds and patient handover during shift change can provide us with opportunities to start the conversation, but what more might we do? Suggestions may include the implementation of reminder systems, safety huddles, and/or stop orders. In essence, these two recommendations remind us that there is a fine line between common practices for patients with legitimate indications, and common practices for patients without legitimate indications. “Choosing wisely” means acknowledging the difference.

What can you do?

  1. Download Diving Into Overuse in Hospitals, a starter kit for reducing unnecessary tests and treatments
  2. Explore the various toolkits developed by clinicians who successfully implemented recommendations in their distinct settings
  3. Start the conversation in your ICU!

For more information, visit:

Choosing Wisely Canada Nursing Lists
This CNA web page has the first non-physician lists of specialist nursing recommendations in general nursing, critical care, infection prevention and control, and gerontological nursing.

Canadian Association of Critical Care Nurses Education/Certification/Resources
Information on critical care nursing certification, Canadian nursing programs, preparing conference abstracts, and more.

Choosing Wisely Canada
Lists of the nursing “don’ts” for general nursing, gerontological nursing, infection prevention and control, critical care nursing, as well as other resources.

Basil Evan, RN, BA, BN, is the quality officer for the Shared Health/WRHA critical care program.

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