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Using Choosing Wisely in ICU to reduce unnecessary testing

In the Intensive Care Unit, blood tests and chest radiographs are usually requested on a routine, time-scheduled basis, and many may be unnecessary. The Fiona Stanley Hospital in Perth has developed a replacement protocol to reduce unnecessary tests and will evaluate and optimise this protocol in a large clinical study.

South Metropolitan Health Service, Fiona Stanley Hospital ICU
Caption: South Metropolitan Health Service, Fiona Stanley Hospital ICU

There are good reasons for standardising blood tests and chest radiographs in the ICU. Using the same tests for all patients at set times during the day can reduce the risk of missing important findings. Added to which, ICUs are complex environments with a great many staff and having set rules to follow can reduce the risk of mistakes being made.

However, this approach leads to unnecessary tests being performed, impacting on patient safety, and using resources and valuable clinicians’ time. A survey of 201 intensive care clinicians (nurses, junior doctors, and senior doctors) across Australia found that 33% of routine blood tests and chest radiographs were considered unnecessary.

Targeted testing protocols for the ICU

A team at the Fiona Stanley Hospital, is undertaking a series of initiatives that are looking at replacing standardised testing protocols with targeted testing. This will focus on tests that are deemed clinically indicated as determined by the treating ICU team, usually during the consultant ward round.

Following the Choosing Wisely principle of ensuring the right amount of care, they have identified which of the present standardised tests are unnecessary and how targeted testing can be introduced safely and efficiently.

Recognising that consumer involvement is an integral focus of Choosing Wisely, the ICU team sought consumer input as part of their study. Consumer forums highlighted there was clear recognition by ICU patients and next of kin that unnecessary testing may be harmful, but that addressing this should not be primarily about cost saving. Although there were high levels of agreement for an intervention to reduce unnecessary tests, a majority believed that more liberal testing was preferable, possibly owing to the present lack of definitive evidence to support a targeted approach.

The study also identified 24 possible points of intervention at which behavioural changes could be made using a theoretical framework, COM-B (the Capability, Opportunity, Motivation-Behaviour model). The framework provides a robust method of describing and reporting evidence as well as allowing for future accurate replication of successful interventions. A review of previous studies identified targeted interventions that had proved successful. This list was further refined through feedback from intensive care clinicians and patients.

A clinical trial to evaluate targeted testing protocols

This feedback, and framework to identify behavioural interventions, have been used to inform the design of a proposed targeted testing clinical trial. The Targeted Intensive Care Test Ordering Cluster Trial (TICTOC) will be Australia and NZ-wide and include more than 66 ICUs serving 75,000 critically ill patients.

The study harnessed the Choosing Wisely principle of working in a multidisciplinary team. It was managed by a team that included experts in intensive care medicine and intensive care nursing, behavioural and implementation science, clinical trial design, health economics, clinical quality registries, and a consumer.

The study identified that the trial would require: a management committee to acquire, disseminate, and coordinate intervention-related information; a targeted testing guideline for sites; educational material; medical and nursing champions; and site audit and feedback.

Towards reducing unnecessary tests in the ICU

Funding is being sought for the trial, which will test the hypothesis that a targeted testing intervention is as safe as routine test ordering, and it will provide the necessary evidence for future work in this area. Reducing unnecessary diagnostic testing in ICUs is globally recognised as an area requiring attention. The work being undertaken at Fiona Stanley Hospital exemplifies Choosing Wisely principles of evidence-based outcomes, based on sound scientific research, with a focus on harm prevention and improved quality of care.

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