Metrics details Abstract The belief that, for the individual patient, the benefit of prompt and continued use of antimicrobials outweighs any potential harm is a significant barrier to improved stewardship of these vital agents. Antimicrobial stewardship may be perceived as utilitarian rationing, seeking to preserve the availability of effective antimicrobials by limiting the development of resistance in a manner which could conflict with the immediate treatment of the patient in need. This view does not account for the growing evidence of antimicrobial-associated harm to individual patients.
Belief-based phenomena also contribute to the disproportionate preference for the default option. The preselected choice may appear to be a recommendation, which is particularly true when the person or organization providing the default option is reviews icyu option to be trustworthy. Additionally, decision makers may believe the default option reflects social or prescriptive norms.
Interprofessional Rounds in the ICU Introduction Interprofessional rounds in the intensive care unit ICU setting allow for scheduled discussions among various healthcare providers to review and discuss clinical information and develop concise care plans for critically ill patients. Rounding as a unit allows for each discipline of the healthcare team to address their goals, issues, and concerns. In addition, they give specialized input to the daily care plan.
Remaining with the default may also protect decision makers from future psychological harm. By choosing an alternative, the decision maker assumes more personal responsibility for future outcomes.
Therefore, people who are particularly averse to risk or regret may seek the protection of the default option as they anticipate potential negative outcomes. These include medical directors of the ICU, nurse managers, directors of respiratory or physical therapy, and individual clinicians.
To preserve choice and autonomy, all options should be clearly presented and equally available. Assuming the role of choice architect Because any manner of framing a choice with or without default options has consequences, the choice architect must evaluate the risks and benefits of encouraging choices that decision makers might not prefer, with those of failing to encourage choices that decision makers would prefer.
For example, cardiopulmonary resuscitation CPR may be justified as the default approach for patients suffering in-hospital cardiac arrest because overall the frequency and magnitude of harms of providing unwanted CPR may be small reviews icyu option to reviews icyu option associated with failing to provide desired CPR. Choosing appropriate settings Most critical care decisions require careful deliberation, which a default option may truncate or bypass. When one option provides clear benefits for a large majority of patients, offering a default option may effectively and efficiently guide behavior.
In contrast, when the optimal choice is uncertain, providing a default option may lead to suboptimal decision making.
Customized defaults may overcome this by modifying the option set on the basis of patient-specific information [ 8 ]. But it may be preferable to try to avoid defaults altogether when the very process of engaging in decision making is important.
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For example, when CPR carries a high likelihood of harm and negligible opportunity for benefit, offering a care plan that does not include CPR as the default may decrease burdens on decision makers and improve the overall quality of care. But when both a transition to comfort-based care and a time-limited trial of aggressive critical care are reasonable options, avoiding defaults entirely may engage patients or surrogates in expressing their values, thereby enabling clinicians to provide more individualized guidance on which care plans may best promote those values.
Presenting the default Responsible use of defaults requires a carefully constructed presentation of the decision that includes all available choices. Because a default option results in a particular action without any active participation by the decision maker, individuals encountering a default may be reviews icyu option of the decision or perceive that they have no choice.
To preserve autonomy, it reviews icyu option important that decision makers readily appreciate that they are engaging in decision making, and that multiple options exist.
Based largely on this reasoning, the Institute of Medicine concluded in that to change the organ donation default in the United States from an opt-in to an opt-out system, a massive public education campaign would be required to ensure adequate awareness that decisions were being made [ 9 ].
Additionally, selecting an alternative choice should not be prohibitively difficult. Although deviating from the default will always require additional action, the effort and persistence required to make an alternative choice should be proportional to the degree to which other choices may be preferable for some patients.
A nearly costless deviation from the default option, such as unselecting venous thromboembolism prophylaxis VTEP from a default admission order set, may be minimally paternalistic [ 8 ].
Default options in the ICU: widely used but insufficiently understood
By contrast, a procedural or substantive barrier — such as requiring that physicians type an explanation to unselect such prophylaxis — may be used to ensure that the alternative is selected wisely and not because of decision making errors.
Unfortunately, formal evaluations of these defaults prior to implementation and following use have been limited. Therefore, the intended and unintended consequences of most default options in the ICU have not been fully examined.
Here, we review recent studies of defaults in the ICU, including order sets and protocolized care, technological prompts, and communication strategies. Order sets and protocols Diagnosis-specific order sets and care protocols are intended to streamline the decision making process and reduce errors. Such protocolized care may also create a standard unit-based practice that bedside professionals e.
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These have been used in the prevention of device-related infections [ 25 — 34 ] and nutrition management [ 35 — 37 ]. In an effort to reduce catheter-associated urinary tract infections, Parry et al. With accompanying educational efforts, catheter use and catheter-associated urinary tract infections decreased significantly over a month period, although the authors detected wide differences in the effect across care units.
By contrast, a cluster randomized trial in 18 ICUs that changed the default enteral nutrition provided to mechanically ventilated patients found no substantial increase in the reviews icyu option of patients achieving goal nutrition delivery [ 37 ].
Patient, family-centred care interventions within the adult ICU setting: An integrative review
Similarly, despite promising evidence in adult populations, a recent systematic review of the use of protocolized mechanical ventilation weaning in children found no improvements in patient outcomes [ 39 ]. Together, these data suggest that simply implementing protocols that change defaults may be insufficient to overcome practice patterns.
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When choice architecture is neglected, defaults may lose power [ 194041 ]. Therefore, for defaults to exert their maximal and intended effects, they must be created and implemented with clear attention to exactly how they may change behaviors. For example, Khanna et al. Additionally, Yu et al.
As defaults in the form of order sets and protocols proliferate in the ICU, effects on both patient outcomes and provider competence will be needed. Technological prompts Critical care reviews icyu option reach decision makers quickly through the use of computerized provider order entry and electronic health record technologies.
In addition to order sets and protocols that make use of these systems, individual medication and diagnostic orders and Reviews icyu option alarms often rely on defaults.
Similarly, electronic monitoring alarms used in the ICU are often based on default settings that are too sensitive, resulting in many false alarms. In a thoughtful but small study, Inokuchi et al. Rather than harnessing the potential power of technology, ICUs may become victim to poorly designed defaults. Additionally, although choice architects often match defaults to published guidelines, this may not translate well into their use as decision support tools.
Particularly given the clear unintended consequences of frequent alarms and alerts [ 55 ], these types of reviews icyu option reviews icyu option either first be evaluated in an experimental setting or at the very least systematically evaluated as a quality-improvement initiative following implementation. Communication strategies Defaults may be used reviews icyu option decision support tools for patients and their surrogate decision makers considering complex choices.
Decision makers rely on the clear presentation of options to understand a choice is at hand. One particularly unsettling example of a policy in which decision makers were not aware that a choice was being made regards the previously widespread practice of establishing default DNR order for all nursing home residents.
The Centers for Medicare and Medicaid statement prohibited the practice in when it became clear that many residents were not aware of the default DNR order policy, the alternatives available to them, or the relative risks and benefits of these important choices [ 62 — 64 ].
We not only found that default options for comfort-oriented care greatly increased the proportions of patients who chose such a care strategy, but that this effect persisted even when we specifically alerted patients to the default intervention. Reviews icyu option results suggest that default options may be powerful even in such presumably value-sensitive decisions as end-of-life care, and that the potential effects of defaults may be maintained even by actively promoting awareness of the default setting.
Last year, Lu et al.
Because providers often cannot avoid setting default options, they should at least be aware of their role as choice architect and frame their discussions with patients and families mindfully.
These include daily laboratory tests or other diagnostics without clinical indications, sedating all mechanically ventilated patients, often deeply, and continuing life support for patients with poor prognoses [ 67 ].
The other two items on the Reviews icyu option 5 List may also represent default practices in certain ICUs: reviews icyu option use of blood transfusions and of parenteral nutrition. These practice patterns each appear to be harmful on the basis of current evidence, and yet exist as routine care in ICUs, in part, because they function as hidden defaults.
This anticipated survivorship experience highlights the importance of collaboration between the fields of critical care and rehabilitation to optimize post-COVID recovery. Although most individuals infected with SARS-CoV-2 seem to be asymptomatic or experience mild symptoms such as persistent cough, with reviews icyu option pain and chest tightnessthe pandemic has resulted in an unprecedented spike in the incidence of ARDS and critical illness. The success of critical care medicine in reducing mortality will result in a large number of survivors of COVID Although old age, pre-existing physical frailty, psychological symptoms for example, anxiety and depression and cognitive impairment for example, dementia are risk factors, even those without such risk factors are at risk for long-lasting sequelae. Optimizing the COVID survivorship experience, based on this knowledge, demands careful implementation of evidence-based critical care interventions combined with robust rehabilitation programmes that begin in the ICU and continue after discharge.
Defaults have potential to improve efficiency and protect against systematic errors in decision making. Yet appropriate use demands foresight and intention as well as additional study. Preimplementation experimental data may lead to more effective defaults, and postimplementation monitoring will provide additional insight into the implications of their use. Defaults may be used in the ICU to implement guidelines, improve efficiency, and protect patients, but there may be unintended consequences from defaults, such as decreased engagement in decision making and lack of individualization of care.
Current ICU defaults include care protocols and order sets, technology-based presets, communication strategies, and defaults hidden in common care patterns. Published research has failed to show conclusive evidence for or against the use of defaults in critical care, which may be due to heterogeneity across environments and preimplementation care patterns.
When creating defaults, their power as behavior change and decision support tools should be used to maximize their potential impact with preimplementation and postimplementation experiments and studies used to reveal intended and unintended consequences.