Wise Choices in the Intensive Care Unit

NCT07013175 | Recruiting DMC

• 1 other identifier: WICH-ICU
• Study Type: interventional
• Target: 10,000
• Locations: 1 country
• Sites: 2

Brief Summary

Aim: to evaluate if the Choosing Wisely campaign can be introduced without harming critically ill patients. Background: Each year, around 45,000 patients are admitted to Sweden's 81 ICUs (intensive care units), costing 6-7 billion SEK (6% of total healthcare expenditure). The high costs of health care are partly attributable to overuse of diagnostic tests. Up to 30% of these tests lead to treatments that provide no benefit for patients, some of them may even be harmful(1-3). To improve quality of care while combating this problem of cost, the American Board of Internal Medicine Foundation developed the Choosing Wisely Campaign, tasking professional societies to develop lists of top five medical services patients and physicians should question. Patients in the ICU, can especially benefit from this paradigm shift. They are subjected to multiple testing on a daily - sometimes hourly - basis, therefore this field of medicine responded to the campaign quickly. Two sets of top-five-lists of tests and interventions that can be questioned have been published(4 5). In multiple countries, including Sweden, the Choosing Wisely campaign is gathering traction among critical care physicians and is on the verge of being introduced. It is both common-sensical and will save money, so health care leaders are positive. However, the investigators have an opportunity, and a duty, to assess the evidence; can the Choosing Wisely campaign be introduced without harming ICU patients? The present study thus aims to evaluate the introduction of the Choosing Wisely campaign in the context of the ICU. Is this change of care strategy associated with changes in 30-day-mortality? Secondary outcomes include ICU length of stay, use of non-invasive- or invasive mechanical ventilation and continuous renal replacement therapy. This is a registry-based cluster randomized controlled study (R-RCT), targeting Swedish ICU's across multiple regions. Primary and secondary outcomes will be retrieved from the Swedish Intensive care Register (SIR), making ICU participation easier and less costly.

Conditions

Critical Illness; Ventilation; Outcome; Dialysis; Acute Kidney Injury

Keywords

critical illness; choosing wisely

Outcome Measures

Primary Outcomes (1)

• 30-day mortality

  Death within 30 days of ICU admission

  30 days after index ICU admission

Secondary Outcomes (4)

• ICU length of stay

  Up to one year after index ICU admission

• Time in invasive/ non-invasive mechanical ventilation

  Up to one year after index ICU admission

• Time on continuous renal replacement therapy

  Up to one year after index ICU admission

• ICU readmission

  72 hours post ICU discharge

Other Outcomes (1)

• ICU readmission

  Within 72 hours of ICU discharge

Study Arms (2)

Choosing wisely intervention

ACTIVE COMPARATOR

The Choosing Wisely (CW) protocol in the critical care setting; specifically minimizing the number of arterial blood gases, number of venous tests and number of chest x-rays

Procedure: Choosing wisely protocol

Choosing wisely control

NO INTERVENTION

Regular critical care

Interventions

Choosing wisely protocol PROCEDURE

Se arm description

Choosing wisely intervention

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Patients 18 years or older, treated in Swedish ICU's

You may not qualify if:

• Patients under the age of 18 years

Sponsors & Collaborators

• Karolinska Institutet: lead
• Uppsala-Örebro Regional Research Council: collaborator
• Vastra Gotaland Region: collaborator
• Region Jönköping County: collaborator
• Region Skane: collaborator
• Region Stockholm: collaborator
• Sormland County Council, Sweden: collaborator

Study Sites (2)

Karolinska University Hospital

Stockholm, 171 76, Sweden

RECRUITING

Karolinska Institutet

Stockholm, Sweden

RECRUITING

Related Publications (7)

• Costante A, Chen XK, Dudevich A, Dennis Christy A, Francis L, Chui C. Overuse of Tests and Treatments: Has Canada Made Progress? Healthc Q. 2023 Jan;25(4):10-12. doi: 10.12927/hcq.2023.27024.

  PMID: 36826234 BACKGROUND

• Mafi JN, Reid RO, Baseman LH, Hickey S, Totten M, Agniel D, Fendrick AM, Sarkisian C, Damberg CL. Trends in Low-Value Health Service Use and Spending in the US Medicare Fee-for-Service Program, 2014-2018. JAMA Netw Open. 2021 Feb 1;4(2):e2037328. doi: 10.1001/jamanetworkopen.2020.37328.

  PMID: 33591365 BACKGROUND

• Shrank WH, Rogstad TL, Parekh N. Waste in the US Health Care System: Estimated Costs and Potential for Savings. JAMA. 2019 Oct 15;322(15):1501-1509. doi: 10.1001/jama.2019.13978.

  PMID: 31589283 BACKGROUND

• Halpern SD, Becker D, Curtis JR, Fowler R, Hyzy R, Kaplan LJ, Rawat N, Sessler CN, Wunsch H, Kahn JM; Choosing Wisely Taskforce; American Thoracic Society; American Association of Critical-Care Nurses; Society of Critical Care Medicine. An official American Thoracic Society/American Association of Critical-Care Nurses/American College of Chest Physicians/Society of Critical Care Medicine policy statement: the Choosing Wisely(R) Top 5 list in Critical Care Medicine. Am J Respir Crit Care Med. 2014 Oct 1;190(7):818-26. doi: 10.1164/rccm.201407-1317ST.

  PMID: 25271745 BACKGROUND

• Zimmerman JJ, Harmon LA, Smithburger PL, Chaykosky D, Heffner AC, Hravnak M, Kane JM, Kayser JB, Lane-Fall MB, Matos RI, Mauricio RV, Murphy DJ, Nurok M, Reddy AJ, Ringle E, Seferian EG, Smalls-Mantey NM, To KB, Kaplan LJ. Choosing Wisely For Critical Care: The Next Five. Crit Care Med. 2021 Mar 1;49(3):472-481. doi: 10.1097/CCM.0000000000004876.

  PMID: 33555779 BACKGROUND

• Salisbury AC, Reid KJ, Alexander KP, Masoudi FA, Lai SM, Chan PS, Bach RG, Wang TY, Spertus JA, Kosiborod M. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Arch Intern Med. 2011 Oct 10;171(18):1646-53. doi: 10.1001/archinternmed.2011.361. Epub 2011 Aug 8.

  PMID: 21824940 BACKGROUND

• Bodley T, Levi O, Chan M, Friedrich JO, Hicks LK. Reducing unnecessary diagnostic phlebotomy in intensive care: a prospective quality improvement intervention. BMJ Qual Saf. 2023 Aug;32(8):485-494. doi: 10.1136/bmjqs-2022-015358. Epub 2023 Jan 19.

  PMID: 36657786 BACKGROUND

MeSH Terms

Conditions

Critical Illness; Respiratory Aspiration; Acute Kidney Injury

Condition Hierarchy (Ancestors)

Disease Attributes; Pathologic Processes; Pathological Conditions, Signs and Symptoms; Respiration Disorders; Respiratory Tract Diseases; Renal Insufficiency; Kidney Diseases; Urologic Diseases; Female Urogenital Diseases; Female Urogenital Diseases and Pregnancy Complications; Urogenital Diseases; Male Urogenital Diseases

Study Officials

• Max B Bell, MD, PhD

  N32276 PMI/Karolinska

  PRINCIPAL INVESTIGATOR

Central Study Contacts

Max B Bell, MD, PhD

CONTACT

+46708278533; max.bell@regionstockholm.se

Emma Larsson, MD, PhD

CONTACT

+46733661661; emma.ca.larsson@regionstockholm.se

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: TREATMENT
• Intervention Model: SEQUENTIAL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: MD, PhD

Model Details: There are two phases in this block randomized stepped-wedge ICU study, the control phase and the intervention phase. All participating ICU's start with a control period. During this phase, clinical monitors assess the number of arterial blood gases, -venous tests and number of chest x-rays performed at the ICU. This monitoring will assess all patients treated during a week and report tests per patient per day. As ICU's are randomized to the intervention phase the same clinical monitoring will be performed. Importantly, after six- and 12 months (irrespective of randomization allocation, if the ICU is still in the control- or intervention phase), the clinical monitor will re-assess the testing/diagnostic metrics.

Study Record Dates

• First Submitted: June 2, 2025
• First Posted: June 10, 2025
• Study Start: November 3, 2025
• Primary Completion (Estimated): December 31, 2026
• Study Completion (Estimated): December 31, 2027
• Last Updated: December 2, 2025

Record last verified: 2025-11

Data Sharing

• IPD Sharing: Will not share

Locations

SE (2)