Intensive Care Medicine

, Volume 45, Issue 10, pp 1443–1446 | Cite as

De-implementing low value care in critically ill patients: a call for action—less is more

  • Henry T. StelfoxEmail author
  • Annette M. Bourgault
  • Daniel J. Niven
Less is More in ICU

“More care is not always better [1].” As clinicians we are tasked with caring for patients while doing no harm. The pursuit of our mission has historically been driven by iteratively implementing new innovations designed to improve healthcare. Patients have benefited from this approach; however, an unintended consequence has been an increased number of clinical practices, some of which are low-value. A low-value practice is a practice for “which evidence suggests it confers no or very little benefit for patients, or the risk of harm exceeds probable benefit, or, more broadly, the added costs of the intervention do not provide proportional added benefits [2]”. The use of low-value practices compromises healthcare by increasing the complexity of care, exposing patients to unnecessary risks and adverse events, misallocating valuable resources, and potentially delaying treatment for other patients [3, 4]. These challenges are increasingly recognized in the care of critically ill patients...


De-implementation Intensive care units Critical care Information science Health services research Quality of health care 



  1. 1.
    Cassel CK, Guest JA (2012) Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA 307:1801–1802CrossRefGoogle Scholar
  2. 2.
    Elshaug AG, Rosenthal MB, Lavis JN, Brownlee S, Schmidt H, Nagpal S, Littlejohns P, Srivastava D, Tunis S, Saini V (2017) Levers for addressing medical underuse and overuse: achieving high-value health care. Lancet 390:191–202CrossRefGoogle Scholar
  3. 3.
    Badgery-Parker T, Pearson S-A, Dunn S, Elshaug AG (2019) Measuring hospital-acquired complications associated with low-value care. JAMA Intern Med 179:499–505CrossRefGoogle Scholar
  4. 4.
    Korenstein D, Chimonas S, Barrow B, Keyhani S, Troy A, Lipitz-Snyderman A (2018) Development of a conceptual map of negative consequences for patients of overuse of medical tests and treatments. JAMA Intern Med 178:1401–1407CrossRefGoogle Scholar
  5. 5.
    Niven DJ, Rubenfeld GD, Kramer AA, Stelfox HT (2015) Effect of published scientific evidence on glycemic control in adult intensive care units. JAMA Intern Med 175:801–809CrossRefGoogle Scholar
  6. 6.
    Montini T, Graham ID (2015) “Entrenched practices and other biases”: unpacking the historical, economic, professional, and social resistance to de-implementation. Implement Sci 10:24CrossRefGoogle Scholar
  7. 7.
    Helfrich CD, Rose AJ, Hartmann CW, van Bodegom-Vos L, Graham ID, Wood SJ, Majerczyk BR, Good CB, Pogach LM, Ball SL, Au DH, Aron DC (2018) How the dual process model of human cognition can inform efforts to de-implement ineffective and harmful clinical practices: a preliminary model of unlearning and substitution. J Eval Clin Pract 24:198–205CrossRefGoogle Scholar
  8. 8.
    Sauro K, Bagshaw SM, Niven D, Soo A, Brundin-Mather R, Parsons Leigh J, Cook DJ, Stelfox HT (2019) Barriers and facilitators to adopting high value practices and de-adopting low value practices in Canadian intensive care units: a multimethod study. BMJ Open 9:e024159–e024159CrossRefGoogle Scholar
  9. 9.
    Koo KK, Sun JC, Zhou Q, Guyatt G, Cook DJ, Walter SD, Meade MO (2011) Pulmonary artery catheters: evolving rates and reasons for use. Crit Care Med 39:1613–1618CrossRefGoogle Scholar
  10. 10.
    Wiener RS, Welch HG (2007) Trends in the use of the pulmonary artery catheter in the United States, 1993–2004. JAMA 298:423–429CrossRefGoogle Scholar
  11. 11.
    Upvall MJ, Bourgault AM (2018) De-implementation: a concept analysis. Nurs Forum 53:376–382CrossRefGoogle Scholar
  12. 12.
    Norton WE, Chambers DA, Kramer BS (2019) Conceptualizing de-implementation in cancer care delivery. J Clin Oncol 37:93–96CrossRefGoogle Scholar
  13. 13.
    Niven DJ, Mrklas KJ, Holodinsky JK, Straus SE, Hemmelgarn BR, Jeffs LP, Stelfox HT (2015) Towards understanding the de-adoption of low-value clinical practices: a scoping review. BMC Med 13:255CrossRefGoogle Scholar
  14. 14.
    Kahn JM, Le TQ (2016) Adoption and de-adoption of drotrecogin alfa for severe sepsis in the United States. J Crit Care 32:114–119CrossRefGoogle Scholar
  15. 15.
    Lyu PF, Hockenberry JM, Gaydos LM, Howard DH, Buchman TG, Murphy DJ (2016) Impact of a sequential intervention on albumin utilization in critical care. Crit Care Med 44:1307–1313CrossRefGoogle Scholar
  16. 16.
    Stelfox HT, Brundin-Mather R, Soo A, Parsons Leigh J, Niven DJ, Fiest KM, Doig CJ, Zuege DJ, Kushner B, Clement F, Straus SE, Cook DJ, Bagshaw SM, Sauro KM (2019) A multicentre controlled pre-post trial of an implementation science intervention to improve venous thromboembolism prophylaxis in critically ill patients. Intensive Care Med 45:211–222CrossRefGoogle Scholar
  17. 17.
    Niven DJ, McCormick TJ, Straus SE, Hemmelgarn BR, Jeffs L, Barnes TRM, Stelfox HT (2018) Reproducibility of clinical research in critical care: a scoping review. BMC Med 16:26CrossRefGoogle Scholar
  18. 18.
    Bourgault AM, Upvall MJ (2019) De-implementation of tradition-based practices in critical care: a qualitative study. Int J Nurs Pract 25:1–9CrossRefGoogle Scholar
  19. 19.
    Gershengorn HB, Wunsch H, Scales DC, Rubenfeld GD (2018) Trends in use of daily chest radiographs among US adults receiving mechanical ventilation. JAMA Netw Open 1:e181119CrossRefGoogle Scholar
  20. 20.
    Munshi L, Gershengorn HB, Fan E, Wunsch H, Ferguson ND, Stukel TA, Rubenfeld GD (2017) Adjuvants to mechanical ventilation for acute respiratory failure. adoption, de-adoption, and factors associated with selection. Ann Am Thorac Soc 14:94–102CrossRefGoogle Scholar
  21. 21.
    Gershengorn HB, Wunsch H (2013) Understanding changes in established practice: pulmonary artery catheter use in critically ill patients. Crit Care Med 41:2667–2676CrossRefGoogle Scholar
  22. 22.
    Menegueti MG, Ciol MA, Bellissimo-Rodrigues F, Auxiliadora-Martins M, Gaspar GG, Canini S, Basile-Filho A, Laus AM (2019) Long-term prevention of catheter-associated urinary tract infections among critically ill patients through the implementation of an educational program and a daily checklist for maintenance of indwelling urinary catheters: a quasi-experimental study. Medicine (Baltimore) 98:e14417CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Critical Care Medicine, Cumming School of MedicineMcCaig Tower, University of CalgaryCalgaryCanada
  2. 2.Department of Community Health Sciences, Cumming School of MedicineUniversity of CalgaryCalgaryCanada
  3. 3.O’Brien Institute for Public Health, Cumming School of MedicineUniversity of CalgaryCalgaryCanada
  4. 4.Alberta Health ServicesAlbertaCanada
  5. 5.College of Nursing, Academic Health Sciences CenterUniversity of Central FloridaOrlandoUSA
  6. 6.Orlando HealthOrlandoUSA

Personalised recommendations