Optimising a targeted test reduction intervention for patients admitted to the intensive care unit: The Targeted Intensive Care Test Ordering Cluster Trial intervention.

BACKGROUND: Approaches to routine diagnostic testing in the intensive care unit include time-scheduled testing and targeted testing. Blood tests and chest radiographs requested on a routine, time-scheduled basis may reduce the risk of missing important findings. Targeted testing, considering individual patient needs, may reduce unnecessary testing, wasted clinician time, and costs. However, existing evidence of targeted testing interventions is generally of low quality, and the optimal testing approach is uncertain. OBJECTIVES: The aim of the study was to describe the development of an intervention to reduce unnecessary diagnostic test ordering by clinicians working in intensive care, with the aim of informing the design of a pivotal clinical trial. METHODS: The Capability, Opportunity, Motivation-Behaviour model was used as a theoretical framework for change. The intervention components were informed by systematically identifying, assessing, and classifying targeted testing interventions in behavioural terms. Feedback from intensive care clinicians and patients was sought using surveys and a consumer reference group. RESULTS: The mean percentage of routine tests considered unnecessary by 201 intensive care clinicians was 33 (standard deviation = 16). When presented with a statement of the pros and cons for targeted versus liberal testing (n = 154), 93 (60%) consumer survey respondents preferred a more liberal approach, 33 (21%) preferred a more restrictive approach, and 28 (18%) were unsure. There were 24 behavioural interventions identified and incorporated into the final intervention. This had five major components: (i) a management committee to acquire, disseminate, and coordinate intervention-related information, (ii) a targeted testing guideline for sites, (iii) educational material for sites, (iv) site medical and nursing champions, and (v) site audit and feedback. CONCLUSIONS: Although surveyed intensive care clinicians report substantial unnecessary routine diagnostic testing, on the basis of currently available evidence, consumers prefer a more liberal approach. This feedback, and a framework to identify behavioural interventions, has been used to inform the design of a proposed targeted testing clinical trial.

Complementary and alternative pain therapy in the emergency department.

One primary reason patients go to emergency departments is for pain relief. Understanding the physiologic dynamics of pain, pharmacologic methods for treatment of pain, as well CAM therapies used in treatment of pain is important to all providers in emergency care. Asking patients about self-care and treatments used outside of the emergency department is an important part of the patient history. Complementary and alternative therapies are very popular for painful conditions despite the lack of strong research supporting some of their use. Even though evidenced-based studies that are double blinded and show a high degree of interrater observer reliability do not exist, patients will likely continue to seek out CAM therapies as a means of self-treatment and a way to maintain additional life control. Regardless of absolute validity of a therapy for some patients, it is the bottom line: "it seems to help my pain." Pain management distills down to a very simple endpoint, patient relief, and comfort. Sham or science, if the patient feels better, feels comforted, feels less stressed, and more functional in life and their practices pose no health risk, then supporting their CAM therapy creates a true wholistic partnership in their health care.CAM should be relatively inexpensive and extremely safe. Such is not always the case, as some patients have discovered with the use of botanicals. It becomes an imperative that all providers be aware of CAM therapies and informed about potential interactions and side effects when helping patients manage pain and explore adding CAM strategies for pain relief. The use of regulated breathing, meditation, guided imagery, or a massage for a pain sufferer are simple but potentially beneficial inexpensive aids to care that can be easily employed in the emergency department. Some CAM therapies covered here, while not easily practiced in the emergency department, exist as possibilities for exploration of patients after they leave, and may offer an improved sense of well-being and empowerment in the face of suffering and despair. The foundations of good nutrition, exercise, stress reduction, and reengagement in life can contribute much to restoring the quality of life to a pain patient. Adding nondrug therapies of physical therapy, cognitive-behavioral therapy, TENS, hypnosis, biofeedback, psychoanalysis, and others can complete the conventional picture. Adding in simple mind/body therapies, touch therapies, acupuncture, or others may be appropriate in select cases, and depending on the circumstances, may effect and enhance a conventional pain management program. Armed with an understanding of pain dynamics and treatments, practitioners can better meet patient needs, avoid serious side effects, and improve care when addressing pain management in the emergency department.