Nursing
Canadian Nurses Association
Last updated: August 2024
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The use of indwelling urinary catheters among hospital patients is common. Yet it can also lead to preventable harms such as urinary tract infection, sepsis and delirium. Guidelines support routine assessment of appropriate urinary catheter indications —including acute urinary obstruction, critical illness and end-of-life care—and minimizing their duration of use. Strategies consistent with CAUTI (catheter-associated urinary tract infection) guidelines regarding inappropriate urinary catheter use have been shown to reduce health care-associated infections.
Sources:
Association for Professionals in Infection Control and Epidemiology. APIC implementation guide: guide to preventing catheter-associated urinary tract infections [Internet]. 2014 Apr [cited 2016 Oct 14].
Choosing Wisely Canada. Canadian Society of Hospital Medicine: Five things physicians and patients should question [Internet]. 2020 Feb [cited 2020 Aug 20].
Colli J, et al. National trends in hospitalization from indwelling urinary catheter complications, 2001-2010. Int Urol Nephrol. 2014 Feb;46(2):303-8. PMID: 23934618.
Gray J, Rachakonda A, Karnon J. Pragmatic Review of interventions to prevent catheter-associated urinary tract infections (cautis) in adult inpatients. Journal of Hospital Infection. 2023;136:55–74. PMID: 37015257.
Hu, F.-W., Tsai, C.-H., Lin, H.-S., Chen, C.-H., & Chang, C.-M. (2017). Inappropriate urinary catheter reinsertion in hospitalized older patients. American Journal of Infection Control, 45(1), 8–12. PMID: 28065334.
Jain P, et al. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med. 1995 Jul 10;155(13):1425-9. PMID: 7794092.
Landrigan CP, et al. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010 Nov 25;363(22):2124-34. PMID: 21105794.
Lo E, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Sep;35 Suppl 2:S32-47. PMID: 25376068.
Miller BL, et al. A multimodal intervention to reduce urinary catheter use and associated infection at a Veterans Affairs Medical Center. Infect Control Hosp Epidemiol. 2013 Jun;34(6):631-3. PMID: 23651896.
Mitchell et al. Trends in health care–associated infections in acute care hospitals in Canada: an analysis of repeated point-prevalence surveys. CMAJ. 2019 Sept; 191(36): E981-E988. PMID: 31501180.
National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. [Internet]. 2019 Mar [cited 2019 Aug 26].
Ramanathan R, et al. Urinary tract infections in surgical patients. Surg Clin North Am. 2014 Dec;94(6):1351-68. PMID: 25440128.
Mitchell et al. Trends in health care–associated infections in acute care hospitals in Canada: an analysis of repeated point-prevalence surveys. CMAJ. 2019 Sept; 191(36): E981-E988. PMID: 31501180.
Related Resources:
Toolkit: Lose the Tube – A toolkit for appropriate use of urinary catheters in hospitals
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Many studies show that, once target control is achieved, routine self-monitoring of blood glucose (SMBG) does little to control blood sugar for most adults with type 2 diabetes who don’t use insulin or other medications that could increase risk for hypoglycemia. It should be noted that SMBG may be indicated during acute illness, medication change or pregnancy; when a history or risk of hypoglycemia exists (e.g., if using a sulfonylurea), and when individuals need monitoring to maintain targets — considerations that should be part of assessment and client education.
Sources:
Cameron C, et al. Cost-effectiveness of self-monitoring of blood glucose in patients with type 2 diabetes mellitus managed without insulin. CMAJ. 2010 Jan 12;182(1):28-34. PMID: 20026626.
Canadian Agency for Drugs and Technologies in Health. Optimal therapy recommendations for the prescribing and use of blood glucose test strips. CADTH Technol Overv. 2010;1(2):e0109. PMID: 22977401.
Canadian Diabetes Association. Self-monitoring of blood glucose (SMBG) recommendation tool for healthcare providers [Internet]. 2018 [cited 2019 Aug 26].
Choosing Wisely Canada. Canadian Society for Endocrinology and Metabolism: Five things physicians and patients should question [Internet]. 2019 Jul [cited 2020 Aug 20].
Choosing Wisely Canada. College of Family Physicians of Canada: Thirteen things physicians and patients should question [Internet]. 2019 Jul [cited 2016 Oct 21].
Gomes T, et al. Blood glucose test strips: options to reduce usage. CMAJ. 2010 Jan 12;182(1):35-8. PMID: 20026624.
Mandala et al. Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin. Cochrane Database of Systematic Reviews 2012, Issue 1. [cited 2019 Aug 26].
O’Kane MJ, et al. Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial. BMJ. 2008 May 24;336(7654):1174-7. PMID: 18420662.
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Additional layers of bedding can limit the pressure-dispersing capacities of therapeutic surfaces (such as therapeutic mattresses or cushions). As a result, extra sheets and pads can contribute to skin breakdown and impede the healing of existing pressure wounds.
Sources:
Institute for Healthcare Improvement. How-to guide: prevent pressure ulcers. Cambridge, MA: IHI; 2011.
Kayser SA, Phipps L, VanGilder CA, Lachenbruch C. Examining Prevalence and Risk Factors of Incontinence-Associated Dermatitis Using the International Pressure Ulcer Prevalence Survey. J Wound Ostomy Continence Nurs. 2019 Jul; 46(4): 285-290. PMID: 31276451.
Norton et al. Chapter 3: Best Practice Recommendation for the Prevention and management of pressure injuries. 2018 Jan 24 [cited 27 Aug 2019].
Registered Nurses’ Association of Ontario. Assessment and management of pressure injuries for the interprofessional team. 3rd ed. [Internet]. 2016 [cited 2016 Oct 18].
Williamson R, et al. The effect of multiple layers of linens on surface interface pressure: results of a laboratory study. Ostomy Wound Manage. 2013 Jun;59(6):38-48. PMID: 23749661.
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Oxygen is frequently used to relieve shortness of breath. However, supplemental oxygen does not benefit patients who are short of breath but not hypoxic. Supplemental flow of air is as effective as oxygen for non-hypoxic dyspnea.
Sources:
Abernethy AP, et al. Effect of palliative oxygen versus (room) air in relieving breathlessness in patients with refractory dyspnea: a double-blind, randomized controlled trial. Lancet. 2010 Sep 4;376(9743):784-793. PMID: 20816546.
Booth S, et al. Does oxygen help dyspnea in patients with cancer? Am J Respir Crit Care Med. 1996 May;153(5):1515-8. PMID: 8630595.
Bruera E, et al. A randomized controlled trial of supplemental oxygen versus air in cancer patients with dyspnea. Palliat Med. 2003 Dec;17(8):659-63. PMID: 14694916.
Choosing Wisely Canada. Canadian Society of Palliative Care Physicians: Five things physicians and patients should question [Internet]. 2020 Jul [cited 2020 Aug 20].
Marciniuk DD, et al. Managing dyspnea in patients with advanced chronic obstructive pulmonary disease: A Canadian Thoracic Society clinical practice guideline. Can Respir J. 2011 Mar-Apr;18(2):69-78. PMID: 21499589.
National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management NICE guideline [NG115]. 2019 Jul 26.
Ontario Health Technology Assessment Service COPD Collaborative. Chronic obstructive pulmonary disease (COPD) evidentiary framework [Internet]. 2012 Mar 1 [cited 2016 Oct 18].
Philip J, et al. A randomized, double-blind, crossover trial of the effect of oxygen on dyspnea in patients with advanced cancer. J Pain Symptom Manage. 2006 Dec;32(6):541-50. PMID: 17157756.
Uronis HE, et al. Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: a systematic review and meta-analysis. Br J Cancer. 2008 Jan 29;98(2):294-9. PMID: 18182991.
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Adult incontinence containment products are frequently used for continent patients (especially women) with low mobility. Yet the literature associates their use with multiple adverse outcomes including diminished self-esteem and perceived quality of life, and higher incidence rates of dermatitis, pressure wounds and urinary tract infections. Among older adults, nurses should conduct a thorough assessment to determine the risk of such outcomes before initiating or continuing the use of incontinence containment products. The development of a continence care plan should be a shared decision-making process that includes the known wishes of clients regarding care needs and the perspectives of carers and the health care team.
Sources:
Agnew R, et al. Promoting urinary continence with older people: a selective literature review. Int J Older People Nurs. 2009 Mar;4(1):58-62. PMID: 20925803.
Cave CE. Evidence-based continence care: an integrative review. Rehabil Nurs. 2016 Aug 11. PMID: 27510945.
Colborne, M., & Dahlke, S. (2017). Nurses’ perceptions and management of urinary incontinence in hospitalized older adults: An integrative review. Journal of Gerontological Nursing, 43(10), 46-55. PMID: 28556873.
National Institute for Health and Care Excellence. Urinary incontinence and pelvic organ prolapse in women: Management [Internet]. 2019 Apr [cited 29 Aug 2019].
Netsch D. Continence Care Literature Review 2012. J Wound Ostomy Continence Nurs. 2013 Nov-Dec;40(Suppl.): S21-9.
Norton et al. Chapter 3: Best Practice Recommendation for the Prevention and management of pressure injuries. 2018 Jan 24 [cited 27 Aug 2019].
Zisberg, A. Incontinence brief use in acute hospitalized patients with no prior incontinence. J Wound Ostomy Continence Nurs. 2011 Sep-Oct;38(5):559-64. PMID: 21873910.
Zisberg A, et al. In-hospital use of continence aids and new-onset urinary incontinence in adults aged 70 and older. J Am Geriatr Soc. 2011 Jun;59(6):1099-104. PMID: 21649620.
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Tube feeding for older adults with advanced dementia offers no benefit over careful feeding assistance related to the outcomes of aspiration pneumonia and the extension of life. While food is the preferred form of obtaining nutrition, oral supplements may be beneficial if this intervention meets the person’s known goals of care. Tube feeding may contribute to client discomfort and result in agitation, the use of physical and/or chemical restraint and worsening pressure wounds.
Sources:
Allen VJ, et al. Use of nutritional complete supplements in older adults with dementia: systematic review and meta-analysis of clinical outcomes. Clin Nutr. 2013 Dec;32(6):950-7. PMID: 23591150.
American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. American Geriatrics Society feeding tubes in advanced dementia position statement. J Am Geriatr Soc. 2014 Aug;62(8):1590-3. PMID: 25039796.
Choosing Wisely Canada. Canadian Geriatrics Society: Five things physicians and patients should question [Internet]. 2019 Jul [cited 2020 Aug 21].
Gabriel SE, et al. Getting the methods right: the foundation of patient-centered outcomes research. N Engl J Med. 2012 Aug 30;367(9):787-90. PMID: 22830434.
Hanson LC. Tube feeding versus assisted oral feeding for persons with dementia: using evidence to support decision-making. Ann Longterm Care. 2013 Jan;21(1):36-39.
Hanson LC, et al. Improving decision-making for feeding options in advanced dementia: a randomized, controlled trial. J Am Geriatr Soc. 2011 Nov;59(11):2009-16. PMID: 22091750.
Ijaopo EO, Ijaopo RO. Tube feeding in individuals with advanced dementia: A review of its burdens and perceived benefits. Journal of Aging Research. 2019;2019:1–16. PMID: 31929906.
Lee, Y., Hsu, T., Liang, C., Yeh, T., Chen, T., Chen, N., & Chu, C. (2020). The Efficacy and Safety of Tube Feeding in Advanced Dementia Patients: A Systemic Review and Meta-Analysis Study. Journal of the American Medical Directors Association. PMID: 32736992.
Palecek EJ, et al. Comfort feeding only: a proposal to bring clarity to decision-making regarding difficulty with eating for persons with advanced dementia. J Am Geriatr Soc. 2010 Mar;58(3):580-4. PMID: 20398123.
Teno JM, et al. Decision-making and outcomes of feeding tube insertion: a five-state study. J Am Geriatr Soc. 2011 May;59(5):881-6. PMID: 21539524.
Related Resources:
Patient Pamphlet: Feeding Tubes for People with Alzheimer’s Disease: When you need them – and when you don’t
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People with dementia frequently exhibit responsive behaviors, which are often misinterpreted as aggression, resistance to care and challenging or disruptive behaviours. In such instances antipsychotic medicines are regularly prescribed. The benefit of these drugs is limited, however, and they can also cause serious harm including premature death. Their use should be limited to cases where non-pharmacologic measures have failed and where patients pose an imminent threat to themselves or others. Identifying and addressing the causes of behaviour change can render drug treatment unnecessary. If a nurse caring for a patient feels that medication is not the appropriate intervention, the nurse has a responsibility to discuss these concerns with the prescriber.
Sources:
Alberta Health Services. Appropriate use of antipsychotics (AUA) toolkit [Internet]. 2013 [cited 2016 Oct 19].
Bjerre, L. et al. Deprescribing antipsychotics for behavioural and psychological symptoms of dementia and insomnia – Evidence-based clinical practice guideline. 2018, Jan. Canadian Family Physician; 64(1): 17-27.
Brodaty H, et al. Meta-analysis of nonpharmacological interventions for neuropsychiatric symptoms of dementia. Am J Psychiatry. 2012 Sep;169(9):946-53. PMID: 22952073.
Choosing Wisely Canada. Canadian Geriatrics Society: Five things physicians and patients should question [Internet]. 2020 Jul [cited 2020 Sept 10].
Dyer SM, Harrison SL, Laver K, Whitehead C, Crotty M. An overview of systematic reviews of pharmacological and non-pharmacological interventions for the treatment of behavioral and psychological symptoms of dementia. Int Psychogeriatr. 2018;30(3):295-309. PMID: 29143695.
Gill SS, et al. Antipsychotic drug use and mortality in older adults with dementia. Ann Intern Med. 2007 Jun 5;146(11):775-86. PMID: 17548409.
Gill SS, et al. Atypical antipsychotic drugs and risk of ischaemic stroke: population based retrospective cohort study. BMJ. 2005 Feb 26;330(7489):445. PMID: 15668211.
Joller P, et al. Approach to inappropriate sexual behaviour in people with dementia. Can Fam Physician. 2013 Mar;59(3):255-60. PMID: 23486794.
Lee PE, et al. Atypical antipsychotic drugs in the treatment of behavioural and psychological symptoms of dementia: systematic review. BMJ. 2004 Jul 10;329(7457):75. PMID: 15194601.
National Health Service. Appropriate prescribing of antipsychotic medication in … [Internet]. Antipsychotic-Prescribing-Toolkit-for-Dementia. National Health Service; 2022 [cited 2024 Apr 30].
Registered Nurses’ Association of Ontario. Delirium, dementia, and depression in older adults: assessment and care [Internet]. 2016 Jul [cited 2016 Oct 19].
Rochon PA, et al. Antipsychotic therapy and short-term serious events in older adults with dementia. Arch Intern Med. 2008 May 26;168(10):1090-6. PMID: 18504337.
Schneider LS, et al. Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. Am J Geriatr Psychiatry. 2006 Mar;14(3):191-210. PMID: 16505124.
Seitz DP, et al. Efficacy and feasibility of nonpharmacological interventions for neuropsychiatric symptoms of dementia in long term care: a systematic review. J Am Med Dir Assoc. 2012 Jul;13(6):503-6.e2. PMID: 22342481.
Related Resources:
Patient Pamphlet: Treating Disruptive Behaviour in People with Dementia: Antipsychotic drugs are usually not the best choice
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Signs and symptoms suggestive of urinary tract infection (UTI) are increased frequency, urgency, pain or burning on urination, supra-pubic pain, flank pain and fever. Dark, cloudy and/or foul-smelling urine may not be suggestive of UTI but rather of inadequate fluid intake. Cohort studies have found no adverse outcomes associated with asymptomatic bacteriuria for older adults. Not only does antimicrobial treatment for such bacteriuria in older adults show no benefits, it increases adverse antimicrobial effects. Consensus criteria have been developed for the specific clinical symptoms that (when associated with bacteriuria) define UTI. Exceptions to these criteria include recommended screening for and treatment of asymptomatic bacteriuria before urologic procedures where mucosal bleeding is anticipated. If a nurse caring for a patient feels that medication is not the appropriate intervention, the nurse has a responsibility to discuss these concerns with the prescribers.
Sources:
Abrutyn E, et al. Does asymptomatic bacteriuria predict mortality and does antimicrobial treatment reduce mortality in elderly ambulatory women? Ann Intern Med. 1994 May 15;120(10):827-33. PMID: 7818631.
Blondel-Hill et al. AMMI Canada position statement on asymptomatic bacteriuria. 2019 Jan [cited 2020 Sept 10].
Centers for Disease Control and Prevention. National Healthcare Safety Network (NHSN) Patient Safety Component Manual: Chapter 17: CDC/NHSN surveillance definitions for specific types of infections [Internet]. 2020 Jan [cited 2020 Sept 10].
Choosing Wisely Canada. Canadian Geriatrics Society: Five things physicians and patients should question [Internet]. 2019 Jul[cited 2020 Sept 10].
Choosing Wisely Canada. Using antibiotics wisely in long-term care: Key practice change recommendations. 2019 Oct [2020 Sept 10].
Fekete, T. (2024). Asymptomatic bacteriuria in adults. UpToDate.
Juthani-Mehta M. Asymptomatic bacteriuria and urinary tract infection in older adults. Clin Geriatr Med. 2007 Aug;23(3):585-94. PMID: 17631235.
Mum’s Health. Anti-infective guidelines for community-acquired infections. 13th ed. [Internet]. 2013 [cited 2016 Oct 18].
Nicolle LE, et al. Infectious Diseases Society of America guidelines on Asymptomatic Bacteriuria. Clin Infect Dis. 2019 Mar 21; 68(10): e83-e110.
Rowe TA, et al. Diagnosis and management of urinary tract infection in older adults. Infect Dis Clin North Am. 2014 Mar;28(1):75-89. PMID: 24484576.
Toward Optimized Practice (TOP) Working Group for Urinary Tract Infections in Long Term Care Facilities. Diagnosis and management of urinary tract infections in long term care facilities [Internet]. 2015 Jan [cited 2020 Sept 10].
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Antidepressant response rates are higher for moderate or severe adult depression. For mild depressive symptoms a complete assessment, ongoing support and monitoring, psychosocial interventions and lifestyle modifications should be the first lines of treatment. This approach can avoid the side-effects of medication and establish etiological factors important to future assessment and management. Antidepressants are appropriate in cases of persistent mild depression where a past history of more severe depression exists or where other interventions have failed. If a nurse caring for a patient feels that medication is not the appropriate intervention, the nurse has a responsibility to discuss these concerns with the prescriber.
Sources:
Barbui C, et al. Efficacy of antidepressants and benzodiazepines in minor depression: systematic review and meta-analysis. Br J Psychiatry. 2011 Jan;198(1):11-6. PMID: 21200071.
Choosing Wisely Canada. Canadian Academy of Child and Adolescent Psychiatry, Canadian Academy of Geriatric Psychiatry, Canadian Psychiatric Association: Thirteen things physicians and patients should question [Internet]. 2017 Jun [cited 2016 Oct 21].
Cuijpers P, et al. Are psychosocial and pharmacologic interventions equally effective in the treatment of adult depressive disorders? A meta-analysis of comparative studies. J Clin Psychiatry. 2008 Nov;69(11):1675-85. PMID: 18945396.
Esposito E, et al. Frequency and adequacy of depression treatment in a Canadian population sample. Can J Psychiatry. 2007 Dec;52(12):780-9. PMID: 18186178.
Fournier JC, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA. 2010 Jan 6;303(1):47-53. PMID: 20051569.
Kirsch I, et al. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med. 2008 Feb;5(2):e45. PMID: 18303940.
National Collaborating Centre for Mental Health. Depression: the NICE guideline on the treatment and management of depression in adults. Updated ed. [Internet]. 2020 [cited 2020 Sept 10].
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Administering medications intravenously requires additional equipment such as syringes, IV tubing, and IV bags, which significantly generates more waste compared to enteral routes. Research indicates that IV antibiotics have a greater carbon footprint than their oral counterparts. Many medications, including antimicrobials, gastric acid suppressants, anti-epileptic drugs, and pain relievers, are equally safe and effective when given enterally. Additionally, reducing IV administration can decrease the risk of IV-related complications, such as phlebitis, thrombophlebitis, infiltration, extravasation, catheter-related infections, hematoma, and thrombosis. Advocating for switching from IV to oral therapy, when clinically appropriate, benefits patients by increasing mobility, improving quality of life, and allowing for earlier discharge. This approach reduces hospital-acquired infections, length of stay, drug costs, and waste.
Sources:
Al-Hasan, M. N., & Rac, H. (2020). Transition from intravenous to oral antimicrobial therapy in patients with uncomplicated and complicated bloodstream infections. Clinical microbiology and : the official publication of the European Society of Clinical Microbiology and Infectious Diseases, 26(3), 299–306. PMID: 31128289.
Alves J, Prendki V, Chedid M, Yahav D, Bosetti D, Rello J; ESCMID Study group of infections in the elderly (ESGIE). Challenges of antimicrobial stewardship among older adults. Eur J Intern Med. 2024 Feb 14:S0953-6205(24)00017-7. Epub ahead of print. PMID: 38360513.
Eleftheriotis G, Marangos M, Lagadinou M, Bhagani S, Assimakopoulos SF. Oral Antibiotics for Bacteremia and Infective Endocarditis: Current Evidence and Future Perspectives. Microorganisms. 2023 Dec 18;11(12):3004. PMID: 38138148.
Jung J, Cozzi F, Forrest GN. Using antibiotics wisely. Curr Opin Infect Dis.
2023 Dec 1;36(6):462-472. Epub 2023 Sep 21.
PMID: 37732791.van den Broek AK, Prins JM, Visser CE, van Hest RM. Systematic review: the bioavailability of orally administered antibiotics during the initial phase of a systemic infection in non-ICU patients. BMC Infect Dis. 2021 Mar 20;21(1):285. PMID: 33743592.
Walpole S, Eii M, Aldridge C. Medicines are responsible for 22% of the NHS’s Carbon Footprint: How do the footprints of intravenous and oral antibiotics compare? Federation of Infection Societies Conference abstract. 2021.
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Disposal of unused medical supplies is common during patient transfers. To minimize waste, suggested practices include centralized supply carts, as-needed room restocking, and keeping emergency medications available but unopened.
Sources:
Morrow, J., Hunt, S., Rogan, V., Cowie, K., Kopacz, J., Keeler, C., Billick, M. B., & Kroh, M. (2013). Reducing waste in the critical care setting. Nursing leadership (Toronto, Ont.), 26 Spec No 2013, 17–26. https://doi.org/10.12927/cjnl.2013.23362. PMID: 24860948.
Wohlford, S., Esteves-Fuentes, N., & Carter, K. F. (2020). Reducing Waste in the Clinical Setting. The American journal of nursing, 120(6), 48–55. PMID: 32443125.
Yu, A., & Baharmand, I. (2021). Environmental Sustainability in Canadian Critical Care: A Nationwide Survey Study on Medical Waste Management. Healthcare quarterly (Toronto, Ont.), 23(4), 39–45. PMID: 33475491.
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Despite advancements in patient care, unnecessary tests and interventions at the end of life are still common. Invasive procedures, like dialysis, bloodwork, and imaging, can cause discomfort and impose on patients, often misaligning with their wishes. In these situations, nurses should advocate for their patients by questioning the necessity of such diagnostic procedures, ensuring that the patient’s preferences and quality of life are prioritized.
Sources:
Cardona-Morrell, M., Kim, J., Turner, R. M., Anstey, M., Mitchell, I. A., & Hillman, K. (2016). Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem. International journal for quality in health care: journal of the International Society for Quality in Health Care, 28(4), 456–469. PMID: 27353273.
Kass, J. S., Lewis, A., & Rubin, M. A. (2018). Ethical Considerations in End-of-life Care in the Face of Clinical Futility. Continuum (Minneapolis, Minn.), 24(6), 1789–1793. PMID: 30516606.
McCormack, R., Sui, J., Conroy, M., & Stodart, J. (2011). The usefulness of phlebotomy in the palliative care setting. Journal of palliative medicine, 14(3), 297–299. PMID: 21265635.
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The Canadian Nurses Association (CNA) established its Choosing Wisely Canada nursing list by convening a 12-member nursing working group (NWG) of diverse nurse experts from across Canada representing a broad range of geographical regions, practice settings and experience. The NWG began considering its potential list by reviewing existing recommendations, including items from Choosing Wisely Canada’s specialty societies and the American Academy of Nursing (AAN) Choosing Wisely® list, which had already undergone rigorous evidence reviews. In addition, members brought forward recommendations on new evidence-based items. The NWG appraised 195 items for relevance to nursing using a structured process developed for this work. Each of these (171 Choosing Wisely Canada physician-related items, 15 AAN Choosing Wisely items and nine independently submitted items) was appraised by two independent reviewers. Using a modified Delphi process for the next two rounds of revision, the group then refined and adapted 36 items until reaching consensus on a final nine-item list. A literature review was conducted to confirm the evidence for these items, and supporting nursing research was added where appropriate. Subsequently, the final list underwent extensive consultation, in which further input was obtained from nursing experts in patient safety, various members of the Canadian Network of Nursing Specialties, CNA, its jurisdictional members and patient advocates. In November 2016, the Choosing Wisely Canada nursing list was presented to CNA’s board of directors, who gave it their full endorsement and support.
Sources:
Association for Professionals in Infection Control and Epidemiology. APIC implementation guide: guide to preventing catheter-associated urinary tract infections [Internet]. 2014 Apr [cited 2016 Oct 14].
Choosing Wisely Canada. Canadian Society of Hospital Medicine: Five things physicians and patients should question [Internet]. 2020 Feb [cited 2020 Aug 20].
Colli J, et al. National trends in hospitalization from indwelling urinary catheter complications, 2001-2010. Int Urol Nephrol. 2014 Feb;46(2):303-8. PMID: 23934618.
Gray J, Rachakonda A, Karnon J. Pragmatic Review of interventions to prevent catheter-associated urinary tract infections (cautis) in adult inpatients. Journal of Hospital Infection. 2023;136:55–74. PMID: 37015257.
Hu, F.-W., Tsai, C.-H., Lin, H.-S., Chen, C.-H., & Chang, C.-M. (2017). Inappropriate urinary catheter reinsertion in hospitalized older patients. American Journal of Infection Control, 45(1), 8–12. PMID: 28065334.
Jain P, et al. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med. 1995 Jul 10;155(13):1425-9. PMID: 7794092.
Landrigan CP, et al. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010 Nov 25;363(22):2124-34. PMID: 21105794.
Lo E, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Sep;35 Suppl 2:S32-47. PMID: 25376068.
Miller BL, et al. A multimodal intervention to reduce urinary catheter use and associated infection at a Veterans Affairs Medical Center. Infect Control Hosp Epidemiol. 2013 Jun;34(6):631-3. PMID: 23651896.
Mitchell et al. Trends in health care–associated infections in acute care hospitals in Canada: an analysis of repeated point-prevalence surveys. CMAJ. 2019 Sept; 191(36): E981-E988. PMID: 31501180.
National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. [Internet]. 2019 Mar [cited 2019 Aug 26].
Ramanathan R, et al. Urinary tract infections in surgical patients. Surg Clin North Am. 2014 Dec;94(6):1351-68. PMID: 25440128.
Mitchell et al. Trends in health care–associated infections in acute care hospitals in Canada: an analysis of repeated point-prevalence surveys. CMAJ. 2019 Sept; 191(36): E981-E988. PMID: 31501180.
Related Resources:
Toolkit: Lose the Tube – A toolkit for appropriate use of urinary catheters in hospitals
Cameron C, et al. Cost-effectiveness of self-monitoring of blood glucose in patients with type 2 diabetes mellitus managed without insulin. CMAJ. 2010 Jan 12;182(1):28-34. PMID: 20026626.
Canadian Agency for Drugs and Technologies in Health. Optimal therapy recommendations for the prescribing and use of blood glucose test strips. CADTH Technol Overv. 2010;1(2):e0109. PMID: 22977401.
Canadian Diabetes Association. Self-monitoring of blood glucose (SMBG) recommendation tool for healthcare providers [Internet]. 2018 [cited 2019 Aug 26].
Choosing Wisely Canada. Canadian Society for Endocrinology and Metabolism: Five things physicians and patients should question [Internet]. 2019 Jul [cited 2020 Aug 20].
Choosing Wisely Canada. College of Family Physicians of Canada: Thirteen things physicians and patients should question [Internet]. 2019 Jul [cited 2016 Oct 21].
Gomes T, et al. Blood glucose test strips: options to reduce usage. CMAJ. 2010 Jan 12;182(1):35-8. PMID: 20026624.
Mandala et al. Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin. Cochrane Database of Systematic Reviews 2012, Issue 1. [cited 2019 Aug 26].
O’Kane MJ, et al. Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial. BMJ. 2008 May 24;336(7654):1174-7. PMID: 18420662.
Institute for Healthcare Improvement. How-to guide: prevent pressure ulcers. Cambridge, MA: IHI; 2011.
Kayser SA, Phipps L, VanGilder CA, Lachenbruch C. Examining Prevalence and Risk Factors of Incontinence-Associated Dermatitis Using the International Pressure Ulcer Prevalence Survey. J Wound Ostomy Continence Nurs. 2019 Jul; 46(4): 285-290. PMID: 31276451.
Norton et al. Chapter 3: Best Practice Recommendation for the Prevention and management of pressure injuries. 2018 Jan 24 [cited 27 Aug 2019].
Registered Nurses’ Association of Ontario. Assessment and management of pressure injuries for the interprofessional team. 3rd ed. [Internet]. 2016 [cited 2016 Oct 18].
Williamson R, et al. The effect of multiple layers of linens on surface interface pressure: results of a laboratory study. Ostomy Wound Manage. 2013 Jun;59(6):38-48. PMID: 23749661.
Abernethy AP, et al. Effect of palliative oxygen versus (room) air in relieving breathlessness in patients with refractory dyspnea: a double-blind, randomized controlled trial. Lancet. 2010 Sep 4;376(9743):784-793. PMID: 20816546.
Booth S, et al. Does oxygen help dyspnea in patients with cancer? Am J Respir Crit Care Med. 1996 May;153(5):1515-8. PMID: 8630595.
Bruera E, et al. A randomized controlled trial of supplemental oxygen versus air in cancer patients with dyspnea. Palliat Med. 2003 Dec;17(8):659-63. PMID: 14694916.
Choosing Wisely Canada. Canadian Society of Palliative Care Physicians: Five things physicians and patients should question [Internet]. 2020 Jul [cited 2020 Aug 20].
Marciniuk DD, et al. Managing dyspnea in patients with advanced chronic obstructive pulmonary disease: A Canadian Thoracic Society clinical practice guideline. Can Respir J. 2011 Mar-Apr;18(2):69-78. PMID: 21499589.
National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management NICE guideline [NG115]. 2019 Jul 26.
Ontario Health Technology Assessment Service COPD Collaborative. Chronic obstructive pulmonary disease (COPD) evidentiary framework [Internet]. 2012 Mar 1 [cited 2016 Oct 18].
Philip J, et al. A randomized, double-blind, crossover trial of the effect of oxygen on dyspnea in patients with advanced cancer. J Pain Symptom Manage. 2006 Dec;32(6):541-50. PMID: 17157756.
Uronis HE, et al. Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: a systematic review and meta-analysis. Br J Cancer. 2008 Jan 29;98(2):294-9. PMID: 18182991.
Agnew R, et al. Promoting urinary continence with older people: a selective literature review. Int J Older People Nurs. 2009 Mar;4(1):58-62. PMID: 20925803.
Cave CE. Evidence-based continence care: an integrative review. Rehabil Nurs. 2016 Aug 11. PMID: 27510945.
Colborne, M., & Dahlke, S. (2017). Nurses’ perceptions and management of urinary incontinence in hospitalized older adults: An integrative review. Journal of Gerontological Nursing, 43(10), 46-55. PMID: 28556873.
National Institute for Health and Care Excellence. Urinary incontinence and pelvic organ prolapse in women: Management [Internet]. 2019 Apr [cited 29 Aug 2019].
Netsch D. Continence Care Literature Review 2012. J Wound Ostomy Continence Nurs. 2013 Nov-Dec;40(Suppl.): S21-9.
Norton et al. Chapter 3: Best Practice Recommendation for the Prevention and management of pressure injuries. 2018 Jan 24 [cited 27 Aug 2019].
Zisberg, A. Incontinence brief use in acute hospitalized patients with no prior incontinence. J Wound Ostomy Continence Nurs. 2011 Sep-Oct;38(5):559-64. PMID: 21873910.
Zisberg A, et al. In-hospital use of continence aids and new-onset urinary incontinence in adults aged 70 and older. J Am Geriatr Soc. 2011 Jun;59(6):1099-104. PMID: 21649620.
Allen VJ, et al. Use of nutritional complete supplements in older adults with dementia: systematic review and meta-analysis of clinical outcomes. Clin Nutr. 2013 Dec;32(6):950-7. PMID: 23591150.
American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. American Geriatrics Society feeding tubes in advanced dementia position statement. J Am Geriatr Soc. 2014 Aug;62(8):1590-3. PMID: 25039796.
Choosing Wisely Canada. Canadian Geriatrics Society: Five things physicians and patients should question [Internet]. 2019 Jul [cited 2020 Aug 21].
Gabriel SE, et al. Getting the methods right: the foundation of patient-centered outcomes research. N Engl J Med. 2012 Aug 30;367(9):787-90. PMID: 22830434.
Hanson LC. Tube feeding versus assisted oral feeding for persons with dementia: using evidence to support decision-making. Ann Longterm Care. 2013 Jan;21(1):36-39.
Hanson LC, et al. Improving decision-making for feeding options in advanced dementia: a randomized, controlled trial. J Am Geriatr Soc. 2011 Nov;59(11):2009-16. PMID: 22091750.
Ijaopo EO, Ijaopo RO. Tube feeding in individuals with advanced dementia: A review of its burdens and perceived benefits. Journal of Aging Research. 2019;2019:1–16. PMID: 31929906.
Lee, Y., Hsu, T., Liang, C., Yeh, T., Chen, T., Chen, N., & Chu, C. (2020). The Efficacy and Safety of Tube Feeding in Advanced Dementia Patients: A Systemic Review and Meta-Analysis Study. Journal of the American Medical Directors Association. PMID: 32736992.
Palecek EJ, et al. Comfort feeding only: a proposal to bring clarity to decision-making regarding difficulty with eating for persons with advanced dementia. J Am Geriatr Soc. 2010 Mar;58(3):580-4. PMID: 20398123.
Teno JM, et al. Decision-making and outcomes of feeding tube insertion: a five-state study. J Am Geriatr Soc. 2011 May;59(5):881-6. PMID: 21539524.
Related Resources:
Patient Pamphlet: Feeding Tubes for People with Alzheimer’s Disease: When you need them – and when you don’t
Alberta Health Services. Appropriate use of antipsychotics (AUA) toolkit [Internet]. 2013 [cited 2016 Oct 19].
Bjerre, L. et al. Deprescribing antipsychotics for behavioural and psychological symptoms of dementia and insomnia – Evidence-based clinical practice guideline. 2018, Jan. Canadian Family Physician; 64(1): 17-27.
Brodaty H, et al. Meta-analysis of nonpharmacological interventions for neuropsychiatric symptoms of dementia. Am J Psychiatry. 2012 Sep;169(9):946-53. PMID: 22952073.
Choosing Wisely Canada. Canadian Geriatrics Society: Five things physicians and patients should question [Internet]. 2020 Jul [cited 2020 Sept 10].
Dyer SM, Harrison SL, Laver K, Whitehead C, Crotty M. An overview of systematic reviews of pharmacological and non-pharmacological interventions for the treatment of behavioral and psychological symptoms of dementia. Int Psychogeriatr. 2018;30(3):295-309. PMID: 29143695.
Gill SS, et al. Antipsychotic drug use and mortality in older adults with dementia. Ann Intern Med. 2007 Jun 5;146(11):775-86. PMID: 17548409.
Gill SS, et al. Atypical antipsychotic drugs and risk of ischaemic stroke: population based retrospective cohort study. BMJ. 2005 Feb 26;330(7489):445. PMID: 15668211.
Joller P, et al. Approach to inappropriate sexual behaviour in people with dementia. Can Fam Physician. 2013 Mar;59(3):255-60. PMID: 23486794.
Lee PE, et al. Atypical antipsychotic drugs in the treatment of behavioural and psychological symptoms of dementia: systematic review. BMJ. 2004 Jul 10;329(7457):75. PMID: 15194601.
National Health Service. Appropriate prescribing of antipsychotic medication in … [Internet]. Antipsychotic-Prescribing-Toolkit-for-Dementia. National Health Service; 2022 [cited 2024 Apr 30].
Registered Nurses’ Association of Ontario. Delirium, dementia, and depression in older adults: assessment and care [Internet]. 2016 Jul [cited 2016 Oct 19].
Rochon PA, et al. Antipsychotic therapy and short-term serious events in older adults with dementia. Arch Intern Med. 2008 May 26;168(10):1090-6. PMID: 18504337.
Schneider LS, et al. Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. Am J Geriatr Psychiatry. 2006 Mar;14(3):191-210. PMID: 16505124.
Seitz DP, et al. Efficacy and feasibility of nonpharmacological interventions for neuropsychiatric symptoms of dementia in long term care: a systematic review. J Am Med Dir Assoc. 2012 Jul;13(6):503-6.e2. PMID: 22342481.
Related Resources:
Patient Pamphlet: Treating Disruptive Behaviour in People with Dementia: Antipsychotic drugs are usually not the best choice
Abrutyn E, et al. Does asymptomatic bacteriuria predict mortality and does antimicrobial treatment reduce mortality in elderly ambulatory women? Ann Intern Med. 1994 May 15;120(10):827-33. PMID: 7818631.
Blondel-Hill et al. AMMI Canada position statement on asymptomatic bacteriuria. 2019 Jan [cited 2020 Sept 10].
Centers for Disease Control and Prevention. National Healthcare Safety Network (NHSN) Patient Safety Component Manual: Chapter 17: CDC/NHSN surveillance definitions for specific types of infections [Internet]. 2020 Jan [cited 2020 Sept 10].
Choosing Wisely Canada. Canadian Geriatrics Society: Five things physicians and patients should question [Internet]. 2019 Jul[cited 2020 Sept 10].
Choosing Wisely Canada. Using antibiotics wisely in long-term care: Key practice change recommendations. 2019 Oct [2020 Sept 10].
Fekete, T. (2024). Asymptomatic bacteriuria in adults. UpToDate.
Juthani-Mehta M. Asymptomatic bacteriuria and urinary tract infection in older adults. Clin Geriatr Med. 2007 Aug;23(3):585-94. PMID: 17631235.
Mum’s Health. Anti-infective guidelines for community-acquired infections. 13th ed. [Internet]. 2013 [cited 2016 Oct 18].
Nicolle LE, et al. Infectious Diseases Society of America guidelines on Asymptomatic Bacteriuria. Clin Infect Dis. 2019 Mar 21; 68(10): e83-e110.
Rowe TA, et al. Diagnosis and management of urinary tract infection in older adults. Infect Dis Clin North Am. 2014 Mar;28(1):75-89. PMID: 24484576.
Toward Optimized Practice (TOP) Working Group for Urinary Tract Infections in Long Term Care Facilities. Diagnosis and management of urinary tract infections in long term care facilities [Internet]. 2015 Jan [cited 2020 Sept 10].
Barbui C, et al. Efficacy of antidepressants and benzodiazepines in minor depression: systematic review and meta-analysis. Br J Psychiatry. 2011 Jan;198(1):11-6. PMID: 21200071.
Choosing Wisely Canada. Canadian Academy of Child and Adolescent Psychiatry, Canadian Academy of Geriatric Psychiatry, Canadian Psychiatric Association: Thirteen things physicians and patients should question [Internet]. 2017 Jun [cited 2016 Oct 21].
Cuijpers P, et al. Are psychosocial and pharmacologic interventions equally effective in the treatment of adult depressive disorders? A meta-analysis of comparative studies. J Clin Psychiatry. 2008 Nov;69(11):1675-85. PMID: 18945396.
Esposito E, et al. Frequency and adequacy of depression treatment in a Canadian population sample. Can J Psychiatry. 2007 Dec;52(12):780-9. PMID: 18186178.
Fournier JC, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA. 2010 Jan 6;303(1):47-53. PMID: 20051569.
Kirsch I, et al. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med. 2008 Feb;5(2):e45. PMID: 18303940.
National Collaborating Centre for Mental Health. Depression: the NICE guideline on the treatment and management of depression in adults. Updated ed. [Internet]. 2020 [cited 2020 Sept 10].
Al-Hasan, M. N., & Rac, H. (2020). Transition from intravenous to oral antimicrobial therapy in patients with uncomplicated and complicated bloodstream infections. Clinical microbiology and : the official publication of the European Society of Clinical Microbiology and Infectious Diseases, 26(3), 299–306. PMID: 31128289.
Alves J, Prendki V, Chedid M, Yahav D, Bosetti D, Rello J; ESCMID Study group of infections in the elderly (ESGIE). Challenges of antimicrobial stewardship among older adults. Eur J Intern Med. 2024 Feb 14:S0953-6205(24)00017-7. Epub ahead of print. PMID: 38360513.
Eleftheriotis G, Marangos M, Lagadinou M, Bhagani S, Assimakopoulos SF. Oral Antibiotics for Bacteremia and Infective Endocarditis: Current Evidence and Future Perspectives. Microorganisms. 2023 Dec 18;11(12):3004. PMID: 38138148.
Jung J, Cozzi F, Forrest GN. Using antibiotics wisely. Curr Opin Infect Dis.
2023 Dec 1;36(6):462-472. Epub 2023 Sep 21.
PMID: 37732791.
van den Broek AK, Prins JM, Visser CE, van Hest RM. Systematic review: the bioavailability of orally administered antibiotics during the initial phase of a systemic infection in non-ICU patients. BMC Infect Dis. 2021 Mar 20;21(1):285. PMID: 33743592.
Walpole S, Eii M, Aldridge C. Medicines are responsible for 22% of the NHS’s Carbon Footprint: How do the footprints of intravenous and oral antibiotics compare? Federation of Infection Societies Conference abstract. 2021.
Morrow, J., Hunt, S., Rogan, V., Cowie, K., Kopacz, J., Keeler, C., Billick, M. B., & Kroh, M. (2013). Reducing waste in the critical care setting. Nursing leadership (Toronto, Ont.), 26 Spec No 2013, 17–26. https://doi.org/10.12927/cjnl.2013.23362. PMID: 24860948.
Wohlford, S., Esteves-Fuentes, N., & Carter, K. F. (2020). Reducing Waste in the Clinical Setting. The American journal of nursing, 120(6), 48–55. PMID: 32443125.
Yu, A., & Baharmand, I. (2021). Environmental Sustainability in Canadian Critical Care: A Nationwide Survey Study on Medical Waste Management. Healthcare quarterly (Toronto, Ont.), 23(4), 39–45. PMID: 33475491.
Cardona-Morrell, M., Kim, J., Turner, R. M., Anstey, M., Mitchell, I. A., & Hillman, K. (2016). Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem. International journal for quality in health care: journal of the International Society for Quality in Health Care, 28(4), 456–469. PMID: 27353273.
Kass, J. S., Lewis, A., & Rubin, M. A. (2018). Ethical Considerations in End-of-life Care in the Face of Clinical Futility. Continuum (Minneapolis, Minn.), 24(6), 1789–1793. PMID: 30516606.
McCormack, R., Sui, J., Conroy, M., & Stodart, J. (2011). The usefulness of phlebotomy in the palliative care setting. Journal of palliative medicine, 14(3), 297–299. PMID: 21265635.
About Choosing Wisely Canada
Choosing Wisely Canada is the national voice for reducing unnecessary tests and treatments in health care. One of its important functions is to help clinicians and patients engage in conversations that lead to smart and effective care choices.
Web: choosingwiselycanada.org
Email: info@choosingwiselycanada.org
Twitter: @ChooseWiselyCA
Facebook: /ChoosingWiselyCanada
Canadian Nurses Association
Canadian Gerontological Nursing Association
Last updated: May 2024
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While antimicrobial treatments can be lifesaving, they are not without side-effects, particularly for an older person. Antimicrobial use is only appropriate if it aligns with the older person’s wishes and goals of care. Life-prolonging use of antimicrobials may be inconsistent with a patient’s wishes or a palliative approach to care. Talk with the older person and their family to ensure they understand the impact of antimicrobial treatment.
Sources:
Centers for Disease Control and Prevention. Core Elements of Hospital Antibiotic Stewardship Programs: 2019 [Internet]. 2019 [cited 2020 Sept 11].
Reimer-Kirkham S, et al. ‘Close to’ a palliative approach: nurses’ and care aides’ descriptions of caring for people with advancing chronic life-limiting conditions. J Clin Nurs. 2016 Aug;25(15-16):2189-99. PMID: 27312279.
Sawatzky R, et al. Embedding a Palliative Approach in Nursing Care Delivery: An Integrated Knowledge Synthesis. ANS Adv Nurs Sci. 2017 Jul/Sep;40(3):261-277. PMID: 27930401.
The 2019 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019 Apr;67(4):674-694. PMID: 30693946.
Scottish Antimicrobial Prescribing Group. Good Practice Recommendations for antimicrobial use in frail elderly patients in NHS Scotland [Internet]. 2018 Apr [cited 2019 Nov].
Toward Optimized Practice. Diagnosis and Management of Nursing Home Acquired Pneumonia [Internet].2015 Mar [cited 2018 January].
Toward Optimized Practice. Diagnosis and Management of Urinary Tract Infection in Long Term Care Facilities [Internet]. 2015 Jan [cited 2018 January].
van Buul LW, et al. Antibiotic use and resistance in long term care facilities. J Am Med Dir Assoc. 2012 Jul;13(6):568.e1-13. PMID: 22575772.
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When antimicrobials are indicated and consistent with an older person’s plan of care, intravenous formulations should not be the first choice unless there is no other safe and effective route of administration. Many antimicrobials have excellent bioavailability and only in rare instances need to be administered intravenously. Use of oral formulations of these medications reduces the need for placement and maintenance of venous access devices and their associated complications. In addition, reduced need for venous access can prevent transfer of an older person away from their current setting to accommodate a higher level of care.
Sources:
Association of Medical Microbiology and Infectious Disease. Five things physicians and patients should question in infectious disease [Internet]. 2019 Jun [cited 2020 Sept 11].
Barlam et al. (2016). Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clinical Infectious Diseases, Volume 62, Issue 10, 15 May 2016, Pages e51–e77. https://doi.org/10.1093/cid/ciw118.
Centers for Disease Control and Prevention. Core Elements of Hospital Antibiotic Stewardship Programs: 2019 [Internet]. 2019 [cited 2020 Sept 11].
Chapman, A. L., Patel, S., Horner, C., Green, H., Guleri, A., Hedderwick, S., … & Seaton, R. A. (2019). Updated good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) in adults and children in the UK. JAC-Antimicrobial Resistance, 1(2), dlz026.
The 2019 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019 Apr;67(4):674-694. PMID: 30693946.
Toward Optimized Practice. Diagnosis and Management of Nursing Home Acquired Pneumonia [Internet].2015 Mar [cited 2018 January].
van Buul LW, et al. Antibiotic use and resistance in long term care facilities. J Am Med Dir Assoc. 2012 Jul;13(6):568.e1-13. PMID: 22575772.
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Transfers to hospital for assessment and treatment of a change in condition have become customary. However, harms can outweigh benefit and may result in increased morbidity. In one Canadian study, approximately half of hospitalizations were considered avoidable. Transfer often results in long periods in an unfamiliar and stressful environment for the older person. Other hazards include delirium, hospital-acquired infections, medication side effects, lack of sleep, and rapid loss of muscle strength while bedridden. Frail older persons assessed and treated in their current settings have the opportunity to receive more individualized care and better comfort and end-of-life care. If a transfer is unavoidable, a person-centred collaborative approach is necessary to communicate the older person’s functionality and plan of care to ensure their needs are met. Much consideration should be given to the older person’s goals of care, including integrating a palliative approach to care.
Sources:
Lemoyne, S.E., Herbots, H.H., De Blick, D. et al. Appropriateness of transferring nursing home residents to emergency departments: a systematic review. BMC Geriatr 19, 17 (2019). https://doi.org/10.1186/s12877-019-1028-z.
Long Term Care Medical Directors Association of Canada. Six things physicians and patients should question [Internet]. 2019 Aug [cited 2020 Sept 11].
Ouslander JG, et al. The Interventions to Reduce Acute Care Transfers (INTERACT) quality improvement program: an overview for medical directors and primary care clinicians in long term care. J Am Med Dir Assoc. 2014 Mar;15(3):162-170. PMID: 24513226.
Reimer-Kirkham S, et al. ‘Close to’ a palliative approach: nurses’ and care aides’ descriptions of caring for people with advancing chronic life-limiting conditions. J Clin Nurs. 2016 Aug;25(15-16):2189-99. PMID: 27312279.
Sawatzky R, et al. Embedding a Palliative Approach in Nursing Care Delivery: An Integrated Knowledge Synthesis. ANS Adv Nurs Sci. 2017 Jul/Sep;40(3):261-277. PMID: 27930401.
Walker JD, et al. Identifying potentially avoidable hospital admissions from Canadian long-term care facilities. Med Care. 2009 Feb;47(2):250-4. PMID: 19169127.
Walsh EG, et al. Potentially avoidable hospitalizations of dually eligible Medicare and Medicaid beneficiaries from nursing facility and Home- and Community-Based Services waiver programs. J Am Geriatr Soc. 2012 May;60(5):821-9. PMID: 22458363.
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Continuous bed rest or limited ambulation during a hospital stay causes deconditioning and loss of muscle mass and is one of the primary factors for loss of walking independence in hospitalized older adults. Up to 65% of older persons who can walk independently will lose this ability during a hospital stay. Walking during the hospital stay is critical for maintaining this functional ability. Loss of walking independence increases the length of hospital stay, the need for rehabilitation services, the possibility of placement in a nursing home, and the risk for falls both during and after discharge from the hospital. It also places higher demands on caregivers and increases the risk of death. Compared with older persons who don’t walk during their hospital stay, those that do are able to walk farther by discharge, are discharged from the hospital sooner, have improved ability to perform basic daily living tasks independently, and have a faster recovery rate after surgery.
Sources:
American Academy of Nursing. Twenty things nurses and patients should question [Internet]. 2018 Jul [cited 2019 Oct 16].
Canadian Agency for Drugs and Technologies in Health. Rapid Response: Mobilization of Adult Inpatients in Hospitals or Long-Term/Chronic Care [Internet]. 2014 [cited 2018 January].
Coker RH, et al. Bed rest promotes reductions in walking speed, functional parameters, and aerobic fitness in older, healthy adults. J Gerontol A Biol Sci Med Sci. 2015 Jan;70(1):91-6. PMID: 25122628.
English KL, et al. Protecting muscle mass and function in older adults during bed rest. Curr Opin Clin Nutr Metab Care. 2010 Jan;13(1):34-9. PMID: 19898232.
Kortebein P, et al. Functional impact of 10 days of bed rest in healthy older adults. J Gerontol A Biol Sci Med Sci. 2008 Oct;63(10):1076-81. PMID: 18948558.
Liu B, et al. Outcomes of Mobilisation of Vulnerable Elders in Ontario (MOVE ON): a multisite interrupted time series evaluation of an implementation intervention to increase patient mobilisation. Age Ageing. 2018 Jan 1;47(1):112-119. PMID: 28985310.
Padula CA, et al. Impact of a nurse-driven mobility protocol on functional decline in hospitalized older adults. J Nurs Care Qual. 2009 Oct-Dec;24(4):325-31. PMID: 19395979.
Pashikanti L, et al. Impact of early mobilization protocol on the medical-surgical inpatient population: an integrated review of literature. Clin Nurse Spec. 2012 Mar-Apr;26(2):87-94. PMID: 22336934.
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Restraints are most often applied when an older person is distressed or has a change in medical status. These situations require immediate assessment and attention, not restraint. Restraints can be mechanical, physical, chemical or environmental in nature — for example, devices or medications that can be used to restrict a person’s movement. Perceived benefits of restraints are often outweighed by their significant potential for harm, including serious complications and even death. Safe, quality care can be achieved using a least-restraint approach.
Sources:
Alberta Health Services. Restraint as a Last Resort Toolkit [Internet]. 2018 [cited 2018 January].
American Academy of Nursing. Twenty things nurses and patients should question [Internet]. 2014 Oct [cited 2019 Oct 16].
Appropriate Use of Antipsychotics (AUA) Toolkit Working Group, Alberta Health Services. AUA Toolkit for Care Teams [Internet]. 2016 [cited 2018 January].
Avoidance of physical restraint use among hospitalized older adults: A review of clinical effectiveness and guidelines. Ottawa: CADTH; 2019 Feb. (CADTH rapid response report: summary with critical appraisal).
Bourbonniere M, et al. Organizational characteristics and restraint use for hospitalized nursing home residents. J Am Geriatr Soc. 2003 Aug;51(8):1079-84. PMID: 12890069.
Canadian Agency for Drugs and Technologies in Health. Rapid Response – Removal of Physical Restraints in Long Term Care Settings: Clinical Safety and Harm [Internet]. 2013 Dec 11 [cited 2018 January]
Choosing Wisely Canada. When Psychosis Isn’t the Diagnosis: A Toolkit For Reducing Inappropriate Use Of Antipsychotics In Long Term Care [Internet]. 2019 May [cited 2018 January].
Evans LK, et al. Avoiding restraints in patients with dementia: understanding, prevention, and management are the keys. Am J Nurs. 2008 Mar;108(3):40-9; quiz 50. PMID: 18316908.
Evans L, et al. Two decades of research on physical restraint: impact on practice and policy. In: Hinshaw A, Grady P, ed. Shaping Health Policy Through Nursing Research. 1st ed. New York, NY: Springer; 2018:167-184.
Minnick AF, et al. Prevalence and variation of physical restraint use in acute care settings in the US. J Nurs Scholarsh. 2007;39(1):30-7. PMID: 17393963.
Registered Nurses’ Association of Ontario. Promoting Safety: Alternative Approaches to the use of Restraints [Internet]. 2012 Feb [cited 2017 October].
Registered Nurses’ Association of Ontario. Delirium, Dementia, And Depression In Older Adults: Assessment And Care, 2nd edition [Internet]. 2016 Jul [cited 2018 October].
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Individualized turning plans should be developed to align with the older person’s care needs. Turning an older person q2h is often considered the gold standard implemented in many areas of health care to aid in the avoidance of skin breakdown and pressure injuries. However, there is little evidence to support this particular frequency of repositioning. In some cases, it is far too frequent; in others, it is not frequent enough. For older persons at low risk for skin breakdown, this practice may severely impact their quality of life due to sleep deprivation and disruption, leading to delirium, depression and other psychiatric impairments. Excessive repositioning of an older adult may also result in shearing forces that can lead to pressure injuries. Conversely, q2h turning may be inadequate for persons at higher risk for skin breakdown, including those with decreased tissue tolerance and limited mobility. To facilitate an appropriate turning schedule for older adults of all risk levels, it is crucial to use a validated tool to assess each client’s risk for skin breakdown and develop an individualized turning plan.
Sources:
BC Provincial Interprofessional Skin & Wound Committee in collaboration with Occupational Therapists, Physiotherapists, and Would Clinicians. Guideline: Prevention of Pressure Injury in Adults & Children. 2018 Feb.
Bergstrom N, et al. Turning for Ulcer ReductioN: a multisite randomized clinical trial in nursing homes. J Am Geriatr Soc. 2013 Oct;61(10):1705-13. PMID: 24050454.
European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019.
Gillespie BM, Walker RM, Latimer SL, Thalib L, Whitty JA, McInnes E, Chaboyer WP. Repositioning for pressure injury prevention in adults. Cochrane Database of Systematic Reviews 2020, Issue 6. Art. No.: CD009958. DOI: 10.1002/14651858.CD009958.pub3. PMID: 32484259.
Kamdar BB, et al. The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU. Crit Care Med. 2013 Mar;41(3):800-9. PMID: 23314584.
Kamdar BB, et al. Sleep deprivation in critical illness: its role in physical and psychological recovery. J Intensive Care Med. 2012 Mar-Apr;27(2):97-111. PMID: 21220271.
Norton L, et al. Best Practice Recommendations for the Prevention and Management of Pressure Injuries [Internet]. Last updated 2018 Jan 24 [cited 2018 January].
Pilkington S, et al. Causes and consequences of sleep deprivation in hospitalised patients. Nurs Stand. 2013 Aug 7-13;27(49):35-42. PMID: 23924135.
Registered Nurses’ Association of Ontario. Assessment and Management of Pressure Injuries for the Interprofessional Team [Internet]. 2016 Jun 10 [cited 2017 October].
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The Canadian Nurses Association (CNA) and the Canadian Gerontological Nursing Association (CGNA) established its Choosing Wisely Canada nursing list by convening an 11-member nursing working group (NWG). The group consisted of gerontological nursing experts from across Canada, representing a broad range of geographical regions and practice settings. The NWG began considering its list by reviewing existing recommendations, including items from Choosing Wisely Canada’s specialty societies and the American Academy of Nursing (AAN) Choosing Wisely list, both of which had already undergone rigorous evidence reviews. In addition, members brought forward recommendations on new evidence-based items. The NWG appraised 260 items for their relevance to gerontological nursing using a structured process developed for this work. Each of these items (227 Choosing Wisely Canada items, 20 AAN Choosing Wisely items and 13 independently submitted items) was appraised by two independent reviewers and then validated by the group. Using a modified Delphi process for the next two rounds of revision, the group refined and adapted 17 items until it reached consensus on a final six-item list. A literature review was conducted to confirm the evidence for these items and supporting nursing research was added where appropriate. The list subsequently underwent extensive consultation, with input from nursing experts in patient safety, members of the Canadian Network of Nursing Specialties, patient advocates, CNA jurisdictional members, CNA nurses, principal nurse advisors, the Canadian Agency for Drugs and Technologies in Health (CADTH) and Choosing Wisely Canada’s internal clinician reviewers. In March of 2018, the Choosing Wisely Canada gerontological nursing list was presented to the CGNA executive and CNA board, both of whom gave it their full endorsement and support.
Sources:
Centers for Disease Control and Prevention. Core Elements of Hospital Antibiotic Stewardship Programs: 2019 [Internet]. 2019 [cited 2020 Sept 11].
Reimer-Kirkham S, et al. ‘Close to’ a palliative approach: nurses’ and care aides’ descriptions of caring for people with advancing chronic life-limiting conditions. J Clin Nurs. 2016 Aug;25(15-16):2189-99. PMID: 27312279.
Sawatzky R, et al. Embedding a Palliative Approach in Nursing Care Delivery: An Integrated Knowledge Synthesis. ANS Adv Nurs Sci. 2017 Jul/Sep;40(3):261-277. PMID: 27930401.
The 2019 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019 Apr;67(4):674-694. PMID: 30693946.
Scottish Antimicrobial Prescribing Group. Good Practice Recommendations for antimicrobial use in frail elderly patients in NHS Scotland [Internet]. 2018 Apr [cited 2019 Nov].
Toward Optimized Practice. Diagnosis and Management of Nursing Home Acquired Pneumonia [Internet].2015 Mar [cited 2018 January].
Toward Optimized Practice. Diagnosis and Management of Urinary Tract Infection in Long Term Care Facilities [Internet]. 2015 Jan [cited 2018 January].
van Buul LW, et al. Antibiotic use and resistance in long term care facilities. J Am Med Dir Assoc. 2012 Jul;13(6):568.e1-13. PMID: 22575772.
Association of Medical Microbiology and Infectious Disease. Five things physicians and patients should question in infectious disease [Internet]. 2019 Jun [cited 2020 Sept 11].
Barlam et al. (2016). Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clinical Infectious Diseases, Volume 62, Issue 10, 15 May 2016, Pages e51–e77. https://doi.org/10.1093/cid/ciw118.
Centers for Disease Control and Prevention. Core Elements of Hospital Antibiotic Stewardship Programs: 2019 [Internet]. 2019 [cited 2020 Sept 11].
Chapman, A. L., Patel, S., Horner, C., Green, H., Guleri, A., Hedderwick, S., … & Seaton, R. A. (2019). Updated good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) in adults and children in the UK. JAC-Antimicrobial Resistance, 1(2), dlz026.
The 2019 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019 Apr;67(4):674-694. PMID: 30693946.
Toward Optimized Practice. Diagnosis and Management of Nursing Home Acquired Pneumonia [Internet].2015 Mar [cited 2018 January].
van Buul LW, et al. Antibiotic use and resistance in long term care facilities. J Am Med Dir Assoc. 2012 Jul;13(6):568.e1-13. PMID: 22575772.
Lemoyne, S.E., Herbots, H.H., De Blick, D. et al. Appropriateness of transferring nursing home residents to emergency departments: a systematic review. BMC Geriatr 19, 17 (2019). https://doi.org/10.1186/s12877-019-1028-z.
Long Term Care Medical Directors Association of Canada. Six things physicians and patients should question [Internet]. 2019 Aug [cited 2020 Sept 11].
Ouslander JG, et al. The Interventions to Reduce Acute Care Transfers (INTERACT) quality improvement program: an overview for medical directors and primary care clinicians in long term care. J Am Med Dir Assoc. 2014 Mar;15(3):162-170. PMID: 24513226.
Reimer-Kirkham S, et al. ‘Close to’ a palliative approach: nurses’ and care aides’ descriptions of caring for people with advancing chronic life-limiting conditions. J Clin Nurs. 2016 Aug;25(15-16):2189-99. PMID: 27312279.
Sawatzky R, et al. Embedding a Palliative Approach in Nursing Care Delivery: An Integrated Knowledge Synthesis. ANS Adv Nurs Sci. 2017 Jul/Sep;40(3):261-277. PMID: 27930401.
Walker JD, et al. Identifying potentially avoidable hospital admissions from Canadian long-term care facilities. Med Care. 2009 Feb;47(2):250-4. PMID: 19169127.
Walsh EG, et al. Potentially avoidable hospitalizations of dually eligible Medicare and Medicaid beneficiaries from nursing facility and Home- and Community-Based Services waiver programs. J Am Geriatr Soc. 2012 May;60(5):821-9. PMID: 22458363.
American Academy of Nursing. Twenty things nurses and patients should question [Internet]. 2018 Jul [cited 2019 Oct 16].
Canadian Agency for Drugs and Technologies in Health. Rapid Response: Mobilization of Adult Inpatients in Hospitals or Long-Term/Chronic Care [Internet]. 2014 [cited 2018 January].
Coker RH, et al. Bed rest promotes reductions in walking speed, functional parameters, and aerobic fitness in older, healthy adults. J Gerontol A Biol Sci Med Sci. 2015 Jan;70(1):91-6. PMID: 25122628.
English KL, et al. Protecting muscle mass and function in older adults during bed rest. Curr Opin Clin Nutr Metab Care. 2010 Jan;13(1):34-9. PMID: 19898232.
Kortebein P, et al. Functional impact of 10 days of bed rest in healthy older adults. J Gerontol A Biol Sci Med Sci. 2008 Oct;63(10):1076-81. PMID: 18948558.
Liu B, et al. Outcomes of Mobilisation of Vulnerable Elders in Ontario (MOVE ON): a multisite interrupted time series evaluation of an implementation intervention to increase patient mobilisation. Age Ageing. 2018 Jan 1;47(1):112-119. PMID: 28985310.
Padula CA, et al. Impact of a nurse-driven mobility protocol on functional decline in hospitalized older adults. J Nurs Care Qual. 2009 Oct-Dec;24(4):325-31. PMID: 19395979.
Pashikanti L, et al. Impact of early mobilization protocol on the medical-surgical inpatient population: an integrated review of literature. Clin Nurse Spec. 2012 Mar-Apr;26(2):87-94. PMID: 22336934.
Alberta Health Services. Restraint as a Last Resort Toolkit [Internet]. 2018 [cited 2018 January].
American Academy of Nursing. Twenty things nurses and patients should question [Internet]. 2014 Oct [cited 2019 Oct 16].
Appropriate Use of Antipsychotics (AUA) Toolkit Working Group, Alberta Health Services. AUA Toolkit for Care Teams [Internet]. 2016 [cited 2018 January].
Avoidance of physical restraint use among hospitalized older adults: A review of clinical effectiveness and guidelines. Ottawa: CADTH; 2019 Feb. (CADTH rapid response report: summary with critical appraisal).
Bourbonniere M, et al. Organizational characteristics and restraint use for hospitalized nursing home residents. J Am Geriatr Soc. 2003 Aug;51(8):1079-84. PMID: 12890069.
Canadian Agency for Drugs and Technologies in Health. Rapid Response – Removal of Physical Restraints in Long Term Care Settings: Clinical Safety and Harm [Internet]. 2013 Dec 11 [cited 2018 January]
Choosing Wisely Canada. When Psychosis Isn’t the Diagnosis: A Toolkit For Reducing Inappropriate Use Of Antipsychotics In Long Term Care [Internet]. 2019 May [cited 2018 January].
Evans LK, et al. Avoiding restraints in patients with dementia: understanding, prevention, and management are the keys. Am J Nurs. 2008 Mar;108(3):40-9; quiz 50. PMID: 18316908.
Evans L, et al. Two decades of research on physical restraint: impact on practice and policy. In: Hinshaw A, Grady P, ed. Shaping Health Policy Through Nursing Research. 1st ed. New York, NY: Springer; 2018:167-184.
Minnick AF, et al. Prevalence and variation of physical restraint use in acute care settings in the US. J Nurs Scholarsh. 2007;39(1):30-7. PMID: 17393963.
Registered Nurses’ Association of Ontario. Promoting Safety: Alternative Approaches to the use of Restraints [Internet]. 2012 Feb [cited 2017 October].
Registered Nurses’ Association of Ontario. Delirium, Dementia, And Depression In Older Adults: Assessment And Care, 2nd edition [Internet]. 2016 Jul [cited 2018 October].
BC Provincial Interprofessional Skin & Wound Committee in collaboration with Occupational Therapists, Physiotherapists, and Would Clinicians. Guideline: Prevention of Pressure Injury in Adults & Children. 2018 Feb.
Bergstrom N, et al. Turning for Ulcer ReductioN: a multisite randomized clinical trial in nursing homes. J Am Geriatr Soc. 2013 Oct;61(10):1705-13. PMID: 24050454.
European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019.
Gillespie BM, Walker RM, Latimer SL, Thalib L, Whitty JA, McInnes E, Chaboyer WP. Repositioning for pressure injury prevention in adults. Cochrane Database of Systematic Reviews 2020, Issue 6. Art. No.: CD009958. DOI: 10.1002/14651858.CD009958.pub3. PMID: 32484259.
Kamdar BB, et al. The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU. Crit Care Med. 2013 Mar;41(3):800-9. PMID: 23314584.
Kamdar BB, et al. Sleep deprivation in critical illness: its role in physical and psychological recovery. J Intensive Care Med. 2012 Mar-Apr;27(2):97-111. PMID: 21220271.
Norton L, et al. Best Practice Recommendations for the Prevention and Management of Pressure Injuries [Internet]. Last updated 2018 Jan 24 [cited 2018 January].
Pilkington S, et al. Causes and consequences of sleep deprivation in hospitalised patients. Nurs Stand. 2013 Aug 7-13;27(49):35-42. PMID: 23924135.
Registered Nurses’ Association of Ontario. Assessment and Management of Pressure Injuries for the Interprofessional Team [Internet]. 2016 Jun 10 [cited 2017 October].
About Choosing Wisely Canada
Choosing Wisely Canada is the national voice for reducing unnecessary tests and treatments in health care. One of its important functions is to help clinicians and patients engage in conversations that lead to smart and effective care choices.
Web: choosingwiselycanada.org
Email: info@choosingwiselycanada.org
Twitter: @ChooseWiselyCA
Facebook: /ChoosingWiselyCanada
Canadian Nurses Association
Infection Prevention and Control Canada
Last updated: May 2024
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Don’t do a urine dip or send urine specimens for culture when patients/clients/residents (including the elderly or persons with diabetes) do not have urinary tract symptoms or when following up to confirm effective treatment. Testing should only be done when there are urinary tract infection (UTI) symptoms such as urinary discomfort, frequency, urgency, supra-pubic pain, flank pain or fever. Dark, cloudy and/or foul-smelling urine may not be suggestive of UTI but rather of inadequate fluid intake. Delirium by itself is not considered a symptom of cystitis in non-catheterized patients. Testing often shows bacteria in the urine, with as many as 50% of those tested showing bacteria without localizing symptoms to the genitourinary tract. Over-testing and treating asymptomatic bacteriuria with antibiotics lead to an increased risk of diarrhea and infection with Clostridium difficile. Overuse of antibiotics contributes to increasing antimicrobial resistance. The only exceptions to such overuse are screening in early pregnancy, for which there are clear guidelines, and screening for asymptomatic bacteriuria before urologic procedures in which mucosal bleeding is anticipated.
Sources:
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin; No. 91: Treatment of urinary tract infections in nonpregnant women. Obstet Gynecol. 2008 Mar;111(3):785-94. PMID: 18310389.
Anti-Infective Guidelines for Community-Acquired Infections. 14th Edition [Internet]. Toronto (ON): MUMS Guideline Clearinghouse; 2019 [cited 2019 Jul 25].
Choosing Wisely Canada. Association of Medical Microbiology and Infectious Diseases Canada: Five things physicians and patients should questions [Internet]. 2017 Jun [cited 2017 Sep 25].
Choosing Wisely Canada. Long Term Care Medical Directors Association of Canada: Six things physicians and patients should questions [Internet]. 2017 Jan 8 [cited 2017 Sep 25].
Fekete, T. (2024b). Asymptomatic bacteriuria in adults. UpToDate.
Juthani-Mehta, M. Asymptomatic bacteriuria and urinary tract infection in older adults Clin Geriatr Med. 2007 Aug;23(3):585-94, vii. PMID: 17631235.
Happe J, et al. Surveillance definitions of infections in Canadian long term care facilities. Infection Prevention and Control Canada (IPAC Canada). Can J Infect Control. Fall 2017 (Suppl):10-17) [cited 2019 Jul 25].
High KP, et al. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009 Jan 15;48(2):149-71. PMID: 19072244.
Nicolle LE, et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America.[Internet]. 2019 [cited 2019 Jul 25].
Sloane PD, et al. Urine culture testing in community nursing homes: Gateway to antibiotic overprescribing. Infect Control Hosp Epidemiol. 2017 May;38(5):524-531. PMID: 28137327.
Stone ND, et al. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol. 2012 Oct;33(10):965-77. PMID: 22961014.
Zabarsky TF, et al. Sustained reduction in inappropriate treatment of asymptomatic bacteriuria in a long-term care facility through an educational intervention. Am J Infect Control. 2008 Sep;36(7):476-80. PMID: 18786450.
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Since the vast majority of upper respiratory infections are viral, antibiotics are rarely indicated and may lead to adverse effects. Overuse or misuse of antibiotics can lead to increased antibiotic resistance in the individual and the larger society. Antiviral drugs are authorized for influenza treatment and prophylaxis in Canada. Their use will depend on a number of factors such as patient risk, relevant history and the duration and severity of symptoms. If a nurse caring for a patient feels that medication is not the appropriate intervention, the nurse has a responsibility to discuss these concerns with the prescribers.
Sources:
Choosing Wisely Canada. College of Family Physicians of Canada: Thirteen things physicians and patients should question [Internet]. 2019 Jul [cited 2019 Jul 25].
Government of Canada. Information for health professionals: Flu (Influenza) [Internet]. 2018 Oct 25 [cited 2019 Jul 25].
Hirschmann JV. Antibiotics for common respiratory tract infections in adults. Arch Intern Med. 2002 Feb 11;162(3):256-64. PMID: 11822917.
Low D. Reducing antibiotic use in influenza: Challenges and rewards. Clin Microbiol Infect. 2008 Apr;14(4):298-306. PMID: 18093237.
Schumann SA, et al. Patients insist on antibiotics for sinusitis? Here is a good reason to say “no”. J Fam Pract. 2008 Jul;57(7):464-8. PMID: 18625169.
Smith SR, et al. Treatment of mild to moderate sinusitis. Arch Intern Med. 2012 Mar 26;172(6):510-3. PMID: 22450938.
World Health Organization. The evolving threat of antimicrobial resistance: Options for action [Internet]. 2012 [cited 2017 Sep 25].
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Gloves should only be worn: (1) when a point-of-care risk assessment indicates a risk of contact with broken skin, blood or body fluids, mucous membranes or contaminated surfaces (as per routine practices); (2) for situations where additional (contact) precautions are indicated; or (3) for contact with chemicals (e.g., during environmental cleaning, preparing chemotherapy, etc.). When a task requires gloves, they should be put on immediately beforehand and removed immediately after, at which point hands should be cleaned. Gloves are not necessary for social touch (e.g., shaking hands) or when contact is limited to intact skin (e.g., taking blood pressure, dressing a client) or clean surfaces. Don’t wear multiple layers of gloves and don’t substitute gloves for hand hygiene. Hand hygiene is the single most important way to prevent transmission of infection, and alcohol-based hand rub (ABHR) is the preferred method. If gloves must be worn, after cleaning hands, allow them to dry before putting on gloves to reduce the risk of chronic irritant contact dermatitis (ICD) and colonization of hands. If hands are not visibly soiled, this risk could be reduced by avoiding handwashing and using ABHR instead.*
Sources:
* “An alcohol-based hand rub (ABHR) is the preferred method of hand hygiene in healthcare settings, unless exceptions apply (i.e., when hands are visibly soiled with organic material, if exposure to norovirus and potential spore-forming pathogens such as Clostridium difficile is strongly suspected or proven, including outbreaks involving these organisms)”. Public Health Agency of Canada. Hand hygiene practices in healthcare settings [Internet]. 2012 [cited 2017 Sep 25].
Boyce JM, et al. Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol. 2002 Dec;23(12 Suppl):S3-40. PMID: 12515399.
Canadian Agency for Drugs & Technologies in Health. Hand antisepsis procedures: a review of the guidelines [Internet]. 2017 Mar 9 [cited 2017 Sep 25].
Cashman MW, et al. Contact dermatitis in the United States: Epidemiology, economic impact, and workplace prevention. Dermatol Clin. 2012 Jan;30(1):87-98, viii. PMID: 22117870.
Conly JM. Personal protective equipment for preventing respiratory infections: what have we really learned? CMAJ. 2006 Aug 1;175(3):263. PMID: 16880447.
Fuller C, et al. “The dirty hand in the latex glove”: a study of hand hygiene compliance when gloves are worn. Infect Control Hosp Epidemiol. 2011 Dec;32(12):1194-9. PMID: 22080658.
Korniewicz DM, et al. Barrier protection with examination gloves: Double versus single. Am J Infect Control. 1994 Feb;22(1):12-5. PMID: 8172370.
Marimuthu K, et al. The effect of improved hand hygiene on nosocomial MRSA control. Antimicrob Resist Infect Control. 2014 Nov 26;3:34. PMID: 25937922.
Pittet D, et al. The World Health Organization guidelines on hand hygiene in health care and their consensus recommendations. Infect Control Hosp Epidemiol. 2009 Jul;30(7):611-22. PMID: 19508124.
Provincial Infectious Diseases Advisory Committee (PIDAC). Routine Practices and Additional Precautions In All Health Care Settings, 3rd edition [Internet]. 2012 Nov [cited 2017 Sep 25].
Provincial Infectious Diseases Advisory Committee (PIDAC). Best Practices for Hand Hygiene in All Health Care Settings, 4th edition [Internet]. 2014 Apr [cited 2017 Sep 25].
Public Health Agency of Canada. Routine Practices and Additional Precautions for the Prevention of Transmission of Infection In Health Care Settings [Internet]. 2012 [cited 2017 Sep 25].
Smedley J, et al. Management of occupational dermatitis in healthcare workers: a systematic review. Occup Environ Med. 2012 Apr;69(4):276-9. PMID: 22034544.
World Health Organization. WHO guidelines on hand hygiene in health care [Internet]. 2009 [cited 2017 Sep 27].
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Don’t routinely send specimens for testing or screening (e.g., for methicillin-resistant Staphylococcus aureus [MRSA]) unless clinical evidence of infection is present (e.g., for incisions or eyes). If the highest quality specimen that can be obtained is through a swab of infected skin, tissue or wound, cleanse the area with sterile saline beforehand to reduce surface contaminants. Do not take a specimen of the discharge unless it is specifically ordered. Improperly collected or poor-quality specimens (including swabs) can reduce patient safety by prompting antimicrobial therapy (in cases of colonization) and increase laboratory and pharmacy expenses. To promote sensible antimicrobial use and optimize the treatment of infected patients, while reducing unnecessary microbiology lab workup, attention should be paid to appropriate specimen collection.
Sources:
Avdic E, et al. The role of the microbiology laboratory in antimicrobial stewardship programs. Infect Dis Clin North Am. 2014 Jun;28(2):215-35. PMID: 24857389.
Bonham P. Swab cultures for diagnosing wound infections: a literature review and clinical guideline. J Wound Ostomy Continence Nurs. 2009 Jul-Aug;36(4):389-95. PMID: 19609159.
MacVane SH, et al. The Role of Antimicrobial Stewardship in the Clinical Microbiology Laboratory: Stepping Up to the Plate. Open Forum Infect Dis. 2016 Sep 21;3(4):ofw201. PMID: 27975076.
Miller JM. Poorly Collected Specimens May Have a Negative Impact on Your Antibiotic Stewardship Program. Clinical Microbiology Newsletter. 2016 Mar 15:38(6);43-8.
Morency-Potvin P, et al. Antimicrobial Stewardship: How the Microbiology Laboratory Can Right the Ship. Clin Microbiol Rev. 2016 Dec 14;30(1):381-407. PMID: 27974411.
Registered Nurses’ Association of Ontario. Assessment and Management of Pressure Injuries for the Interprofessional Team, Third Edition [Internet]. 2016 [cited 2017 Nov 1].
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Don’t routinely collect or process specimens for Clostridioides (formerly Clostridium) difficile testing when stool is not diarrhea (i.e., does not take the shape of the specimen container), the patient has had a prior nucleic acid amplification test result within the past seven days (e.g., polymerase chain reaction) or as a test of cure. A positive test in the absence of diarrhea likely represents C. difficile colonization. Repeated C. difficile testing within seven days of a negative test generally adds little diagnostic value. A test of cure in patients with recent C. difficile infection is also not recommended, as colonization may continue indefinitely. Contact precautions are required until symptoms (i.e., diarrhea) resolve.
Sources:
Aichinger E, et al. Nonutility of repeat laboratory testing for detection of Clostridium difficile by use of PCR or enzyme immunoassay. J Clin Microbiol. 2008 Nov;46(11):3795-7. PMID: 18784320.
Choosing Wisely Canada. Association of Medical Microbiology and Infectious Diseases Canada: Five things physicians and patients should questions [Internet]. 2017 Jun [cited 2017 Sep 25].
Luo RF, et al. Is repeat PCR needed for diagnosis of Clostridium difficile infection? J Clin Microbiol. 2010 Oct;48(10):3738-41. PMID: 20686078.
Luo RF, et al. Alerting physicians during electronic order entry effectively reduces unnecessary repeat PCR testing for Clostridium difficile. J Clin Microbiol. 2013 Nov;51(11):3872-4. PMID: 23985918.
Public Health Agency of Canada. Clostridium Difficile Infection: Infection Prevention and Control Guidance for Management in Acute Care Settings [Internet]. 2013 Jan 11 [cited 2017 Sep 25].
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Invasive devices (such as central venous catheters and endotracheal tubes) should not be used without specific indication (determined by appropriate clinical assessment) and should not be left in place without daily re-assessment. If required, invasive devices should not be used longer than necessary, as they breach skin and body integrity and are portals of entry for infection.
Sources:
Association for Professionals in Infection Control and Epidemiology. APIC implementation guide: Guide to preventing central line-associated infections [Internet]. 2015 Dec [cited 2017 Sep 25].
Canadian Patient Safety Institute. Central Line-Associated Bloodstream Infection (CLABSI): Getting Started Kit [Internet]. 2012 Jun [cited 2017 Sep 25].
Canadian Patient Safety Institute. Ventilator-Associated Pneumonia Infection (VAP): Getting Started Kit [Internet]. 2012 Jun [cited 2019 Jul 25].
Centers for Disease Control and Prevention. Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 [Internet]. 2011 [cited 2017 Sep 25].
Klompas M, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Aug;35(8):915-36. PMID: 25026607.
Marschall J, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Jul;35(7):753-71. PMID: 24915204
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Shaving hair (e.g., preoperatively, for vascular access device insertion or electrode application) can result in microscopic cuts and abrasions to the underlying skin surface. According to World Health Organization guidelines, hair should not be removed unless it interferes with a surgical procedure. The use of razors (shaving) prior to surgery increases incidents of wound infection when compared to clipping, depilatory use or the non-removal of hair. If hair must be removed, clipper use is sufficient for any body part (razor use is not appropriate for any operative site). Clippers should be used as close to the time of surgery as possible. To facilitate better contact for electrodes or vascular access device dressings, disposable (or cleaned and disinfected reusable-head) surgical clippers should be used.
Sources:
Allegranzi B, et al. New WHO Recommendations on Perioperative Measures for Surgical Site Infection Prevention: An Evidence-based Global Perspective. Lancet. 2016;16(12): 276-87. PMID: 27816413.
Anderson DJ, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Jun;35(6):605-27. PMID: 24799638.
Association of periOperative Registered Nurses. Guidelines for Perioperative Practice [Internet]. 2017 [cited 2017 Sep 25].
Broekman ML. Neurosurgery and shaving: what’s the evidence? J Neurosurg. 2011 Oct;115(4):670-8. PMID: 21721875.
Canadian Patient Safety Institute. Surgical site infection [Internet]. 2016 [cited 2017 Sep 25].
Infusion Nurses Society. Infusion therapy standards of practice (standard 33) [Internet]. 2016 [cited 2017 Sep 27].
Operating Room Nurses Association of Canada. The ORNAC Standards, Guidelines, and Position Statements for Perioperative Registered Nursing Practice, 13th edition [Internet]. 2017 [cited 2019 Jul 25].
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The Canadian Nurses Association (CNA) and Infection Prevention and Control (IPAC) Canada established its Choosing Wisely Canada nursing list by convening an eight-member nursing working group (NWG). The group consisted of infection prevention and control nursing experts from across Canada, representing a broad range of geographical regions and practice settings. The NWG began considering its list by reviewing existing recommendations, including items from Choosing Wisely Canada’s specialty societies and the American Academy of Nursing (AAN) Choosing Wisely list, both of which had already undergone rigorous evidence reviews. In addition, members brought forward recommendations on new evidence-based items. The NWG appraised 298 items for their relevance to nursing using a structured process developed for this work. Each of these items (217 from Choosing Wisely Canada, 15 from AAN Choosing Wisely and 66 that were independently submitted) was appraised by two independent reviewers then validated by the group. Using a modified Delphi process for the next two rounds of revision, the group refined and adapted 30 items until it reached consensus on a final seven-item list. A literature review was conducted to confirm the evidence for these items, and supporting nursing research was added where appropriate. The list subsequently underwent extensive consultation, with input from nursing experts in patient safety, members of the Canadian Network of Nursing Specialties, patient advocates, CNA jurisdictional members, CNA nurses, the Canadian Association for Drugs and Technologies in Health (CADTH) and Choosing Wisely Canada’s internal clinician reviewers. In September 2017, the Choosing Wisely Canada nursing list was presented to the IPAC Canada and CNA boards, who gave it their full endorsement and support.
Sources:
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin; No. 91: Treatment of urinary tract infections in nonpregnant women. Obstet Gynecol. 2008 Mar;111(3):785-94. PMID: 18310389.
Anti-Infective Guidelines for Community-Acquired Infections. 14th Edition [Internet]. Toronto (ON): MUMS Guideline Clearinghouse; 2019 [cited 2019 Jul 25].
Choosing Wisely Canada. Association of Medical Microbiology and Infectious Diseases Canada: Five things physicians and patients should questions [Internet]. 2017 Jun [cited 2017 Sep 25].
Choosing Wisely Canada. Long Term Care Medical Directors Association of Canada: Six things physicians and patients should questions [Internet]. 2017 Jan 8 [cited 2017 Sep 25].
Fekete, T. (2024b). Asymptomatic bacteriuria in adults. UpToDate.
Juthani-Mehta, M. Asymptomatic bacteriuria and urinary tract infection in older adults Clin Geriatr Med. 2007 Aug;23(3):585-94, vii. PMID: 17631235.
Happe J, et al. Surveillance definitions of infections in Canadian long term care facilities. Infection Prevention and Control Canada (IPAC Canada). Can J Infect Control. Fall 2017 (Suppl):10-17) [cited 2019 Jul 25].
High KP, et al. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009 Jan 15;48(2):149-71. PMID: 19072244.
Nicolle LE, et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America.[Internet]. 2019 [cited 2019 Jul 25].
Sloane PD, et al. Urine culture testing in community nursing homes: Gateway to antibiotic overprescribing. Infect Control Hosp Epidemiol. 2017 May;38(5):524-531. PMID: 28137327.
Stone ND, et al. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol. 2012 Oct;33(10):965-77. PMID: 22961014.
Zabarsky TF, et al. Sustained reduction in inappropriate treatment of asymptomatic bacteriuria in a long-term care facility through an educational intervention. Am J Infect Control. 2008 Sep;36(7):476-80. PMID: 18786450.
Choosing Wisely Canada. College of Family Physicians of Canada: Thirteen things physicians and patients should question [Internet]. 2019 Jul [cited 2019 Jul 25].
Government of Canada. Information for health professionals: Flu (Influenza) [Internet]. 2018 Oct 25 [cited 2019 Jul 25].
Hirschmann JV. Antibiotics for common respiratory tract infections in adults. Arch Intern Med. 2002 Feb 11;162(3):256-64. PMID: 11822917.
Low D. Reducing antibiotic use in influenza: Challenges and rewards. Clin Microbiol Infect. 2008 Apr;14(4):298-306. PMID: 18093237.
Schumann SA, et al. Patients insist on antibiotics for sinusitis? Here is a good reason to say “no”. J Fam Pract. 2008 Jul;57(7):464-8. PMID: 18625169.
Smith SR, et al. Treatment of mild to moderate sinusitis. Arch Intern Med. 2012 Mar 26;172(6):510-3. PMID: 22450938.
World Health Organization. The evolving threat of antimicrobial resistance: Options for action [Internet]. 2012 [cited 2017 Sep 25].
* “An alcohol-based hand rub (ABHR) is the preferred method of hand hygiene in healthcare settings, unless exceptions apply (i.e., when hands are visibly soiled with organic material, if exposure to norovirus and potential spore-forming pathogens such as Clostridium difficile is strongly suspected or proven, including outbreaks involving these organisms)”. Public Health Agency of Canada. Hand hygiene practices in healthcare settings [Internet]. 2012 [cited 2017 Sep 25].
Boyce JM, et al. Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol. 2002 Dec;23(12 Suppl):S3-40. PMID: 12515399.
Canadian Agency for Drugs & Technologies in Health. Hand antisepsis procedures: a review of the guidelines [Internet]. 2017 Mar 9 [cited 2017 Sep 25].
Cashman MW, et al. Contact dermatitis in the United States: Epidemiology, economic impact, and workplace prevention. Dermatol Clin. 2012 Jan;30(1):87-98, viii. PMID: 22117870.
Conly JM. Personal protective equipment for preventing respiratory infections: what have we really learned? CMAJ. 2006 Aug 1;175(3):263. PMID: 16880447.
Fuller C, et al. “The dirty hand in the latex glove”: a study of hand hygiene compliance when gloves are worn. Infect Control Hosp Epidemiol. 2011 Dec;32(12):1194-9. PMID: 22080658.
Korniewicz DM, et al. Barrier protection with examination gloves: Double versus single. Am J Infect Control. 1994 Feb;22(1):12-5. PMID: 8172370.
Marimuthu K, et al. The effect of improved hand hygiene on nosocomial MRSA control. Antimicrob Resist Infect Control. 2014 Nov 26;3:34. PMID: 25937922.
Pittet D, et al. The World Health Organization guidelines on hand hygiene in health care and their consensus recommendations. Infect Control Hosp Epidemiol. 2009 Jul;30(7):611-22. PMID: 19508124.
Provincial Infectious Diseases Advisory Committee (PIDAC). Routine Practices and Additional Precautions In All Health Care Settings, 3rd edition [Internet]. 2012 Nov [cited 2017 Sep 25].
Provincial Infectious Diseases Advisory Committee (PIDAC). Best Practices for Hand Hygiene in All Health Care Settings, 4th edition [Internet]. 2014 Apr [cited 2017 Sep 25].
Public Health Agency of Canada. Routine Practices and Additional Precautions for the Prevention of Transmission of Infection In Health Care Settings [Internet]. 2012 [cited 2017 Sep 25].
Smedley J, et al. Management of occupational dermatitis in healthcare workers: a systematic review. Occup Environ Med. 2012 Apr;69(4):276-9. PMID: 22034544.
World Health Organization. WHO guidelines on hand hygiene in health care [Internet]. 2009 [cited 2017 Sep 27].
Avdic E, et al. The role of the microbiology laboratory in antimicrobial stewardship programs. Infect Dis Clin North Am. 2014 Jun;28(2):215-35. PMID: 24857389.
Bonham P. Swab cultures for diagnosing wound infections: a literature review and clinical guideline. J Wound Ostomy Continence Nurs. 2009 Jul-Aug;36(4):389-95. PMID: 19609159.
MacVane SH, et al. The Role of Antimicrobial Stewardship in the Clinical Microbiology Laboratory: Stepping Up to the Plate. Open Forum Infect Dis. 2016 Sep 21;3(4):ofw201. PMID: 27975076.
Miller JM. Poorly Collected Specimens May Have a Negative Impact on Your Antibiotic Stewardship Program. Clinical Microbiology Newsletter. 2016 Mar 15:38(6);43-8.
Morency-Potvin P, et al. Antimicrobial Stewardship: How the Microbiology Laboratory Can Right the Ship. Clin Microbiol Rev. 2016 Dec 14;30(1):381-407. PMID: 27974411.
Registered Nurses’ Association of Ontario. Assessment and Management of Pressure Injuries for the Interprofessional Team, Third Edition [Internet]. 2016 [cited 2017 Nov 1].
Aichinger E, et al. Nonutility of repeat laboratory testing for detection of Clostridium difficile by use of PCR or enzyme immunoassay. J Clin Microbiol. 2008 Nov;46(11):3795-7. PMID: 18784320.
Choosing Wisely Canada. Association of Medical Microbiology and Infectious Diseases Canada: Five things physicians and patients should questions [Internet]. 2017 Jun [cited 2017 Sep 25].
Luo RF, et al. Is repeat PCR needed for diagnosis of Clostridium difficile infection? J Clin Microbiol. 2010 Oct;48(10):3738-41. PMID: 20686078.
Luo RF, et al. Alerting physicians during electronic order entry effectively reduces unnecessary repeat PCR testing for Clostridium difficile. J Clin Microbiol. 2013 Nov;51(11):3872-4. PMID: 23985918.
Public Health Agency of Canada. Clostridium Difficile Infection: Infection Prevention and Control Guidance for Management in Acute Care Settings [Internet]. 2013 Jan 11 [cited 2017 Sep 25].
Association for Professionals in Infection Control and Epidemiology. APIC implementation guide: Guide to preventing central line-associated infections [Internet]. 2015 Dec [cited 2017 Sep 25].
Canadian Patient Safety Institute. Central Line-Associated Bloodstream Infection (CLABSI): Getting Started Kit [Internet]. 2012 Jun [cited 2017 Sep 25].
Canadian Patient Safety Institute. Ventilator-Associated Pneumonia Infection (VAP): Getting Started Kit [Internet]. 2012 Jun [cited 2019 Jul 25].
Centers for Disease Control and Prevention. Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 [Internet]. 2011 [cited 2017 Sep 25].
Klompas M, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Aug;35(8):915-36. PMID: 25026607.
Marschall J, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Jul;35(7):753-71. PMID: 24915204
Allegranzi B, et al. New WHO Recommendations on Perioperative Measures for Surgical Site Infection Prevention: An Evidence-based Global Perspective. Lancet. 2016;16(12): 276-87. PMID: 27816413.
Anderson DJ, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Jun;35(6):605-27. PMID: 24799638.
Association of periOperative Registered Nurses. Guidelines for Perioperative Practice [Internet]. 2017 [cited 2017 Sep 25].
Broekman ML. Neurosurgery and shaving: what’s the evidence? J Neurosurg. 2011 Oct;115(4):670-8. PMID: 21721875.
Canadian Patient Safety Institute. Surgical site infection [Internet]. 2016 [cited 2017 Sep 25].
Infusion Nurses Society. Infusion therapy standards of practice (standard 33) [Internet]. 2016 [cited 2017 Sep 27].
Operating Room Nurses Association of Canada. The ORNAC Standards, Guidelines, and Position Statements for Perioperative Registered Nursing Practice, 13th edition [Internet]. 2017 [cited 2019 Jul 25].
About Choosing Wisely Canada
Choosing Wisely Canada is the national voice for reducing unnecessary tests and treatments in health care. One of its important functions is to help clinicians and patients engage in conversations that lead to smart and effective care choices.
Web: choosingwiselycanada.org
Email: info@choosingwiselycanada.org
Twitter: @ChooseWiselyCA
Facebook: /ChoosingWiselyCanada
Canadian Nurses Association
Canadian Association of Critical Care Nurses
Last updated: May 2024
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While it’s common to insert indwelling urinary catheters for critical care patients, prolonged use can lead to catheter-associated urinary tract infections (CAUTI), urosepsis, increased hospital stays and other complications. Although critical illness can be a legitimate indication for urinary catheter use, daily assessment of urinary catheters is recommended. Some evidence indicates that reminder systems or stop orders in critical care settings can reduce the incidence of CAUTI and catheter duration.
Sources:
American Association of Critical-Care Nurses. Prevention of Catheter-Associated Urinary Tract Infections in Adults. [Internet]. 2015 [cited March 2019].
Association for Professionals in Infection Control and Epidemiology. APIC implementation guide: guide to preventing catheter-associated urinary tract infections [Internet]. 2014 Apr [cited 2016 Oct 14].
Canadian Patient Safety Institute. Hospital Harm Improvement Resource: Urinary Tract Infection [Internet]. 2016 Apr.
Chant, C., Smith, O., Marshall, J., Friedrich, J. Relationship of catheter-associated urinary tract infection to mortality and length of stay in critically ill patients: A systematic review and meta-analysis of observational studies. Critical Care Medicine. 2011;39(5):1167-1173. PMID: 21242789.
Colli J, et al. National trends in hospitalization from indwelling urinary catheter complications, 2001-2010. Int Urol Nephrol. 2014 Feb;46(2):303-8. PMID: 23934618.
Gray J, Rachakonda A, Karnon J. Pragmatic Review of interventions to prevent catheter-associated urinary tract infections (cautis) in adult inpatients. Journal of Hospital Infection. 2023;136:55–74. PMID: 37015257.
Lo, E, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Sep;35 Suppl 2:S32-47. PMID: 25376068.
Meddings J., Rogers M., Macy M., Siant, S. Systematic review and meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Clinical Infectious Diseases. 2010 Sept;51(5);5: 550-560. doi: 10.1086/655133 PMID: 20673003.
Miller BL, et al. A multimodal intervention to reduce urinary catheter use and associated infection at a Veterans Affairs Medical Center. Infect Control Hosp Epidemiol. 2013 Jun;34(6):631-3. PMID: 23651896.
Ramanathan R, et al. Urinary tract infections in surgical patients. Surg Clin North Am. 2014 Dec; 94(6): 1351-68. PMID: 25440128.
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The treatment of delirium is multifactorial, including environmental stimulation, ongoing mobilization and family presence. Guidelines recommend against using benzodiazepines for sedation, unless otherwise indicated (e.g., withdrawal related to alcohol or benzodiazepine use). The inappropriate administration of benzodiazepines may harm a critically ill patient by inadvertently increasing the incidence of delirium or the length of stay in an ICU. Nonpharmacologic strategies should be used, along with monitoring, assessing and treating pain. Preliminary research has shown that implementing nurse-driven daily awakening protocols and best practice bundles such as ABCDE may improve outcomes, including decreases in length of overall hospital stay, ventilator days and risk of ICU-acquired delirium.
Sources:
American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. American Geriatrics Society Abstracted Clinical Practice Guideline for Postoperative Delirium in Older Adults. J Am Geriatr Soc; 2015 Jan;63(1):142-50. PMID: 25495432.
American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc.; 2015 Nov;63(11):2227-46. PMID: 26446832.
Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM, Coursin DB, Herr DL, Tung A, Robinson BR, Fontaine DK, Ramsay MA, Riker RR, Sessler CN, Pun B, Skrobik Y, Jaeschke R; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013 Jan;41(1):263-306. PMID: 23269131.
Campbell N, Boustani MA, Ayub A, Fox GC, Munger SL, Ott C, Guzman O, Farber M, Ademuyiwa A, Singh R. Pharmacological management of delirium in hospitalized adults—a systematic evidence review. J Gen Intern Med; 2009 Jul;24(7):848-53. PMID: 19424763.
The American Geriatrics Society 2019 Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society; 2019;67(4):674-94. PMID: 30693946.
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The intention to use physical restraints to prevent self-extubation or accidental removal of lines or tubes is often misguided. In fact, some research has found restraints have the potential to cause harm to critically ill patients, including complications but not limited to unplanned extubation, increased risk for delirium, and prolonged recovery. The use of physical restraints in ICU patients in Canada is common and significantly higher comparable to some European countries. Guidelines recognize the paucity of evidence to substantiate the use of physical restraints as an effective strategy. The use of physical restraints can be minimized by maintaining direct visual observation of patients, permitting the presence of family care partners, initiating spontaneous awakening and breathing trials (to support removal of endotracheal tube and thus reduce need for restraints), and assessing delirium and the need for mobilization. Decreased use of physical restraints is an important indicator of quality nursing care.
Sources:
Alberta Health Services. Restraint as a last resort – Critical care [Internet]. 2018 Feb.
Abraham, J., Hirt, J., Richter, C., Köpke, S., Meyer, G., & Möhler, R. (2022). Interventions for preventing and reducing the use of physical restraints of older people in general hospital settings. The Cochrane database of systematic reviews, 8(8), CD012476.
Da Silva et al. Unplanned endotracheal extubations in the intensive care Unit: Systematic review, critical appraisal, and evidence-based recommendations. Anesthesia and Analgesia. 2012;114(5). PMID: 22366845.
Devlin J. W., et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Critical Care Medicine. 2018;46(9): e825-e873. PMID: 30113379.
Luk E, et al. Predictors of physical restraint use in Canadian intensive care units. Critical Care. 2014 Mar;18(2):R46. PMID: 24661688.
Maccioli GA, et al. Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: Use of restraining therapies–American College of Critical Care Medicine Task Force 2001-2002. Critical Care Medicine. 2003;31(11): 2665-2676. PMID: 14605540.
Minnick AF, et al. Prevalence and variation of physical restraint use in acute care settings in the US. J Nurs Scholarsh. 2007;39(1):30-7. PMID: 17393963.
Physical Restraints for the Prevention of Self-Extubation or Line or Tube Removal in Critically Ill Patients: Clinical Effectiveness and Guidelines. Ottawa: CADTH; 2019 May. (CADTH rapid response report: summary of abstracts).
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In emergency situations, intravenous (IV) access can be difficult to obtain. Nurses often lose time trying to insert peripheral IVs, and insertion of central venous catheters may be initiated. However, intraosseous (IO) access is a faster and safer option, with less chance of complications, when inserted by trained personnel.
Sources:
Dolister M, et al. Intraosseous vascular access is safe, effective and costs less than central venous catheters for patients in the hospital setting. Journal of Vascular Access. 2013 Jul-Sep;14(3): 216-224. PMID: 23283646.
Leidel B, et al. Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study. Patient Safety in Surgery. 2009 Oct;3(24).
Perron C. Intraosseous infusion [Internet]. 2017.
Petitpas F, et al. Use of intra-osseous access in adults: A systematic review. Critical Care. 2016;20(102).
Phillips L, et al. Recommendations for the use of intraosseous vascular access for emergent and nonemergent situations in various health care settings: A consensus paper. Crit Care Nurse. 2010;30(6): e1-e7. PMID: 21078467.
The Role of the Registered Nurse in the Use of Intraosseous Vascular Access Devices. (2020). Journal of Infusion Nursing, 43(3), 117–120.
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Central venous or peripherally inserted central catheters require close monitoring for signs of central line-associated bloodstream infections (CLABSI) and should be reviewed daily during multidisciplinary rounds to ensure the appropriateness of the catheter and its intended use. Peripheral intravenous catheters should be assessed daily and removed if they are not part of the continued plan of care or the lumen remains dormant for greater than 24 hours. Unless medically necessary for parenteral nutrition or vasoactive support, the strategies to mitigate CLABSI in central venous access should include considering an access device that is the least invasive with the greatest likelihood of reaching the end of the planned therapy with the lowest rate of replacements and complications.
Sources:
Alberta Health Services. Calgary health region: Central vascular catheter (CVC) management protocol. 2007.
Beville, A. S. M., Heipel, D., Vanhoozer, G., & Bailey, P. (2021). Reducing Central Line Associated Bloodstream Infections (CLABSIs) by Reducing Central Line Days. Current infectious disease reports, 23(12), 23.
Canadian Patient Safety Institute. Central line-associated bloodstream infection (CLABSI): Getting started kit [Internet]. 2012.
Chopra V, et al. The Michigan appropriateness guide for intravenous catheters (MAGIC): Results from a multispecialty panel using the RAND/UCLA appropriateness method. Annals of internal medicine. 2015;163(6 Suppl): S1-S40. PMID: 26369828.
Gorski LA, et al. Infusion therapy standards of practice. Journal of Infusion Nursing. 2016;39(1S): S1-S159. PMID: 27922994.
Velasquez Reyes DC, et al. Prevention of central venous line associated bloodstream infections in adult intensive care units: A systematic review. Intensive and Critical Care Nursing. 2017;43: 12–22. PMID: 28663107.
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The Canadian Nurses Association (CNA) and the Canadian Association of Critical Care Nurses (CACCN) established its Choosing Wisely Canada nursing list by convening an 11-member nursing working group (NWG). The group consisted of critical care nursing experts from across Canada, representing a broad range of geographical regions and practice settings. The NWG began considering its list by reviewing existing recommendations, including items from Choosing Wisely Canada’s specialty societies and the American Academy of Nursing (AAN) Choosing Wisely list, both of which had already undergone rigorous evidence reviews. In addition, members brought forward recommendations on new evidence-based items. The NWG appraised 331 items for their relevance to critical care nursing using a structured process developed for this work. Each of these items (302 Choosing Wisely Canada items, 25 AAN Choosing Wisely items and 4 independently submitted items) was appraised by two working group members and then validated by the group. Using a modified Delphi process for the next two rounds of revision, the group refined and adapted 14 items until it reached consensus on a final six-item list. A literature review was conducted to confirm the evidence for these items, with support from the Canadian Agency of Drugs & Technologies (CADTH) and supporting nursing research was added where appropriate. The list subsequently underwent extensive consultation, with input from nursing experts in patient safety, members of the Canadian Network of Nursing Specialties, patient advocates, CNA jurisdictional members, CNA nurses, principal nurse advisors, CADTH and Choosing Wisely Canada’s internal clinician reviewers. In March of 2020, the Choosing Wisely Canada critical care nursing list was presented to the CNA Board of Directors, who gave it their full endorsement and support.
Sources:
American Association of Critical-Care Nurses. Prevention of Catheter-Associated Urinary Tract Infections in Adults. [Internet]. 2015 [cited March 2019].
Association for Professionals in Infection Control and Epidemiology. APIC implementation guide: guide to preventing catheter-associated urinary tract infections [Internet]. 2014 Apr [cited 2016 Oct 14].
Canadian Patient Safety Institute. Hospital Harm Improvement Resource: Urinary Tract Infection [Internet]. 2016 Apr.
Chant, C., Smith, O., Marshall, J., Friedrich, J. Relationship of catheter-associated urinary tract infection to mortality and length of stay in critically ill patients: A systematic review and meta-analysis of observational studies. Critical Care Medicine. 2011;39(5):1167-1173. PMID: 21242789.
Colli J, et al. National trends in hospitalization from indwelling urinary catheter complications, 2001-2010. Int Urol Nephrol. 2014 Feb;46(2):303-8. PMID: 23934618.
Gray J, Rachakonda A, Karnon J. Pragmatic Review of interventions to prevent catheter-associated urinary tract infections (cautis) in adult inpatients. Journal of Hospital Infection. 2023;136:55–74. PMID: 37015257.
Lo, E, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Sep;35 Suppl 2:S32-47. PMID: 25376068.
Meddings J., Rogers M., Macy M., Siant, S. Systematic review and meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Clinical Infectious Diseases. 2010 Sept;51(5);5: 550-560. doi: 10.1086/655133 PMID: 20673003.
Miller BL, et al. A multimodal intervention to reduce urinary catheter use and associated infection at a Veterans Affairs Medical Center. Infect Control Hosp Epidemiol. 2013 Jun;34(6):631-3. PMID: 23651896.
Ramanathan R, et al. Urinary tract infections in surgical patients. Surg Clin North Am. 2014 Dec; 94(6): 1351-68. PMID: 25440128.
American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. American Geriatrics Society Abstracted Clinical Practice Guideline for Postoperative Delirium in Older Adults. J Am Geriatr Soc; 2015 Jan;63(1):142-50. PMID: 25495432.
American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc.; 2015 Nov;63(11):2227-46. PMID: 26446832.
Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM, Coursin DB, Herr DL, Tung A, Robinson BR, Fontaine DK, Ramsay MA, Riker RR, Sessler CN, Pun B, Skrobik Y, Jaeschke R; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013 Jan;41(1):263-306. PMID: 23269131.
Campbell N, Boustani MA, Ayub A, Fox GC, Munger SL, Ott C, Guzman O, Farber M, Ademuyiwa A, Singh R. Pharmacological management of delirium in hospitalized adults—a systematic evidence review. J Gen Intern Med; 2009 Jul;24(7):848-53. PMID: 19424763.
The American Geriatrics Society 2019 Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society; 2019;67(4):674-94. PMID: 30693946.
Alberta Health Services. Restraint as a last resort – Critical care [Internet]. 2018 Feb.
Abraham, J., Hirt, J., Richter, C., Köpke, S., Meyer, G., & Möhler, R. (2022). Interventions for preventing and reducing the use of physical restraints of older people in general hospital settings. The Cochrane database of systematic reviews, 8(8), CD012476.
Da Silva et al. Unplanned endotracheal extubations in the intensive care Unit: Systematic review, critical appraisal, and evidence-based recommendations. Anesthesia and Analgesia. 2012;114(5). PMID: 22366845.
Devlin J. W., et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Critical Care Medicine. 2018;46(9): e825-e873. PMID: 30113379.
Luk E, et al. Predictors of physical restraint use in Canadian intensive care units. Critical Care. 2014 Mar;18(2):R46. PMID: 24661688.
Maccioli GA, et al. Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: Use of restraining therapies–American College of Critical Care Medicine Task Force 2001-2002. Critical Care Medicine. 2003;31(11): 2665-2676. PMID: 14605540.
Minnick AF, et al. Prevalence and variation of physical restraint use in acute care settings in the US. J Nurs Scholarsh. 2007;39(1):30-7. PMID: 17393963.
Physical Restraints for the Prevention of Self-Extubation or Line or Tube Removal in Critically Ill Patients: Clinical Effectiveness and Guidelines. Ottawa: CADTH; 2019 May. (CADTH rapid response report: summary of abstracts).
Dolister M, et al. Intraosseous vascular access is safe, effective and costs less than central venous catheters for patients in the hospital setting. Journal of Vascular Access. 2013 Jul-Sep;14(3): 216-224. PMID: 23283646.
Leidel B, et al. Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study. Patient Safety in Surgery. 2009 Oct;3(24).
Perron C. Intraosseous infusion [Internet]. 2017.
Petitpas F, et al. Use of intra-osseous access in adults: A systematic review. Critical Care. 2016;20(102).
Phillips L, et al. Recommendations for the use of intraosseous vascular access for emergent and nonemergent situations in various health care settings: A consensus paper. Crit Care Nurse. 2010;30(6): e1-e7. PMID: 21078467.
The Role of the Registered Nurse in the Use of Intraosseous Vascular Access Devices. (2020). Journal of Infusion Nursing, 43(3), 117–120.
Alberta Health Services. Calgary health region: Central vascular catheter (CVC) management protocol. 2007.
Beville, A. S. M., Heipel, D., Vanhoozer, G., & Bailey, P. (2021). Reducing Central Line Associated Bloodstream Infections (CLABSIs) by Reducing Central Line Days. Current infectious disease reports, 23(12), 23.
Canadian Patient Safety Institute. Central line-associated bloodstream infection (CLABSI): Getting started kit [Internet]. 2012.
Chopra V, et al. The Michigan appropriateness guide for intravenous catheters (MAGIC): Results from a multispecialty panel using the RAND/UCLA appropriateness method. Annals of internal medicine. 2015;163(6 Suppl): S1-S40. PMID: 26369828.
Gorski LA, et al. Infusion therapy standards of practice. Journal of Infusion Nursing. 2016;39(1S): S1-S159. PMID: 27922994.
Velasquez Reyes DC, et al. Prevention of central venous line associated bloodstream infections in adult intensive care units: A systematic review. Intensive and Critical Care Nursing. 2017;43: 12–22. PMID: 28663107.
About Choosing Wisely Canada
Choosing Wisely Canada is the national voice for reducing unnecessary tests and treatments in health care. One of its important functions is to help clinicians and patients engage in conversations that lead to smart and effective care choices.
Web: choosingwiselycanada.org
Email: info@choosingwiselycanada.org
Twitter: @ChooseWiselyCA
Facebook: /ChoosingWiselyCanada
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A toolkit for appropriate use of urinary catheters in hospitals.
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A toolkit for reducing inappropriate antipsychotics use in long-term care.
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When you need them and when you don’t.
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Antipsychotic drugs are usually not the best choice