Wise Choices in the Intensive Care Unit (WICH-ICU)

WIse CHoices in the Intensive Care Unit, a Cluster Randomized Registry Based Clinical Trial

Aim: to evaluate if the Choosing Wisely campaign can be introduced without harming critically ill patients.

Background: Each year, around 45,000 patients are admitted to Sweden's 81 ICUs (intensive care units), costing 6-7 billion SEK (6% of total healthcare expenditure). The high costs of health care are partly attributable to overuse of diagnostic tests. Up to 30% of these tests lead to treatments that provide no benefit for patients, some of them may even be harmful(1-3). To improve quality of care while combating this problem of cost, the American Board of Internal Medicine Foundation developed the Choosing Wisely Campaign, tasking professional societies to develop lists of top five medical services patients and physicians should question. Patients in the ICU, can especially benefit from this paradigm shift. They are subjected to multiple testing on a daily - sometimes hourly - basis, therefore this field of medicine responded to the campaign quickly. Two sets of top-five-lists of tests and interventions that can be questioned have been published(4 5).

In multiple countries, including Sweden, the Choosing Wisely campaign is gathering traction among critical care physicians and is on the verge of being introduced. It is both common-sensical and will save money, so health care leaders are positive. However, the investigators have an opportunity, and a duty, to assess the evidence; can the Choosing Wisely campaign be introduced without harming ICU patients?

The present study thus aims to evaluate the introduction of the Choosing Wisely campaign in the context of the ICU. Is this change of care strategy associated with changes in 30-day-mortality? Secondary outcomes include ICU length of stay, use of non-invasive- or invasive mechanical ventilation and continuous renal replacement therapy. This is a registry-based cluster randomized controlled study (R-RCT), targeting Swedish ICU's across multiple regions. Primary and secondary outcomes will be retrieved from the Swedish Intensive care Register (SIR), making ICU participation easier and less costly.

Study Overview

• Status: Recruiting
• Conditions: Critical Illness; Ventilation; Acute Kidney Injury; Dialysis; Outcome
• Intervention / Treatment: Procedure: Choosing wisely protocol

Detailed Description

Purpose and aims Aim: to evaluate if the Choosing Wisely campaign can be introduced without harming critically ill patients.

Background: Each year, around 45,000 patients are admitted to Sweden's 81 ICUs (intensive care units), costing 6-7 billion SEK (6% of total healthcare expenditure). The high costs of health care are partly attributable to overuse of diagnostic tests. Up to 30% of these tests lead to treatments that provide no benefit for patients, some of them may even be harmful. To improve quality of care while combating this problem of cost, the American Board of Internal Medicine Foundation developed the Choosing Wisely Campaign, tasking professional societies to develop lists of top five medical services patients and physicians should question. Patients in the ICU, can especially benefit from this paradigm shift. They are subjected to multiple testing on a daily - sometimes hourly - basis, therefore this field of medicine responded to the campaign quickly. Two sets of top-five-lists of tests and interventions that can be questioned have been published.

In multiple countries, including Sweden, the Choosing Wisely campaign is gathering traction among critical care physicians and is on the verge of being introduced. It is both common-sensical and will save money, so health care leaders are positive. However, the investigators have an opportunity, and a duty, to assess the evidence; can the Choosing Wisely campaign be introduced without harming ICU patients?

The present study thus aims to evaluate the introduction of the Choosing Wisely campaign in the context of the ICU. Is this change of care strategy associated with changes in 30-day-mortality? Secondary outcomes include ICU length of stay, use of non-invasive- or invasive mechanical ventilation and continuous renal replacement therapy as well as unplanned readmissions. This is a registry-based cluster randomized controlled study (R-RCT), targeting Swedish ICU's across multiple regions. Primary and secondary outcomes will be retrieved from the Swedish Intensive care Register (SIR), making ICU participation easier and less costly.

Survey of the field Investigations on mortality, ICU length of stay (LOS) or effect on organ support among critically ill patients after the introduction of the Choosing Wisely protocol are lacking. Evidence suggests that routine laboratory testing is associated with preventable harms, such as hospital-acquired anemia and further unnecessary testing.

Can ICUs reduce unnecessary diagnostics? A Canadian single center before- and after study aimed at reducing (unnecessary diagnostic) phlebotomy in the ICU. They showed a decrease of 6.6mL/patient-day, blood tube consumption decreased, amounting to 13276 tubes saved over 11 months. Red blood cell transfusions decreased significantly.

Study design Research questions Can the Choosing Wisely protocol, specifically minimizing the number of arterial blood gases, -venous tests and -chest x-rays, be introduced safely in Swedish ICU's?

P: Adult patients treated in Swedish intensive care units.

I: The Choosing Wisely (CW) protocol, specifically minimizing the number of arterial blood gases, number of venous tests and number of chest x-rays

C: ICU care as of today, without the introduction of the CW protocol. Each ICU is its own and others' control.

O: Primary outcome: 30-day-mortality. Secondary outcomes: ICU length of stay, time in invasive/ non-invasive mechanical ventilation, time on continuous renal replacement therapy and unplanned readmissions within 72 hours of ICU discharge.

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

Outcomes from this R-RCT will be extracted using the Swedish Intensive care Register (SIR). These include the primary outcome, 30-day-mortality and secondary outcomes: ICU length of stay, time in invasive/non-invasive mechanical ventilation, time on continuous renal replacement therapy.

• Study Type: Interventional
• Enrollment (Estimated): 10000
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Max B Bell, MD, PhD; Phone Number: +46708278533; Email: max.bell@regionstockholm.se
• Study Contact Backup: Name: Emma Larsson, MD, PhD; Phone Number: +46733661661; Email: emma.ca.larsson@regionstockholm.se

Study Locations

• Sweden
  • Stockholm, Sweden, 171 76
    • Recruiting
    • Karolinska University Hospital
    • Contact: Max Birger Bell; Phone Number: +46708278533; Email: max.bell@regionstockholm.se
  • Stockholm, Sweden
    • Recruiting
    • Karolinska Institutet
    • Contact: Max Bell, MD, PhD; Email: max.bell@regionstockholm.se
    • Principal Investigator: Max Bell, MD, PhD

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

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

Exclusion Criteria:

• Patients under the age of 18 years

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Sequential Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Choosing wisely intervention; The Choosing Wisely (CW) protocol in the critical care setting; specifically minimizing the number of arterial blood gases, number of venous tests and number of chest x-rays	Procedure: Choosing wisely protocol; Se arm description
No Intervention: Choosing wisely control; Regular critical care

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
30-day mortality	Death within 30 days of ICU admission	30 days after index ICU admission

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
ICU length of stay	Days in the ICU after index ICU admission	Up to one year after index ICU admission
Time in invasive/ non-invasive mechanical ventilation	Days in the ICU in invasive or non-invasive mechanical ventilation	Up to one year after index ICU admission
Time on continuous renal replacement therapy	Days in the ICU on continuous renal replacement therapy	Up to one year after index ICU admission
ICU readmission	Unplanned ICU readmission within 72h of ICU discharge	72 hours post ICU discharge

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
ICU readmission	Readmissions after ICU discharge	Within 72 hours of ICU discharge

Collaborators and Investigators

• Sponsor: Karolinska Institutet
• Collaborators: Vastra Gotaland Region; Region Jönköping County; Region Skane; Region Stockholm; Uppsala-Örebro Regional Research Council; Sormland County Council, Sweden
• Investigators: Principal Investigator: Max B Bell, MD, PhD, N32276 PMI/Karolinska

Publications and helpful links

General Publications

• Halpern SD, Becker D, Curtis JR, Fowler R, Hyzy R, Kaplan LJ, Rawat N, Sessler CN, Wunsch H, Kahn JM; Choosing Wisely Taskforce; American Thoracic Society; American Association of Critical-Care Nurses; Society of Critical Care Medicine. An official American Thoracic Society/American Association of Critical-Care Nurses/American College of Chest Physicians/Society of Critical Care Medicine policy statement: the Choosing Wisely(R) Top 5 list in Critical Care Medicine. Am J Respir Crit Care Med. 2014 Oct 1;190(7):818-26. doi: 10.1164/rccm.201407-1317ST.
• Costante A, Chen XK, Dudevich A, Dennis Christy A, Francis L, Chui C. Overuse of Tests and Treatments: Has Canada Made Progress? Healthc Q. 2023 Jan;25(4):10-12. doi: 10.12927/hcq.2023.27024.
• Mafi JN, Reid RO, Baseman LH, Hickey S, Totten M, Agniel D, Fendrick AM, Sarkisian C, Damberg CL. Trends in Low-Value Health Service Use and Spending in the US Medicare Fee-for-Service Program, 2014-2018. JAMA Netw Open. 2021 Feb 1;4(2):e2037328. doi: 10.1001/jamanetworkopen.2020.37328.
• Shrank WH, Rogstad TL, Parekh N. Waste in the US Health Care System: Estimated Costs and Potential for Savings. JAMA. 2019 Oct 15;322(15):1501-1509. doi: 10.1001/jama.2019.13978.
• Zimmerman JJ, Harmon LA, Smithburger PL, Chaykosky D, Heffner AC, Hravnak M, Kane JM, Kayser JB, Lane-Fall MB, Matos RI, Mauricio RV, Murphy DJ, Nurok M, Reddy AJ, Ringle E, Seferian EG, Smalls-Mantey NM, To KB, Kaplan LJ. Choosing Wisely For Critical Care: The Next Five. Crit Care Med. 2021 Mar 1;49(3):472-481. doi: 10.1097/CCM.0000000000004876.
• Salisbury AC, Reid KJ, Alexander KP, Masoudi FA, Lai SM, Chan PS, Bach RG, Wang TY, Spertus JA, Kosiborod M. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Arch Intern Med. 2011 Oct 10;171(18):1646-53. doi: 10.1001/archinternmed.2011.361. Epub 2011 Aug 8.
• Bodley T, Levi O, Chan M, Friedrich JO, Hicks LK. Reducing unnecessary diagnostic phlebotomy in intensive care: a prospective quality improvement intervention. BMJ Qual Saf. 2023 Aug;32(8):485-494. doi: 10.1136/bmjqs-2022-015358. Epub 2023 Jan 19.

Study record dates

Study Major Dates

• Study Start (Actual): November 3, 2025
• Primary Completion (Estimated): December 31, 2026
• Study Completion (Estimated): December 31, 2027

Study Registration Dates

• First Submitted: June 2, 2025
• First Submitted That Met QC Criteria: June 2, 2025
• First Posted (Actual): June 10, 2025

Study Record Updates

• Last Update Posted (Actual): December 2, 2025
• Last Update Submitted That Met QC Criteria: November 24, 2025
• Last Verified: November 1, 2025

More Information

Terms related to this study

• Keywords: critical illness; choosing wisely
• Additional Relevant MeSH Terms: Urogenital Diseases; Pathologic Processes; Male Urogenital Diseases; Kidney Diseases; Urologic Diseases; Female Urogenital Diseases; Female Urogenital Diseases and Pregnancy Complications; Disease Attributes; Respiratory Tract Diseases; Respiration Disorders; Renal Insufficiency; Pathological Conditions, Signs and Symptoms; Critical Illness; Acute Kidney Injury; Respiratory Aspiration
• Other Study ID Numbers: WICH-ICU

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: This study uses data on a block level from participating ICUs; therefore it is not feasible to share IPD, but we may opt to share other information

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No