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Letter to the Editor

Continuous Medical Education Changes Practice: One Year After SMART and SALT-ED

Siuba, Matthew T. DO; Bauer, Seth R. PharmD; Mireles-Cabodevila, Eduardo MD

Author Information
Critical Care Explorations: June 2019 - Volume 1 - Issue 6 - p e0017
doi: 10.1097/CCE.0000000000000017
  • Open

To the Editor:

Prompt, consistent uptake of evidence-based medicine into clinical practice is a perpetual challenge. There is limited evidence regarding what interventions effectively change practice. Recurring exposure to information over time is often cited as an effective method for knowledge retention (so-called “spaced repetition”) (1), although the transfer to patient care is less certain (2). One year after the publication of two landmark trials (Isotonic Solutions and Major Adverse Renal Events Trial [SMART] [3] and Saline against Lactated Ringer’s or Plasma-Lyte in the Emergency Department [SALT-ED] [4]) which demonstrated the benefits of using balanced crystalloids over 0.9% saline, we examined our ICU’s practices in the context of ongoing, repetitive interprofessional education.

We evaluated the concurrent curricula for pulmonary and critical care medicine fellows, advanced practice providers (APPs), critical care faculty, pharmacists, and pharmacy residents from the time of publication of SMART and SALT-ED through the calendar year. Four distinct education sessions occurred over the year. First, many of the learners attended the Society for Critical Care Medicine (SCCM) Congress in February 2018, which coincided with the release of the articles as well as announcement of results. Second, on April 2018, the pharmacy curriculum included a pro-con debate on balanced crystalloids versus 0.9% saline. In June 2018, a journal club directed to our fellows, APPs, and staff featuring SMART and SALT-ED trial, with attendance by critical care pharmacists and pharmacy trainees as well. Finally, in October 2018, Dr. Todd Rice, the senior author for both papers, gave a lecture to the department of critical care on this topic. The timeline for these sessions is plotted in Figure 1, along with the proportion of 0.9% saline versus lactated Ringer’s (LR) given over time. The proportion of LR steadily rose from 36% to greater than 75% with each educational session, in the absence of any directive from the department or unit leadership, changes to order sets, medication stocking practices, or any other interventions.

Figure 1.:
Crystalloids given monthly, with educational interventions plotted over time. Society of Critical Care Medicine’s (SCCM) 47th Annual Congress, which coincided with the release of Isotonic Solutions and Major Adverse Renal Events Trial (SMART) (3) and Saline against Lactated Ringer’s or Plasma-Lyte in the Emergency Department (SALT-ED) (4).

In our case, continuous interprofessional education in the form of spaced repetition seemed to be an effective method to change practice. However, this is not the case for many other interventions (e.g., low tidal volume ventilation). What other factors accounted for this success? A team approach with a low-complexity intervention has higher likelihood of success (5), and this resonates with our experience. Choosing LR over 0.9% saline was simple, inexpensive, and without perceived harm. The controversy in the choice was low amongst our team members, and no member had a strong opinion favoring saline. Simply by physicians and advanced practice providers requesting LR more frequently and pharmacists recommending LR over 0.9% saline for fluid boluses, the nursing staff became engaged, eager to learn why a new fluid was being chosen and suggested, which generated opportunities for informal education at the point of care. Anecdotally we also noticed a shift in their behavior; when asked to give a fluid bolus, often the response became “LR or saline?” Although the curricular planning happened in a top-down fashion, the behavioral change appeared to have occurred on the “ground level.”

Concurrent education for physicians and pharmacists provided a level of redundancy to increase the likelihood of penetrance of this behavior change. Perhaps it created a critical mass of learners sufficient to reach a “tipping point” (6). Having a network of multiprofessional caregivers engaged in education and practice appears to have fostered the creation of a new social norm without specific changes to policies, choice architecture, or other frequently used interventions (7). Further work on implementing evidence-based practice should target similarly simple practice changes (i.e., items that are not multistep or higher-complexity) with structured interprofessional educational interventions to see if comparable effects are observed.

All authors have participated in the design of the study, data collection, interpretation of the results, and critical revision of the article for important intellectual content and final approval of the article submitted.


1. Tabibian B, Upadhyay U, De A, et al. Enhancing human learning via spaced repetition optimization. Proc Natl Acad Sci U S A 2019; 116:3988–3993
2. Mazmanian PE, Davis DA, Galbraith R; American College of Chest Physicians Health and Science Policy Committee: Continuing medical education effect on clinical outcomes: Effectiveness of continuing medical education: American College of Chest Physicians evidence-based educational guidelines. Chest 2009; 135:49S–55S
3. Semler MW, Self WH, Wanderer JP, et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med 2018; 378:829–839
    4. Self WH, Semler MW, Wanderer JP, et al.; SALT-ED Investigators: Balanced crystalloids versus saline in noncritically ill adults. N Engl J Med 2018; 378:819–828
      5. Berenholtz S, Pronovost PJ. Barriers to translating evidence into practice. Curr Opin Crit Care 2003; 9:321–325
      6. Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference. 2000New York, Brown.
      7. Kinzig AP, Ehrlich PR, Alston LJ, et al. Social norms and global environmental challenges: The complex interaction of behaviors, values, and policy. Bioscience 2013; 63:164–175
      Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.