Sources of variability in uncertain medical decisions in the ICU: a process tracing study

Developing an intervention around referral and admissions to intensive care: a mixed-methods study

Background

Intensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.

Objectives

To explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.

Methods

A mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UK intensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records. The tool was tested for inter-rater and intersite reliability in 120 patient records.

Results

Influences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importance of interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.

Limitations

Limitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approach that mitigated the potential limitations of the component studies.

Conclusions

Decision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve the decision-making for and, ultimately, the care of critically ill patients.

Future work

Further research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of training for clinicians involved in these decisions should be a priority for future work.

Study registration

The systematic reviews of this study are registered as PROSPERO CRD42016039054, CRD42015019711 and CRD42015019714.

Funding

The National Institute for Health Research Health Services and Delivery Research programme. The University of Aberdeen and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates fund the Health Economics Research Unit.

Dyspnea, Eosinopenia, Consolidation, Acidemia and Atrial Fibrillation Score and BAP-65 Score, Tools for Prediction of Mortality in Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Comparative Pilot Study

Introduction

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) being common and often fatal, prognostic tools in AECOPD are lacking.

Materials and Methods

A prospective, observational study was carried out in fifty patients of AECOPD admitted in A and E department. Dyspnea, Eosinopenia, Consolidation, Acidemia and atrial Fibrillation (DECAF) score and elevated blood urea nitrogen, altered mental status, pulse >109, age >65 (BAP-65) score were calculated. Dyspnea was scored using extended Medical Research Council Dyspnoea score. Data were collected and analyzed using SPSS 17.0 software.

Results

Forty-one patients were discharged and 9 (18%) died during treatment. Patients who were discharged and patients who died during hospital stay were compared. There was no significant difference in terms of sociodemographic variables, presence of comorbidities, and other markers of disease severity. A significant difference was found in blood counts, blood urea, serum creatinine, acidotic respiratory failure, and atrial fibrillation. A higher value of DECAF score and BAP-65 score was found more commonly in patients who died. Sensitivity for prediction of mortality for DECAF score and BAP-65 score was 100% and specificity was 34.1% and 63.4%, respectively. Sensitivity for prediction of need for invasive ventilation for DECAF score and BAP-65 score was 80% and 100%, respectively, and specificity was 80% and 60%, respectively.

Conclusion

Both DECAF and BAP-65 scores were found to be good predictors of mortality and need for ventilation in this pilot study.

Understanding Decision Making in Critical Care

BACKGROUND

Human decision making involves the deliberate formulation of hypotheses and plans as well as the use of subconscious means of judging probability, likely outcome, and proper action.

RATIONALE

There is a growing recognition that intuitive strategies such as use of heuristics and pattern recognition described in other industries are applicable to high-acuity environments in medicine. Despite the applicability of theories of cognition to the intensive care unit, a discussion of decision-making strategies is currently absent in the critical care literature.

CONTENT

This article provides an overview of known cognitive strategies, as well as a synthesis of their use in critical care. By understanding the ways by which humans formulate diagnoses and make critical decisions, we may be able to minimize errors in our own judgments as well as build training activities around known strengths and limitations of cognition.