Internists' and intensivists' roles in intensive care admission decisions: a qualitative study

Hospital factors that influence ICU admission decision-making: a qualitative study of eight hospitals

PURPOSE

Some hospitals in the United States (US) use intensive care 20 times more than others. Since intensive care is lifesaving for some but potentially harmful for others, there is a need to understand factors that influence how intensive care unit (ICU) admission decisions are made.

METHODS

A qualitative analysis of eight US hospitals was conducted with semi-structured, one-on-one interviews supplemented by site visits and clinical observations.

RESULTS

A total of 87 participants (24 nurses, 52 physicians, and 11 other staff) were interviewed, and 40 h were spent observing ICU operations across the eight hospitals. Four hospital-level factors were identified that influenced ICU admission decision-making. First, availability of intermediate care led to reallocation of patients who might otherwise be sent to an ICU. Second, participants stressed the importance of ICU nurse availability as a key modifier of ICU capacity. Patients cared for by experienced general care physicians and nurses were less likely to receive ICU care. Third, smaller or rural hospitals opted for longer emergency department patient-stays over ICU admission to expedite interhospital transfer of critically ill patients. Fourth, lack of clarity in ICU admission policies led clinicians to feel pressured to use ICU care for patients who might otherwise not have received it.

CONCLUSION

Health care systems should evaluate their use of ICU care and establish institutional patterns that ensure ICU admission decisions are patient-centered but also account for resources and constraints particular to each hospital.

Trained intensivist coverage and survival outcomes in critically ill patients: a nationwide cohort study in South Korea

BACKGROUND

The difference in survival outcomes between closed and open intensive care unit (ICU) designs with respect to trained intensivist coverage remains unknown. We aimed to investigate whether trained intensivist coverage is associated with mortality in critically ill patients admitted to the ICU in South Korea.

METHODS

This population-based cohort study used nationwide registration data from South Korea. This study enrolled all adult patients admitted to the ICU between January 1, 2016, and December 31, 2019. Patients, who were admitted ICU in a hospital that employed trained intensivists, were designated as the intensivist group.

RESULTS

This study included 1,147,493 critically ill patients admitted to the ICU. The intensivist and non-intensivist groups consisted of 484,004 (42.2%) and 663,489 (57.8%) patients, respectively. Mixed effect logistic regression revealed a 22% lower in-hospital mortality rate (odds ratio: 0.78. 95% confidence interval: 0.74, 0.81; P < 0.001) than that in the non-intensivist group. Mixed effect Cox regression revealed a 15% lower 1-year mortality rate (hazard ratio: 0.85. 95% confidence interval: 0.83, 0.89; P < 0.001) in the intensivist group than that in the non-intensivist group. Moreover, the in-hospital mortality was significantly lower in the intensivist group than that in the non-intensivist group, irrespective of age, Charlson comorbidity index, surgery or non-surgery associated admission, and invasive treatment during ICU stay.

CONCLUSIONS

A closed ICU design with trained intensivist coverage was associated with lower in-hospital and 1-year mortality rates. Our results suggest that hospitals should employ trained intensivists to improve both short-term and long-term survival outcomes of critically ill patients.

Anticipating need for intensive care in the healthcare trajectory of patients with chronic disease: A qualitative study among specialists

Introduction

We investigated the reflections and perceptions of non-ICU physicians about anticipating the need for ICU admission in case of acute decompensation in patients with chronic disease.

Methods

We performed a qualitative multicentre study using semi-structured interviews among non-ICU specialist physicians. The interview guide, developed in advance, focused on 3 questions: (1) What is your perception of ICU care? (2) How do you think advance directives can be integrated into the patient’s healthcare goals? and (3) How can the possibility of a need for ICU admission be integrated into the patient’s healthcare goals? Interviews were recorded, transcribed and analysed by thematic analysis. Interviews were performed until theoretical saturation was reached.

Results

In total, 16 physicians (8 women, 8 men) were interviewed. The main themes related to intensive care being viewed as a distinct specialty, dispensing very technical care, and with major human and ethical challenges, especially regarding end-of-life issues. The participants also mentioned the difficulty in anticipating an acute decompensation, and the choices that might have to be made in such situations. The timing of discussions about potential decompensation of the patient, the medical culture and the presence of advance directives are issues that arise when attempting to anticipate the question of ICU admission in the patient’s healthcare goals or wishes.

Conclusion

This study describes the perceptions that physicians treating patients with chronic disease have of intensive care, notably that it is a distinct and technical specialty that presents challenging medical and ethical situations. Our study also opens perspectives for actions that could promote a pluridisciplinary approach to anticipating acute decompensation and ICU requirements in patients with chronic disease.

Physicians' Views and Agreement about Patient- and Context-Related Factors Influencing ICU Admission Decisions: A Prospective Study

Background: Single patient- and context-related factors have been associated with admission decisions to intensive care. How physicians weigh various factors and integrate them into the decision-making process is not well known. Objectives: First, to determine which patient- and context-related factors influence admission decisions according to physicians, and their agreement about these determinants; and second, to examine whether there are differences for patients with and without advanced disease. Method: This study was conducted in one tertiary hospital. Consecutive ICU consultations for medical inpatients were prospectively included. Involved physicians, i.e., internists and intensivists, rated the importance of 13 factors for each decision on a Likert scale (1 = negligible to 5 = predominant). We cross-tabulated these factors by presence or absence of advanced disease and examined the degree of agreement between internists and intensivists using the kappa statistic. Results: Of 201 evaluated patients, 105 (52.2%) had an advanced disease, and 140 (69.7%) were admitted to intensive care. The mean number of important factors per decision was 3.5 (SD 2.4) for intensivists and 4.4 (SD 2.1) for internists. Patient’s comorbidities, quality of life, preferences, and code status were most often mentioned. Inter-rater agreement was low for the whole population and after stratifying for patients with and without advanced disease. Kappa values ranged from 0.02 to 0.34 for all the patients, from −0.05 to 0.42 for patients with advanced disease, and from −0.08 to 0.32 for patients without advanced disease. The best agreement was found for family preferences. Conclusion: Poor agreement between physicians about patient- and context-related determinants of ICU admission suggests a lack of explicitness during the decision-making process. The potential consequences are increased variability and inequity regarding which patients are admitted. Timely advance care planning involving families could help physicians make the decision most concordant with patient preferences.

Decision-making around admission to intensive care in the UK pre-COVID-19: a multicentre ethnographic study

Predicting who will benefit from admission to an intensive care unit is not straightforward and admission processes vary. Our aim was to understand how decisions to admit or not are made. We observed 55 decision-making events in six NHS hospitals. We interviewed 30 referring and 43 intensive care doctors about these events. We describe the nature and context of the decision-making and analysed how doctors make intensive care admission decisions. Such decisions are complex with intrinsic uncertainty, often urgent and made with incomplete information. While doctors aspire to make patient-centred decisions, key challenges include: being overworked with lack of time; limited support from senior staff; and a lack of adequate staffing in other parts of the hospital that may be compromising patient safety. To reduce decision complexity, heuristic rules based on experience are often used to help think through the problem; for example, the patient's functional status or clinical gestalt. The intensive care doctors actively managed relationships with referring doctors; acted as the hospital generalist for acutely ill patients; and brought calm to crisis situations. However, they frequently failed to elicit values and preferences from patients or family members. They were rarely explicit in balancing burdens and benefits of intensive care for patients, so consistency and equity cannot be judged. The use of a framework for intensive care admission decisions that reminds doctors to seek patient or family views and encourages explicit balancing of burdens and benefits could improve decision-making. However, a supportive, adequately resourced context is also needed.