This project regarding critical care admissions, which started in February 2015, is funded by the NIHR's Health Services and Delivery Research programme. The research focuses on the process of referral and admission decisions for intensive care and the factors that influence these decisions. Intensive care unit (ICU) admission offers potentially life-saving treatments, but is associated with burdens of distressing and invasive interventions.
Patients not admitted to ICUs are more likely to die and timely admission to the ICU has better outcomes. ICU mortality is around 30 per cent and, for those who survive ICU hospital mortality, is over 10 per cent. ICU survivors often need ongoing medical care for many years. Predicting who will benefit from ICU treatment, and who to admit, presents a difficult clinical and ethical challenge.
There are currently no national guidelines on criteria or processes for making these decisions. The limited empirical evidence suggests that:
- There is marked variability in decision-making among clinicians
- Non-medical factors such as age and resources influence decision-making
- Clinicians demonstrate a prognostic pessimism that does not correlate with objective data
- Decisions are not communicated to patients and families
This variability suggests that clinicians may be influenced by a range of different factors in their decision-making processes, which in turn raises concern about potential inequity for patients. There is a clear need to ensure that the decisions are consistent, transparent and ethically justifiable, and that clinicians and families are supported in the process.
This study will:
- Explore the current experience of clinicians and families with regard to these decisions
- Identify the key factors that stakeholders and the public feel should be considered in the decision-making process
- Develop and implement a support framework to facilitate decision-making
The project has four work packages (WPs):
- WP1: We will describe current practice and explore the experience of key participants: ICU physicians, clinicians referring patients to ICUs, and patients' families. Data will be collected through interviews and observation of the decision-making process at six hospitals across two NHS regions. We will examine how evidence and values influence decisions. Views will be taken on how decisions should and should not be made. Data will be analysed using thematic and ethical analysis to provide both descriptive and normative insights into the decision making process
- WP2: We will conduct a Discrete Choice Experiment (DCE), designed using factors identified in WP1 and in the literature, to identify preferences of ICU physicians and ICU outreach nurses regarding factors determining patients' admissions to ICUs. In addition we will use recent advances in DCE methodology to investigate decision rules used by respondents when making their choice
- WP3: Informed by WPs 1 and 2, we will develop, implement and test a decision support framework to guide clinicians through the decision-making process, together with a patient/family support document to help them understand and participate in the process. A consensus conference of key stakeholders will help to refine the support tool
- WP4: We will develop and test an evaluation tool for assessing the impact of the decision support framework on decision-making. We will conduct focused systematic reviews of the relevant literature to inform each stage of the project. Outputs: this project will provide new information on ICU referral and admission decisions and will deliver a support framework to guide clinicians through this difficult process
Dr Chris Bassford (Joint Principal Investigator)
Dr Anne-Marie Slowther (Joint Principal Investigator)
Tel: 02476 151607