Gatekeeping in intensive care

Gatekeeping in intensive care: what factors influence professionals’ decision-making surrounding admission to the intensive care unit

Informed by a literature review and data from observation and interviews with ICU clinicians and outreach nurses, we designed a choice experiment. Senior intensive care doctors (consultants) and nurses were presented with pairs of patient profiles and asked to prioritize one of the patients in each task for admission to ICU. For the consultants, patient’s age had the largest impact at admission followed by the views of their family, and severity of their main comorbidity. Physiologic measures indicating severity of illness had less impact than the gestalt assessment by the ICU registrar. We identified four distinct decision-making patterns, defined by the relative importance given to different factors. 

Outcome and Translation

ICU consultants vary in the importance they give to different factors in deciding who to prioritize for ICU admission. Transparency regarding which factors have been considered in the decision-making process could reduce variability and potential inequity for patients.

HERU researchers involved in this research project: Mandy Ryan and Nicolas Krucien

External collaborators: C. Bassford, F. Griffiths, G. Perkins, S. Quinton, K. Rees and A.M. Slowther (University of Warwick)

Publications

Bassford, C.R., Krucien, N.Ryan, M., Griffiths, F.E., Svantesson, M., Fritz, Z., Perkins, G.D., Quinton, S. and Slowther, A.-M. (2019) 'U.K. intensivists’ preferences for patient admission to ICU: evidence from a choice experiment'Critical Care Medicine, 47(11), 1522-1530.

Bassford, C., Griffiths, F., Svantesson, M., Ryan, M.Krucien, N., Dale, J., Rees, S., Rees, K., Ignatowicz, A., Parsons, H., Flowers, N., Fritz, Z., Perkins, G., Quinton, S., Symons, S., White, C., Huang, H., Turner, J., Brooke, M., McCreedy, A., Blake, C. and Slowther, A. (2019) 'Developing an intervention around referral and admissions to intensive care: a mixed-methods study', Health Services and Delivery Research, 7(39).

Presentations

Krucien, N. (2017) 'Agency in health care: whose preferences count in intensive care unit referrals?', 5th International Choice Modelling Conference, Cape Town, South Africa, 3-5 April 2017.