An Observational Study of Decision Making by Medical Intensivists

Abstract

Objectives: The ICU is a place of frequent, high-stakes decision making. However, the number and types of decisions made by intensivists have not been well characterized. We sought to describe intensivist decision making and determine how the number and types of decisions are affected by patient, provider, and systems factors.

Design: Direct observation of intensivist decision making during patient rounds.

Setting: Twenty-four-bed academic medical ICU.

Subjects: Medical intensivists leading patient care rounds.

Intervention: None.

Measurements and main results: During 920 observed patient rounds on 374 unique patients, intensivists made 8,174 critical care decisions (mean, 8.9 decisions per patient daily, 102.2 total decisions daily) over a mean of 3.7 hours. Patient factors associated with increased numbers of decisions included a shorter time since ICU admission and an earlier slot in rounding order (both p < 0.05). Intensivist identity explained the greatest proportion of variance in number of decisions per patient even when controlling for all other factors significant in bivariable regression. A given intensivist made more decisions per patient during days later in the 14-day rotation (p < 0.05). Female intensivists made significantly more decisions than male intensivists (p < 0.05).

Conclusions: Intensivists made over 100 daily critical care decisions during rounds. The number of decisions was influenced by a variety of patient- and system-related factors and was highly variable among intensivists. Future work is needed to explore effects of the decision-making burden on providers' choices and on patient outcomes.

Figure 1.

Types and frequency of all decisions. Other = decisions marked as “other” during initial coding or categories with less than 1% of all decisions: hematologic management, infection management, code status decision, and code management.

Figure 2.

Variation in decisions per patient by intensivist for the average patient Each point represents the intensivis’s predicted number of decisions per patient for the average patient. All included variables are held at their sample means. The model includes factors from bivariable analysis that had a p value of less than 0.2 and variables that were hypothesized to increase the number of decisions per patient-day: physician identity, Acute Physiology and Chronic Health Evaluation III score, time since admission, day in the intensivis’s rounding block, location in the daily rounding order, and total new patients on the team.