Decision-making in ICU - A systematic review of factors considered important by ICU clinician decision makers with regard to ICU triage decisions

Abstract

Background: The ICU is a scarce resource within a high-stress, high-stakes, time-sensitive environment where critically ill patients with life-threatening conditions receive expensive life-sustaining care under the guidance of expert qualified personnel. The implications of decisions such as suitability for admission into ICU are potentially dire and difficult.

Objectives: To conduct a systematic review of clinicians' subjective perceptions of factors that influence the decision to accept or refuse patients referred to ICU.

Results: Twenty studies yielded 56 different factors classified into patient, physician and environmental. Common, important factors were: acute illness severity and reversibility; presence and severity of comorbidities; patient age, functional status, state-of-mind and wishes; physician level of experience and perception of patient QOL; and bed availability. Within-group variability among physicians and thought-deed discordance were demonstrated.

Conclusions: The complex and dynamic ICU triage decision is affected by numerous interacting factors. The literature provides some indication of these factors, but fail to show complexities and interactions between them. A decision tree is proposed. Further research should include a reflection on how decisions for admission to ICU are made, such that a better understanding of these processes can be achieved allowing for improved individual and group consistency.

Keywords: Critical care; Factors influencing ICU admission decisions; ICU admission; ICU decision making; ICU triage; Intensive care unit; Subjective factors.