Factors influencing multidisciplinary clinical decision-making in the critical care unit: a systematic review and mixed-methods meta-synthesis

Abstract

Background: The intensive care unit (ICU) is a dynamic environment that necessitates daily clinical decisions regarding organ support treatments. The decision-making process varies significantly between clinicians (i.e. doctors, nurses, and allied healthcare practitioners), even where internationally accepted treatment guidance exists. The factors and the processes influencing clinical decision-making are poorly understood. This systematic review aims to generate a decision-making model by evaluating current evidence on the decision-making process and the factors that affect decisions on organ support treatments in the ICU.

Methods: We conducted a systematic search on three databases (PubMed, Embase, and CINAHL) including all papers exploring factors that influenced organ support decisions (PROSPERO: CRD42021283290). A mixed-methods meta-synthesis was performed to enable the generation of distinct themes and subthemes used to generate the decision-making model.

Results: After screening 8967 records, 33 studies met the inclusion criteria and were included in the analysis. The mixed-method interpretation of the data found that decision-making can be linear and primarily dictated by patient factors (i.e. patient's clinical parameters). However, the analysis identified 11 factors that can influence and strain clinician's decision-making. Four themes: 1) human, 2) team, 3) system, and 4) patient emerged as the potential modifiable factors to optimise the decision-making process.

Conclusions: Decision-making surrounding organ support treatment is complex and dynamic. However, there are four distinctive potentially modifiable themes that influence the multidisciplinary decision-making process. Further studies should focus on understanding interventions to improve decision-making and if different decision-making processes directly affect patients' outcomes.

Systematic review protocol: PROSPERO (CRD42021283290).

Keywords: complex decisions; decision model; decision-making; multidisciplinary; organ support.

Fig 1

Flow diagram showing an example of the process followed for ‘qualitising’ quantitative data.

Fig 2

PRISMA flow diagram showing the systematic search and review of articles. Adapted from our work in BMJ Open Respiratory Research. PRISMA, Preferred Items for Systematic Reviews and Meta-Analyses.

Fig 3

Linear decision-making process and potential factors affecting this model. COPD, chronic obstructive pulmonary disease; GCS, Glasgow Coma Scale; FiO₂, fraction of inspired oxygen; PEEP, positive end expiratory pressure; PS, pressure support; Pa_co2, partial pressure of carbon dioxide in arterial blood; Pa_o2, partial pressure of oxygen in arterial blood; pH, a measure of the concentration of protons (H⁺) in a solution and, therefore, its acidity or alkalinity.

Fig 4

Joint display representing the four key themes that emerged from the mixed-method analysis which comprise and influence the complex decision-making model. This figure illustrates the interplay of modifiable and intrinsic factors in complex decision-making. Modifiable factors are potential targets for improvement, while intrinsic factors represent contextual realities that must be considered. Modifiable factors: elements that can be influenced by interventions, training, or organisational change (e.g. team culture, support, protocols). Intrinsic factors: elements that are inherent to the patient, clinician, or context and are less amenable to change (e.g. patient condition, clinician experience, uncertainty). CDSS, clinical decision support system.