Implementing an intervention to improve decision making around referral and admission to intensive care: Results of feasibility testing in three NHS hospitals

Abstract

Rationale, aims, and objectives:Decisions about whether to refer or admit a patient to an intensive care unit (ICU) are clinically, organizationally, and ethically challenging. Many explicit and implicit factors influence these decisions, and there is substantial variability in how they are made, leading to concerns about access to appropriate treatment for critically ill patients. There is currently no guidance to support doctors making these decisions.We developed an intervention with the aim of supporting doctors to make more transparent, consistent, patient-centred, and ethically justified decisions. This paper reports on the implementation of the intervention at three NHS hospitals in England and evaluates its feasibility in terms of usage, acceptability, and perceived impact on decision making. Methods:A mixed method study including quantitative assessment of usage and qualitative interviews. Results:There was moderate uptake of the framework (28.2% of referrals to ICU across all sites during the 3-month study period). Organizational structure and culture affected implementation. Concerns about increased workload in the context of limited resources were obstacles to its use. Doctors who used it reported a positive impact on decision making, with better articulation and communication of reasons for decisions, and greater attention to patient wishes. The intervention made explicit the uncertainty inherent in these decisions, and this was sometimes challenging. The patient and family information leaflets were not used. ---This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. 56J Eval Clin Pract. 2020;26:56-65. wileyonlinelibrary.com/journal/jep Conclusions: While it is feasible to implement an intervention to improve decision making around referral and admission to ICU, embedding the intervention into existing organizational culture and practice would likely increase adoption. The doctor-facing elements of the intervention were generally acceptable and were perceived as making ICU decision making more transparent and patient-centred. While there remained difficulties in articulating the clinical reasoning behind some decisions, the intervention offers an important step towards establishing a more clinically and ethically sound approach to ICU admission.

Decision‐making around admission to intensive care in the UK pre‐COVID‐19: a multicentre ethnographic study

“…We undertook a multicentre ethnographic study in the UK to further understand decisions to admit or not to ICU. Data from this study have been used to: describe the process around decision‐making [18]; to design a discrete choice experiment [19]; to develop and test a decision support framework [20]; and to undertake an ethical analysis (manuscript submitted). This paper reports the various ways ICU doctors make the decision to admit or not to the ICU and considers how they can be best supported to maximise decision quality.…”

Checklist to aid young physicians managing obstetric emergencies in rural India: a quality improvement initiative

“…The MoHFW (GOI) issues guidelines for whether to admit or refer a patient suffering from complications during labour such as postpartum Haemorrhage. 12 However, there are no validated tools for evaluating clinical decision making in real-time clinical practise 13 on whether to admit or refer a patient, which is one of the most important decisions to be made in a resourcelimited setting such as ours. Our ANC checklist aids inexperienced clinicians in making such crucial decisions.…”

UK consultants’ experiences of the decision-making process around referral to intensive care: an interview study

“…11 12 This complex situation was the departure for a multidimensional mixed methods project, Understanding and Improving the Decision-Making Process Surrounding Admission to the Intensive Care Unit, conducted at six NHS trusts in the Midlands, UK. 11–14 15 The present paper is a substudy of the wider project.…”