Decision-making in the ICU: An analysis of the ICU admission decision-making process using a ‘20 Questions’ approach

BACKGROUND: Deciding to admit a patient into the intensive care unit (ICU) is a high-stakes, high-stress, time-sensitive process. Elucidating the complexities of these decisions can contribute to a more efficient, effective process. OBJECTIVES: To explore physicians’ strategic thought processes in ICU triage decisions and identify important factors. METHODS: Practitioners (N=29) were asked to decide on ICU referrals of two hypothetic cases using a modified ‘20 Questions’ approach. Demographic data, decisions when full information was available, feedback on questions, rating of factors previously identified as important and influence of faith and personality traits were explored. RESULTS: Of the 735 questions asked, 95.92% were patient related. There were no significant differences in interview variables between the two cases or with regard to presentation order. The overall acceptance rate was 68.96%. Refusals were associated with longer interview times (p=0.014), as were lower ICU bed capacity (p=0.036), advancing age of the practitioner (p=0.040) and a higher faith score (p=0.004). Faith score correlated positively with the number of questions asked (p=0.028). There were no significant correlations with personality trait stanines. When full information was available, acceptances for Case A decreased (p=0.003) but increased for Case B (p=0.026). The net reclassification improvement index was –0.138 (p=0.248). Non-subspecialists were more likely to change their decisions (p=0.036). CONCLUSION: Limiting information to what is considered vital by using a ‘20 Questions’ approach and allowing the receiving practitioner to create the decision frame may assist with ICU admission decisions. Practitioners should consider the metacognitive elements of their decision-making. CONTRIBUTIONS OF THE STUDY: The study used a novel approach to explore physicians’ decision-making process for admitting a patient to the intensive care unit (ICU). Understanding the main factors that influence the decision-making process will allow for streamlining the referral process, more effective selection of patients most likely to benefit from ICU treatment, and prevent inappropriate admissions into the ICU. The findings can also help to improve data capture tools and encourage practitioners to critically reflect on their decision-making processes.