Identifying ICU admission decision patterns in a ‘20-questions game’ approach using network analysis

BACKGROUND: The complex intensive care unit (ICU) admission decision process has numerous non-linear relationships involving multiple factors. To better describe and analyse this process, exploration of novel techniques to clearly delineate the importance and interrelationships of factors is warranted. Network analysis (NA), based on graph theory, attempts to identify patterns of connections within a network and may be useful in this regard. OBJECTIVES: To identify patterns of ICU decision-making pertaining to patients referred for admission to ICU and to identify key factors, their distribution, connection and relative importance. The secondary aim was to compare subgroups as per decision outcomes and case labels. METHODS: NA was performed using Gephi software package as a secondary analysis on a dataset generated from a previous study on ICU admission decision-making process using a 20-questions game approach. The data were standardised and coded up to a quaternary level for this analysis. RESULTS: The coding process generated 31 nodes and 964 edges. Regardless of the measure used (centrality, prestige, authority and hubs), properties of the acute illness, progress of the acute illness and properties of comorbidities emerged consistently as among the most important factors and their relative rankings differed. Using different measures allowed important factors to emerge differentially. The six subgroups that emerged from the modularity measure bore little resemblance to traditional factor subgroups. Differences were noted in the subgroup comparisons of decision outcomes and case prognoses. CONCLUSION: The use of NA with its various measures has facilitated a more comprehensive exploration of the ICU admission decision, allowing us to reflect on the process. Further studies with larger datasets are needed to elucidate the exact role of NA in decision-making processes. CONTRIBUTIONS OF THE STUDY: We performed a novel analysis of a complex decision-making process that allowed for comparison with traditional analytic methods. It allowed for identification of key factors, their distribution, connection and relative importance. This may subsequently allow for reflection on difficult decision-making processes, thereby leading to more appropriate outcomes. Moreover, this may lead to new considerations in developing decision support systems such as the formulation of pro-forma data-capture tools (e.g. referral forms). Further, the way factors have been traditionally subgrouped may need to be reconsidered, with different subgroups being partitioned to better reflect their connection. This study offers a good basis for more advanced future studies in this area to use a new variety of analytical tools.