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An Observational Study of Decision Making by Medical Intensivists
Mary S McKenzie1, Catherine L Auriemma, Jennifer Olenik
11Pulmonary Division, Legacy Medical Group, Portland, OR. 2Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA. 3Department of Medicine, University of California, San Francisco, San Francisco, CA. 4Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA 5Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 6Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 7Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
Objectives:
The ICU is a place of frequent, high-stakes decision making. However, the number and types of decisions made by intensivists have not been well characterized. We sought to describe intensivist decision making and determine how the number and types of decisions are affected by patient, provider, and systems factors.
Design:
Direct observation of intensivist decision making during patient rounds.
Setting:
Twenty-four-bed academic medical ICU.
Subjects:
Medical intensivists leading patient care rounds.
Intervention:
None.
Measurements And Main Results:
During 920 observed patient rounds on 374 unique patients, intensivists made 8,174 critical care decisions (mean, 8.9 decisions per patient daily, 102.2 total decisions daily) over a mean of 3.7 hours. Patient factors associated with increased numbers of decisions included a shorter time since ICU admission and an earlier slot in rounding order (both p < 0.05). Intensivist identity explained the greatest proportion of variance in number of decisions per patient even when controlling for all other factors significant in bivariable regression. A given intensivist made more decisions per patient during days later in the 14-day rotation (p < 0.05). Female intensivists made significantly more decisions than male intensivists (p < 0.05).
Conclusions:
Intensivists made over 100 daily critical care decisions during rounds. The number of decisions was influenced by a variety of patient- and system-related factors and was highly variable among intensivists. Future work is needed to explore effects of the decision-making burden on providers' choices and on patient outcomes.
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