Factors influencing intensive care admission: a mixed methods study of EM and ICU

Twenty-six percent of ICU patients in the UK are referred directly from the Emergency Department (ED). There is limited literature examining the attitudes or practice of ED/ICU physicians towards referrals from the ED to the ICU. We examined these attitudes through a mixed methods study, designing a model incorporating these attitudes to promote a shared mental model between ED and ICU specialities.

Individual semistructured interviews were conducted with 11 ED consultants and 11 ICU consultants at two hospitals in the west of Scotland. Interviews were based on 10 'case-based vignettes' representing patients for whom referral from the ED to the ICU is borderline or challenging. Participants were asked to note whether they would refer/accept the patient from the ED to the ICU. The proportions of participants from each speciality choosing to refer or accept patients were compared using a t-test comparing proportions. The reasons behind these decisions were explored during the semistructured interviews.

Twelve factors emerged as influencing the decisions made by the participants. These belonged three core themes: patient factors, clinician factors and resource factors, which were incorporated into a shared mental model. Two cases demonstrated statistically significant differences in referral rates between specialities. There were also clinically significant differences among other cases.

We have described the attitudes of physicians towards ED to ICU referrals in two west of Scotland hospitals, and we have demonstrated that there is a difference in the aspects of the decision-making process. We have developed a model encompassing all factors considered by participants when assessing these difficult referrals. It is hoped that this model will promote shared and more efficient decision-making in the future.