The ICUPASS Study: Variability, Influencing Factors, and Clinician Stress in ICU Admission Decisions

Objectives The objectives of this study were to quantify the variability in intensive care unit (ICU) admission decisions, identify influencing factors, and measure the associated stress among different groups of healthcare professionals. Design This was a cross-sectional survey using 10 standardised clinical vignettes. Setting The study was conducted in ICUs in the West Midlands, UK. Participants The study included 84 ICU professionals, categorised as decision-makers ([DMs] consultants and senior registrars, n=47) or non-decision-makers ([NDMs] other clinical staff, n=37). Main outcome measures For each vignette, respondents rated the likelihood of admission, associated stress, and likelihood of admission with unlimited resources on a 10-point Likert scale. The primary reason for non-admission was also selected. Results Admission likelihood was heterogeneous across all vignettes (median 5, IQR 6), with no significant difference between DMs and NDMs. DMs reported significantly lower stress than NDMs (median 4 vs 5, p<0.001). Clinically ambiguous vignettes showed the highest variability and stress. Counterintuitively, admission likelihood was significantly lower under a hypothetical unlimited-resources scenario (median 3 vs 5, p<0.001). "Futility" was the most common reason cited for non-admission. Conclusions Substantial variability and stress are inherent to ICU admission decisions, even among experienced clinicians. Subjective clinician factors shape decisions alongside objective patient data, underscoring the need for decision-support tools in ambiguous cases and strategies to ease the psychological burden on clinical staff.