An Observational Study of Decision Making by

Medical Intensivists
Mary S. McKenzie, MD, MSHP1,2; Catherine L. Auriemma, MD2,3; Jennifer Olenik, MD3;
Elizabeth Cooney, MPH2,4,5; Nicole B. Gabler, PhD, MHA2,4,5; Scott D. Halpern, MD, PhD2,4,5,6,7
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.
Pulmonary Division, Legacy Medical Group, Portland, OR.
Fostering Improvement in End-of-Life Decision Science Program,
University of Pennsylvania, Philadelphia, PA.
3
Department of Medicine, University of California, San Francisco, San
Francisco, CA.
4
Leonard Davis Institute Center for Health Incentives and Behavioral
Economics, University of Pennsylvania, Philadelphia, PA
5
Center for Clinical Epidemiology and Biostatistics, Perelman School of
Medicine at the University of Pennsylvania, Philadelphia, PA.
6
Department of Medical Ethics and Health Policy, Perelman School of
Medicine at the University of Pennsylvania, Philadelphia, PA.
7
Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA.
This work was performed at the Hospital of the University of Pennsylvania,
Philadelphia, PA.
Drs. McKenzie and Auriemma contributed equally to this article.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journals website (http://journals.lww.com/ccmjournal).
Dr. McKenzies institution received grant support (Penn-Carnegie Mellon University [CMU] Roybal Center and University Research Foundation
Award). Dr. Auriemma received support for travel from the Doris Duke Clinical Research Fellowship. Her institution received grant support from the
Doris Duke Clinical Research Fellowship. Ms. Cooney consulted for Emmi
Solutions (reviewed and edited content for web program). Dr. Halpern
received support for article research from the National Institutes of Health.
He was supported by Penn-CMU Roybal Center and University Research
Foundation Award. His institution received grant support from the Agency
for Healthcare Research and Quality. The remaining authors have disclosed that they do not have any potential conflicts of interest.
Address requests for reprints to: Scott D. Halpern, MD, PhD, 719 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104. E-mail: shalpern@
exhange.upenn.edu
1
2

Copyright 2015 by the Society of Critical Care Medicine and Wolters

Kluwer Health, Inc. All Rights Reserved.
DOI: 10.1097/CCM.0000000000001084

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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. (Crit Care Med 2015; 43:16601668)
Key Words: attending rounds; critical care; decision making;
intensive care unit; thinking

edical decision making is an inherently complex

process, particularly among critically ill patients in
whom multiple organ systems and social circumstances must be considered simultaneously (14). To date, only
one study has characterized the frequency with which decisions are made in the ICU (5). Although this study suggests
intensivists experience a significant decision-making burden,
it did not use standardized assessments across respondents and
did not assess factors associated with this burden.
It is possible that patient, provider, and systems variables
influence the number of decisions made daily by intensivists.
For example, recent studies have documented relationships
between ICU strain or occupancy and decisions to admit or
discharge patients (69). Similar relationships have not been
explored across the broader realm of ICU decision making.
ICU decision making is also a key contributor to quality
of care. Several studies identify decision making as central to
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Clinical Investigations

patient and family satisfaction (10, 11). In a survey of family

members of ICU patients, good decision making was a key
determinant of family satisfaction (12). Following discharge
from the ICU, disappointment with clinical decision making
was a predictor of dissatisfaction with ICU care (13). Although
these studies focused on the broad family experience and
not individual physician decision making, they highlight the
importance of physician decision making in patient- and family-centered outcomes.
It is possible that the decision-making burden among intensivists could have untoward implications for the quality of care.
Nonmedical evidence indicates that repeated decision making
alters the decision-making process and influences subsequent
choices in subconscious ways (14, 15). As a first step toward
understanding how intensivist decision making may impact
patient care, we sought to describe the intensivists decisions,
including their frequency, type, and variability among patients
and physicians. Patient outcomes and quality of decision making were not assessed.
Preliminary results of this study were previously reported in
abstract form (16).

MATERIALS AND METHODS

This study was conducted in the Hospital of the University of
Pennsylvanias Medical ICU (MICU), a 24-bed closed unit in
which critical care physicians (intensivists) manage all patients
in 14-day rotation blocks. Patients are divided between two
care teams based on admitting schedule. Each team comprises
one intensivist, one critical care fellow, six medical residents,
and one advanced nurse practitioner or physicians assistant.
During morning rounds, the intensivist-led team establishes
each patients daily care plan. During this period, patients are
discussed in a nonrandom order based on patient and workflow influences.
We directly observed morning rounds for 80 days between
August 27, 2012, and January 12, 2013. We observed 85% of
intensivists who attended in the MICU that academic year,
excluding the studys senior author. All observed intensivists
provided written informed consent prior to observation. No
intensivists declined participation. We restricted observation
to days 214 of each service block and excluded days staffed
by a covering provider not scheduled for the entire 14-day
block. Finally, we selected 45 days of observation for each of
17 attendings based on investigator availability.
Study data were collected and managed using Research
Electronic Data Capture (REDCap) software (Vanderbilt
University, Nashville, TN) (17). All data were collected by
one of three investigators. We established satisfactory interrater reliability ( > 0.7) prior to study initiation during
which all three investigators observed rounds simultaneously
and compared coding after rounds completion. Investigators
recorded the number and types of critical care decisions,
rounding duration, patient order, and family presence on
rounds. A decision was recorded when an action plan was
verbalized following a clearly stated problem. Confirming
objective data or stating adherence to ICU policies was
Critical Care Medicine

not recorded as decisions. Because ultimate responsibility

falls to the attending, all decisions verbalized by the team
were attributed to the intensivists. This included decisions
made exclusively by the attending and decisions verbalized by other team members while the intensivist was present. Observation was restricted to verbal decisions without
inclusion of electronic orders.
All decisions were recorded for each patient rounded on
during an observation day. Decisions were sorted into 18 categories with 126 subcategories (Table 1). The decision matrix
was created during observations prior to the pilot phase by
author M.S.M. The decision matrix was finalized prior to any
data collection and not modified during the study period. The
timing of each decision was recorded, and each decision was
coded as either a decision to continue or change the current
therapy.
We recorded physician characteristics, including age, race,
gender, and years since fellowship training, and patient-level
factors, including Acute Physiology and Chronic Health
Evaluation (APACHE) III score (18) and ICU admission
source. One patient without an APACHE III score was excluded
from all analyses.
During our study period, a randomized trial of intensivist nighttime staffing was simultaneously ongoing (19). Given
the potential impact on daytime intensivists decision making,
we recorded overnight coverage status for the night prior to
all observed rounds and included it as a covariate in all models. After approximately one third of observations, we began
collecting whether a family member was present on rounds,
hypothesizing that family presence may influence intensivist
decision making.
Physician and patient demographic data are described
as number (percent) for categorical data and median
(interquartile range, IQR) or mean (sd) for nonnormally and
normally distributed continuous data, respectively. Decisions
were evaluated and analyzed for each patient-day (decisions
made for a single patient on 1 d) and total day (including all
patients the intensivist rounded on that day).
Rounding order was coded based on the timing of the first
decision made for each patient. This included rare occasions
(n = 23 patient-days) when a patient was briefly discussed by
the intensivist with another provider (resident or consultant)
but was not formally rounded on until later. In a sensitivity
analysis in which these 23 patient-days were instead coded
as when the full rounding actually occurred, the results were
unchanged (20, 21).
APACHE III scores reflect the patients predicted probability of dying during the hospitalization based on data
available on the day of ICU admission (18). Because our
patient-day observations were not limited to patients
admission days, we created a time variable equal to the
number of days since admission. To provide a more discrete
analysis of how length of stay might influence decisions, we
divided this variable into five intervals: 1) day 1, 2) days 23,
3) days 45, 4) days 69, and 5) day 10 and beyond. This categorical variable was entered as a covariate in all patient-day
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McKenzie et al

Table 1. Decisions Were Classified Into 18

Categories and 126 Subcategories
Decision
Category

Table 1. (Continued). Decisions Were Classified

Into 18 Categories and 126 Subcategories
Decision
Category

Decision Subcategory

Occupational therapy
Ancillary
management
Physical therapy

Laboratory
testing

Swallowing evaluation

Decision Subcategory

Blood panel: one time

Blood panel: repeated measurement
Blood single test: one time

Code
Cardioversion
management
Chest compressions

Blood single test: repeated measurement

Fecal study

Initiate or terminate code

Fluid (other) test

Intubation

Urine single test

Line placement

Urine panel test

Needle decompression

Medications

Thrombolysis

Antacid medication
Antiseizure medication

Code status

Code status decision (not family discussion)

Diagnostic:
imaging
studies

CT scan

Anticoagulation: prophylactic

Echocardiogram

Anticoagulation: therapeutic

Electroencephalogram

Antiemetics

Electrocardiogram

Antihypertensive

Electromyogram

Antimicrobial management

MRI

Antipsychotic/delirium management

Nuclear study

Anxiolytic

Transcranial Doppler ultrasound

Chronotropic medication

Ultrasound

Code medication

Radiograph

Diabetic management

Disposition
decision

End-of-life care provisions (not code status)

Transfer out of ICU

Electrolyte management

Family meeting Family meeting: goals of care

Family meeting: information sharing
Hematology
Cryoprecipitate transfusion
management
Fresh-frozen plasma transfusion

Hepatorenal syndrome treatment

Hypnotic
Immunosuppression
Inhaler therapy

Platelet transfusion

Inotropic medication

RBC transfusion

Other

Hemodynamic Bicarbonate administration

management
Cardiac pacing

Pain management
Renal medication

Cardioversion

Sedation

Fluid management: colloid

Steroids

Fluid management: crystalloid

Goal: fluid status

Tachycardia: rate control

Goal: physiologic variable

Tachycardia: rhythm control

Infection
Source control: drain management
management
Source control: line management
(Continued)
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Vaccine
Vasopressor
Vitamin

Source control: surgery

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Diuretic therapy

(Continued)
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Clinical Investigations

Table 1. (Continued). Decisions Were Classified

Into 18 Categories and 126 Subcategories
Decision
Category

Table 1. (Continued). Decisions Were Classified

Into 18 Categories and 126 Subcategories
Decision
Category

Decision Subcategory

Activity level
Nursing/
general care Bladder pressure

Pulmonary
management

Extubate
Intubate

Foley tube

Invasive ventilator management

Noninvasive ventilator management

Rectal tube

Oxygen supplementation

Wound care

Paralysis

Enteral

Positioning to improve oxygenation

Free water

Pulmonary vasodilator

Nil per os

Respiratory therapy: mechanical intervention

Oral
Renal
replacement
therapy

Total parenteral nutrition

Obtain
information

Extracorporeal membrane oxygenation

Drain management
Ostomy management

Nutrition/
electrolytes

Decision Subcategory

Consultant

Continuous renal replacement

Hemodialysis: intermittent

Family/friend
Nonphysician (ethics, legal)
Outpatient provider
Outside hospital clinician

Other

Other (free text)

Procedure

Arterial line
Biopsy: other tissue
Bronchoscopy
Bronchoscopy
Central venous line
Central venous line
Chest tube
Cooling protocol
Desensitization
Endoscopy
Hemodialysis line
Hyperbaric therapy
Inferior vena cava filter placement
Lumbar puncture
Nasogastric tube/lavage
Orogastric tube
Other
Paracentesis
Percutaneous endoscopic gastronomy tube
Pulmonary artery catheter
Thoracentesis
Tracheostomy
(Continued)

Critical Care Medicine

models. Patients who had been discharged from the ICU

previously and were readmitted without leaving the hospital
had APACHE III adjustment based on their index ICU stay.
These patients were flagged with an additional readmission
variable to provide further risk adjustment
The primary outcome for day-level (n = 80) analyses was
total decisions per day per intensivist. The primary outcome
for patient-day analyses (n = 920) was decisions per patient per
day. We specifically sought to evaluate how the total number of
new patients affected decision making. Measures of severity of
illness were included in all models. Other independent variables were included if they were clinically relevant and associated with the outcome in bivariate analyses at p value less than
or equal to 0.2. These variables were added in a step-wise fashion based on association strength and removed if their addition reduced the explained variance (20, 21).
After confirming appropriate normality, linear regression was
used for day-level and patient-level analyses. Physicians were
modeled as a fixed effect in patient-and day-level analyses to adjust
for within physician correlation of the number of decisions made
per patient and to prevent confounding by practice differences
among physicians. Because some patients who were observed
multiple times contributed multiple patient-days, patient-level
clustered analyses were performed but did not alter results (data
not presented). All models use robust variance estimators (20, 21).
In day-level analyses, physicians were modeled as random effects
to enable assessments of how measured characteristics influenced
the number of decisions made each day. In secondary analyses, we
modeled physician as a fixed effect in day-level analyses. Restricted
analyses were performed for observations when family presence was recorded (620 of 920 patient observations). Reported
p values are two sided. Statistical analyses were performed using
Stata 12.1 software (Stata Datacorp, College Station, TX). The
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McKenzie et al

Table 2.

Intensivist Characteristics

Table 3.

Patient Characteristics

Characteristica

All Intensivists
(n = 17)

Characteristica

Age

40.1 (3752)

Age

Race

All Patients
(n = 374)

61.8 (49.869.0)

Race

White

14 (82)

White

183 (49)

Asian

2 (12)

Black

152 (40.6)

Black

1 (6)

Asian

6 (1.6)

Male

13 (76)

Unknown

22 (5.9)
11 (2.9)

Years since training completion

6 (322)

Other

Weeks of medical ICU service in year prior

4 (25)

Male

 ategorical data presented as number (%); continuous data presented as

C
median (interquartile range).

220 (58)

Acute Physiology and Chronic Health

Evaluation III Score

75 (5699)

Unit prior to medical ICU

institutional review board at the University of Pennsylvania

approved this study.

Emergency room

166 (44.5)

General floor

161 (43.0)

RESULTS

Other ICU

22 (6.0)

Seventeen intensivists were observed on 80 days (Table 2).

Intensivists were observed a median of 4 days (IQR, 44.5)
each. Intensivists were a median of 40.1 years old (IQR, 3752)
and had a median of 6 years (IQR, 322) post-fellowship experience. Four (23.5%) intensivists were females.
We observed 920 patient rounds representing 374 unique
patients (Table 3), such that each patient was observed a
median of three times (IQR, 14). Patients were a median
of 62 years old (IQR, 5069). The majority of patients were
either white (49.0%) or black (40.6%). Patients had a median
APACHE III score of 75 (IQR, 5699) and were observed a
median of 4 days (IQR, 112) since initial ICU admission. ICU
and hospital mortality were 17.3% and 20.2%, respectively.
Intensivists provided nocturnal coverage the night prior
to observed rounds for 39 of observed days (49%). The first
observation day for each intensivist was a median of 2 days
(IQR, 23) into the 14-day block. Family presence was assessed
on 55 days, representing 620 of 920 patient rounds (67%).

Outside hospital

22 (6.0)

Direct admission

3 (0.5)

Decisions
We recorded 8,174 critical care decisions. On average, intensivists made 102.325.9 decisions daily with mean rounding
duration of 3.70.92 hours. Number of daily decisions and
rounding duration were weakly correlated (r = 0.29). Mean
daily census included 11.51.5 patients, resulting in roughly
nine decisions made per patient per day. There were 2.01.5
new patients per day. The most frequent decision category was
medication management, representing 36.4% of decisions
(Fig.1). Other common decisions included obtaining input
from another provider (9.7%), laboratory testing (9.4%),
hemodynamic management (7.7%), and pulmonary management (7.4%). Of 18 decision categories, 10 accounted for
fewer than 5% of decisions each (Fig.1). Heat map depiction
of decision frequency by category and physician is available in
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ICU mortality

64 (17.3)

Hospital mortality

75 (20.2)

ICU length of stay (d)

3.4 (1.77.6)

 ategorical data presented as number (%); continuous data presented as

C
median (interquartile range).

Figure 1. Types and frequency of all decisions. Other = decisions marked

as other during initial coding or categories with less than 1% of all
decisions: hematologic management, infection management, code status
decision, and code management.

Supplement Figure 1 (Supplemental Digital Content 1, http://

links.lww.com/CCM/B302).
Decision Analysis
Patient and Day Level. In bivariable linear analyses, patient
factors independently associated with increased numbers of
decisions included being a new admission, a shorter interval
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Clinical Investigations

since initial admission, and an earlier location in rounding

order (all p < 0.05). Patients with higher APACHE III scores
had slightly but nonsignificantly more decisions (p = 0.08).
Physician factors independently associated with increased
decisions per patient in bivariable analyses included being
younger and being female (all p < 0.05). Physician age and
years after fellowship experience were highly correlated; thus,
only age was included in analyses. Physicians made more decisions per patient later in their rounding block (p < 0.05). A figure depicting decisions per patient by rounding day is available
in Supplemental Figure 2 (Supplemental Digital Content 2,
http://links.lww.com/CCM/B303). Total patient census, nocturnist presence the night prior, and family presence did not
significantly alter the number of decisions made per patient.
In multivariable linear models, after including physician as
a fixed effect, each additional variable improved the amount of
explained variance (Table 4). The complete model accounted
for 24% of observed variance as measured by R2. Intensivist
identity explained a greater proportion of the variance in the
number of decisions per patient than did any other measured
factor. The predicted number of decisions per patient varied
greatly among physicians when all other variables included in
the multivariable linear model were held at their mean values
(Fig.2). Seven of 17 intensivists (41%) made at least four additional decisions per patient compared with the reference physician. In modeling the physician as a random effect, physician
gender was the only factor that remained significant. Female
intensivists made significantly more decisions per patient
(-coefficient, 2.77; p < 0.001).
Day Level. Intensivists made an average of 102.325.9 decisions daily during 80 observation days. In bivariable analyses,
physician identity was significantly associated with the number
of decisions (p < 0.001) (Table 5) and explained a greater proportion of the variance in the number of decisions per day than
did any other measured factor. Additional physician factors
independently associated with increased total daily decisions
included younger age and female gender (both p < 0.05). The
intensivists weeks of MICU service, years of post-fellowship
experience, and nocturnal coverage the night prior were not
significantly associated with the number of decisions per day.
The complete model at the day level accounted for a greater
proportion of variance in decisions made (R2 = 0.63) than
the patient-day model. Physicians made more decisions when
there was a larger census (p < 0.05). The teams mean APACHE
III score was not significantly associated with the number
of decisions per day. In modeling the physician as a random
effect, female physicians made significantly more decisions
(-coefficient, 28.01; p = 0.002).
Impact of Family Presence. Family presence was assessed
for 620 of all observed patient rounds (67%). In a restricted
patient-level model of only these observations, the explained
variance was unchanged (R2 = 0.24). Family presence was associated with a small and not statistically significant increase in
the number of decisions made per patient (0.64 decisions per

Critical Care Medicine

Table 4. Patient- and Day-Level Multivariable

Linear Predictive Model (n = 920)
-Coefficient
(95% CI)

Variable

Intensivista
1

Reference

Reference

2

0.56 (0.45 to 1.57)

0.27

3

0.43 (0.74 to 1.61)

0.47

4

0.77 (0.45 to 2.00)

0.21

5

2.29 (1.213.38)

0.00

6

2.31 (0.983.63)

0.00

7

2.30 (1.013.58)

0.00

8

2.66 (1.753.57)

0.00

9

3.31 (1.944.67)

0.00

10

3.62 (2.454.78)

0.00

11

3.70 (2.275.12)

0.00

12

4.09 (2.725.46)

0.00

13

4.16 (2.715.61)

0.00

14

4.71 (3.416.00)

0.00

15

5.30 (3.896.71)

0.00

16

4.92 (3.476.39)

0.00

17

6.23 (4.657.82)

0.00

Acute Physiology and

Chronic Health
Evaluation IIIb

0.02 (0.010.02)

0.00

Days since initial ICU admissionc

01

Reference

Reference

23

1.79 (2.55 to 1.03)

0.00

45

1.51 (2.46 to 0.56)

0.00

610

1.66 (2.50 to 0.82)

0.00

> 10

2.96 (3.75 to 2.17)

0.00

Day of service blockd

0.08 (0.000.16)

Location in rounding ordere 0.15 (0.22 to 0.07)

Total new patients

0.02 (0.22 to 0.22)

0.03
0.00
0.02

Intensivist 1 is reference intensivist. -coefficient represents change in

number of decisions made per patient comparing each intensivist to
intensivist 1.
b
For every 10-point increase in Acute Physiology and Chronic Health
Evaluation III score, intensivists made significantly more decisions.
c
Intensivists make fewer decisions daily for patients who have been in the
medical ICU the longest.
d
Intensivists make more decisions per patient for patients later in their rotation
block.
e
Patients rounded on later in the day have fewer decisions per patient.
f
For each additional increase in total new patients, the number of decisions
per patient increases.
a

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McKenzie et al

and laboratory monitoring.

Decision categories that represented smaller proportions
of the total may nonetheless be
important and may even signal
areas for potential improvement. For example, of 8,174
recorded decisions, intensivists
made only 157 family meeting decisions and 145 ancillary support (occupational
therapy and physical therapy)
decisions. It is unlikely that
these specific decision types
were uniformly made during
parts of the day not observed,
and the ICU under study did
not have protocols addressing
these issues during the study
period. It is possible that these
categories were crowded out
by seemingly more time-senFigure 2. Variation in decisions per patient by intensivist for the average patient. Each point represents the
sitive decisions being made in
intensivists predicted number of decisions per patient for the average patient. All included variables are held at
large volume for patients.
their sample means. The model includes factors from bivariable analysis that had a p value of less than 0.2 and
A key finding of this study is
variables that were hypothesized to increase the number of decisions per patient-day: physician identity, Acute
Physiology and Chronic Health Evaluation III score, time since admission, day in the intensivists rounding block,
the dramatic variability among
location in the daily rounding order, and total new patients on the team.
physicians in the same ICU in
the numbers of decisions made
daily and per patient. Indeed, the physicians identity explained
patient per day; p = 0.06). Inclusion of this variable did not
a greater proportion of the variance in decisions made per
significantly alter the other model coefficients.
Decisions by Clinical Impact. Decisions were also divided patient than any patient characteristic. Prior studies have also
noted variation in physician decision making and practice patinto high and low clinical impact. Code status, disposition, famterns with regard to such decisions as ICU admission, intubaily meetings, invasive hemodynamics, procedures, pulmonary
tion, and withdrawal of life-sustaining therapy (2224). Other
management, and the use of continuous renal replacement
single-center studies have shown that physician-attributable
therapy were all considered high impact decisions. These decidifferences in care provision account for significant variation
sions represented 985 of the total decisions observed (12%). In
in ICU spending and in ICU-based limitations on life supday-level analysis (n = 80), the number of high impact deciport (24, 25). Similar to our study, these data confirm physisions significantly decreased with more years of experience
cian variation in important decision-making tasks, which may
(coefficient, 0.10; p = 0.04) and significantly increased with
a larger patient census (coefficient, 1.02; p = 0.001). All other manifest as variable rounding durations and, perhaps, the
day-level analyses were insignificant.
number of decisions vocalized for any given patient.
Of note, female intensivists made significantly more decisions
than males, even when controlling for other providerDISCUSSION
specific
variables. Research in other fields has noted that
Through direct observation of decision making, this study sugwomen
differ
in their approach to decision making (26, 27).
gests that intensivists make more than 100 critical care decisions
Beyond quantity of decisions, our study was not designed to
daily during morning rounds. This number underestimates the
true decision-making burden, given that critical care decisions further elucidate this difference, though it is an interesting
are routinely made at other times of the day. Although it is dif- point for future study.
A second important finding was that the presence of intenficult to compare this decision-making burden with those of
sivist coverage during the night prior to morning rounds did
other professionals, recent decision research reveals that even
modest levels of repeated decision making impair self-control not significantly influence the number of decisions made
either per patient or per day. This study cannot assess differand alter subsequent choices (14, 15).
This study captures decision-making quantity but can- ences in decision quality with nocturnal coverage, but similar
number of decisions may help explain why the presence of
not comment on decision quality. Decisions were not linked
to patient outcomes. The most frequent decisions included nighttime intensivists also did not lead to changes in patient
managing medications, obtaining further expert opinion, outcomes (18).
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Clinical Investigations

Day-Level Multivariable Linear

Predictive Model (n = 80)
Table 5.

Variable

-Coefficient
(95% CI)

Reference

Reference

Intensivista
 1
 2

8.44 (12.17 to 29.05)

0.42

 3

0.73 (22.89 to 21.42)

0.95

 4

5.99 (19.03 to 31.01)

0.63

 5

22.14 (6.8737.41)

0.01

 6

20.41 (0.2640.57)

0.05

 7

21.31 (7.3334.28)

0.01

 8

23.68 (9.2338.12)

0.01

 9

33.28 (15.6950.87)

0.01

10

29.56 (13.1245.99)

0.01

11

35.09 (17.7652.41)

0.01

12

34.92 (18.1551.69)

0.01

13

39.76 (19.1960.33)

0.01

14

43.79 (16.6470.94)

0.01

15

53.61 (28.1079.12)

0.00

16

49.80 (22.3277.27)

0.00

17

62.32 (48.5876.06)

0.51

Mean Acute Physiology

and Chronic Health
Evaluation IIIb

1.08 (7.21 to 5.05)

0.72

Day of service blockc

0.67 (0.52 to 1.86)

0.27

Total new patients

7.62 (4.2211.03)

0.00

Intensivist 1 is reference intensivist. -coefficient represents change in

number of decisions daily comparing each intensivist to intensivist 1.
The number of decisions made daily does not significantly change for every
10-point increase in the teams mean Acute Physiology and Chronic Health
Evaluation III score.
c
The number of decisions daily does not vary significantly on different days of
the service block when adjusting for other variables.
d
The total daily decisions significantly increase for each additional increase in
total new patients.
a

Third, many patient characteristics influenced the number

of decisions made by intensivists. More time since admission,
likely a marker of decreased acuity, was associated with fewer
decisions. Interestingly, however, the first rounding encounter
with a new patient was also associated with fewer decisions.
This somewhat surprising result may reflect an initial lack of
familiarity with the patient or a tendency to focus on the acute
care issues. Future research is needed to determine whether
intensivists may intentionally defer specific types of decisions
(such as end-of-life decisions) until later in a patients course
when trust and familiarity have been developed.
Fourth, we found that intensivists tended to make more
decisions for patients when a family member was present during
Critical Care Medicine

rounds, though this finding was not significant (p = 0.07). As

family presence on rounds is increasingly encouraged, it is
important to determine whether this finding is replicable and,
if so, what the consequences of this additional decision making
may be for patients and family members.
A key strength of this study is the use of direct observation of multiple providers on multiple days. We recorded
and cataloged a large repository of decisions with very
detailed categorization. Alternative approaches, such as capturing recorded decisions in the electronic medical record,
would miss a large number of decisions, particularly those
for which physicians considered an issue but actively chose
to not alter therapy. Although direct observation is resourceintensive and subject to observer interpretation, we established good interrater reliability ( > 0.7) during a pilot
study prior to data collection.
There are several important limitations to this study. First,
intensivists were observed in a single academic medical center
in the United States. Intensivist decision making may differ
in other settings. Second, because observations were limited
to patient care rounds, we missed decision making at other
points in the day. However, ICU team rounds represent the
majority of patient care discussion. This study likely quantifies a realistic lower bound of the decision-making burden.
Third, the order of rounding was not random. New admissions, unstable patients, and potential discharges influenced
this order. Caution is needed in interpreting the finding
that patients later in the rounding order had fewer decisions. Fourth, as with many studies of patients evaluated
after their ICU admission day, risk-adjustment scores including APACHE III may be less calibrated or discriminant than
desired. We attempted to overcome this by adjusting for the
interval between the rounding day and the ICU admission
day, but residual confounding may persist.
Fifth, although this study was designed to provide a quantitative lower bound of intensivists decision-making burden, we
cannot determine whether this burden is too great. Intensivists
were not asked to provide self-evaluations of whether they found
the decision making to be particularly burdensome, as this would
have revealed our study hypotheses. Finally, each recorded decision required attention and evaluation by the observers, a cognitive burden that may itself have altered the data.
Future studies are needed to confirm our findings and
explore their clinical implications. In addition to decision number, researching decision-making characteristics such as time
to change in management for a particular therapy may help to
understand differences in provider approaches to critical care
(24, 25). Additionally, understanding how care protocols affect
and potentially alleviate provider decision-making burdens
would be beneficial.

CONCLUSIONS
Intensivists make more than 100 critical care decisions each
day. This decision-making burden is influenced by a variety
of patient- and service-related factors and is highly variable
among intensivists. Future work is needed to replicate these
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McKenzie et al

findings and determine the consequences of this decisional

workload for the types of choices made and the outcomes of
patients, family members, and the physicians themselves.

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