Managing the daily intensive care activities – an observation study concerning ad hoc decision-making of charge nurses and intensivists.

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Managing the daily intensive care activities - an observation study concerning ad hoc decision-making of charge nurses and intensivists.

Crit Care. 2011 Aug 8;15(4):R188

Authors: Lundgren-Laine H, Kontio E, Perttila J, Korvenranta H, Forsstrom J, Salantera S

ABSTRACT: INTRODUCTION: Management of daily activities of intensive care units (ICUs) is challenging. ICU shift leaders, charge nurses and intensivists have to make several immediate ad hoc decisions when enabling the fluent flow of unit activities. Even though the management of the ICU activities is quite well supported with the international consensus guidelines, we know only a little about the content of the real clinical decision-making of ICU shift leaders. METHODS: We conducted an observation study with the think-aloud technique to describe the ad hoc decision-making of ICU shift leaders. The study was performed in two university-affiliated hospital ICUs. 12 charge nurses and eight intensivists were recruited. Observations were recorded and transcribed for the qualitative content analysis using the protocol analysis method. The software program NVivo7(R) was used to manage the data. The inter-rater agreement was assessed with percentages and by Cohen's kappa. RESULTS: We identified 463 ad hoc decisions made by the charge nurses and 444 by the intensivists. Related to our data collection time this breaks down to over 230 immediately-made decisions per day (24 hours). We divided the ad hoc decision-making of ICU shift leaders into two types: process-focused and situation-focused. Process-focused decision-making included more permanent information, such as human resources and know-how, and material resources, whereas situation-focused decision-making included decisions about single events such as patient admission. We named eight different categories for the ICU ad hoc decision-making: 1. adverse events, 2. diagnostics, 3. human resources and know-how, 4. material resources, 5. patient admission, 6. patient discharge, 7. patient information and vital signs, and 8. special treatments. CONCLUSIONS: ICU shift leaders make a vast amount of complex ad hoc decisions throughout the day. Often this decision-making involves both intensivists and charge nurses. It forms a bundle that requires versatile immediate information for a successful outcome. In future we need to investigate which information is crucial for the ad hoc decisions. These challenges should also be emphasised when information technology programs for ICU care management are developed.

PMID: 21824420 [PubMed - as supplied by publisher]

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