Clinical Fellow The Hospital for Sick Children Toronto, Ontario, Canada
Background: Pediatric ICU resources are finite and subject to fluctuating demands. In individual patients yes-no decisions about invasive treatments reflect a more continuous range of opinion. We constructed the 9-point Reasonableness-Unreasonableness Scale of Treatment (RUST) to measure these opinions. We hypothesized that in the opinion of ICU clinicians some care provided in ICU could also be reasonably withheld. We called this discretionary care. Objective: To describe the frequency and resources used to provide discretionary care in PICU. Design/Methods: We created 70 vignettes describing patients who were admitted to ICU for at least 7-days and abstracted the number of days of ICU treatments they received. Eligible healthcare professionals provided care to patients in a PICU. In each patient each ICU-therapy was rated using the RUST scale. Discretionary care was defined as where either >50% of respondents indicated the ICU-therapy could reasonably be given or withheld or where >25% of responses were for each of ‘reasonable’ and ‘unreasonable’. We then determined the amount and proportion of each ICU treatment provided that was discretionary. Results: The 70 patients were admitted to PICU for a total number of 1291.0 ICU-days, received 768.9 days mechanical ventilation and 492.6 days of other ICU-therapies. Responses 72 registered nurses (RNs), 16 respiratory therapists (RTs), and 65 physicians revealed that 24.7% of PICU interventions were discretionary, and 2.9% of admissions to ICU were discretionary. When compared to the clinical course of the true cases, there were 77 (20.9%) days of CPAP, 20.5 (62.1%) days of extracorporeal cardiopulmonary support, 9.2 (10.5%) days of high frequency ventilation, and 95.7 (12.4%) days of mechanical ventilation that would be considered discretionary in these 70 children who were admitted to PICU for 1291.0 days.
Conclusion(s): There is a significant proportion of ICU care that was considered discretionary in a sample of ICU health care providers. Days of mechanical ventilation represented the greatest contributor to the number of days of discretionary care in an analysis of 70 true patient cases. There is variance in inter-healthcare provider assessment of defining discretionary care.
