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Investigating the decision-making process surrounding treatment escalation to intensive care and the effect of a decision-making tool using OSCE-style scenarios

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INVESTIGATING THE DECISION-MAKING PROCESS SURROUNDING TREATMENT ESCALATION TO INTENSIVE CARE AND THE EFFECT OF A DECISION-MAKING TOOL USING OSCE-STYLE SCENARIOS

Adam J. Boulton, Hisham Omer, Christopher Bassford

Email: [email protected]

 

INTRODUCTION

•The decision to admit a patient to the intensive care unit (ICU) is complex and involves consideration of numerous factors.
•The use of admission algorithms has been problematic for clinicians and may not be appropriate for this complex decision.1 As such, there is no standardised process for considering ICU admission and few groups have, to date, analysed this decision-making process.2
•There are multiple barriers to investigating the decision-making process thoroughly and robustly in a clinical setting.3 Furthermore, in-depth analysis into the efficacy of decision-making tools is also troublesome in clinical practice. Simulated objective structured clinical examination (OSCE) scenarios may allow assessments of real-time thought processes, including participant analytical and evaluative skills.4, 5
•Structuring the decision-making process for ICU admission may help to improve trainee confidence, comfort, and facilitate communication between clinical teams.
•This group have previously developed an evidence-based decision-making tool/support framework. This study sought to investigate the ICU admission decision-making process using OSCE-style scenarios and to evaluate the impact of a decision-making tool.

METHODS

•Two OSCE-style scenarios were used; each of these involved a patient whose suitability for admission to the ICU could be considered borderline. A family member of each patient was simulated. Participants were intensive care medicine and anaesthetic registrars with experience of making ICU admission decisions.
•Participants completed one scenario, followed by training with the decision-making tool and subsequently a second scenario. Half completed A then B, and half B then A.
•Data was collected by a mixed methods design using clinical note entries, post scenario questionnaires, and semi-structured interviews.
•The outline for scenario A is provided as an example.

RESULTS

•On visual analogue scales of 0-10, participants identified OSCE-style scenarios as being realistic (mean 7.6, SD, 1.2, N=23) and they felt they had learnt from the experience (mean 7.4, SD 1.2, N=22).
•Many of the participants volunteered that the decision-making tool training had provided a useful structure to their decision-making process and one participant felt that the training should be delivered regionally.

CONCLUSIONS

•Initial results report that OSCE-style scenarios were viewed as realistic and a positive learning opportunity by trainees.
•Analysis of data from semi-structured interviews, post scenario questionnaires, and clinical note entries is ongoing and is allowing detailed investigation of the decision-making process and the influence of the decision-making tool training. Our experience and initial results support the use of OSCE-style scenarios as a feasible method of investigating decision-making processes for ICU admissions and examining the impact of a decision-making tool.
•Future studies of decision-making interventions, such as educational tools or training, should consider this type of methodology to evaluate their impact.
 
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