Variation in intubation decisions for patients with chronic obstructive pulmonary disease in one critical care network.
BACKGROUND
Anecdotal evidence suggests variation in intubation decisions for chronic obstructive pulmonary disease (COPD) patients with respiratory failure, but little is known about the extent of or reasons for this variability.


OBJECTIVE
To describe clinician decision-making for patients with exacerbations of COPD considered for intubation.


METHODS
Telephone simulation study.


METHODS
Consultants responsible for COPD admissions in the Heart of England Critical Care network were asked to decide whether or not to admit three patients with COPD to ICU on the basis of information conveyed over the telephone. Consultants were also asked to predict patients survival in ICU hospital and at 180 days on the assumption that the patient did receive ICU care.


RESULTS
Of the 120 consultants, 98 (82%) took part; 89% would admit patient 1, 64% patient 2, and 40% patient 3. The prediction of survival if ICU admission had occurred differed significantly between admitters and non-admitters. Mean predicted post-ICU hospital survival for patient 1 was 46% (95%CI 43-49) for admitters, and 13% (95%CI 6-19) for non-admitters (p < 0.001). The respective figures for patient 2 were 38% (95%CI 34-42) vs. 12% (95%CI 8-15) (p < 0.001), and for patient 3, 28% (95%CI 24-33) vs. 13% (95%CI 10-16) (p < 0.001). For a housebound COPD patient in their mid 70s, the mean (SD) threshold of predicted hospital survival below which consultants would recommend not admitting to ICU was 22% (13.2%).


CONCLUSIONS
Consultants differed markedly in their admitting decisions about identical patients. Objective outcome prediction models might improve equity in ICU bed use for patients with COPD.
Wildman
M J
MJ
Health Services Research Unit, London School of Hygiene and Tropical Medicine, London, UK. Martin.Wildman@lshtm.ac.uk
O'Dea
J
J
Kostopoulou
O
O
Tindall
M
M
Walia
S
S
Khan
Z
Z
D000368:Aged; D003422:Critical Care / Q000379:methods*; D003657:Decision Making; D004630:Emergencies; D005260:Female; D019538:Health Care Surveys; D006760:Hospitalization; D006801:Humans; D007442:Intubation, Intratracheal; D008297:Male; D011446:Prospective Studies; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications / Q000401:mortality / Q000628:therapy*; D012131:Respiratory Insufficiency / Q000209:etiology / Q000401:mortality / Q000628:therapy; D012189:Retrospective Studies; D016896:Treatment Outcome