title: Communication of bed allocation decisions in a critical care unit and accountability for reasonableness.
abstract: BACKGROUND
  Communication may affect perceptions of fair process for intensive care unit bed allocation decisions through its impact on the publicity condition of accountability for reasonableness.
  
  
  METHODS
  We performed a qualitative case study to describe participant perceptions of the communication of bed allocation decisions in an 18-bed university affiliated, medical-surgical critical care unit at Sunnybrook and Women's College Health Sciences Centre. Interviewed participants were 3 critical care physicians, 4 clinical fellows in critical care, 4 resource nurses, 4 "end-users" (physicians who commonly referred patients to the unit), and 3 members of the administrative staff. Median bed occupancy during the study period (Jan-April 2003) was 18/18; daily admissions and discharges (median) were 3. We evaluated our description using the ethical framework "accountability for reasonableness" (A4R) to identify opportunities for improvement.
  
  
  RESULTS
  The critical care physician, resource nurse, critical care fellow and end-users (trauma team leader, surgeons, neurosurgeons, anesthesiologists) functioned independently in unofficial "parallel tracks" of bed allocation decision-making; this conflicted with the official designation of the critical care physician as the sole authority. Communication between key decision-makers was indirect and could exclude those affected by the decisions; notably, family members. Participants perceived a lack of publicity for bed allocation rationales.
  
  
  CONCLUSIONS
  The publicity condition should be improved for critical care bed allocation decisions. Decision-making in the "parallel tracks" we describe might be unavoidable within usual constraints of time, urgency and demand. Formal guidelines for direct communication between key participants in such circumstances would help to improve the fairness of these decisions.
authors.affiliation: Department of Critical Care Medicine, Sunnybrook and Women's College Health Science Centre, University of Toronto, Toronto, Canada. ab.cooper@sw.ca
authors.forename: Andrew B
authors.initials: AB
authors.lastname: Cooper
authors.forename: Amit S
authors.initials: AS
authors.lastname: Joglekar
authors.forename: Jennifer
authors.initials: J
authors.lastname: Gibson
authors.forename: Alissa H
authors.initials: AH
authors.lastname: Swota
authors.forename: Douglas K
authors.initials: DK
authors.lastname: Martin
mesh_terms: D001291:Attitude of Health Personnel; D003659:Decision Making, Organizational; D006740:Hospital Administrators / Q000523:psychology; D006785:Hospitals, University / Q000941:ethics; D006801:Humans; D007362:Intensive Care Units / Q000941:ethics / Q000706:statistics & numerical data*; D033183:Interdisciplinary Communication; D007407:Interviews as Topic; D008505:Medical Staff, Hospital / Q000523:psychology; D009741:Nursing Staff, Hospital / Q000523:psychology; D009864:Ontario; D016134:Organizational Policy; D010343:Patient Admission / Q000592:standards*; D010351:Patient Discharge; D036301:Qualitative Research; D040841:Resource Allocation / Q000941:ethics*; D012941:Social Responsibility; D011795:Surveys and Questionnaires