title: Scarcity: the context of rationing in an Ontario ICU.
abstract: OBJECTIVE
  Clinicians' perceptions of scarcity influence rationing of critical care resources, which may lead to serious adverse outcomes for patients who are denied access. We sought to better understand the phenomenon of scarcity in the critical care setting.
  
  
  METHODS
  Qualitative research methods. We used purposeful sampling to recruit ICU clinicians who were frequently involved in decisions to allocate ICU resources. Thematic analysis was performed to identify concepts related to the phenomenon of scarcity.
  
  
  METHODS
  An ICU of a university-affiliated hospital in Toronto, Canada, between October and December 2007.
  
  
  METHODS
  We conducted 22 interviews with 12 ICU physicians, 4 ICU fellows, 2 ICU nursing team leaders, and 4 ICU resource nurses.
  
  
  RESULTS
  The perception of scarcity arose from a complex interaction of factors within the institution including: 1) practices of non-ICU physicians (e.g., failure to specify end-of-life treatment plans or to secure an ICU bed prior to elective high-risk surgery), 2) family demands for life support and clinicians' perception of a lack of legal support if they opposed these, and 3) inability to transfer patients to non-ICU care settings in a timely manner. Implications of scarcity included: 1) diversions of critically ill patients, 2) premature patient transfers, 3) temporary delivery of critical care in non-ICU locations (e.g., emergency department, postanesthesia care unit), and 4) interprofessional conflicts.
  
  
  CONCLUSIONS
  ICU clinicians' perceptions of scarcity may lead to rationing of critical care resources. We found that nonmedical factors strongly influenced prioritization activity, both for admission and discharge. Although scarcity of ICU beds might be mitigated by process improvements such as patient flow or proactive communication, our findings highlight the importance of a fair process for inevitable limit setting at the bedside.
authors.affiliation: Department of Critical Care Medicine, William Osler Health System, Brampton, Ontario, Canada. andrew.cooper@williamoslerhs.ca
authors.forename: Andrew B
authors.initials: AB
authors.lastname: Cooper
authors.forename: Robert
authors.initials: R
authors.lastname: Sibbald
authors.forename: Damon C
authors.initials: DC
authors.lastname: Scales
authors.forename: Linda
authors.initials: L
authors.lastname: Rozmovits
authors.forename: Tasnim
authors.initials: T
authors.lastname: Sinuff
mesh_terms: D015276:Health Care Rationing / Q000458:organization & administration*; D006785:Hospitals, University / Q000458:organization & administration*; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration*; D007902:Length of Stay; D009864:Ontario; D010351:Patient Discharge; D010360:Patient Transfer; D010465:Perception