Uncertainty and decision-making in Critical Care: lessons from managing COVID-19 ARDS for the next pandemic

Abstract

Abstract Purpose COVID-19 ARDS was an emergent syndrome that led to high volumes of critically ill ventilated patients. We explored influences on decision-making regarding management of COVID-19 ARDS mechanical ventilation to identify modifiable factors to improve preparedness for future pandemics. Methods A systematic review of existing literature and small group interviews informed the development of an international questionnaire (UK, Italy, Germany and Netherlands) on factors influencing COVID-19 ARDS ventilation decision-making in critical care professionals. Participants were asked to rank four high-level themes in order of importance: disease (uncertainties around COVID-19 ARDS), contextual (cognitive strain), environmental (structural logistics) and team factors. Participants also ranked the subthemes within each theme. Thematic analysis was used to derive findings from qualitative data. Kruskal-Wallis, Mann-Whitney U and Kendall’s Tau were used for quantitative data analysis. Results Patient factors (co-morbidities, clinical and biochemical parameters) were the most heavily studied influences in the literature on decision-making regarding organ support, whereas uncertainty was one of the least explored subthemes. In total, 371 critical care professionals from 4 professional groups in 4 countries responded to the questionnaire. Disease uncertainty (lack of applicable guidelines and unfamiliarity with pathophysiology) was ranked as the most important influence on ventilation decision-making for COVID-19 ARDS across regions, professions and experience levels. This was followed by team, then contextual, then environmental factors (p<0.001). Participants were underconfident in their decision-making (median score: 9 out of 20), and this was unaffected by experience (p=0.79) or profession (p=0.58). Higher disease certainty, however, led to increased confidence (p<0.001). Major influences on disease uncertainty were the pathophysiology and natural history of COVID-19 ARDS, information sharing and experience over time. Modifiable influences on disease uncertainty were positive team factors and resource limitations. Conclusion Future pandemic preparedness programmes should target modifiable influences such as information sharing, teamworking and resource limitations to mitigate against the negative influence of uncertainty and thereby improve decision-making overall.