OBJECTIVES: Pediatric ICU (PICU) resources are finite and subject to fluctuating demands. In individual patients yes-no decisions about invasive treatments reflect a more continuous range of opinion. We constructed the 9-point Reasonableness-Unreasonableness Scale of Treatment (RUST) to measure these opinions. We hypothesized that in the opinion of PICU clinicians some care provided in PICU could also be reasonably withheld. We called this discretionary care. We aimed to describe the frequency and resources used to provide discretionary care in PICU.

METHODS: We created 70 vignettes describing true patients who were admitted to a Canadian tertiary pediatric ICU. In each patient each ICU-therapy was rated by PICU healthcare providers (nurses, respiratory therapists and physicians) using the RUST scale. Discretionary care was defined as where either >50% of respondents indicated the ICU-therapy could reasonably be given or withheld or where >25% of responses were for each of ‘reasonable’ and ‘unreasonable’. We then determined the amount and proportion of each ICU treatment provided that was discretionary by evaluating each clinical case and corresponding responses. In order to estimate the cost of ICU interventions, case costing data was sought from the local institution.

RESULTS: The 70 patients were admitted to PICU for a total number of 1291.0 PICU-days. Responses from 208 PICU healthcare providers demonstrated overall 1.43% of admissions to ICU were discretionary. The cost of a day in this ICU was $7308 2023CAD, there was an estimated 201 days of PICU care that was discretionary, resulting in an estimated cost of discretionary ICU admission of 2023CAD $1.47 million.

CONCLUSIONS: There is a significant proportion of ICU care that was considered discretionary in a sample of ICU health care providers. Days of mechanical ventilation represented the greatest contributor to the number of days of discretionary care in an analysis of 70 true patient cases.