Integrating Social Determinants of Health in Critical Care

Abstract

BackgroundSocial determinants of health (SDOH) mediate outcomes of critical illness. Increasingly, professional organizations recommend screening for social risks. Yet, how clinicians should identify and then incorporate SDOH into acute care practice is poorly defined. Research QuestionHow do medical intensive care unit (ICU) clinicians currently operationalize SDOH within patient care, given that SDOH are known to mediate outcomes of critical illness? Study Design and MethodsUsing ethnographic methods, we observed clinical work rounds in three urban ICUs within a single academic health system to capture use of SDOH during clinical care. Adults admitted to the medical ICU with respiratory failure were prospectively sequentially enrolled. Observers wrote field notes and narrative excerpts from rounding observations. We also reviewed electronic medical record (EMR) documentation for up to 90 days following ICU admission. We then qualitatively coded and triangulated data using a constructivist grounded theory approach and the Centers for Disease Control Healthy People SDOH framework. ResultsSixty-six patients were enrolled and over 200 observation hours of clinical work rounds were included in the analysis. ICU clinicians infrequently integrated social structures of patients’ lives into their discussions. Social structures were most frequently invoked when related to: 1) etiologies of acute respiratory failure, 2) decisions on life sustaining therapies, and 3) transitions of care. There was no systematic way in which data about common SDOH were collected (e.g., food and housing insecurity) and some SDOH were rarely or never discussed (e.g., access to education, discrimination, incarceration). InterpretationClinicians do not incorporate many areas of known SDOH into ICU rounds. Improvements in integration of SDOH should leverage the multidisciplinary team, identifying who is best suited to collect information of SDOH during different timepoints in critical illness. Next steps include clinician, patient-, and caregiver-focused assessments of feasibility and acceptability of an ICU-based SDOH assessment.