Operationalizing the Social Determinants of Critical Care

Social 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. We sought to describe how medical intensive care unit (ICU) clinicians currently operationalize social determinants of health (SDOH) within patient care, given that SDOH are known to mediate outcomes of critical illness.

Using ethnographic methods, we observed clinical work rounds, ultimately writing field notes and narrative excerpts and reviewed electronic medical record (EMR) documentation for up to 90 days. Data were qualitatively coded using a constructivist grounded theory approach and frequencies of SDOH topics were quantified according to the Centers for Disease Control Healthy People SDOH framework. We conducted this work in three urban ICUs within a single academic health system, studying clinician discussions of adult patients admitted to the medical ICU with respiratory failure.

Sixty-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. Improved systematic incorporation of SDOH into ICU discussions may reduce critical care disparities and improve patients’ short- and long-term outcomes. Based on existing practice, clinicians may be particularly amenable to SDOH integration during acute illness. Next steps include clinician, patient-, and caregiver-focused assessments of feasibility and acceptability of an ICU-based SDOH assessment.

National Heart, Lung, and Blood Institute (T32HL098054)