Who Really Decides at 2 a.m.? Mapping Formal Structure Against Actual Decision-Making for ICU Transfer in a Community Hospital
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Doctor of Nursing Practice Program, Aspen University
DNP855: Organizational Leadership and Systems-Based Practice
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Who Really Decides at 2 a.m.? Mapping Formal Structure Against Actual Decision-Making for ICU Transfer in a Community Hospital
Organizational charts show who reports to whom, but they rarely show where clinical decisions are actually made. The gap matters most for time-sensitive decisions. This paper maps the formal structure and the actual decision path for one decision in a composite 250-bed community hospital, whether a deteriorating patient on a general ward should be transferred to the intensive care unit at night, identifies the mismatches, and proposes a clearer allocation of decision rights.
The Formal Structure
On paper, authority is clear. The medical staff bylaws assign ICU admission decisions to the intensivist, who at night covers from home and is reached by phone. Ward patients are under the care of hospitalists, with one hospitalist in house overnight for about 140 patients. Nursing reports through nurse managers to the chief nursing officer; at night, a house supervisor represents nursing administration. Bed assignment belongs to a patient flow department that reports to the chief operating officer. The rapid response team, a critical care nurse and a respiratory therapist, is an escalation resource with no admission authority. Mintzberg (1979) would describe the hospital as a professional bureaucracy in which physicians control clinical decisions through their professional authority, while administrative lines control resources.
The Actual Decision Path
Interviews with ward nurses, rapid response nurses, hospitalists, and the house supervisor, and a review of 30 night transfers, revealed a different path. The decision usually starts with the ward nurse, who notices deterioration and calls either the rapid response team or the hospitalist, depending on which the nurse expects to arrive sooner. The rapid response nurse assesses the patient and, in practice, makes the first judgment about whether ICU care is needed. The hospitalist then calls the intensivist, who decides by phone based on the hospitalist's summary, often without hearing from the rapid response nurse who examined the patient. If the ICU is full, the house supervisor and patient flow determine whether a bed can be created, sometimes by transferring another patient out. In practice, the decision to move a patient to intensive care is made by six people in sequence, none of whom owns the whole decision, and the person with the most direct knowledge of the patient rarely speaks to the person with the formal authority.
Mismatches and Their Consequences
Three mismatches stand out. First, knowledge and authority are separated: the rapid response nurse holds the most current assessment, while the intensivist holds the authority and receives information secondhand. Second, the path depends on individual choices, such as whether the ward nurse calls the rapid response team or the hospitalist first, which produce different timelines. Third, bed availability, an administrative resource, effectively overrides clinical judgment when the ICU is full, but no one is formally accountable for that trade-off.
The consequences appear in the record review. The median time from the first call to ICU arrival was 3 hours and 10 minutes, and in 6 of 30 cases the patient had a second rapid response call before transfer. Rapid response systems can reduce cardiopulmonary arrests outside the intensive care unit; a meta-analysis of studies involving nearly 1.3 million hospital admissions found that implementing a rapid response team in adults was associated with a 33.8 percent reduction in such arrests, although not with lower hospital mortality (Chan et al., 2010). A team whose assessment does not reach the decision-maker, however, cannot deliver its full benefit.
Why the Informal Path Evolved
The informal path was not invented carelessly; it grew to fill gaps in the formal structure. When the intensivist began covering from home, hospitalists became the natural intermediaries, and when the rapid response team proved faster than a busy hospitalist, ward nurses began calling it first. The house supervisor's role in creating beds developed because patient flow staff do not work nights. Each adaptation made sense locally, and together they keep the hospital functioning. But informal arrangements have costs: they depend on who is working, they are invisible to new staff, and no one is accountable for their performance. Any redesign must preserve what works in the informal path, such as the rapid response nurse's early assessment, while giving it formal standing. Otherwise, staff will continue to follow the path that works for them regardless of what the policy says.
Clarifying Decision Rights
The proposal does not change who holds authority but makes the actual decision process explicit and connected. First, every rapid response call on a patient who may need ICU care would trigger a three-way call among the rapid response nurse, the hospitalist, and the intensivist, so that the person with the assessment speaks directly to the person with the authority. Second, clear escalation criteria based on the early warning score would specify when the rapid response team, rather than the ward nurse's judgment, must be called first. Third, when the ICU is full, the intensivist and house supervisor would share a defined decision, with the house supervisor accountable for creating capacity within one hour or arranging transfer to another hospital. The design reflects a well-described feature of rapid response systems: detecting deterioration and calling for help is one component, the team's response is another, and the two must be linked for the system to work (Jones et al., 2011).
Measures
Success would be measured by time from first rapid response call to ICU arrival, repeat rapid response calls before transfer, cardiopulmonary arrests on general wards, and the proportion of transfer decisions with documented three-way communication. Staff surveys would ask ward and rapid response nurses whether their assessments reach the decision-maker.
Conclusion
The organizational chart says the intensivist decides who goes to the ICU at night. The actual path involves six people in sequence, separates knowledge from authority, and leaves the trade-off with bed capacity unowned. Mapping the real decision path makes these gaps visible, and clarifying decision rights, without changing formal authority, can connect the people who know the patient with the people who decide.
References
Chan, P. S., Jain, R., Nallmothu, B. K., Berg, R. A., & Sasson, C. (2010). Rapid response teams: A systematic review and meta-analysis. Archives of Internal Medicine, 170(1), 18-26. https://doi.org/10.1001/archinternmed.2009.424
Jones, D. A., DeVita, M. A., & Bellomo, R. (2011). Rapid-response teams. New England Journal of Medicine, 365(2), 139-146. https://doi.org/10.1056/NEJMra0910926
Mintzberg, H. (1979). The structuring of organizations: A synthesis of the research. Prentice-Hall.
How this DNP 855 Module 2 example is structured
DNP855 Module 2 papers typically map organizational structure and where clinical decisions actually get made. Aspen does not publish module deliverables, so check your classroom for the exact prompt. This example describes the formal structure, maps the actual path with data, names mismatches and consequences, proposes clearer decision rights and defines measures.
DNP855 Module 2 questions, answered
What does DNP855 Module 2 usually ask for?
The module typically asks you to map an organization's structure and show where clinical decisions are actually made, often comparing the formal chart with practice. Aspen does not publish module deliverables, so your classroom's instructions govern.
What are decision rights?
The explicit allocation of who recommends, who must be consulted, who decides and who carries out a decision. Making them clear reduces delays and gaps when decisions cross departments.
Do rapid response teams reduce deaths?
A meta-analysis found rapid response teams in adults were associated with a 33.8 percent reduction in cardiopulmonary arrests outside the ICU but not with lower hospital mortality, suggesting their benefit depends on how the whole escalation system works.
Write yours, or have the desk draft it
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