Seips and Institutional Theory: A Study of Work Systems and Isomorphic Pressures in Icu Triage Decision-Making Within Adult Surgical Patients

Background: ICU triage decisions for adult surgical patients are critical yet inconsistently standardized across institutions and services. Although guidelines and risk prediction tools exist, ICU admission decisions frequently reflect local norms, organizational structures, and service-specific practices. To date, ICU triage has not been examined through the combined lenses of sociotechnical systems theory and Institutional Theory. Methods: An empirical qualitative methods study was conducted at a quaternary academic medical center. Data were collected prospectively from providers and staff in Orthopedic, Hepato-Pancreato-Biliary (HPB), Thoracic, and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) surgical services. Providers included attending surgeons, fellows, residents, and advanced practitioners (APs) while staff included surgical schedulers. Intensivists from the two general surgery ICUs, anesthesiologists involved in perioperative assessment, and surgical nursing were also represented in the study population. Data were coded using applied thematic analysis guided by the SEIPS framework and Institutional Theory. Thematic saturation was reached when no new codes or concepts emerged in three consecutive interviews and coding stabilized across services. Results: Twenty-nine participants contributed data. Orthopedic, HPB, and ICU intensivists cited perceived structural gaps - e.g., intermediate care unit (IMC) access or geographical separation of IMCs relative to other units, the absence of floor monitoring, and fragmented medical co-management support outside of the ICU - as key drivers of precautionary ICU use. In contrast, Thoracic clinicians emphasized reliance on telemetry-enabled IMC, while HIPEC clinicians described default ICU admission norms driven by low clinical ambiguity, both of which reduced discretionary variation. ICU admission rationales reflected both clinical criteria (e.g., hemodynamic instability, hourly neurological checks) and organizational dynamics (e.g., trust in floor-level care delivery capabilities, institutional safety culture). All providers cited limited confidence in existing risk prediction tools, variable communication processes, and strong normative institutional pressures influencing triage decisions. Conclusions: In the absence of reliable predictive tools and standardized triage guidelines, ICU admission decisions are shaped as much by organizational context and institutional culture as by clinical risk. Improving ICU triage accuracy will require addressing these sociotechnical and institutional drivers alongside clinical criteria. System-level structural and governance interventions may be needed to better align ICU utilization with patient need.