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Management of daily activities in ICUs is challenging. ICU shift leaders, charge nurses and intensivists have to make several immediate  ad hoc  decisions to enable the fluent flow of ICU activities. Even though the management of ICU activities is quite well delineated by international consensus guidelines, we know only a little about the content of the real clinical decision making of ICU shift leaders.    Methods  We conducted an observational study with the think-aloud technique to describe the  ad hoc  decision making of ICU shift leaders. The study was performed in two university-affiliated hospital ICUs. Twelve charge nurses and eight intensivists were recruited. Observations were recorded and transcribed for qualitative content analysis using the protocol analysis method. The software program NVivo 7 was used to manage the data. The interrater agreement was assessed with percentages and by Cohen's κ.    Results  We identified 463  ad hoc  decisions made by the charge nurses and 444 made by the intensivists. During our data collection time, this breaks down to over 230 immediately made decisions per day (24 hours). We divided the  ad hoc  decision making of ICU shift leaders into two types: process-focused and situation-focused. Process-focused decision making included more permanent information, such as human resources, know-how and material resources, whereas situation-focused decision making included decisions about single events, such as patient admission. We named eight different categories for ICU  ad hoc  decision making: (1) adverse events, (2) diagnostics, (3) human resources and know-how, (4) material resources, (5) patient admission, (6) patient discharge, (7) patient information and vital signs and (8) special treatments.    Conclusions  ICU shift leaders make a great number of complex  ad hoc  decisions throughout the day. Often this decision making involves both intensivists and charge nurses. It forms a bundle that requires versatile, immediate information for a successful outcome. In the future, we need to investigate which information is crucial for  ad hoc  decision making. These challenges should also be emphasised when information technology programs for ICU care management are developed.

Managing daily intensive care activities: An observational study concerning ad hoc decision making of charge nurses and intensivists