Qualitative analysis of disposition decision making for patients referred for admission from the emergency department without definite medical acuity.

Abstract

To map the physician approach when determining disposition for a patient who presents without the level of definite medical acuity that would generally warrant hospitalisation. Since 2018, our US academic county hospital/trauma centre has maintained a database in which hospitalists ('triage physicians') document the rationale and outcomes of requests for admission to the acute care medical ward during each shift. Narrative text from the database was analysed using a grounded theory approach to identify major themes and subthemes, and a conceptual model of the admission decision-making process was constructed. Database entries were included (n=300) if the admission call originated from the emergency department and if the triage physician characterised the request as potentially inappropriate because the patient did not have definite medical acuity. Admission decision making occurs in three main phases: evaluation of unmet needs, assessment of risk and re-evaluation. Importantly, admission decision making is not solely based on medical acuity or clinical algorithms, and patients without a definite medical need for admission are hospitalised when physicians believe a potential issue exists if discharged. In this way, factors such as homelessness, substance use disorder, frailty, etc, contribute to admission because they raise concern about patient safety and/or barriers to appropriate treatment. Physician decision making can be altered by activities such as care coordination, advocacy by the patient or surrogate, interactions with other physicians or a change in clinical trajectory. The decision to admit ultimately remains a clinical determination constructed between physician and patient. Physicians use a holistic process that incorporates broad consideration of the patient's medical and social needs with emphasis on risk assessment; thus, any analysis of hospitalisation trends or efforts to impact such should seek to understand this individual-level decision making.