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

OBJECTIVE: 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. DATA SOURCES/STUDY SETTING: 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. STUDY DESIGN: 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. PARTICIPANTS: 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. RESULTS: 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. CONCLUSIONS: 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.