Background: Given system-level focus on avoidance of unnecessary hospitalizations, better understanding admission decision-making is of utility. Our study sought to identify factors associated with hospital admission versus discharge from the Emergency Department (ED) for a population of patients who were assessed as having low medical acuity at time of decision. Methods: Using an institutional database, we identified ED admission requests received from March 1, 2018 to Feb 28, 2019 that were assessed by a physician at the time of request as potentially inappropriate based on lack of medical acuity. Focused chart review was performed to extract data related to patient demographics, socioeconomic information, measures of illness, and system-level factors such as previous healthcare utilization and day/time of presentation. A binary logistic regression model was constructed to correlate patient and system factors with disposition outcome of admission to the hospital versus discharge from the ED. Physician-reported contributors to admission decision-making and chief complaint/reason for admission were summarized. Results: A total of 349 (77.2%) of 452 calls resulted in admission to the hospital and 103 (22.8%) resulted in discharge from the ED. Predictors of admission included age over 65 (OR 3.5 [95%CI 1.1-11.6], p = 0.039), homelessness (OR 3.3 [95% CI 1.7-6.4], p=0.001), and night/weekend presentation (OR 2.0 [95%CI 1.1-3.5], p = 0.020). The most common contributing factors to the decision to admit reported by the responding physician included: lack of outpatient social support (35.8% of admissions), homelessness (33.0% of admissions), and substance use disorder (23.5% of admissions). Conclusions: Physician medical decision-making regarding the need for hospitalization incorporates consideration of individual patient characteristics, social setting, and system-level barriers. Interventions aimed at reducing unnecessary hospitalizations, especially those involving patients with low medical acuity, should focus on underlying unmet needs and involve a broad set of perspectives.

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BackgroundQuestions regarding the extent to which post-traumatic stress disorder (PTSD) is comorbid with alcohol and drug use are particularly germane in an era when the American College of Surgeons Committee on Trauma (ACS-COT) is considering policy requiring screening, intervention and/or referral services for patients presenting with psychological sequalae of traumatic injury. Literature review revealed few multisite trauma-center-based investigations that have assessed the association between PTSD symptoms and alcohol and drug use comorbidities in injured patients.MethodsThis investigation was a secondary analysis of baseline data collected prior to randomization in a 25-site trauma center pragmatic clinical trial. All 635 patients included in the investigation had elevated PTSD symptom levels at the time of trauma center admission. Self-report questionnaire screening, laboratory toxicology results, and electronic health record data were combined to assess the frequencies of alcohol, stimulant (i.e., amphetamine and cocaine), opioid and marijuana use comorbidities for injured patients. Logistic regression was used to assess the associations between demographic and injury characteristics and alcohol and drug use comorbidity.ResultsThe frequency of patients with one or more alcohol or substance use comorbidity was between 62% and 79%. Over 50% of patients were positive for one or more alcohol or cannabis comorbidity. Approximately 26% of patients were positive for stimulants and 10% for opioid comorbidity.DiscussionThis multisite investigation suggests that between 62% and 79% of hospitalized injury survivors with elevated PTSD symptoms have one or more alcohol or drug use comorbidity. Orchestrated ACS-COT policy and trauma center service delivery development should incorporate the key finding that a substantial majority of patients with high levels of psychological distress (eg, elevated PTSD symptoms) may have alcohol and drug use comorbidities.Level of evidenceLevel II (epidemiological investigation of untreated controls from a multisite randomized clinical trial)Trial registration numberNCT02655354.