How do emergency physicians make discharge decisions?

Abstract

BackgroundOne of the most important decisions that emergency department (ED) physicians make is patient disposition (admission vs discharge).ObjectivesTo determine how ED physicians perceive their discharge decisions for high-acuity patients and the impact on adverse events (adverse outcomes associated with healthcare management).MethodsWe conducted a real-time survey of staff ED physicians discharging consecutive patients from high-acuity areas of a tertiary care ED. We asked open-ended questions about rationale for discharge decisions and use of clinical judgement versus evidence. We searched for 30-day flagged outcomes (deaths, unscheduled admissions, ED or clinic visits). Three trained blinded ED physicians independently reviewed these for adverse events and preventability. We resolved disagreements by consensus. We used descriptive statistics and 95% CIs.ResultsWe interviewed 88.9% (32/36) of possible ED physicians for 366 discharge decisions. Respondents were mostly male (71.9%) and experienced (53.1% >10 years). ED physicians stated they used clinical judgement in 87.6% of decisions and evidence in 12.4%. There were 69 flagged outcomes (18.8%) and 10 adverse events (2.7%, 95% CI 1.1 to 4.5%). All adverse events were preventable (1 death, 4 admissions, 5 return ED visits). No significant associations occurred between decision-making rationale and adverse events.ConclusionsExperienced ED physicians most often relied on clinical acumen rather than evidence-based guidelines when discharging patients from ED high-acuity areas. Neither approach was associated with adverse events. In order to improve the safety of discharge decisions, further research should focus on decision support solutions and feedback interventions.

Antimicrobial treatment decision for non-purulent skin and soft tissue infections in the emergency department

“…[18][19][20][21] For the survey creation, we also sought feedback from several emergency medicine and infectious disease physicians from our institution. We conducted cognitive building exercises for generating appropriate questions.…”

The Sydney Triage to Admission Risk Tool (START) to predict Emergency Department Disposition: A derivation and internal validation study using retrospective state-wide data from New South Wales, Australia

“…One of the most important aspects of treating patients in Emergency Departments (ED) is deciding whether a patient is safe for discharge or requires in-patient admission for further treatment and stabilisation [1]. These are termed disposition decisions and they involve the complex interaction of clinical factors such as diagnoses, severity and response to treatment, as well as social and clinician factors.…”

“…These are termed disposition decisions and they involve the complex interaction of clinical factors such as diagnoses, severity and response to treatment, as well as social and clinician factors. It has been shown that most experienced ED clinicians use clinical judgement to make disposition decisions, however in ED, these are often made in the context of various time pressures, limited clinical information and ED overcrowding which can lead to clinical errors [1, 2]. …”

No Need to Object: Ethical Obligations for Interprofessional Collaboration in Emergency Department Discharge Planning

“…Although the disposition determination process varies among hospitals, the potential for adverse events when the wrong disposition is selected is ubiquitous (Calder et al, 2012;Horwitz et al, 2009;Kennedy, Joyce, Howell, Mottley, & Shapiro, 2010). In the ED, a preventable adverse event is two times more likely to occur than in any other inpatient area (Fordyce et al, 2003).…”