title: 'Heads you win, tails I lose': a critical incident study of GPs' decisions about emergency admission referrals.
abstract: BACKGROUND
  Acute hospital Trusts' inability to cope with the numbers of emergency admissions has led to the production of guidelines by the Department of Health aimed at reducing inappropriate admissions by GPs. There is a paucity of research describing GPs' decisions to (not) admit patients and it is unclear how effective these guidelines are in changing these practices.
  
  
  OBJECTIVE
  To describe GPs' decision-making about referrals for emergency hospital admissions.
  
  
  METHODS
  Observational design using the critical incident technique to elicit data. Eight GPs in West Yorkshire recorded details of memorable emergency admission decisions, both prospective and retrospective consultations. The transcript data were classified by theme using NUD*IST.
  
  
  RESULTS
  Forty prospective and 8 retrospective consultations were analysed. Factors affecting GPs' decisions were:Identification of all consequences for all stakeholders in the decision. Emotional impact on the GP of managing these conflicting needs. 'Peer review' of the GP's professionalism about the decision. Contextual pressures limiting effectiveness of GPs' decision-making.
  
  
  CONCLUSIONS
  Referral decisions require the evaluation of several conflicting consequences for many stakeholders in time-pressured and peer-reviewed situations. These factors encourage the use of heuristics, i.e. GPs' judgements will be influenced more by the social context of the choice than information about the patient's condition. Emergency referral guidelines provide more information to evaluate from another stakeholder; introducing guidelines is likely to increase GPs' use of heuristics and the making of less optimal decisions.
authors.forename: Owen P
authors.initials: OP
authors.lastname: Dempsey
authors.forename: Hilary L
authors.initials: HL
authors.lastname: Bekker
mesh_terms: D003657:Decision Making; D004630:Emergencies; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D010343:Patient Admission / Q000706:statistics & numerical data*; D010821:Physicians, Family / Q000523:psychology*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012189:Retrospective Studies