title: How do emergency physicians make discharge decisions?
abstract: BACKGROUND
  One of the most important decisions that emergency department (ED) physicians make is patient disposition (admission vs discharge).
  
  
  OBJECTIVE
  To determine how ED physicians perceive their discharge decisions for high-acuity patients and the impact on adverse events (adverse outcomes associated with healthcare management).
  
  
  METHODS
  We 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.
  
  
  RESULTS
  We 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.
  
  
  CONCLUSIONS
  Experienced 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.
authors.affiliation: Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Lisa A
authors.initials: LA
authors.lastname: Calder
authors.affiliation: Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Trevor
authors.initials: T
authors.lastname: Arnason
authors.affiliation: Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Christian
authors.initials: C
authors.lastname: Vaillancourt
authors.affiliation: Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Perry
authors.affiliation: Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Ian G
authors.initials: IG
authors.lastname: Stiell
authors.affiliation: Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Alan J
authors.initials: AJ
authors.lastname: Forster
mesh_terms: D003657:Decision Making; D004636:Emergency Service, Hospital; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D010351:Patient Discharge; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011446:Prospective Studies
keywords: clinical care; education; emergency care systems
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