Background: Hospitalization despite lack of medical acuity (so-called “non-medical” or “social” admission) is relatively common, especially in a safety-net setting. Hospitalists directly involved in triaging admission requests from the Emergency Department (ED) bring unique insight of the process. Here, we use a qualitative approach to explore hospitalist perspectives on disposition decisions for patients thought not to be appropriate for inpatient hospitalization.
Methods: This study took place at a large, urban, safety-net, public teaching hospital. At our institution, hospitalists receive all calls for admission to the acute care Medicine service and work with the referring provider to determine appropriate disposition. All calls are logged into a Triage Database using a standardized survey tool to capture details of the admission call including the hospitalist’s assessment of admission appropriateness. In addition, a free-text box is provided to capture narrative. We performed qualitative analysis of free-text responses entered in the Triage Database to better understand the contributors to disposition decision-making as well as physician responses or actions. Triage Database entries were included in the study if admission calls originated from the ED and if the hospitalist assessed that the degree of patient’s medical acuity did not warrant hospitalization. A total of 300 entries met inclusion criteria and free-text responses were exported to Dedoose for qualitative analysis. We used a grounded theory approach in which the study team developed a codebook together based on themes that emerged from close reading of the data. All coding was performed independently by two trained study team members and then discussed collectively in weekly meetings. We used Dedoose to identify codes with inter-rater reliability kappa score of less than 0.80 and reconciled all coding discrepancies as a group.
Results: Multiple distinct considerations were included in disposition decision-making. Unmet medical needs (including procedures or other treatments unavailable as an outpatient) and unmet social needs (including homelessness) were common. Concerns for illness progression, patient compliance, or overall safety were often cited as reasons to admit, as were patient factors such as medical complexity or frailty. Many patients in this cohort had recently been in the ED or hospital which tended to increase concern. Coordination of care with other facilities, other physicians (such as primary care physicians), or other team members (such as case managers) was sometimes successful in avoiding an admission. However, system-level issues (turned away from shelter or nursing facility due to care needs; unable to access necessary services due to time of day; citizenship or funding restrictions) were prominent. Disagreement between physicians regarding severity of illness and comfort with discharge was a frequent source of conflict.
Conclusions: Patients who present to the ED without definite medical illness may still have underlying unmet needs that raise concern. Determination of appropriate disposition for these patients is challenging and differing opinions can cause conflict between physicians. Hospitalists often attempt to intervene with varying degrees of success. Insights gained from this study may be used to inform future interventions.