Mapping out the emergency department disposition decision for high-acuity patients

Study objective: There are sparse data on how emergency health professionals make the important decision of emergency department (ED) patient admission or discharge, also known as the disposition decision. This study seeks to create a process map, a visual step-by-step diagram, and highlight error-prone areas for disposition decisions for high-acuity or nonambulatory ED patients.

Methods: We conducted 6 focus groups at an academic tertiary care ED: residents, social workers and registered nurses, registered nurses only, attending physicians, patient safety committee members, and consensus group from the 5 preceding groups. We asked participants to create a disposition decision process map and identify error-prone areas. We audiotaped, transcribed, and analyzed the sessions for themes, using qualitative techniques.

Results: Forty-two stakeholders with clinical experience from 1 to 30 years participated. We found 9 dominant themes (ordered according to prevalence): triage, ED location of patient assessment, monitoring, diagnosis, departmental busyness, clinical gestalt, response to treatment, social work involvement, and patient and family communication. Groups identified overarching themes such as risk stratification and administrative policy. One group included dynamic elements such as interactions with consultants and handover. Participants described the following contributors to disposition error: triage, diagnostic error, communication error, ED location of patient assessment, and ED crowding.

Conclusion: Participants endorsed triage, diagnostic error, communication error, ED location of patient assessment, and ED crowding as the most important contributors to ED disposition decisionmaking errors. Understanding these factors in clinical decisionmaking is fundamental to improving future ED patient safety.