University of Washington, Seattle, Washington, USA.
Division of General Internal Medicine/Hospital Medicine, Department of Medicine, Harborview Medical Center, Seattle, Washington, USA
BMJ Open. 2021 Jul 14;11(7):e046598. doi: 10.1136/bmjopen-2020-046598.
To map the physician approach when determining disposition for a patient who presents without the level of definite medical acuity that would generally warrant hospitalisation.
DATA SOURCES/STUDY SETTING: Since 2018, our US academic county hospital/trauma centre has maintained a database in which hospitalists ('triage physicians') document the rationale and outcomes of requests for admission to the acute care medical ward during each shift.
Narrative text from the database was analysed using a grounded theory approach to identify major themes and subthemes, and a conceptual model of the admission decision-making process was constructed.
Database entries were included (n=300) if the admission call originated from the emergency department and if the triage physician characterised the request as potentially inappropriate because the patient did not have definite medical acuity.
Admission decision making occurs in three main phases: evaluation of unmet needs, assessment of risk and re-evaluation. Importantly, admission decision making is not solely based on medical acuity or clinical algorithms, and patients without a definite medical need for admission are hospitalised when physicians believe a potential issue exists if discharged. In this way, factors such as homelessness, substance use disorder, frailty, etc, contribute to admission because they raise concern about patient safety and/or barriers to appropriate treatment. Physician decision making can be altered by activities such as care coordination, advocacy by the patient or surrogate, interactions with other physicians or a change in clinical trajectory.
The decision to admit ultimately remains a clinical determination constructed between physician and patient. Physicians use a holistic process that incorporates broad consideration of the patient's medical and social needs with emphasis on risk assessment; thus, any analysis of hospitalisation trends or efforts to impact such should seek to understand this individual-level decision making.
绘制当患者出现的病情严重程度没有达到通常需要住院治疗的明确程度时，医生确定患者处置方式的方法。
数据来源/研究地点：自 2018 年以来，我们的美国学术县医院/创伤中心一直维护着一个数据库，其中医院医师（“分诊医师”）记录每个班次期间要求入住急性护理医疗病房的理由和结果。
使用扎根理论方法分析数据库中的叙述性文本，以确定主要主题和子主题，并构建入院决策过程的概念模型。
如果入院请求来自急诊科，并且分诊医师认为请求可能不合适，因为患者没有明确的医疗严重程度，则将数据库条目（n=300）纳入分析。
入院决策分为三个主要阶段：未满足需求的评估、风险评估和重新评估。重要的是，入院决策不仅仅基于医疗严重程度或临床算法，当医生认为出院存在潜在问题时，即使患者没有明确的住院需求，也会将其收治入院。在这种情况下，无家可归、药物使用障碍、虚弱等因素会导致入院，因为它们会引起对患者安全和/或适当治疗障碍的担忧。医生的决策可以通过护理协调、患者或代理人的倡导、与其他医生的互动或临床轨迹的变化等活动来改变。
入院的决定最终仍然是医生和患者之间的临床决策。医生使用一种整体的过程，将患者的医疗和社会需求广泛纳入考虑，并强调风险评估；因此，任何对住院趋势的分析或影响此类趋势的努力都应该试图理解这种个体层面的决策过程。
