Though there has been significant attention to preventing unnecessary hospital admissions, emerging evidence indicates that some patients who lack acuity of illness warranting admission continue to be hospitalized. In this study, we use a qualitative approach to further explore the hospitalist perspective and determine what factors influence the disposition decision for patients thought not to be appropriate for inpatient hospitalization. All admission calls to the acute care Medicine service at our hospital are logged into a Triage Database on an ongoing basis. This database allows the assessing physician to record a brief written narrative about the case and issues with making admission decisions. Entries were included in the study if admission calls originated from the Emergency Department and if the hospitalist assessed that the degree of patient’s medical acuity did not warrant hospitalization. Three hundred entries met inclusion criteria and were exported to Dedoose for qualitative analysis. A comprehensive codebook was iteratively created through independent coding accompanied by weekly meetings, with a final inter-rater reliability kappa score of 0.79. Using a grounded theory approach, a conceptual model of the admission decision-making process was constructed. We found that many factors are considered during admission assessment, both within and beyond physician control. The decision appears to occur in two distinct steps. First, an initial assessment considers patient factors, unmet medical and social needs, assessment of risk for discharge, and/or system-level barriers. A final admission decision is made after considering the influence of outside pressures such as: emergency department activity, coordination of care, resource constraint, and/or physician disagreements. Some of these factors may strongly outweigh the lack of medical acuity. Future work should investigate how these factors may vary at institutions with differing patient demographics and the effectiveness of possible interventions to alleviate the pressures of non-acute admission assessment factors.

Despite systemic focus on avoiding potentially preventable hospitalizations, little is known about how decisions towards admitting patients are made. This project seeks to identify factors associated with admission or discharge from the Emergency Department (ED), of patients. Within the population of patients who present to the ED but are not medically ill, a subset is admitted anyways. We hypothesized that there would be identifiable demographic, socioeconomic or access differences between those who were admitted vs. those who were not admitted. This was a retrospective cross-sectional study of referrals for admission to the Acute Care Medicine center specifically from the ED. Using an existing database, we identified 452 cases fitting the aforementioned referral inclusion criteria. We performed in-depth chart review to identify relevant factors from demographics, measures of illness and other systems level factors. A chi-squared and t-test analysis was used to compare categorical and continuous variables for statistically significant differences, while a logistic regression model was used to measure admission odds ratios. Our results showed that 349 of the 452 referrals (77.9%) were admitted. Versus discharged patients, admitted patients were typically older (56.6 vs. 53.0 years) and experienced homelessness prior to ED presentation (36.7% vs. 20.4%). Predictors of admission included age over 65 (OR 3.5 [95%CI 1.1-1.6], p = 0.039) and night/weekend presentation (OR 2.0 [95%CI 1.1- 3.5], p = 0.020). The most common contributing factors that physicians identified as key to admission among referrals included lack of outpatient social support (35.8%), homelessness (33.0%) and substance abuse (23.5%). These results suggest that physician admission is predicated upon more than medical acuity, and incorporates patient characteristics and social determinants of health. With respect to the limitations of our setting and study design, this implies a need for closer integration and knowledge of social services into clinical settings.

There is evidence that the decision to admit patients to the hospital is not always correlated with their medical acuity. Emerging evidence suggests that a patient’s environment or psychosocial support may affect their likelihood of admission. However, there has been no comprehensive description of this body of literature. Given the breadth of this field, completion of a scoping review to map the current literature is warranted. The research question which this scoping review explores is: what factors other than medical acuity have been studied in relation to the physician’s decision to admit adult patients into the hospital? The scoping review method used in this review involves the following steps: identifying the research question, identifying and selecting studies that were relevant, charting and summarising the results extracted from these studies, and lastly consultation with stakeholders in order to add valuable insight. We collaborated with a research librarian to perform a comprehensive search of seven databases (PubMed, CINAHL, PsycINFO, EMBASE, Web of Science, Sociological Abstracts, and Social Science Abstracts) that resulted in 15,571 unique abstracts. A two-step screening process is currently underway. First, each abstract was reviewed independently by two research team members. From this, 1,368 abstracts were selected and are now being reviewed in full-text to confirm appropriateness for inclusion in the final analysis. We will next begin creating a narrative summary to describe the study designs used, factors studied, the terminology used, and outcomes identified. This research will provide a comprehensive view of trends that affect hospitalization and can be used to build new policies for treatment practices to improve healthcare in all communities.