How the availability of observation status affects emergency physician decision making

Objective: This study sought to understand how emergency physicians decide to utilize observation services, and how placing a patient under observation influences physicians’ subsequent decision-making. Methods: We conducted in-depth semi-structured interviews with 24 emergency physicians, including 10 from a hospital in the American Midwest, and 14 from two hospitals in central and northern England. Data were extracted from the interview transcripts using open coding and analyzed using axial coding. Results: We found that physicians used a mix of intuitive and analytic thinking in initial decisions to admit, observe, or discharge patients depending on the physician’s individual level of risk aversion. Placing patients under observation made some physicians more systematic, while others cautioned against overreliance on observation services in the face of uncertainty. Conclusions: Emergency physicians routinely make decisions in a highly resource-constrained environment. Observation services can relax these constraints by providing physicians with additional time, but absent clear protocols and metacognitive reflection on physician practice patterns, this may hinder—rather than facilitate—decision-making.