Use or abuse? A qualitative study of physicians’ views on use of observation stays at three hospitals in the United States and England

Objective: Accumulating evidence has seen increasing use of observation stays for patients presenting to EDs requiring diagnostic workup or time-limited treatment plans, but critics suggest that this expansion arises from hospitals’ concerns to maximize revenue, and shifts costs to patients. Perspectives of physicians making decisions to admit, observe or discharge have been absent from the debate. We examined the views of emergency physicians in the US and England on observation stays, and what influences their decisions to use observation services. Methods: We undertook in-depth, qualitative interviews with a purposive sample of physicians in three hospitals across the two countries, and analyzed these using an approach based on the constantcomparison method. Limitations include the number of sites, whose characteristics are not generalizable to all institutions, and the reliance on self-reported interview accounts. Results: Physicians used observation status for the specific presentations for which it is well-evidenced, but acknowledged administrative and financial considerations in their decision making. They also highlighted an important role for observation not described in the literature: as a ‘safe space’, relatively immune from the administrative gaze, where diagnostic uncertainties, socio-medical problems and medico-legal challenges could be contained. Conclusions: Observation status increases the options available to admitting physicians in a way that they valued for its potential benefits to patient safety and quality of care, but some of these have been neglected in the literature to date. Reform to observation status should address these important but previously unacknowledged functions.