Disposition Decisions - Emergency Medicine Research - Ottawa Hospital Research Institute

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Overview

Exploring the decision making process is common in the field of psychology but emerging in emergency medicine. The main principle behind our study is to combine emergency medicine with psychological and patient safety theories. There are three parts to the study: 1) a real time structured interview of Ottawa Hospital emergency department physicians; 2) a mail out survey of all active Ontario emergency physicians; and 3) focus groups of Ottawa Hospital emergency department professionals. Phase 1 of the current study is complete and has revealed Ottawa Hospital emergency physicians most often rely on their clinical acumen and investigation results rather than evidence-based guidelines when discharging patients from high acuity areas of the emergency department (ED). Phase 2 examines the decision making style of all active ED physicians in Ontario. Last, Phase 3 will explore how the ED professionals reach their complex disposition decisions. The overall goal of our research is to make a significant contribution to patient safety and create a basis for future research in the area.

Principal Investigator: Dr. Lisa Calder
Co-Investigators: Dr. Alan Forster, Dr. Ian Stiell
Duration of Study: 2 years

For more information, please contact Dr. Lisa Calder.

Protocol Summary

Background
The disposition decision is one of the most important decisions made in the emergency department. The basis for clinical decision making is complex and little is known about how emergency physicians make decisions on the job. The overall aim of this study is to better understand the basis for decisions to discharge patients home from high acuity areas of the emergency department (ED). Accurate clinical decision making is a critical element to patient safety in emergency medicine.

Objectives
Phase 1: Determine the rationale for Ottawa Hospital emergency physicians’ disposition decisions from high acuity areas of the ED.

Phase 2: Determine the decision making style of all actively practicing Ontario emergency physicians.

Phase 3: Map out how Ottawa Hospital emergency department professionals (physicians, nurses, social workers, and patient safety experts) make disposition decisions.

Methods
Phase 1 involved a real-time structured interview of consenting and practicing emergency physicians at the Ottawa Hospital ED who discharged patients from high acuity areas of the ED between June-August 2008. We interviewed 32 of 36 eligible staff emergency physicians regarding 366 patient encounters. We discovered 70 adverse outcomes and judged that 10 of these were adverse events (adverse outcomes associated with health care management). The results of this study are being submitted for publication.

Phase 2 consists of a psychometric tool which was mailed out utilizing Dillman’s methodology to all emergency physicians in Ontario. The tool is Epstein’s Rational Experiential Inventory 40 (REI-40) which has been found reliable in many diverse populations and investigates rational and experiential decision making. We will explore whether Ottawa Hospital emergency physicians REI-40 scores are correlated to adverse events in the ED (Phase 1 results). Also, we will correlate all emergency physicians’ scores on the REI-40 with demographics.

Lastly, phase 3 involves a pilot focus group with ED residents followed by three additional focus groups with 6-8 ED team members per group (groups will be based on profession). We plan to explore how the ED team makes disposition decision from high acuity areas of the ED. Furthermore, we will examine where errors in disposition decisions occur and brainstorm potential solutions.

Importance
This study will be the first to assess emergency physician’s decision making style in relation to disposition decision. Any contribution of knowledge to this area serves to potentially enhance the safety of our patients and better understand emergency physician’s cognitive processes.