A qualitative study exploring the factors influencing admission to hospital from the Emergency

Objective: The number of emergency admissions to hospital in England and Wales has risen sharply in recent years and is a matter of concern to clinicians, policymakers and patients alike. However, the factors that influence this decision are poorly understood. We aimed to ascertain how non-clinical factors can affect hospital admission rates. Method: We conducted semi-structured interviews with twenty-one participants from three acute hospital trusts. Participants included eleven Emergency Department (ED) doctors, three ED nurses, three managers and four inpatient doctors. A range of seniority was represented among these roles. Interview questions were developed from key themes identified in a theoretical framework developed by the authors to explain admission decision-making. Interviews were recorded, transcribed and analysed by two independent researchers using framework analysis. Findings: Departmental factors such as busyness, time of day and levels of senior support were identified as nonclinical influences upon a decision to admit rather than discharge patients. The four-hour waiting time target, while overall seen as positive, was described as influencing decisions around patient admission, independent of clinical need. Factors external to the hospital such as a patient’s social support and community follow-up were universally considered powerful influences on admission. Lastly, the culture within the ED was described as having a strong influence (either negatively or positively) upon the decision to admit patients. Conclusion: Multiple factors were identified which go some way to explaining marked variation in admission rates observed between different Emergency Departments. Many of these factors require further inquiry through quantitative research in order to understand their influence further.