'Heads you win, tails I lose': A critical incident study of GPs' decisions about emergency admission referrals

Abstract

Background. Acute hospital Trusts' inability to cope with the numbers of emergency admissions has led to the production of guidelines by the Department of Health aimed at reducing inappropriate admissions by GPs. There is a paucity of research describing GPs' decisions to (not) admit patients and it is unclear how effective these guidelines are in changing these practices. Objective. To describe GPs'decision-making about referrals for emergency hospital admissions. Methods. Observational design using the critical incident technique to elicit data. Eight GPs in West Yorkshire recorded details of memorable emergency admission decisions, both prospective and retrospective consultations. The transcript data were classified by theme using NUD*IST. Results. Forty prospective and 8 retrospective consultations were analysed. Factors affecting GPs'decisions were: • Identification of all consequences for all stakeholders in the decision. • Emotional impact on the GP of managing these conflicting needs. • 'Peer review' of the GP's professionalism about the decision. • Contextual pressures limiting effectiveness of GPs' decision-making. Conclusions. Referral decisions require the evaluation of several conflicting consequences for many stakeholders in time-pressured and peer-reviewed situations. These factors encourage the use of heuristics, i.e. GPs' judgements will be influenced more by the social context of the choice than information about the patient's condition. Emergency referral guidelines provide more information to evaluate from another stakeholder; introducing guidelines is likely to increase GPs' use of heuristics and the making of less optimal decisions.