Table 2.

Internal medicine and emergency physician perspectives related to disposition decisions (whether patients require admission at all, whether patients should go to the ICU rather than the IM service, or whether additional testing is necessary before transfer to the floor).^*

Topic/perspectives	Representative IM quotes	Representative EM quotes
Unnecessary admissions IM: It is frustrating to admit people unnecessarily. EM: Acknowledgement of this challenge for IM physicians, but emergency physicians do not get credit for the admissions they do prevent.	Our beds are full and our wards teams are doing their best to discharge everyone that they can safely, but when you get a patient who feels fine and wants to go home…it can just get frustrating for the patient, for you, for everyone. IM resident #1, FG C	We’re not admitting everything. We’re trying our best to filter out the [patients who don’t] need to stay in the hospital because it doesn’t make sense for [IM physicians] to do work that’s unnecessary.... I think sometimes people forget that. EM resident #3, FG G
Attaching a diagnosis to patients admitted for mostly non-medical reasons IM: Non-medical reasons for admission are sometimes appropriate but should be documented. EM: Attaching a diagnosis to a patient, even if equivocal, facilitates admission requests.	...sometimes they’ll put a reason for admission because they’re trying to get the patient upstairs... and the real reason would’ve been more acceptable. They’ll put, “Admit for UTI”...but the real reason is the patient...[has] no social supports and they’re just not safe to discharge, which is kind of an okay reason to admit somebody… IM resident #6, FG A	You’ll often...call something a pneumonia... or call something a UTI that’s kind of borderline. If you can find a label to attach, then it’s easier. ...If we...could ...just say, “...I really don’t know what’s wrong with this patient, but I don’t think they can safely go home”...that would be much more productive. EM resident #3, FG D
Emergency physicians revisiting admission decisions IM: There are instances when revisiting admission decisions would make sense, especially if a patient recovers while waiting in the ED. Shared: ED volume and workflow, especially prolonged ED boarding, makes revisiting such admission decisions challenging for emergency physicians.	There’s a decision...that the patient needs to be admitted...Then the patient sits [in the ED] for 10 hours [during which they become] stable and ready to go home. ….I desperately wish that...the new ...ED team...would be willing to re-evaluate the patient and discharge them... IM attending #1, FG E	We’re just too busy to re-litigate a decision that’s already been made by another resident and attending from our own department. EM resident #3, FG D The other issue...is boarding…[Y]our colleague thought [someone] needed to be hospitalized, and you are now the 3rd or 4th resident...taking care of this patient...waiting for a bed for 18-plus hours. Then you get questions from the medicine team about “Do they really need to be hospitalized?”....We’re trying to justify certain things based on how they look now, and that’s just a tough spot to be in. EM resident #5, FG D
Perceived futility of IM arguing against need for admission Shared: Emergency physicians rarely reverse admission decisions based on IM physician opinion.	I don’t actually call anymore if I think the patient should be discharged...It’s always a lost cause... they’ve made the decision that the patient needs to be admitted to the hospital and so me...saying, “Have you considered not admitting this patient?” it’s just...a waste of everyone’s time. IM attending #2, FG B	I’ve never discharged someone...based on what an internal medicine resident is telling me...they always end up being admitted because we have admitting privileges... At the end of the day, the patient will be coming to them..., which I understand can make them feel [they] have less power…. EM resident #6, FG G
Personal expertise and perspective regarding ICU disposition IM: IM physicians have knowledge and experience with what is logistically possible on the floor. EM: Emergency physicians are the only ones who have seen the patient.	[O]ur opinion on what [qualifies as] a safe patient for the floor is under-valued. I think that’s something that we have more experience than the [physicians in the] emergency room...We know what it’s like to get a patient from the emergency room on the medicine floor...trying to manage with the limited resources you have, and then trying to transfer that patient [to the ICU]. IM resident #8, FG A	[Regarding IM teams requesting re-triage to ICU] That can be sort of frustrating because that’s coming from somebody who has not seen or evaluated the patient at all in person yet, and so we feel like we have the better perspective on that matter. EM resident #1, FG D
Effects of transfer delays from IM requests for additional testing IM: Transfer delays are sometimes in the patient’s best interests. EM: Transfer delays are experienced differently by emergency and IM physicians.	They [emergency physicians] thought that [transfer] delay was a bad thing, but...if...we felt...there needed to be a delay, then that’s in the patient’s interest. IM resident #8, FG A	There are different perceptions of time...what is a long duration vs a short duration. To the emergency department...a [transfer] delay of 2–3 hours is considerable. It is something we strive to avoid. It’s...not acceptable. A delay of 2–3 hours on the floor isn’t perceptible….[IM physicians say,] “Oh, it’s just a few minutes, just do it.” EM attending #2, FG F

^* Bolded sections added for emphasis.

IM, internal medicine; EM, emergency medicine; ED, emergency department; ICU, intensive care unit; FG, focus group.