A cross-sectional study of doctors', managers' and public representatives' views regarding acceptable level of risk in discharges from the emergency department

Background: Discharging a patient from the emergency department (ED) always involves some risk of a poor outcome.

Aim: This study examined the hypothesis that there would be an increasing gradient of risk aversion from physicians through clinicians in management and managers to public representatives regarding an acceptable level of risk when considering discharging a patient from the ED.

Methods: An internet survey was conducted among 180 consultant physicians, 47 clinicians involved in management, 143 senior healthcare managers and 418 public representatives in Ireland. Subjects asked to assess three clinical vignettes for the level of risk for death within the next week that could have been prevented by admission at which discharge from the ED would be acceptable. Choices ranged from 1/100 risk of death to 'no risk of death is acceptable'. The median of each subject's responses was the primary outcome measure.

Results: The response rates were 64% for consultant physicians, 57% for clinicians in management, 53% for managers and 29% for public representatives. The median risk choice (interquartile range) was 1/1000 (1/500-1/5000), 1/1000 (1/500-1/10,000), 1/5000 (1/1000-1/10,000) and 1/10,000 (1/1000-0) in the respective groups (Jonckheere-Terpstra test P < 0.0001). All pairwise comparisons between doctors and managers or public representatives were significant. Older clinicians were significantly more risk tolerant than younger clinicians.

Conclusions: There are significant differences in risk tolerance when considering discharge from the ED between different groups with doctors being most risk tolerant and politicians most risk averse.