UK urgent care health policies advocate senior clinical decision-making at the point of referral into the system. The costs of employing senior clinicians in this role are substantial with little evidence of the value they bring over other strategies, particularly for patient outcomes. We sought to explore current remote and ambulatory emergency care decision-making in acute medical care in a large central healthcare system – NHS Scotland. We found that many sites use remote decision-making for some allocation decisions. However, involvement of clinical expertise varies, and available decision-aids are few. There is also variation in access to resources that facilitate non-admission. Research into the value that senior clinicians bring to this task over other strategies is required.

References

1. NHS England. The NHS long term plan. NHS England; 2019.
2. NHSS Director General. Healthcare standards: Urgent Care [Internet]. 2020 [cited 2021 Apr 27]. Available from: https://www.gov.scot/news/helping-people-get-the-right-care-in-the-rightplace/
3. Reschen ME, Bowen J, Singh S, Rajwani M, Giles M, Price J, et al. Process of care and activity in a clinically inclusive ambulatory emergency care unit: progressive effect over time on clinical outcomes and acute medical admissions. Futur Healthc J. 2020;7(3):234.
4. Abdulwahid MA, Turner J, Mason SM. Senior doctor triage (SDT), a qualitative study of clinicians’ views on senior doctors’ involvement in triage and early assessment of emergency patients. Emerg Med J. 2018;35(7):440–6.
5. Durning SJ, Dong T, Artino AR, van der Vleuten C, Holmboe E, Schuwirth L. Dual processing theory and experts’ reasoning: exploring thinking on national multiple-choice questions. Perspect Med Educ. 2015;4(4):168–75.
6. Patel VL, Groen GJ, Arocha JF. Medical expertise asa function of task difficulty. Mem Cognit [Internet]. 1990;18(4):394–406. Available from: https://doi.org/10.3758/BF03197128
7. Lesgold A, Rubinson H, Feltovich P, Glaser R, Klopfer D, Wang Y. Expertise in a complex skill: Diagnosing x-ray pictures. APA PsycInfo. 1988;
8. Montgomery K. How doctors think: Clinical judgment and the practice of medicine. Oxford University Press; 2005.
9. Kahneman D, Klein G. Conditions for intuitive expertise: a failure to disagree. Am Psychol. 2009;64(6):515.
10. Zsambok CE, Klein G. Naturalistic decision making. Psychology Press; 2014.
11. Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost. 2004;2(8):1247–55.
12. Society for Acute Medicine. Doctors in acute medicine paint “worrying” picture of NHS. 2017.
13. National Institute of Clinical Excellence. Emergency and acute medical care in the over-16s: service delivery and organisation. 2018; Available from: https://www.nice.org.uk/guidance/ng94/ resources/emergency-and-acute-medical-care-in-over-16sservice-delivery-and-organisation-pdf-1837755160261
14. Kienle GS, Kiene H. Clinical judgement and the medical profession. Journal of evaluation in clinical practice. 2011 Aug;17(4):621-7
15. Tversky A, Kahneman D. Judgment under uncertainty: Heuristics and biases. Science (80- ). 1974;185(4157):1124–31.
16. Kahneman D. Thinking, fast and slow. New York: Farrar, Straus and Giroux; 2011.
17. Castro EM, Van Regenmortel T, Vanhaecht K, Sermeus W, Van Hecke A. Patient empowerment, patient participation and patient-centeredness in hospital care: a concept analysis based on a literature review. Patient Educ Couns. 2016;99(12):1923–39.
18. Manski CF. Patient Care Under Uncertainty. Princeton University Press; 2019.
19. Pignatiello GA, Martin RJ, Hickman RL. Decision fatigue: A conceptual analysis. Vol. 25, Journal of Health Psychology. 2020.
20. Shanteau J. Competence in experts: The role of task characteristics. Organ Behav Hum Decis Process. 1992;53(2):252–66.