Consensus Recommendations for Patients with Complex Dispositions: A Modified Delphi Study Among the Strengthening Essential Emergency Departments (SEED)

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Background Some emergency department (ED) patients have complex needs requiring hospitalization but lack acute conditions that meet inpatient admission criteria. Although common, these cases have received little national attention. We convened emergency medicine experts to propose definitions, barriers, and calls to action for this population. Methods We conducted a modified Delphi study using iterative online surveys and an inperson meeting. Panelists were recruited from Strengthening Essential EDs (SEED), a consortium of 15 United States (US) academic safety-net hospitals. Panelists were asked to rank agreement with survey items on a 5-point Likert scale, with elimination of items that failed to reach consensus (defined as <3.75) after each round. Between rounds, we integrated all panelist suggestions and distributed anonymous controlled feedback. The inperson discussion used a modified Liberating Structures framework to elicit feedback, which was used to edit items in real time. Results In total, 35 of 67 (52.2%) panelists from 12 of 15 (80%) institutions attended the inperson discussion, and 22 panelists from 13 institutions participated in ≥1 Delphi survey. The panel reached consensus on a single term and definition—recommending "patients with complex dispositions" defined as "a patient who requires hospitalization due to complex disposition planning needs and identified barriers to safe discharge." The panel also reached consensus on 5 key barriers and 6 calls to action for future work. Conclusions We recommend the term "patients with complex dispositions" to describe patients who require hospitalization due to identified barriers to safe discharge. This term, along with the proposed definition, identified barriers, and calls to action, should be considered and evaluated by a larger and more diverse stakeholder group in the future. We further encourage future work by multidisciplinary teams to evaluate and address this issue in the US health care system.

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