How Do Clinicians Decide to Discharge Someone from Their Out‐patient Clinic?

The objective of this study was to describe the information requirements and beliefs of hospital doctors working in out‐patient departments at the point where a decision to discharge or retain a patient is made. A preliminary assessment of clinical vignettes was followed by discussions using a nominal group technique with doctors working within out‐patient clinics. Nine consultant rheumatologists,seven consultant vascular surgeons and seven senior house officers, on a rotational training scheme in general medicine, took part. Their ranked opinions were the principal outcome measures. In each of the three settings, hospital clinicians affirmed that clinical considerations were the overriding factors involved in the decision to discharge or retain patients. These were mainly expressed as beliefs that the patient should be fully investigated or that the clinical management required skills only available within the speciality out‐patient clinic setting. The senior house officers believed that informal guidelines existed in each of their clinics. Guidelines were usually transmitted by more senior doctors working in the clinic but were, at times, inconsistent so that uncertainty existed for individual discharge decisions. The information requirements and beliefs of senior house officers did not change during the six months between assessments. Consultants working in out‐patient clinics are consistent in their information‐gathering and belief systems. That is to say, consultants in the specialties studied agreed with one another in the discussion groups. They may fail to communicate this fully to their junior staff. Explicit guidelines for junior staff based on diagnostic and disease severity data would be of value in making discharge decisions more consistent.