Graham P. Martin, Brad Wright, Azeemuddin Ahmed, Jay Banerjee, Suzanne Mason, Damian Roland

Accumulating evidence has shown increasing use of observation stays for patients presenting to emergency departments and requiring diagnostic evaluation or time-limited treatment plans, but critics suggest that this expansion arises from hospitals' concerns to maximize revenue and shifts costs to patients. Perspectives of physicians making decisions to admit, observe, or discharge have been absent from the debate. We examine the views of emergency physicians in the United States and England on observation stays, and what influences their decisions to use observation services. We undertook in-depth, qualitative interviews with a purposive sample of physicians in 3 hospitals across the 2 countries and analyzed these using an approach based on the constant-comparison method. Limitations include the number of sites, whose characteristics are not generalizable to all institutions, and the reliance on self-reported interview accounts. Physicians used observation status for the specific presentations for which it is well evidenced but acknowledged administrative and financial considerations in their decisionmaking. They also highlighted an important role for observation not described in the literature: as a "safe space," relatively immune from the administrative gaze, where diagnostic uncertainties, sociomedical problems, and medicolegal challenges could be contained. Observation status increases the options available to admitting physicians in a way that they valued for its potential benefits to patient safety and quality of care, but some of these have been neglected in the literature to date. Reform to observation status should address these important but previously unacknowledged functions.