Physician tolerance of abnormal vital signs at emergency department discharge: a multicountry vignette-based study

Abstract

Abnormal vital signs at emergency department (ED) discharge may raise concerns about patient safety, yet physicians may respond differently to individual physiological abnormalities when making disposition decisions. This study examined physicians’ willingness to discharge patients with isolated abnormal vital signs under otherwise standardized clinical conditions. We conducted a multicountry vignette-based study among physicians in Turkey, Somalia, and Liberia. Five standardized primary vignettes used an identical clinical stem and response format, with only one abnormal vital sign varying in each scenario: heart rate of 110 beats/min, systolic blood pressure of 95 mmHg, oxygen saturation of 93% on room air, respiratory rate of 24 breaths/min, or temperature of 38.3 °C. Physicians rated their willingness to discharge using a 5-point Likert scale. Responses of 4 or 5 were classified as clear willingness to discharge. Repeated-measures generalized estimating equation (GEE) logistic models were used to account for clustering of responses within physicians. A total of 249 physicians participated. Willingness to discharge varied across the five vital-sign scenarios. The highest proportion expressing clear willingness to discharge was observed for SpO₂ 93% on room air (55.0%), followed by systolic blood pressure of 95 mmHg (49.8%), temperature of 38.3 °C (48.6%), and heart rate of 110 beats/min (46.6%). A respiratory rate of 24 breaths/min had the lowest willingness to discharge (24.5%). Compared with SpO₂ 93%, a respiratory rate of 24 breaths/min was associated with substantially lower odds of discharge willingness (adjusted OR 0.23, 95% CI 0.15–0.34; p < 0.001), while a heart rate of 110 beats/min was also associated with lower odds (adjusted OR 0.68, 95% CI 0.48–0.96; p = 0.027). The differences for systolic blood pressure of 95 mmHg and temperature of 38.3 °C were not statistically significant. Physicians demonstrated different levels of willingness to discharge patients depending on the isolated abnormal vital sign presented in otherwise standardized scenarios. Tachypnea was associated with the greatest reluctance to discharge. These findings describe differences in physician decision-making and should not be interpreted as establishing the relative clinical safety of individual vital-sign abnormalities.