What are ‘dispositions’ in Urgent Care?

The majority of the content in this post was provided by a colleague.

In Urgent & Emergency Care, dispositions play a key part in helping us to categorise patients and ensure they get the right response for their clinical need.

‘Dispositions’ are defined here: http://medical-dictionary.thefreedictionary.com/disposition.

It is the third definition we’re interested in here:

3. the plan for continuing health care of a patient following discharge from a given health care facility.

My version of this, with the added context of how we use dispositions in NHS urgent & emergency care is:

A disposition packages the perceived clinical need of a patient in the form of a skill set and a time frame.

e.g. “Speak to a clinician | within 2 hours”

We allocate dispositions using information / input data from the patient and our clinical expertise, and are there to help consistently communicate a point-in-time assessment of a patient’s clinical need in terms of what needs to happen next; they are really only ever recommendations.

Although dispositions are essentially recommendations, some scenarios may have pre-defined dispositions that are considered appropriate.

For example – specific clinical conditions might require a disposition that denotes a response by an ambulance, or Key Performance Indicators (KPIs) such as National Quality Requirements (NQRs) might define a maximum amount of time within which a patient should receive a call back from a General Practitioner (GP).

The decision-making process taken to reach a recommended disposition (skillset and timeframe) will vary between entities too. Different organisations, regions, even clinical IT systems may use different reasoning dependent on specific external factors.

For example – a local region may have recently experienced a high number of clinical incidents with unwell children, and therefore decide that all children are seen by a specialist paediatric service, regardless of their presenting features.

E.g. Disposition of “See paediatric specialist | within 2 hours”

This is still a disposition representing a clinical recommendation – i.e. the recommendation that a child be seen within 2 hours by a paediatric specialist – however the decision on which disposition is appropriate was affected by different factors.

In all situations disposition are based on a combination of expert opinion, relevant evidence, and situational factors and therefore they are always subject to change and re-evaluation.

How are dispositions used?

Once a perceived skillset and timeframe have been “packaged” into a disposition, the response to the patient’s identified need will, and can, vary depending on the availability of services locally, the risk appetite of the responsible organisations or individuals, and the prioritisation within services that are available.

How does this relate to prioritisation?

Prioritisation is the next step and can only ever be relative.

A “package” of information has led to the disposition but other factors will decide which of the patients assigned a similar disposition require priority.

More external factors come into play here, such as the age of the patient, their specific condition, and any co-morbidities they may have.

Again, it is ultimately a matter of expert opinion as to which factors have the greatest weighting when deciding priority (although as we do more with data this is likely to be come more evidence-based and less dependent on pure expert opinion).

All the time expert opinion is a significant part of the decision-making process there will be conflict between different expert perspectives and belief systems.