Influence of non-clinical factors on emergency department decision-making: a Delphi study

Background: Disposition decisions in the emergency department (ED) are expected to rely primarily on clinical need, yet in practice, non-clinical factors frequently shape outcomes. These influences are poorly documented and rarely prioritized systematically. This study sought to achieve consensus among ED physicians on the most impactful non-clinical factors affecting admission decisions. Methods: We conducted a two-round Delphi survey among 34 ED physicians across Israel. Candidate non-clinical factors were derived from prior research and classified into three domains: patient-related, physician-related, and system-related. Participants rated each factor on a Likert scale regarding its frequency of influence, and consensus was defined as ≥ 66% agreement. Non-parametric tests were used to assess associations with physician characteristics. Results: Consensus was reached for all 21 factors after two Delphi rounds. Patient-related factors such as personal preference and family support were rated as commonly influential, while socioeconomic status was considered rarely influential. Physician-related factors including years of experience, field of expertise, and fatigue were commonly influential, whereas gender and cultural background were not. Among system-related factors, inpatient bed capacity and home care availability were frequently influential, whereas adherence to quality indicators and ED arrival time were rarely considered determinants. No significant variation was observed across physician subgroups. Conclusion: This Delphi study highlights that ED admission decisions are shaped not only by clinical needs but also by contextual non-clinical factors spanning patient, physician, and system domains. Recognizing and addressing these influences may support more standardized, equitable, and efficient ED decision-making and inform targeted interventions at institutional and policy levels. Clinical trial number: Not applicable.