Clinician-Reported Consequences and Patient Outcomes in Disputed Emergency Department Admission Referrals: A Systematic Review

Patients in the emergency department (ED) who need admission depend on an inpatient team agreeing to take responsibility for their care.This systematic review examined patient outcomes, patient experiences, and clinician-reported consequences associated with inpatient specialties disputing, declining, redirecting, or deferring ED admission referrals.The review was prospectively registered on PROSPERO (CRD420261538117) and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement.MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Health Management Information Consortium database were searched on 12 October 2026, and the reference lists and citing articles of included studies were checked.Two reviewers independently screened records, extracted data, and appraised quality using the Mixed Methods Appraisal Tool; findings were synthesised narratively, and confidence in qualitative findings was assessed with GRADE-CERQual.Twenty-four studies reported in 28 articles (2005-2026) from 10 countries were included, five of them identified by citation searching.Most of the evidence came from clinicians' reports, and only one study reported outcomes for patients known to have had a disputed referral: in that audit of 109 rejected admission requests, 97 patients (89.0%) were eventually admitted, 66 (60.6%) under the first team contacted, and ED length of stay increased with the number of teams involved.Two record-based studies counted disputes or refusals without reporting outcomes separately for the patients affected.Two hospital-wide interventions that limited bed rejections or clarified emergency physician admitting authority were followed by shorter waits, without concurrent controls.In one interview study, patients who were receiving residents considered inappropriately transferred described more negative experiences.In a qualitative analysis of survey accounts, 40 of 139 physicians (29%) reported that a patient had experienced an adverse event or near miss after transfer from the ED; in a separate survey, 36 of 126 physicians (29%) reported a handoff-related adverse event or near miss.Clinicians attributed disputes to diagnostic uncertainty, workload, bed pressure, unclear or unequal rules on which team must accept, referral timing, and specialty identity and hierarchy.Disputes over which team accepts an ED admission are commonly described, rarely measured, and a potentially modifiable source of delay, but their effect on patient outcomes cannot yet be estimated.Recording the number of teams contacted and the time from first referral to acceptance would allow hospitals to measure the problem and test solutions.