Real-time recording of senior emergency physicians' decisions in two NHS emergency departments: a feasibility study.

BACKGROUND AND IMPORTANCE: Emergency physicians make repeated high-stakes decisions under sustained cognitive and operational pressure. However, the number of real-time decisions has not been studied in NHS emergency departments. OBJECTIVE: This study aimed to assess the feasibility of prospectively recording decisions made by senior emergency physicians using handheld tally counters and describe variation across shift types. DESIGN: Prospective, cross-sectional observational study. SETTINGS AND PARTICIPANTS: Senior emergency physicians, including consultants, senior associate specialists, and registrars, at two district general hospitals within Sandwell and West Birmingham NHS Trust, UK. INTERVENTION OR EXPOSURE: Participants recorded each diagnostic, therapeutic, disposition, or operational decision during day (08:00-16:00), evening (16:00-22:00), and night (22:00-08:00) shifts using handheld counters. OUTCOME MEASURES AND ANALYSIS: The primary outcome was decisions per hour by site and shift. Counts were analyzed using Poisson regression with observation time as an offset, and additional sensitivity analyses were conducted to assess the consistency of the findings. MAIN RESULTS: A total of 5180 decisions were recorded over 504 observation hours, equivalent to 10.3 decisions per hour. Recorded decisions per hour were highest during evening shifts (12.6 per hour) compared with day (9.6 per hour) and night shifts (9.4 per hour). At both sites, evening rates were approximately 30% higher than day and night rates, which were similar to each other. This pattern remained consistent in sensitivity analyses. CONCLUSION: Real-time recording of senior emergency physicians' decisions using handheld counters was feasible in routine NHS emergency practice. Larger multicenter studies are needed to validate the method and explore associations with contextual and clinical outcomes.