OBJECTIVES: The purpose of this study was to describe the utilization of an emergency medicine-led mobile integrated health program, the Mobile Response Program (MRP), by older adults and identify predictors of being dir...OBJECTIVES: The purpose of this study was to describe the utilization of an emergency medicine-led mobile integrated health program, the Mobile Response Program (MRP), by older adults and identify predictors of being directed to the emergency department (ED). METHODS: This retrospective observational cohort study included patients 65 years and older referred to MRP between 4/2021-1/2023. Collected covariates included demographics, comorbidities, referral reasons and outcomes, and for accepted referrals number of visits, tests, treatments, and disposition. We used logistic regression to identify predictors of being referred to the ED as compared to evaluation and treatment by MRP. RESULTS: During the study, 1167 referrals were made for older adults of which 813 were accepted and received a visit, and 129 were declined and directed to the ED. Common referral reasons included shortness of breath, cough/upper respiratory infection, soft tissue infection, volume overload, urinary complaints, and confusion. Predictors of MRP declining the referral and directing patients to the ED included confusion, fall, dizziness, and failure to thrive, whereas referrals for cough had higher odds of acceptance. Among patients with an MRP visit, 19% were directed to the ED, and an additional 4% were directed to the ED but declined to go. Predictors of ED direction after MRP visits included confusion, failure to thrive, electrocardiogram performance, and nebulizer treatments; visits with COVID testing or antibiotic administration had lower odds of being directed to the ED. CONCLUSIONS: Among older adults referred to the MRP for acute medical needs, most were safely treated at home. Geriatric syndromes and non-specific complaints were associated with greater odds of being directed to the ED from the original referral and after MRP evaluation. These findings can help improve the design of these programs to meet the needs of older adults.
A young physician reflects on the toll of emergency medicine and finds relief through interoception.A young physician reflects on the toll of emergency medicine and finds relief through interoception.
Burud G, Lopes E, Bhimani S
… +9 more, Goyal P, Niznik J, Donvan K, Dodson A, Musgrow K, Anton G, Hwang U, Meyer ML, Casey MF
Acad Emerg Med
· 2026 Apr · PMID 41973408
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OBJECTIVES: Patients and experts agree that potentially inappropriate medications should be reconsidered after adverse drug events (ADEs), yet emergency providers are often hesitant to discuss deprescribing in deference...OBJECTIVES: Patients and experts agree that potentially inappropriate medications should be reconsidered after adverse drug events (ADEs), yet emergency providers are often hesitant to discuss deprescribing in deference to outpatient prescribers. We sought to explore patient communication preferences for deprescribing in the emergency department (ED) after an ADE. METHODS: We conducted a cross-sectional survey study of older adults aged 65 years and older presenting to a southeastern, academic ED from June 2024 to October 2024. While awaiting results, eligible participants completed a best-worst scaling survey comparing seven potential ED communication strategies for prompting deprescription of daily aspirin. The primary analysis tested whether an ED-initiated "therapeutic pause" ("Considering your bleeding, I would like you to hold your aspirin until you can discuss with your primary care provider") was preferred by > 50% of participants over a generic discharge referral to a primary care provider through a one-sided binomial test. Secondary analyses used conditional logistic regression to evaluate relative preference across all seven deprescribing phrases. RESULTS: In total, 102 patients completed the survey with a mean (SD) age of 75 years old (std dev 7). Among all respondents, 62% (95% CI, 52%-71%) preferred an ED-initiated 'therapeutic pause' of aspirin with primary care follow-up to the generic PCP deferral approach (p = 0.01). The least preferred statement was a strict deprescribing recommendation ("I do not think you need aspirin anymore"), which was selected as the least-favored communication approach in 65% of choice tasks. In conditional logistic regression, the therapeutic pause had greater odds of being selected as most preferred compared to the least preferred phrase (OR 9.3; 95% CI, 6.3-13.8). CONCLUSION: Our study suggests that ED physicians may take a proactive approach in addressing potential deprescribing in caring for patients with ADEs, such as initiating a therapeutic pause of aspirin after an episode of bleeding.
Prucnal CK, Meeker MA, Cash RE
… +7 more, Nelson EL, Greenough PG, Hallisey SD, Ilg AM, Kabrhel C, Seethala RR, Jansson PS
Acad Emerg Med
· 2026 Apr · PMID 41973406
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BACKGROUND: In select situations, patients experiencing out-of-hospital cardiac arrest (OHCA) may be candidates for extracorporeal cardiopulmonary resuscitation (ECPR). Eligibility criteria for ECPR typically include a m...BACKGROUND: In select situations, patients experiencing out-of-hospital cardiac arrest (OHCA) may be candidates for extracorporeal cardiopulmonary resuscitation (ECPR). Eligibility criteria for ECPR typically include a maximum time (usually 30 min) from arrest to arrival at an ECPR-capable center, which may exclude populations based on geographic factors. METHODS: Using geospatial modeling, we calculated drive times to ECPR-capable hospitals in Boston utilizing census block group centroid coordinates as proxy sites for OHCA locations. We used a fixed dispatch-to-scene arrival time of 7.4 min, extrapolated from Boston EMS median transport time data. We set conditions at the 50th (24 min), 25th (18 min), and 10th (13 min) percentiles for EMS on-scene time and, for each condition, determined access to ECPR with an arrest to arrival criterion of less than 30 min. We analyzed the effect of high- versus low-traffic conditions and then derived the arrest to arrival time necessary to achieve access for 90% of the city. RESULTS: The entire City of Boston was excluded from ECPR with median times and current eligibility criteria. Decreasing time-on-scene to the 25th percentile led to increased access: 16% of block groups with low traffic and 6% of block groups with high traffic. At the 10th percentile for time-on-scene, 55% of block groups had access with low traffic and 28% had access with high traffic. To achieve access for 90% of the city under high-traffic conditions at the 50th percentile for time-on-scene, the criterion for arrest to arrival would need to be extended to 55.8 min. CONCLUSIONS: The current arrest to arrival criterion for ECPR excludes the entire City of Boston using median transportation and on-scene times. Increasing access to ECPR should include efforts to decrease prehospital duration, such as minimizing time-on-scene for potential OHCA cases. Future study should examine potential levers to improve access, such as novel prehospital ECPR delivery models, air-based transport, and liberalized arrest to arrival criteria.
INTRODUCTION: Adrenaline and noradrenaline are cornerstones of critical care. Traditionally, delivery of these drugs has been through central venous access due to concerns over the safety of peripheral venous access. How...INTRODUCTION: Adrenaline and noradrenaline are cornerstones of critical care. Traditionally, delivery of these drugs has been through central venous access due to concerns over the safety of peripheral venous access. However, central venous access also may lead to delays and complications, so there is increasing use of peripheral vasoactive drugs. There is evidence for the safety of peripheral administration in controlled theatre and intensive care settings but limited evidence in Prehospital and Retrieval Medicine. METHODS: We conducted a prospective, observational cohort study including patients transferred by Lifeflight Medicine from April 2022 to August 2023. The primary outcome was to establish the safety of peripheral adrenaline and noradrenaline. Patients receiving adrenaline or noradrenaline via peripheral intravenous cannula were included and data on venous access, drug delivery, and complications during transfer was collected. Patients were followed to 24 h post arrival to the receiving facility. RESULTS: A total of 656 patients were screened, 468 met the inclusion criteria. Patients were predominantly men (60%), median age of 64, 74% of patients were transferred by rotary wing. Noradrenaline was the most common infusion (72%) with a median dose of 0.1 μg/kg/min, and 0.13 μg/kg/min for adrenaline. The anterior cubital fossa was the most common infusion site (78%). Septic shock was the most common indication (47%). The median duration of infusion was 85 min. 93.4% of patients experienced no events with the peripheral infusion; of the remaining 31 patients, 13 (2.8%) had minor technical issues with drug delivery, 14 (3%) had minor complications affecting patient care and 4 (0.8%) required conversion to central access in transit. There were no tissue complications at 24 h follow-up. CONCLUSION: Our data suggests that adrenaline and noradrenaline may be safely administered peripherally in Prehospital and Retrieval Medicine environments, with a low overall risk of complications. TRIAL REGISTRATION: The study was pre-registered on the Australian and New Zealand Clinical Trials Registry (ACTRN12622000404729).
OBJECTIVES: Multicenter evaluation of emergency department (ED) risk stratification tools is often limited by barriers to patient-level data sharing. We used the HEART score as a clinical use case to evaluate whether a f...OBJECTIVES: Multicenter evaluation of emergency department (ED) risk stratification tools is often limited by barriers to patient-level data sharing. We used the HEART score as a clinical use case to evaluate whether a federated diagnostic meta-analytic approach yields performance estimates comparable to those obtained from centralized patient-level analysis for predicting 30-day major adverse cardiovascular events (MACE30). METHODS: We conducted a retrospective, multicenter observational study across six EDs between January 1, 2020, and December 31, 2023. Adult patients presenting with chest pain who had a documented HEART score were included. MACE30 was defined as acute myocardial infarction, coronary revascularization, or all-cause mortality. The diagnostic performance of the HEART score was evaluated using a federated bivariate random-effects meta-analysis based on site-level 2 × 2 tables, yielding pooled sensitivity, specificity, and hierarchical summary receiver operating characteristic (HSROC) estimates. These results were compared with performance metrics derived from centralized patient-level analysis. RESULTS: Among 57,906 ED encounters with documented HEART scores, MACE30 occurred in 2.2%. In federated meta-analysis, the HEART score demonstrated high specificity and negative predictive value, consistent with its intended rule-out function, with modest between-site variability. The pooled HSROC area under the curve was 0.759 (95% CI, 0.646-0.831). Centralized patient-level analysis yielded similar discrimination (AUROC 0.785; 95% CI, 0.776-0.794). Differences between federated and centralized estimates were small and clinically modest, reflecting preservation of site-level heterogeneity and variation in outcome prevalence across EDs. CONCLUSIONS: Federated diagnostic meta-analysis produced HEART score performance estimates closely aligned with those obtained from centralized patient-level data. This approach enabled scalable, privacy-preserving multicenter evaluation of ED risk-stratification tools while accommodating heterogeneity across practice settings.
BACKGROUND: Management of severe hyponatremia requires rapid correction with 100-150 mL of 3% sodium chloride (HTS), but the lack of commercially available, ready-to-use HTS doses may contribute to delays and dosing erro...BACKGROUND: Management of severe hyponatremia requires rapid correction with 100-150 mL of 3% sodium chloride (HTS), but the lack of commercially available, ready-to-use HTS doses may contribute to delays and dosing errors. In contrast, 8.4% sodium bicarbonate (HTB) is available as a 50 mL prefilled syringe and provides a comparable sodium load, though it is not a guideline-endorsed intervention. This study evaluated whether HTB produces a serum sodium increase comparable to HTS. METHODS: The primary purpose of this retrospective cohort study was to determine the number of patients whose serum sodium concentrations increased ≥ 4 mEq/L following administration of HTB or HTS. Patients were included if they were adults, had an initial serum sodium concentration ≤ 120 mEq/L, and received a single dose of HTB (50 mL) or HTS (100 mL) from January 2019 through December 2024. RESULTS: A total of 21 patients were included in each group. The number of patients whose post-intervention serum sodium concentration increased by ≥ 4 mEq/L in the HTB and HTS groups was 10 (48%) and 2 (10%), respectively (p = 0.01). The median (IQR) change in serum sodium concentrations following study drug administration in the HTB and HTS groups was 3 mEq/L (1 to 5) and 0 mEq/L (-0.5 to 2), respectively (p = 0.005). There were no significant differences between the groups in the change in serum bicarbonate concentrations, chloride concentrations, and anion gap levels following study drug administration. No osmotic demyelination syndrome events were reported in the total population. CONCLUSIONS: This study found that a single 50 mL dose of HTB more often resulted in obtainment of guideline-recommended post-intervention serum sodium goal concentrations than a 100 mL HTS dose. Additional studies are needed to confirm these findings and provide a more comprehensive assessment of safety and efficacy outcomes.
Merchant RC, Chapman B, Martinez PM
… +5 more, Krotulski A, Walton S, Carmen Vargas-Torres, Broach J, Babu KM
Acad Emerg Med
· 2026 Apr · PMID 41931114
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OBJECTIVES: In this pilot, observational study, we characterized naloxone doses individuals received after suspected opioid overdoses in comparison to concentrations of fentanyl, xylazine, central nervous system (CNS) de...OBJECTIVES: In this pilot, observational study, we characterized naloxone doses individuals received after suspected opioid overdoses in comparison to concentrations of fentanyl, xylazine, central nervous system (CNS) depressants, and stimulants detected in their blood. METHODS: Adults (≥ 18 years old) with suspected opioid overdose presenting to two academic urban US emergency departments (EDs) were recruited between October 2022 and January 2025. Naloxone parenteral equivalents administered prior to ED arrival were compared to fentanyl and xylazine as well as to CNS depressant (e.g., benzodiazepines) and stimulant (e.g., cocaine) blood concentrations. RESULTS: Of the 106 participants, 72% had detectable concentrations of fentanyl; 49% xylazine; 44% CNS depressants; and 74% stimulants. Total mean naloxone parenteral equivalents administered were 3.45 mg (SD 2.13), median 4.0 (IQR 2-4), and mean first dose was 1.98 (SD 1.1), median 2.0 (IQR 2-2). Xylazine concentrations increased moderately as fentanyl concentrations increased (Spearman ρ = 0.45, p < 0.001). Participants whose fentanyl concentrations were in the 4th quartile had received more naloxone (4.67 mg) than those with fentanyl concentrations in the 3rd, 2nd, and 1st quartiles (4.67, 3.22, and 2.74 mg of naloxone, respectively) (p < 0.01 for all comparisons). Of the 52 participants exposed to xylazine, those with xylazine concentrations in the 4th quartile generally had received more naloxone (5.03 mg) than those in the 3rd, 2nd, and 1st xylazine quartiles (3.35, 2.92, and 3.27 mg of naloxone, respectively), but these comparisons did not reach statistical significance (p > 0.05). CONCLUSIONS: The typical dose of naloxone needed in suspected opioid overdoses within a fentanyl endemic area was 4 mg. This dose was similar when xylazine co-exposure occurred, although it tended to be higher with higher xylazine concentrations detected. However, fentanyl was also present at higher levels when greater amounts of xylazine were present.
OBJECTIVES: To examine trends in clinician staffing in the context of rising Emergency Department (ED) boarding we describe five-year national trends (2019-2023) in boarding hours, attending physician and PA/NP coverage,...OBJECTIVES: To examine trends in clinician staffing in the context of rising Emergency Department (ED) boarding we describe five-year national trends (2019-2023) in boarding hours, attending physician and PA/NP coverage, and hospitalist and nursing support across a multicenter cohort of U.S. EDs. METHODS: We conducted a retrospective cohort study using data from the Association of Academic Chairs of Emergency Medicine (AACEM) and Academy of Administrators in Academic Emergency Medicine (AAAEM) annual benchmarking survey for academic years 2019 through 2023. The analysis included primary academic, academic affiliate, and community affiliate EDs. Boarding hours, attending physician and PA/NP hours, nursing support, and hospitalist care for patients boarding were evaluated over time. Outcomes were stratified by hospital classification. RESULTS: 63 EDs were included in our analysis. Median boarding hours/day increased 61.1% from 206.36 (IQR 89.87, 373.11) to 332.47 (137.43, 548.09) (p = 0.01), while median attending hours remained stable over this time frame from 72.00 (53.90, 91.50) to 72.00 (56.00, 88.00) (p = 0.56). The boarding-to-attending hour ratio increased 55.6% overall from 2.97 (1.33, 4.04) to 4.62 (2.15, 7.42) (p = 0.002). Hospitals providing nursing support for boarders increased 53.6% (95% CI 3.20%, 134.40%) which was statistically significant, whereas hospitalist management of boarding patients increased 28.7% (95% CI 2.60%, 68.10%) which was not statistically significant. CONCLUSION: ED boarding hours increased substantially over the study period without a proportionate rise in attending staffing, resulting in a marked increase in boarding burden per physician hour. While some hospitals provided funding for increased nursing and hospital coverage to care for boarding patients, these measures have not kept pace with rising boarding demands. These findings highlight a growing mismatch between workload and staffing, underscoring the need for updated staffing models and system-level strategies to address the operational and clinical challenges of ED boarding.
STUDY OBJECTIVE: Regional anesthesia techniques for traumatic rib fractures are rapidly being adopted by clinicians in emergency medicine to augment early pain management; however, the impact of "single-shot" techniques...STUDY OBJECTIVE: Regional anesthesia techniques for traumatic rib fractures are rapidly being adopted by clinicians in emergency medicine to augment early pain management; however, the impact of "single-shot" techniques remains unclear. This systematic review and network meta-analysis was designed to identify the most effective single-shot regional anesthesia (SSRA) techniques on early pain reduction and other outcomes in adult patients with rib fractures. METHODS: We searched PubMed, MEDLINE, EMBASE, CINAHL, and CENTRAL for randomized clinical trials that compared SSRA techniques for the purpose of rib fracture management. The primary outcome was pain score reported at 4-8 h. Secondary outcomes included pain scores to 24 h, respiratory function, opioid requirements, respiratory and procedural complications, hospital length of stay, and mortality. A random-effects meta-analysis was performed on pooled data for each pairwise comparison with effect sizes expressed as weighted mean differences (MD). Network meta-analysis was conducted using a Bayesian framework to simultaneously compare multiple treatments via a common comparator (standard care). RESULTS: We included nine randomized clinical trials with 738 patients. The pooled estimated MD in pain scores at 4-8 h for SSRA techniques compared to standard care -1.81 (95% credible interval [CrI], -2.11 to -1.51; moderate certainty). SSRA was also associated with a significant reduction in opioid requirements at 24 h (MD, -9.35 [95% CrI -11.1 to -7.59]; moderate certainty). NMA failed to demonstrate that any one SSRA technique was more conclusively beneficial than another. Confidence in these results was moderate to low, due to inconsistency in the control arms, imprecision of results, and substantial heterogeneity. CONCLUSION: The use of SSRA techniques compared to standard care or placebo likely reduces pain scores in the early phase of management of patients with rib fractures. Further studies using standardized controls are required to delineate superiority between different SSRA techniques. TRIAL REGISTRATION: PROSPERO Registration: CRD420251003934.
Acad Emerg Med
· 2026 Apr · PMID 41910596
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INTRODUCTION: Patients with Parkinson's disease (PD) frequently present to the Emergency Department (ED). Whether for PD-related complications or unrelated concerns, maintaining their antiparkinsonian medication regimen...INTRODUCTION: Patients with Parkinson's disease (PD) frequently present to the Emergency Department (ED). Whether for PD-related complications or unrelated concerns, maintaining their antiparkinsonian medication regimen without interruption is crucial. Delays or omissions can lead to significant morbidity and mortality. Despite this, the importance of timely ordering and administration of antiparkinsonian medications is often underrecognized in the ED. METHODS: We performed a retrospective chart review across a single health system comprising one academic and five community EDs, three of which are critical access hospitals. Adults aged ≥ 65 years with an active outpatient carbidopa-levodopa (C-L) prescription presenting between September 1, 2024, and August 31, 2025, were included. The primary outcome was the proportion of patients who received their prescribed C-L during the ED encounter. Timeliness was assessed using two definitions: a primary, idealized standard of administration within 30 min of the scheduled dose, and a secondary, system-based standard of administration within a two-hour window. RESULTS: A total of 282 patient encounters involving 87 unique patients were included (mean age 80.1 years; 61.7% male; 99.3% White). Mean ED length of stay (LOS) was 8 h and 53 min. C-L was administered in only 91 encounters (32.3%). Among the 282 ED encounters, 12 (4.3%) met the idealized timeliness definition for C-L administration, and 18 (6.4%) met the system-defined standard. Among the 91 encounters with a C-L order, 13.2% met the ideal definition and 19.8% met the system standard. Mean time from ED arrival to medication administration was 6 h 11 min. Most administrations occurred 1-4 h (39.6%) or 4-8 h (26.4%) after the scheduled dose. CONCLUSION: Less than one-third of older adults with PD received their home antiparkinsonian medication in the ED, and fewer than 10% received it on time. Targeted interventions to ensure timely medication administration are needed to prevent iatrogenic harm in this vulnerable population.
BACKGROUND: Older adults account for a disproportionate share of emergency department (ED) visits and are often present with complex needs. Frailty is a key determinant of adverse outcomes in this population. We previous...BACKGROUND: Older adults account for a disproportionate share of emergency department (ED) visits and are often present with complex needs. Frailty is a key determinant of adverse outcomes in this population. We previously developed the Emergency Department Frailty Scale (ED-FraS), a novel clinician-judgment-based instrument. This study prospectively validated the ED-FraS when used by triage nurses and evaluated its predictive performance for hospital admission and ED length of stay (EDLOS). METHODS: This prospective observational study was conducted at a tertiary academic medical center in Taiwan between February and July 2025. Triage nurses assessed patients aged ≥ 65 years using the ED-FraS during routine triage encounters. We evaluated the association between ED-FraS levels (1-5) and hospital admission and EDLOS. We compared the predictive performance of ED-FraS, the standard Taiwan Triage and Acuity Scale (TTAS), and a modified TTAS (mTTAS), which integrated frailty scores. Discriminative ability was measured using the area under the receiver operating characteristic curve (AUROC). RESULTS: A total of 550 older adults were enrolled (mean age 77.2 years). Higher ED-FraS levels were significantly associated with increased admission rates (25.0% in level 1 vs. 59.4% in level 5) and prolonged median EDLOS (2.6 vs. 27.3 h). The mTTAS demonstrated superior discriminatory ability for hospital admission (AUROC 0.720) compared to TTAS (0.657) or ED-FraS alone (0.638). Nurses reported the tool was feasible, taking < 30 s to complete. CONCLUSIONS: The ED-FraS is a feasible and valid tool for identifying older adults at risk of adverse outcomes during triage. Integrating frailty assessment into standard triage systems enhances risk stratification and may improve resource allocation for vulnerable older adults.
Pavuluri SK, Bray A, Sherak R
… +3 more, Hooper CD, Sangal RB, Melnick ER
Acad Emerg Med
· 2026 Mar · PMID 41877320
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BACKGROUND: Emergency departments (EDs) are high-stakes environments where crowding, boarding, and frequent exposure to violence amplify risks to both patients and staff. Conceptual frameworks suggest interdependence bet...BACKGROUND: Emergency departments (EDs) are high-stakes environments where crowding, boarding, and frequent exposure to violence amplify risks to both patients and staff. Conceptual frameworks suggest interdependence between teamwork, well-being, and patient safety, but the empirical basis for these relationships remains underdeveloped. Our objective was to conduct a scoping review examining the intersections between teamwork, patient safety, and well-being in EDs, with the aim of characterizing existing evidence and identifying gaps to inform future research and practice. METHODS: With a medical librarian, we searched Ovid MEDLINE, PubMed, and CINAHL from inception to 2025 using terms related to emergency services, interprofessional teamwork, burnout, and patient safety. Eligible studies included empirical evaluations of team-based interventions or correlates in ED settings; reviews, protocols, and opinion pieces were excluded. Two reviewers independently screened titles, with disagreements adjudicated through abstract review. Full texts were assessed by a second pair of reviewers. Data were extracted into a standardized template following Arksey and O'Malley's methodological framework. RESULTS: Of 346 studies screened, 16 met inclusion criteria. No study evaluated all three domains simultaneously. Seven studies assessed teamwork-safety relationships using survey or simulation methods and reported associations between stronger teamwork and fewer missed care events, improved safety culture, or enhanced communication. Seven studies examined the teamwork-well-being dyad, finding consistent associations with lower burnout, improved morale, and reduced turnover intentions. Only two studies addressed well-being-safety, reporting negative correlations between job dissatisfaction, poor teamwork climate, and self-reported errors. CONCLUSION: Evidence supports associations between teamwork, well-being, and patient safety in the ED, but research remains fragmented, methodologically limited, and rarely addresses all three domains together. Across all domains, studies were limited by reliance on self-reported perceptions, heterogeneous measurement instruments, and lack of ED-specific, longitudinal, or controlled designs. Future studies should leverage multi-institutional, ED-specific designs with objective safety outcomes to build a robust evidence base.
Haimovich AD, Jansen N, Nessen S
… +6 more, Yoon S, Mulqueen S, Maclean K, Kerman H, Berry SD, Chary A
Acad Emerg Med
· 2026 Mar · PMID 41877312
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BACKGROUND: Persons living with dementia (PLWD) frequently experience prolonged stays in the emergency department (ED), an environment poorly suited to their complex needs. Sleep disruption is common in this setting and...BACKGROUND: Persons living with dementia (PLWD) frequently experience prolonged stays in the emergency department (ED), an environment poorly suited to their complex needs. Sleep disruption is common in this setting and may heighten delirium risk. While inpatient sleep interventions show promise, their adaptation to the ED remains unexplored. This study used a co-design approach to identify strategies to promote sleep for PLWD boarding overnight in the ED. METHODS: We conducted a qualitative co-design study using semi-structured interviews and focus groups with ED nurses, technicians, caregivers of PLWD, and community advisors. Participants were recruited from two Massachusetts EDs, a post-acute rehabilitation facility, and a community advisory board. Transcripts were analyzed thematically using a combined inductive-deductive approach informed by the Consolidated Framework for Implementation Research (CFIR). RESULTS: Twenty-six participants (15 ED clinicians, 3 caregivers, 8 community advisors) contributed perspectives. Three overarching domains emerged: (1) current practices-participants described the ED as a noisy, brightly lit, and disruptive environment that undermines sleep; (2) potential solutions-stakeholders suggested structured nighttime routines, clustering of care tasks, noise and light reduction strategies, delirium carts offering non-pharmacologic interventions, and greater caregiver involvement; and (3) barriers and facilitators-participants emphasized staffing constraints, lack of dementia-specific training, and the need for local "champions" to sustain interventions. Community advisors stressed tailoring approaches to individual patient needs and involving caregivers in decision-making. CONCLUSIONS: Through participatory co-design, we identified multilevel strategies to improve sleep for PLWD boarding in the ED. Interventions that reduce environmental stimulation, integrate familiar routines, and enhance staff dementia training may mitigate sleep disruption and delirium risk. Future work will evaluate implementation feasibility and downstream effects on patient outcomes across diverse ED settings.
Chary AN, Bhananker AR, Franks R
… +10 more, Bowman J, Haimovich AD, Martell V, Schoenfeld EM, Gettel CJ, Liu SW, Ouchi K, Kennedy M, Naik A, Shah MN
Acad Emerg Med
· 2026 Mar · PMID 41873940
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BACKGROUND: People with dementia are often hospitalized from the emergency department (ED) for conditions that could potentially be treated in the outpatient setting. In scenarios of clinical equipoise-where either admis...BACKGROUND: People with dementia are often hospitalized from the emergency department (ED) for conditions that could potentially be treated in the outpatient setting. In scenarios of clinical equipoise-where either admission or discharge may be appropriate-little is known about how emergency physicians make disposition decisions. METHODS: We conducted a qualitative study with attending emergency physicians at a single academic medical center. Interviews included open-ended questions about disposition decision-making in general as well as structured case scenarios using a think-aloud protocol. We used an inductive approach to code interview data and elucidate themes about the factors emergency physicians consider in disposition decisions for people with dementia in situations of clinical equipoise. RESULTS: We interviewed twenty-one physicians with an average of 10.5 years of clinical practice (range 5-21 years). Five themes emerged: (1) assessing availability of, reliability of, and burden faced by caregivers; (2) anticipating clinical trajectory and feasibility of outpatient follow-up; (3) identifying acute cognitive changes that may reflect serious underlying illness; (4) navigating medicolegal concerns; and (5) weighing potential harms of hospitalization. Among these, caregiver assessments and clinical trajectories were discussed most frequently, with physicians describing informal and variable approaches to caregiving assessments. While many physicians recognized the risk of discharging a delirious patient, few acknowledged that hospitalization itself could contribute to delirium or other harms. Overall, emergency physicians' decisions were shaped not only by patient characteristics, but by the surrounding health system's capacity to support timely and safe outpatient care. CONCLUSIONS: ED disposition decisions for people with dementia often depend on caregiving context and health system constraints. Improving alignment of admission decisions with patients' and care partners' values and preferences may require structured approaches to assessing caregiver capacity and communicating risks of hospitalization. Health system investment in outpatient infrastructure and alternatives to admission may better support emergency physicians in making safe, patient-centered decisions.