ARRANGE CP, a Multidisciplinary Decision-Making Protocol for Delayed Emergency Department Disposition: A Qualitative Case Study

In the emergency department of a hospital, the primary goal is to act as a rapid gateway: patients arrive with urgent needs, receive immediate assessment and stabilization, and then move to the next appropriate place, whether that is going home, being admitted to a ward, or transferring to another facility. This flow is essential for keeping the department open and safe for new arrivals. However, a specific type of patient often gets stuck in this gateway. These are individuals with complex medical, social, or legal problems that make it difficult to decide where they should go next. They might lack a family member to make decisions for them, face language barriers, or require a transfer that no other hospital will accept. When these decisions are delayed, the patient remains in the emergency room, occupying a bed that is designed for short-term care, not long-term management. This creates a bottleneck that slows down the entire system and leaves the patient without a clear doctor in charge.

For years, hospitals have tried to solve this by relying on informal negotiations. A doctor in the emergency room would call a specialist, ask for help, and hope for a quick answer. If that failed, they might call a senior doctor, or lean on personal relationships to get a decision made. This approach works sometimes, but it is unpredictable. It depends entirely on who is on duty, how well they know each other, and how much time they have to make phone calls. It places a heavy emotional and mental burden on the emergency staff, who feel responsible for patients they cannot move, while other departments wait for someone else to take the lead. The question researchers asked was whether a formal, structured way of making these decisions could replace this chaotic, person-dependent system with something clearer and fairer.

A team of researchers at a large hospital in South Korea investigated this by studying a new protocol they had recently introduced, called the ARRANGE Critical Pathway. This was not a medical treatment for a specific disease, but rather a set of rules for how the hospital staff should talk to each other and make decisions when a patient was stuck. The researchers wanted to understand how this new system actually worked in the real world and how the doctors, nurses, and hospital leaders felt about it. They did not simply count how many patients moved faster; instead, they sat down with eighteen different staff members—emergency doctors, specialists from other departments, nurses, and hospital administrators—and asked them to describe their experiences in detail. They listened to stories about the old way of doing things and compared them to the new way, looking for changes in how responsibility was shared and how stress was managed.

Before this new protocol existed, the staff described a situation where responsibility for stuck patients seemed to vanish. When a patient needed a bed but no department would accept them, the emergency room staff felt they were the only ones holding the bag. They described a "parallel standoff," where different departments would consult with each other but wait for someone else to make the first move. One doctor might think it was the job of another department to decide, while that department thought it was the first doctor's job. This left the patient in limbo. The staff felt that the only way to get things moving was through informal persuasion, repeated phone calls, or asking a senior leader to intervene. This process was exhausting. It relied on personal connections, meaning that a patient's fate could depend on whether the emergency doctor happened to know the right person in the other department. It also created a sense of moral distress, where staff felt they were failing their patients because the system offered no clear path forward.

The new protocol, ARRANGE, changed the rules of engagement. When a patient met specific criteria for being stuck—such as having tried all consultations without success or lacking a decision-maker—the emergency physician would reconfirm the status and report the case to the Director of the Emergency Medical Center to determine whether the protocol should be activated. Once activated, a designated manager opened a secure online channel that brought together the emergency team, the specialists who might admit the patient, social workers, and hospital leaders. In this space, the patient's situation was discussed openly under the guidance of the emergency center director. If a decision still could not be made, the process had a built-in step to bring in the hospital's vice president for medical affairs to help finalize the choice. The researchers found that this shift from informal chatting to a formal meeting structure made a profound difference. The staff reported that the burden of responsibility was no longer carried by a single person or a single department. Instead, the decision became a shared institutional act.

The most significant change the staff noticed was the arrival of senior decision-makers into the conversation. In the past, junior doctors were often afraid to contact senior leaders directly, and decisions were delayed because no one felt authorized to make the call. The new protocol made it normal and expected for senior leaders to step in. The staff described this as a "ray of light" in a dark situation. Because the leaders were present and authorized to decide, the endless back-and-forth stopped. A decision was made, and the patient could finally move. The staff felt a sense of relief and accomplishment, knowing that the system had finally worked for a patient who had been stuck for a long time. They felt that the protocol legitimized the escalation of the problem, turning a personal struggle into an organizational solution.

However, the researchers also found that the new system was not perfect. While the structure was in place, the staff pointed out several gaps that needed to be filled for the system to work smoothly in the long run. Some staff members were not fully aware of how the protocol worked or when to use it. The online communication channel, while helpful, sometimes felt fragmented, with people posting updates but not having a real-time discussion. The staff suggested that the system needed a "moderator," someone to actively guide the conversation, ask specific questions to each department, and ensure that everyone was heard. They also noted that the protocol focused heavily on getting the patient admitted, but once the patient was admitted, the responsibility for their long-term care sometimes fell back onto the admitting department without a clear plan for sharing that burden. The staff felt that for the system to be truly sustainable, it needed clearer rules for when to start the process, better training for everyone involved, and a way to track what happened to these patients after they left the emergency room.

The study concludes that the core problem of stuck patients is not just a lack of hospital beds or a delay in medical tests, but a lack of clear accountability. When no one knows who is in charge of making the final decision, the patient stays stuck. The researchers found that by creating a formal structure that brings senior leaders into the room and shares the responsibility across the whole hospital, it is possible to break the deadlock. This approach transforms the decision from a personal favor or a difficult negotiation into a standard part of hospital governance. While the new protocol did not solve every problem, it provided a clear path forward where there was none before, reducing the emotional toll on the staff and ensuring that complex patients received a decision rather than being left in the waiting room. The findings suggest that for hospitals to handle their most difficult cases, they need to build systems that make it easy for leaders to step in and share the weight of the decision, rather than leaving it to individuals to figure out on their own.