A Systematic Review of Patient Complexity and Clinical Protocols: Acute-on-Chronic Multi-Morbidity Management in the Emergency Department
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complex multi-morbidity, emergency medicine, geriatrics, clinical protocols, nursing assessment, care transitions, polypharmacy, patient complexity.
Abstract
Background: The 21st-century Emergency Department (ED) is faced with a rising number of patients with complex multi-morbidity (CMM) presenting with acute deteriorations, or "acute-on-chronic" illness. These patients have intricate interactions between chronic diseases, polypharmacy, cognitive impairment, and social vulnerability that frustrate traditional single-organ emergency care and lead to diagnostic uncertainty, iatrogenic harm, and poor outcomes.
Aim: The aim of this review was to summarize the literature on acute-on-chronic CMM in the ED and present the argument for the need to develop specialized, interdisciplinary protocols for physicians and nurses to improve care for this vulnerable population.
Methods: A narrative synthesis of the literature was conducted. The review analyzed the nature of CMM patients, critiqued existing care models like Geriatric ED guidelines, and proposed new protocol elements. Two new conceptual tools were developed: a nursing assessment framework and a formal communication tool for transitions in care.
Results: The comparison confirmed the presence of a mismatch between CMM patient needs and usual ED functioning. While models like GEDA provide a foundation, a more comprehensive, protocol-based solution is required. The review prompted the creation of two helpful tools: a protocol for a thorough nursing assessment (covering cognition, function, and social context) and a standard handoff tool for ensuring safe transitions to primary care.
Conclusion: A paradigm shift toward proactive, holistic, protocol-driven care is required for acute-on-chronic CMM patients. Specialized interprofessional protocols are fundamental to advancing patient safety and promoting sustainable emergency care. Future research must focus on the validation of complexity screening tools and the evaluation of the impact of these protocols on patient-centered outcomes.
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References
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Copyright (c) 2025 Abdulmajeed Obaid Alanazi, Saleh Ashway Nahar Alshammari, A Majed Farhan Awad Al-Hazmi, Owaed Awad Alhazmi, Amer Mudhhi Suayn Alhazmi, Tahani Hakami, Hanen Ibrahim Safar, Yusif Husin Al Enazi, Ayman Mohammed Altayyari, Bandar Saleem Alharbi, Nabeel Albalawe, Khaled Fayez Zaal Alanazi
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