Carr, Brendan M.

This study examines the patient- and hospital-level variation in time to initiation of inpatient management among patients admitted to general medical services.

Abstract Inpatient boarding (holding patients in the emergency department [ED] while awaiting an inpatient bed) is associated with increased risk of delirium, medication safety events, and hospital mortality in older adults. We investigated boarding trends across age strata to determine if older patients had elevated rates compared to younger patients. Administrative data for ED encounters resulting in admission from 3 healthcare systems (2 Midwest, 1 Northeast) from 1/1/19 to 12/31/24 were reviewed. Age was categorized by strata: < 21, 21-64, 65-74, 75-84, and ≥ 85. Based on the CMS Age Friendly Hospital Measures, the proportion of patients boarding for 3+ hours was calculated within each year and age strata. Boarding rates varied substantially by system and age group. At Systems 1 (S1) and 3 (S3), ≥ 85 patients had the highest rates (S1: 54.9%, S3: 70.9% in 2024) and, at System 2 (S2), all adult patients (21+) had similar rates (20.5-22.4% in 2024). Boarding rates increased in all systems over the study period. At S1 and S3, < 21 patients had the highest average yearly increase in boarding (S1: 7.4%, S3: 3.9%). At S2, boarding increased most in ≥ 85 (23.9%). In this multisystem evaluation, approximately one in two older adults experience ED boarding, with the oldest patients (≥ 85) facing the greatest exposure to boarding in recent years. These findings taken alongside known delays and safety risks associated with boarding and patient care complexity amongst the oldest adults may result in disproportionate harm to some of the most vulnerable patients.

Abstract Introduction The rapidly ageing population and multimorbidity are associated with increased emergency department (ED) visits by older adults. In the ED, older adults have higher risk of hospitalization, functional and cognitive decline, and mortality. Boarding, holding admitted patients in the ED awaiting a hospital bed, exacerbates these negative outcomes, which disproportionately affect older adults. Methods We conducted a cross-sectional analysis to investigate US boarding trends by age using clinical administrative data from 5 health systems and publicly available NHAMCS data from 2018 to 2024. Results Boarding ≥3 h in the ED has increased across diverse hospital types, with oldest adults (85+) facing the greatest risk (System 4: IRR [95% CI] = 1.18 [1.15-1.20], System 5: IRR [95% CI] = 1.20 [1.17-1.23], System 3 [Community Hospital]: IRR [95% CI] = 1.25 [1.19-1.33]). These results were recapitulated at the national level in NHAMCS (IRR [95% CI] = 1.30 [1.05-1.61]). Discussion The trend of increased boarding has serious implications for patients, caregivers, and health systems. The 2025 CMS Age-Friendly Hospital Measure offers opportunities to improve processes and procedures to mitigate the negative effects of hospital boarding on older patients. We highlight opportunities to address this challenge, including ongoing quality improvement initiatives, bed prioritization algorithms, and alternate admission pathways.

Abstract Incidental findings in diagnostic imaging are common, but follow-up recommendations often lack consistency. The Society of Radiologists in Ultrasound (SRU) issued guidelines in 2021 for managing incidentally detected gallbladder polyps, aiming to balance follow-up with avoiding overtreatment. There is variable adherence to these guidelines in radiology reports, however, which makes it difficult for the clinician to pursue appropriate follow-up for the patient. The purpose of this project is to test the feasibility of a Large Language Model (LLM)–based tool to incorporate SRU guidelines into radiology reports. Additionally, we propose a framework for closely integrating societal follow-up recommendations into radiology reports, using this tool as an example. Following institutional review board approval, we retrospectively reviewed gallbladder ultrasound examinations performed on adult ED patients in 2022. Data on patient demographics and radiology report content were collected. Using the 2021 SRU guidelines, we developed an interactive tool employing a retriever-augmented generator (RAG) and prompt engineering. A board-certified radiologist tested the accuracy, whereas a board-certified emergency medicine physician assessed the clarity and consistency of the recommendations. The interactive tool, GB-PRL, outperformed leading closed-source and open-source LLMs, achieving 100% accuracy in risk categorization and follow-up recommendations on hypothetical user queries (P < 0.001). The tool also showed superior accuracy compared to radiology reports on retrospective data (P = 0.04). Although GB-PRL demonstrated greater clarity and consistency, the improvement from the radiology reports was not statistically significant (P = 0.22). Further work is needed for prospective testing of GB-PRL before integrating it into clinical practice.

To retrospectively evaluate the trends in utilization and results of computed tomography pulmonary angiography (CTPA study) for detection of acute pulmonary embolism (PE) in the hospital inpatients during different phases of COVID-19 public health emergency. We conducted an Institutional Review Board (IRB)-approved retrospective review of CTPA studies for our hospital inpatients in the years from 2019 to 2023, ranging from the prepandemic year (2019) to the year coinciding with the end of public health declarations (2023). Collected characteristics included patient age, patient sex, and result of the study. The utilization of CTPA studies for inpatients was higher in 2020 to 2023, compared to 2019 (3.8% in 2023 compared to 2.4% in 2019, P < .001). The increase in utilization was also statistically significant in each group, when stratified by age and sex (OR = 1.46 for female, OR = 1.71 for male, OR = 1.93 for elderly, and OR = 1.29 for non-elderly inpatients in 2023, compared to 2019). The positivity rate of acute PE in the inpatients was overall higher in 2021, 2022, and 2023, compared to 2019 (for example, 18.5% in 2023 compared to 14.3% in 2019, P = .01). When stratified by age and sex, only the non-elderly patients continued to have a significantly higher rate of acute PE in 2023, compared to 2019 (OR = 1.39). While studies spanning longer time frames and involving multiple institutions are needed to understand and generalize this conclusion, we conclude that the utilization and positivity rates of CTPA studies in inpatients remains high at the end of the COVID-19 pandemic public health emergency.