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

Background Delayed disposition of complex emergency department (ED) patients is often managed through informal, person-dependent negotiation, creating uncertainty regarding decision-making authority and accountability. We explored how the ARRANGE Critical Pathway (ARRANGE CP), a multidisciplinary escalation protocol for delayed ED disposition, operated in routine practice and how healthcare professionals experienced its implementation. Methods We conducted a qualitative case study in the ED of a tertiary hospital in South Korea, where ARRANGE CP was formally implemented on December 23, 2024. Between October and November 2025, semistructured, one-on-one, in-depth interviews were conducted with 18 purposively sampled participants: 5 emergency physicians, 4 physicians from non-emergency clinical departments, 2 Flow Managers, 4 ED nurses, and 3 hospital leadership participants. All 18 transcripts were independently coded by three researchers using an iterative, codebook-based thematic analysis informed by Braun and Clarke’s six-phase framework. Results Before ARRANGE CP implementation, participants described delayed disposition as a recurrent structural problem characterized by unclear decision-making authority and accountability, with coordination dependent on repeated individual contact, informal persuasion, and ad hoc escalation. Delayed disposition was perceived as threatening patient safety and contributing to moral and emotional burden among healthcare professionals. After implementation, participants perceived a more formalized multidisciplinary decision-making structure, with formal escalation, involvement of senior decision-makers, redistribution of responsibility, and reduced individual burden. However, persistent challenges included gaps in awareness, uncertainty about activation criteria, roles and process flow, fragmented communication and limited real-time interaction, and the need to extend coordination and accountability beyond the initial disposition decision. Conclusions Participants perceived ARRANGE CP as shifting delayed ED disposition from fragmented, person-dependent negotiation toward a more formalized model of multidisciplinary decision-making and shared accountability. Sustainable implementation may require clearer activation criteria, explicit role allocation, structured communication and active moderation, psychologically safe interdepartmental discussion, outcome monitoring, and mechanisms for continued coordination and accountability beyond the initial disposition decision.