Sundown

Cross-cover at midnight

Agitated and delirious patients are a familiar overnight page for any hospitalist, and the answer is rarely straightforward. The night clinician is often cross-covering dozens of patients they haven't personally admitted, and the differential is wide — it could be a life-threatening cause that needs work-up now, or a patient who needs reorientation and a calm presence at the bedside. Delirium affects roughly one in five hospitalized older adults and is independently associated with longer length of stay, higher in-hospital mortality, falls, sitter requirements, and post-discharge cognitive decline.

In most modern hospitals, the page arrives through a HIPAA-protected secure-messaging app on the clinician's phone. The standard-of-care workup is well-established. The difficulty is not knowledge. It's assembly under load. A thorough chart review at the moment of the page — the anticholinergic burden, the recent deliriogenic exposures, the missed urinalysis, the untouched bowel regimen, the QTc that matters if antipsychotics are considered — takes longer than the minute or two the hospitalist has before walking to the bedside, especially on a night when the emergency room is also calling.

Sundown is a small experiment in what could happen in that minute. In the prototype, when a simulated secure message contains a delirium or agitation signal, a deterministic chart review runs against an evidence-anchored set of items — recent deliriogenic medications, anticholinergic burden, Foley status, last bowel movement, electrolytes, QTc, baseline cognitive status, sensory aids, recent procedures. Items that should be present but aren't are surfaced as gaps. The hospitalist reads one screen on the way to the bedside, walks in with the differential already narrowing, and gets to the assessment faster.

Same shape as Lowfire and Foldspace. The chart and the references are the source of truth — Beers criteria, the anticholinergic burden calculator, AAFP and StatPearls workup standards. AI handles the language only. The clinician examines the patient and decides what matters.