Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: Healthcare is a significant contributor to global greenhouse gas emissions, with emergency departments being among the most resource-intensive settings. Despite increasing awareness of climate change and its health implications, structured sustainability education remains lacking in emergency medicine graduate medical education training. We evaluated the impact of a brief, educational intervention on emergency medicine (EM) residents’ knowledge, attitudes, and self-reported behaviors related to sustainability.

Methods: We conducted a prospective pre/post interventional study at two community-based EM residency programs. Emergency medicine residents completed a baseline survey assessing sustainability-related knowledge, attitudes, and self-reported behaviors, followed by a video on sustainable clinical practice and a peer-reviewed paper on the environmental impact of inhalers. Immediate postcourse and one-month follow-up surveys were administered to evaluate short- and intermediate-term changes. Our primary outcome measure was change in sustainability-related knowledge scores. Secondary outcomes included changes in attitudes toward sustainability and self-reported sustainability-related clinical behaviors. Survey responses were analyzed using descriptive statistics, paired t tests and repeated-measures analysis of variance, as appropriate.

Results: Of 41 eligible EM residents across two residency programs, 34 completed the baseline survey (82.9%), 28 completed the immediate post-intervention survey (68.3%), and 30 completed the one-month follow-up survey (73.2%). Knowledge scores at baseline were 55.0% and increased to 68.0% immediately after the intervention (P < .001). At one month, knowledge scores remained higher than baseline (65.0%) (P = .003). Attitudes improved significantly immediately post-intervention (P = .001), despite already neutral-to-positive baseline levels. Two self-reported behavior items improved at one month: preferential prescribing of dry-powder inhalers, which were described in the educational materials as having less of an environmental impact than aerosolized inhalers (12.0% to 37.0%, P < .050) and self-reported efforts to reduce unnecessary waste (56.0% to 87.0%, P < .050), with overall self-reported behavior change (P = .001). Nebulizer-related prescribing did not significantly change. The open-ended item showed similar thematic patterns at both baseline and after one month, with most residents describing simple waste-reduction actions (eg, minimizing disposables), and no significant shift in qualitative categories.

Discussion and Conclusion: A brief, structured sustainability module delivered via a video format was feasible and well-received by EM residents. Preliminary data suggest improvements in knowledge, attitude, and self-reported behaviors, highlighting the potential for scalable sustainability education within graduate medical training. However, these findings should be interpreted in the context of a small sample size and self-reported outcomes.

Climate change is increasing the frequency, duration, and intensity of extreme heat events, creating a growing public health threat for older adults. Age-related physiologic decline, comorbid chronic diseases, polypharmacy, and social vulnerability all contribute to reduced heat tolerance and higher rates of heat-related morbidity and mortality. Emergency departments (ED) are increasingly encountering older adults presenting with minor heat illness, heat stroke, and exacerbations of chronic illnesses triggered by heat exposure. This review synthesizes current evidence describing why older adults are disproportionately affected by extreme heat, highlights key social and environmental determinants of vulnerability, and outlines clinical and public health strategies that emergency clinicians and EDs can assist with to reduce risk. As global temperatures rise, proactive prevention, early recognition, and coordinated community interventions are essential to protect this high-risk population.

Climate hazards are causing increasingly frequent and severe disasters. The populations most impacted by the health and social costs of disasters include language minorities, displaced individuals, and low-income communities. This commentary explores three key issues. First, climate hazards lead to displacement and increase vulnerability by disrupting housing, livelihoods, and access to care. Second, current emergency and disaster frameworks often overlook equity in communication, access to care, and recovery. Third, practical solutions can prioritize equity across mitigation, preparedness, response, and recovery. We review evidence on climate displacement, legal protections, and the roles of the health system. We highlight recurring operational opportunities, such as language access, navigation barriers, and fragmented recovery efforts. We also propose feasible strategies aligned with implementation science, including multilingual warning systems, interpreter-ready triage, mobile clinics, community health worker networks, simplified recovery navigation, and policy changes to reduce documentation barriers. This commentary aims to help emergency leaders, public health agencies, and community partners turn intentions into measurable, sustainable equity improvements. Prioritizing language access and legal realities in disaster planning can reduce preventable health issues and accelerate recovery for groups most affected by climate change.

Introduction: Virtual care is expected to play an increasingly important role in the Canadian healthcare system, with the 2023-2024 Health Canada Departmental Plan outlining the advancement of digital health solutions as a focal point. However, key outcomes of transitioning from traditional in-person healthcare appointments to a virtual model of care are not yet well-described. Here, we apply the Sustainability in Quality Improvement (SusQI) framework to patients seen in a novel pediatric virtual urgent care (VUC) program to quantify the environmental, economic, and social impacts of virtual care.

Methods: We conducted a retrospective analysis of provincial pediatric VUC visits staffed by pediatric emergency physicians and nurse practitioners during the 2020-2025 fiscal years. We focused on three key metrics: (1) economic value, measured as travel costs avoided; (2) environmental value, measured in fuel saved (L) and carbon emissions reduced (kg CO₂ eq); and (3) social value, assessed using Ontario Marginalization (ON-Marg) Index quintiles.

Results: A total of 12,900 virtual visits were completed during the study period, 99.9% via the Webex platform. Net savings totaled $998,100. Environmental benefits included 128,700 L of fuel saved and 384,200 kg CO₂ eq emissions avoided. Summary ON-Marg Index scores were similar between groups (2.87 for in-person emergency department (ED) visits; 2.91 for virtual visits). Data collected between July 2023-April 2025 show that 10.6% (353) of visits resulted in subsequent in-person ED presentation.

Conclusion: Virtual urgent care resulted in significant financial and environmental savings per visit. These benefits included reduced financial and time burdens for families, lower hospital-related expenditures, improved environmental performance, and diversion of low-acuity cases from the ED. Comparable ON-Marg scores between patients seen virtually and in-person suggest accessibility across socioeconomic groups. These findings indicate that pediatric VUC is a viable complement to traditional care, providing meaningful cost and environmental savings while ensuring equitable access.

Introduction: Global temperatures are increasing because of climate change, affecting human health. Elevated ambient temperature has been shown to increase rates of trauma presentations in emergency departments and to increase antisocial behavior, such as violent crime. To better understand how to reduce the burden on trauma hospitals, we must better understand the relationship between ambient temperature, trauma patients, and intentional injury. We sought to examine the relationship between trauma rates and minimum and maximum daily temperatures and assess whether the assault trauma mechanism had the strongest association between weather and trauma rates.

Methods: We conducted a retrospective cohort study of full and partial trauma team activations that presented to a Level I trauma center in New York from 2012 to 2019, inclusive. Daily maximum and minimum temperatures were divided into quintile ranges. Traumas were classified by injury type and mechanism as either unintentional, assault, or intentional self-harm. We used generalized linear models with a Poisson distribution to examine the relationship between maximum and minimum temperature ranges and trauma rates, controlling for precipitation.

Results: Increasing daily minimum and maximum temperatures positively correlated with increasing trauma activations. While all trauma types increased with increasing temperature, assault traumas showed the highest rate of increase (P < .001). Compared to the lowest temperature quintile (< 46 °F), the two highest maximum temperature quintiles (> 73 °F and 83 °F) showed an increase in assault rates of 83% and 65% (incident rate ratio 1.83 [95% CI, 1.46–2.29] and 1.65 [95% CI, 1.32–2.07], respectively).

Conclusion: Trauma rates have a positive association with increasing ambient temperature rates. This temperature effect is largest among the assault group, suggesting that as temperatures continue to increase, so too will traumas that are the result of interpersonal violence.

Introduction: Recent recommendations suggest emergency medical personnel should consider rapid whole-body cooling for heat stroke patients. Cold-water immersion maximizes cooling rate and subsequent outcomes following heat stroke. Body bags filled with ice and water may provide portable, accessible partial cold-water immersion for this setting. The purpose of this study was to determine whole-body cooling rates when using body bags to facilitate partial cold-water immersion to treat exertional hyperthermia.

Methods: A total of 9 healthy participants (8 male; mean [SD] age, 24 [4] years; height, 175 [7] cm; body mass, 83.6 [21.6] kg) completed our randomized-crossover field study. Following hydration verification, participants completed a self-paced 400 warm-up run, 1,609 m run, and 10-m sprints until rectal temperature (T-rec) reached 39.2 °C or volitional exhaustion. Following exercise, participants were cooled for a maximum of 30 minutes lying supine in the shade (control; CON) or in body bags filled with 20 gallons of ice water (5.2 [1.6] °C). Following cooling, participants sat upright for a 15-minute recovery. T-rec and heart rate (HR) were taken throughout exercise, every minute of cooling, and every 5 minutes of recovery. Participants completed both trials separated by 1 week in random order.

Results: Wet bulb globe temperature between trials was not significantly different (grand mean, 28.43 [1.03] °C; P = .73). There was no difference in participant maximum T-rec (body bag, 38.98 [.23] °C; CON, 38.93 [.39] °C; P = .45); HR (body bag, 183 [14] beats per minute [bpm]; CON, 189 [13] bpm; P = .21); rating of perceived exertion (P >.99); thirst (P = .62); or thermal sensation (P = .73) during exercise. Fluid consumed (P = .40), body mass change (P = .90), 400 m run times (P = .19) and 1,609 m run times (P = .17) were no different between trials. Whole-body cooling rate for body bag was .102 (.04) °C/min, whereas CON produced a cooling rate of .040 (.04) °C/min (95% CI, .030-.095; P = .002). Total cooling time was significantly faster (13.2 (5.8) min) with BB compared to CON (27.6 (4.2) min; 95% CI, 9.2-19.5; P = .002).

Conclusion: In clinical settings where full-body cold-water immersion is not feasible, or during emergency transport, partial immersion via body bags offers acceptable cooling rates for hyperthermic patients. Emergency medical personnel could apply these data for support in updating heat stroke protocols to include partial immersion via body bag during transport, or immediately upon emergency department arrival.

Introduction: The healthcare sector contributes 5.4–7.0% of Australia’s total carbon dioxide (CO₂) emissions. Among the most ubiquitous items used in healthcare organisations, whether it be hospital, clinic, or community health centres, are gloves.

Methods: We reviewed two case studies of the “Gloves Off!” sustainability initiative to compare reduction in glove use and improvement in hand hygiene practice—one that featured a “low-intensity” campaign (Hospital A) and the other a “high-intensity” campaign (Hospital B).

Results: A comparison of glove use over the year before and after implementation of the Gloves Off! campaign shows that Hospital A achieved a 2.6% reduction (0.4% reduction per patient), while Hospital B achieved an 11.4% reduction in total glove consumption (7.8% reduction in glove use per patient).

Conclusion: Sustainability initiatives can be initiated within busy emergency departments with reduced unnecessary use of nonsterile gloves, decreased CO₂ emissions, and cost savings. 

Introduction: In Lebanon, it is common for multiple family members to accompany patients to the ED. In this cultural context, where family is closely involved with patient care, we sought to identify and compare factors associated with satisfaction among patients and their companions during the same emergency department (ED) visit.

Methods: This cross-sectional, telephone-based survey compared factors associated with satisfaction among adult patients and their companions, during the same ED visit, at a tertiary-care center in Beirut, Lebanon. Adult patients presenting to the ED with intermediate- or low-acuity complaints were included in the study. We administered a questionnaire to patients and their companions covering six domains, including demographics, general admission, nursing and medical teams, discharge process, and overall satisfaction. Satisfaction was then categorized into high and low. We conducted an analysis of variables associated with high overall satisfaction for each group.

Results: A total of 100 patients and 100 companions completed the survey, with a 45.7% response rate. Among companions, the top three factors associated with high overall satisfaction were: respect of confidentiality and privacy (odds ratio 12.98, 95% CI, 4.79-35.19), length of stay before being seen by triage nurse (9.77, 3.68-25.89), and overall ED length of stay (9.56, 3.7-24.37). Among patients, the top three factors associated with high overall satisfaction were: amount of time the physician spent with the patient (20.26, 7.10-57.82); overall ED length of stay (19.71, 5.44-71.39), and length of stay before being seen by the emergency physician team (13.26, 4.84-36.35). All variables were statistically significant for both patients and companions except for the discharge process, which was only significant for companions.

Conclusion: This study suggests that patients and companions may have different experiences of their ED visit, highlighting the top factors associated with satisfaction for each group. Emergency department efforts aimed at enhancing patient experience should also consider processes related to companion experience in cultural contexts where family/relatives play an integral role in patient care.

Introduction: Frequent emergency department (ED) users, particularly those with high rates of use, often experience complex social determinants of health (SDOH) that contribute to their repeated visits and may lead to adverse health outcomes. Our objective in this study was to characterize the needs most commonly affecting this population, which may support the creation of tailored interventions with a higher chance of success.

Methods: This was a retrospective analysis of patients evaluated by an ED social medicine team in a large urban academic ED from May 2021–December 2023. Patients were identified either via frequent ED use (patients with the 10 highest number of visits each month) or referred by ED staff. We assigned 11 categories of medical, mental health, and social needs through chart review and team documentation. The primary outcome was the identification of distinct need-based subgroups among patients with high ED use, using latent class analysis of documented social, mental health, and medical needs.

Results: Of the 181 patients, representing approximately 0.4% of the ED patient population, 149 (82.3%) were frequent ED users, with a median of 14 ED visits annually (IQR 8-21), while the rest were referred by ED staff (median 2 visits (1-4.25). The majority were non-Hispanic Black (159, 87.8%) and publicly insured (163, 90.0%). The most common needs were related to housing instability (116, 64.1%) and limited access to outpatient care (112, 61.9%). Latent class analysis revealed four distinct subgroups, all of which included limited access to outpatient care: 1) primarily limited access to outpatient care (40, 22.1%); 2) housing instability and other basic needs (27, 14.9%); 3) housing instability, psychotic disorders, other basic needs, and inability to live independently (23, 12.7%); and 4) housing instability, substance use, and psychotic disorders (91, 50.3%).

Conclusion: This analysis identified four distinct need-based subgroups of  frequent ED users, suggesting the need for tailored, multifaceted interventions. Housing instability, psychiatric illness, substance use, and outpatient care access were prevalent across groups, underscoring the importance of including resources for these basic needs in any programs developed for this population. Findings support prioritizing coordinated care models, particularly those that incorporate housing, behavioral health, substance use resources, and navigation support, for this vulnerable population.

Introduction: Pain is the most prevalent complaint for the more than 155 million patients accessing emergency care in the United States. Appropriate and timely management of pain is a measure of quality emergency care. However, the opioid crisis has created a need for multimodal and alternative approaches to successful pain management. Models for integrating such approaches in emergency departments (ED) are understudied. Therefore, we chose to investigate the impact of live preferential music (LPM) in the management of acute musculoskeletal pain.

Methods: This prospective, randomized, double-blind intervention study was designed with block randomization clustered by day of the week to live preferred music versus usual care. To ensure blinding, patients were deceived that the study focus was on pain assessment without disclosure that there was an intervention. A total of 2,262 patients were screened, and 272 patients (94 interventions, 128 usual care controls, and 50 declined-music intervention) were recruited from two free-standing EDs. All subjects received analgesics per prescription, had vital signs measured, and completed baseline and follow-up Pain Intensity Number Scale (0-10) scores via PAINReportIt. We calculated morphine equivalents for pain medications in the ED.

Results: The mean age of the 222 patients in the per-protocol analytic sample was 48.3 years (95% confidence interval, 45.9-50.7); 64% were female, 29% Black; and their triage acuity was 4% emergent Emergency Severity Index (ESI) 2, 52% urgent ESI 3, and 44% less urgent ESI 4. There were absolute reductions in current pain intensity from baseline in both the control (–1.21) and intervention (–1.34) groups (difference –0.14, 95% CI, –0.48 to 0.76). However, the difference was not significant in posttest pain intensity when controlling for baseline pain intensity (P = .29). Qualitative analysis reflected patient-reported reduction in the perception of pain as a common theme. Vital signs and morphine equivalents were similar between groups.

Conclusion: This study demonstrated that live preferential music interventions are feasible to study rigorously in the ED. Patients were enrolled using deception and were not informed of the study’s focus on music or their potential exposure to music. However, they were told initially that they would be part of a pain assessment study. Although significant between-group differences were not observed, the general theme of patient-reported reduction in the perception of pain suggests that a more highly powered study might detect significant effects in pain reduction with LPM. Variation in clinician care strategies and evolving federal guidelines for pain management may have influenced study processes and outcomes.

Introduction: Gaps in care integration and coordination contribute to emergency department (ED) crowding and preventable hospitalizations, necessitating innovative solutions to improve care transitions and reduce acute care use. This study evaluates whether attendance at a nurse-led ambulatory intermediate care clinic (AICC) reduces three-month ED visits and hospitalizations compared to missed AICC appointments.

Methods: This retrospective cohort study at a single academic center analyzed AICC appointments from the first three years of clinic operations using multivariable logistic regression models, controlling for demographic, socioeconomic, and clinical factors. Our primary outcome measure was an ED visit within three months of the AICC appointment; our secondary outcome measure was hospitalization within three months. Robustness was assessed using Poisson, negative binomial, and zero-inflated models.

Results: Among 2,698 appointments analyzed (mean age 51.5 years; 49.7% female), patients who attended their AICC appointment had a lower absolute ED visit rate compared with those who missed it (250/2,389 [10.5%] vs 47/309 [15.2%]; risk difference, 4.75%; 95% CI, 0.56-8.93%; P = .03). Missing an AICC appointment was significantly associated with greater odds of an ED visit (OR, 1.54; 95% CI, 1.07-2.21; P = .02). Hospitalization rates were 47.3% versus 53.4% (P = .04), although missing an AICC appointment was not significantly associated with increased hospitalizations (OR, 1.28; 95% CI, 1.00-1.64; P = .05). Findings were consistent across robustness analyses.

Conclusion: The ambulatory intermediate care clinic model was associated with fewer ED visits but not reduced hospitalizations, suggesting that intermediate care can improve timely access and address acute care needs but may be insufficient to influence more complex drivers of inpatient admissions. Future research should explore strategies to enhance coordination and optimize the role of intermediate care within broader health system workflows.

Introduction: Emergency department (ED) crowding may alter physician decision-making, yet little is known about how real-time physician workload affects diagnostic imaging use. We examined the association between physician patient load and the proportion of patients who received diagnostic imaging, including computed tomography (CT), CT with intravenous (IV) contrast, CT without contrast, plain radiography, magnetic resonance imaging (MRI), and ultrasound (US).

Methods: We conducted a retrospective cohort study of all ED visits at an academic tertiary care center (January 2019–December 2024). Physician workload was defined as the sequential patient assignment order per physician per day (range 1–17). Our primary outcome measures were binary indicators of whether each imaging modality was ordered during the ED visit: CT (any); CT with IV contrast; CT without IV contrast; radiograph, MRI; and US. Multivariable logistic regression with physician-clustered robust standard errors estimated adjusted odds ratios (aOR) for each imaging modality, controlling for age, sex, triage acuity, chief complaint, and temporal factors. We also performed mixed-effects logistic regression with physician random intercepts and a within-between (Mundlak) decomposition. Absolute risk differences (ARD) were computed for the 17th versus the first patient.

Results: Among 287,925 encounters across approximately 41,132 physician shifts managed by 77 physicians, higher workload was associated with decreased odds of imaging for most modalities. Computed tomography with IV contrast showed the strongest effect (aOR 0.990, 95% CI, 0.986–0.994; within-physician aOR 0.991; ARD −2.2 percentage points [pp], from 21.8% to 19.6%). Results were as follows: any CT, aOR 0.994 (0.991–0.997); ARD −1.9 pp (from 38.7% to 36.8%); radiograph, aOR 0.994 (0.990–0.998, P < .001); ARD −1.6 pp (from 44.2% to 42.6%); US, aOR 0.994 (0.990–0.998, P < .001); ARD −0.7 pp (from 9.9% to 9.2%); and MRI was nonsignificant in the pooled model (aOR 0.993, P = .09) but significant in the mixed-effects model (P < .001). Noncontrast CT was unaffected (aOR 1.000, P = .87). Intraclass correlation coefficients ranged from 0.020–0.047, indicating 2–5% of imaging variance was attributable to physician-level differences.

Conclusion: Higher physician workload was associated with modestly reduced imaging use, particularly for resource-intensive modalities. Noncontrast CT was unaffected. Within-physician analyses were consistent with the interpretation that these effects reflect real-time behavioral adaptation rather than physician practice style alone. These findings highlight a trade-off between throughput and diagnostic testing that warrants further study of its impact on clinical outcomes.

Introduction: Effective communication in the emergency department (ED) is essential for safe patient care. Electronic health record (EHR)-integrated secure messaging may improve communication workflows, but limited evidence exists comparing clinician satisfaction across modalities in the ED. This study evaluated physician satisfaction with an EHR-integrated secure messaging tool compared to existing communication methods for non-emergent communication.

Methods: We conducted an electronic pre-post survey study at an urban academic ED following implementation of an EHR-integrated secure messaging tool in October 2024. The primary outcome was overall communication satisfaction pre-post implementation. We also compared nursing communication satisfaction and repeat consult order proportions. Survey domains (ease of use, efficiency, timeliness, clarity, overall satisfaction) were graded using a four-point forced-choice Likert scale.

Results: Response rates were 35% (33/95) pre-implementation and 36% (34/95) post-implementation. Although face-to-face communication maintained superior clarity ratings, secure chat received significantly higher overall satisfaction than phone communication (median 3 [IQR 3–4] vs 2 [2–3], P < .001) and higher ratings than the existing consult workflow across all domains (all P ≤ .03). Overall nursing communication satisfaction shifted toward higher scores post-implementation (median 3 [3–4] vs 3 [2–3], P = .03). Repeat consult order proportion decreased from 22% to 18% (risk difference, −3.5%; 95% CI, −4.5% to −2.5%; P < .001).

Conclusion: Electronic health record-integrated secure messaging demonstrated high user satisfaction among emergency physicians and may reduce repeat consultant communications. Secure chat provides a complementary communication channel in the ED setting.

Introduction: Early Warning Scores (EWS) are used to support decisions regarding triage and early intervention of patient deterioration in emergency departments (ED) and other clinical environments. We synthesized evidence from systematic reviews on the predictive performance and clinical impact of EWS and their modifications in adult in-hospital populations.

Methods: We conducted and reported an overview of reviews following the Joanna Briggs Institute (JBI) methodology, PRIOR statement, and our predefined protocol. A systematic search of MEDLINE (Ovid) and Epistemonikos was performed in May 2025. Two reviewers independently screened studies, extracted data, and critically appraised systematic reviews. We included systematic reviews of adult in-hospital populations evaluating EWS as either prognostic tools for deterioration or mortality, or as interventions implemented within track-and-trigger or rapid response systems. Primary study overlap was quantified using the corrected covered area (CCA). We synthesized evidence narratively and tabularly, emphasizing ED-related data.

Results: From 502 records identified, 21 systematic reviews comprising 343 primary studies were included. We identified ED-relevant evidence in 12 reviews. In ED populations, EWS demonstrated moderate-to-good discrimination for mortality and clinical deterioration (National EWS area under the receiver operating characteristic curve (AUROC) values: 0.88 for 24-hour mortality, 0.86 for 48-hour mortality). Across ED and mixed acute-care cohorts, Early Warning Scores also showed fair performance for predicting ICU admission and composite adverse outcomes (AUROC ~0.70–0.75). In sepsis-focused analyses relevant to ED populations, quick Sequential Organ Failure Assessment (qSOFA) demonstrated low sensitivity but high specificity for 28/30-day mortality (sensitivity 0.41, 95% CI, 0.24–0.62; specificity 0.88, 95% CI, 0.81–0.92). The SOFA score showed high sensitivity and moderate specificity for in-hospital mortality (sensitivity 0.89, 95% CI, 0.88–0.90; specificity 0.69, 95% CI, 0.68–0.69). Evidence on the clinical impact of EWS implementation in ED and other emergency settings was limited and heterogeneous.

Conclusion: In EDs, Early Warning Scores support early risk stratification and identification of patients at risk of deterioration, particularly for short-term mortality and escalation of care. Their impact on patient-important outcomes remains uncertain. Early Warning Scores should complement clinical judgment, triage systems, and structured escalation protocols. They should not be a standalone tool. Future research should prioritize standardized thresholds, transparent reporting, and rigorous comparative and implementation studies defining the role of EWS in emergency care.

Introduction: Emergency medicine literature has long debated the “black cloud” and “white cloud” phenomena, which suggest individual variability in exposure to acutely ill patients. If true, this variation may have significant implications for resident training. This study investigates whether emergency medicine (EM) residents consistently encounter differing volumes of high-acuity clinical encounters throughout their training.

Methods: This retrospective cohort study analyzed 11 years of electronic health record (HER) data from a Midwestern academic emergency department to quantify the number of acutely ill adult patients seen by EM residents across three years of training, using a consensus-based set of clinical criteria. Our primary outcome was the concordance of the ranking of each resident within their cohort by number of acutely ill patients seen during postgraduate year one (PGY 1) compared to PGY 3. Statistical analyses to assess this outcome included weighted kappa and linear regression.

Results: A total of 93 EM residents met the criteria for inclusion and saw a total of 359,736 patients during their residency (average 3,493 per resident). Residents saw an average of 167.5 (19.8) acutely ill patients during their residency training. This volume increased sharply by year, with PGY-1 residents seeing an average of 23.8 (7.3) acutely ill patients, and PGY-3 residents seeing an average of 100.3 (19.4). Both weighted kappa (κ = -.274) and linear regression analysis (β = -0.84; 95% CI, -1.4 to -0.31; P = .002) indicated that a resident who saw more acutely ill patients than average in PGY 1 was more likely to see fewer acutely ill patients than average during PGY 3. Results were unaffected by the COVID-19 years or subsequent critical care fellowship pursuit.

Conclusion: “Cloud type” (as measured by EHR-documented care for acutely ill patients) does not appear to be a stable trait over time. Our findings are consistent with previous studies that found no association between residents’ “cloudiness” and objective measures of workload. Using EHR data to track resident clinical exposures helps educators identify training gaps and target remediation through in situ or simulated experiences.

Introduction: Residency program leaders shape the academic pipeline in emergency medicine (EM). We assessed current demographics and postgraduate training among EM residency leadership in the United States.

Methods: We conducted a national, cross-sectional survey of all Accreditation Council for Graduate Medical Education–accredited EM residency program leadership via an online, confidential questionnaire. Primary outcomes were the prevalence of any postgraduate fellowship training and any secondary board certification (ie, additional board certification beyond EM) as a complementary marker of advanced credentialing distinct from fellowship training. Programs were grouped by National Resident Matching Program (NRMP) region.

Results: We received 103 program responses (35.9%). Any fellowship training was reported by 25.5% of program directors (PD), 40.0% of associate program directors (APD), and 42.8% of assistant PDS. Compared with the 2014–2015 national survey, fellowship training increased from approximately 20–25% to 40–43% among APD and assistant PDs, while remaining similar among PDs (~25% previously vs 26% in the current survey). Any secondary board certification was reported by 8.8% of PDs, 5.0% of APDs, and 8.2% of assistant PDs. Medical education was the most common fellowship (n = 54), followed by ultrasound (n = 24), toxicology (n = 16), simulation (n = 15), pediatric EM (n = 11), critical care (n = 7), emergency medical services (n = 5), and administration (n = 3). Programs in the western United States reported the highest proportions of leaders with either fellowship or secondary certification across roles.

Conclusion: Postgraduate fellowship and secondary board certification remain uncommon overall among EM residency leaders, but fellowship completion is more prevalent among junior leaders compared with a decade earlier. These data provide an updated, role-specific snapshot to inform leadership development and workforce planning.

Introduction: Podcasts have become a widely used educational tool in emergency medicine. In this study, a podcast was used as the intervention. This podcast consisted of a brief audio summary of weekly in-person conference content produced by residents and faculty. We assessed whether a resident-led, curriculum-based podcast summary improved knowledge retention and learner engagement compared to a standard written summary format.

Methods: This mixed-methods prospective cohort study conducted at a single urban academic hospital included 54 emergency medicine residents and approximately 66 attending physicians. The study unfolded in three phases: eight weeks of standard written conference summaries (control); followed by eight weeks of written plus podcast conference summaries (intervention); and a four-week post-intervention period with surveys. The primary outcome was knowledge retention, measured by weekly postconference quiz scores comparing the written-summary phase (control) with the podcast phase. Secondary outcomes included learner satisfaction, podcast usage patterns (downloads and self-reported listening), and self-reported impact on clinical application of conference content. Data included quiz scores, survey responses, and podcast analytics. Statistical comparisons of quiz performance were made using paired t-tests. Thematic analysis of open-ended responses was performed using Braun and Clarke’s framework.

Results: Mean quiz scores were 73.1% (standard deviation [SD] 6.6) during the written phase and 73.7% (SD 14.4) during the podcast phase with no statistically significant difference in weekly quiz performance between conditions (paired t-test, P = .92). An exploratory linear trend analysis suggested a steeper week-to-week improvement during the podcast phase, but this post-hoc finding should be interpreted cautiously. Although the podcast did not improve knowledge retention compared with the existing written summary, learners reported high satisfaction, perceived reinforcement of key concepts, and convenient asynchronous access.

Conclusion: In this mixed-methods study, a residency-run podcast summary did not improve quiz-based knowledge retention compared with an existing written conference summary. However, learners reported high satisfaction, perceived reinforcement of key concepts, and convenient asynchronous access.

Introduction: Older adults frequently present to the emergency department (ED) with low-energy blunt chest trauma, and clinically important intrathoracic injuries may be under-detected during the initial evaluation. We aimed to evaluate whether bedside findings—particularly focal chest tenderness patterns (including anterior chest wall tenderness [ACWT] and lateral compression tenderness)—were associated with computed tomography (CT)-confirmed intrathoracic injury in older adults with low-energy blunt chest trauma, while also examining chest pain and early warning scores (EWS) as adjunct clinical variables.

Methods: A single-center prospective study included 136 patients 65 years or older presenting within 24 hours of low-energy blunt trauma that did not meet prespecified high-energy criteria. The primary outcome was any intrathoracic pathology on chest CT during the index ED visit. Secondary analyses examined associations between CT-confirmed injury and bedside findings (including chest pain, ACWT, lateral compression tenderness, thoracic spine tenderness, visible chest skin trauma, and auscultatory abnormalities), routine clinical variables, and laboratory measures; rib fracture and disposition were treated as prespecified exploratory analyses. The National Early Warning Score and Modified Early Warning Score were evaluated as exploratory physiologic comparators. Routine laboratory testing at presentation included arterial blood gas analysis. Chest CT performed during the index ED visit served as the imaging reference standard, with intravenous contrast use determined by clinical indication. The National Emergency X-Radiography Utilization Study (NEXUS) chest criteria informed routine imaging selection. Logistic regression identified independent associations, and diagnostic performance metrics were calculated for key bedside tenderness findings.

Results: For 136 studied patients, mean age was 78.9 (9.2) years, and 60.3% of patients were female. Ground-level falls accounted for 72.8% of injuries. Chest pain was reported in 19.9% of patients. Lateral compression tenderness (21.3%) and ACWT (25.0%) were the most common examination findings. On univariable analysis, chest pain and lateral compression tenderness were associated with intrathoracic pathology; in multivariable analysis, ACWT was the only independent bedside predictor of the primary outcome (adjusted odds ratio [OR] 4.18, 95% CI, 1.85–9.44; P < .001). For rib fracture, ACWT, chest pain, and lateral compression tenderness remained independently associated. For intrathoracic injury, ACWT had a sensitivity of 47.6% (95% CI, 32.0–63.6), specificity of 85.1% (95% CI, 76.3–91.6), positive predictive value of 58.8% (95% CI, 44.5–71.8), negative predictive value of 78.4% (95% CI, 72.9–83.1), a positive likelihood ratio of 3.2 (95% CI, 1.79–5.70), and a negative likelihood ratio of 0.62 (95% CI, 0.46–0.83), supporting its role as a rule-in bedside cue. Lateral compression tenderness was also associated with intrathoracic injury (OR 3.81, 95% CI, 1.62–8.94; P = .002).

Conclusion: In older adults with low-energy blunt chest trauma, focal chest tenderness findings—especially anterior chest wall tenderness, lateral compression tenderness, and chest pain—were associated with higher odds of CT-confirmed thoracic injury; however, ACWT was the only independent bedside predictor of the primary outcome. These findings function as rule-in rather than rule-out cues. Early warning scores showed limited utility for anatomic injury detection in this cohort and should not be interpreted as trauma-specific imaging decision tools.

Background: Traumatic brain injury (TBI) is a leading cause of death and disability in the United States. Rural residence and low community income are independently associated with poorer health outcomes, mediated by variations in injury mechanism and healthcare access. We evaluated the impact of geographic location on injury patterns and acute‐care metrics in adults with TBI treated at Maryland’s statewide Level I trauma center.

Methods: Adults (≥18 years of age) with radiographically confirmed TBI admitted between 2017 and 2021 were identified retrospectively from the institutional trauma registry. Rural residence was defined using Rural-Urban Commuting Area codes. This single-center study included only patients surviving to hospital admission. Primary outcomes included hospital length of stay (LOS) and discharge to hospice or death. Secondary outcomes included intensive care unit (ICU) and ventilator days and discharge disposition.

Results: Of 2,812 patients diagnosed with TBI during the study period, 267 (9.5%) resided in rural areas. Compared with nonrural patients, rural patients were older (median age 67 vs 60 years, P < .001) and lived in lower income communities. However, after adjustment for demographic and clinical covariates, rural residence was not associated with higher hospital LOS quartile category (adjusted odds ratio [aOR] 1.18; 95% CI, 0.91-1.53; P = .20), discharge to hospice or death (aOR 1.67; 95% CI, 0.95-2.94), or discharge to a nonhome setting (aOR 0.93; 95% CI, 0.66-1.31). Groups showed no significant differences in critical care use, including ICU and ventilator durations. Worse outcomes were associated primarily with injury severity, including lower Glasgow Coma Scale scores and higher Injury Severity Scores.

Conclusion: In a well-established regional trauma network, we found that among patients admitted with traumatic brain injury, residing in a rural area was not independently associated with worse in-hospital outcomes compared to patients who resided in nonrural (urban and suburban) communities. These findings suggest that a coordinated statewide trauma triage and access to tertiary neurotrauma care may help other systems similarly reduce rural disparities after severe head injury.

Introduction: Traumatic cardiac arrest is associated with poor survival and significant consumption of hospital resources. Determining which patients have survivable injuries allows for judicious use of resources. Our aim was to determine whether cardiac activity on point-of-care ultrasound (POCUS) during traumatic cardiac arrest was associated with increased patient survival and the charges of continued resuscitation in patients that do have cardiac activity on POCUS.

Methods: We conducted this single-center retrospective study at an urban, Level I trauma center of consecutive patients arriving in traumatic cardiac arrest from August 2016–December 2023 who had a cardiac POCUS performed during the initial resuscitation efforts. Our primary outcome was to determine whether cardiac activity on POCUS during the arrest was associated with increased patient survival to neurologically intact hospital discharge. Secondary objectives included determining whether there was a correlation between cardiac activity on POCUS during traumatic cardiac arrest and survival to hospital admission. Additionally, we evaluated hospital charges and length of stay associated with continued resuscitation in patients who demonstrated cardiac activity on ultrasound.

Results: We identified 134 patients in traumatic cardiac arrest, of whom 74 (55.2%) had a cardiac POCUS performed and met inclusion criteria. A total of 17 patients had cardiac activity noted on the initial POCUS, with two (11%) surviving to hospital discharge (95% CI, 1.3-39.7). The two survivors initially categorized as being in traumatic cardiac arrest were ultimately found to have medical etiologies and not trauma. Of the 57 patients who had no cardiac activity noted on POCUS, none survived to hospital discharge (95% CI, 0-6.3%). More patients survived to hospital admission who had cardiac activity on their initial POCUS compared with those who had no cardiac activity (odds ratio [OR], 49.8; 95% CI, 5.5-446.9; P < .001). More patients survived to hospital discharge as well, but this was not statistically significant (OR, 18.6; 95% CI, 0.84-406.7, P = .06). Traumatic cardiac arrest patients who had present cardiac activity had longer code times prior to terminating efforts (26.6 vs 7.7 minutes, P < .001) and had higher overall charges per patient ($91,321 vs $10,032), P < .001).

Conclusion: The absence of cardiac activity on POCUS in patients with traumatic cardiac activity is likely to be fatal. The presence of cardiac activity was associated with increased resuscitation times, charges, and survival to hospital admission but not necessarily to hospital discharge.

Introduction: Pediatric traumatic extremity or digit amputations are preventable causes of morbidity. The object of this study was to evaluate the etiology and outcomes of these injuries in our region. We used the Childhood Opportunity Index to explore the role of social determinants of health.

Methods: We performed a retrospective cohort study at an academic children’s hospital on all pediatric patients younger than 18 years who presented with a traumatic digit or extremity amputation between January 1, 2014, to July 31, 2024. Metrics such as patient demographics, injury severity, prehospital course, hospital events and follow-up were abstracted. The Childhood Opportunity Index assigns a 0-100 composite score of region-based childhood opportunity determined from home ZIP codes. Our primary outcome measure was mechanism of injury. Secondary outcomes included length of stay, need for initial surgical intervention, subsequent operations, or unplanned readmissions.

Results: A total of 73 patients presented with a traumatic amputation of a digit or extremity. The median age was 12.7. The top three causes of amputations were all-terrain vehicle (ATV) crashes, fireworks, and entrapment in an object. All-terrain vehicle crashes were the most common cause in all age groups from 5-17, while caught in an object was the most common for ages 0-4. The median Injury Severity Score was 5 (IQR 7). The three most common sites of amputation were right index finger (21), right long finger (17), and left long finger (15). Thirty-three children (45.2%) had more than one amputation. The highest number of amputations in a single patient was 10. All patients underwent a surgical intervention, and there were no mortalities. The median Childhood Opportunity Index score of the cohort was low at 19 (IQR 33), with 73% (n = 53) of the cohort originating from a very low (n = 37) or low (n = 16) index region. A rising index score was weakly associated with a decrease in total number of amputations (ρ = -0.25 [CI, -0.45 to -0.02, P = .04]).

Conclusion: A. total of 73 children in our region suffered a traumatic digit or extremity amputation, mostly due to ATV crashes and fireworks. Most patients originated from a neighborhood of very low or low Childhood Opportunity Index scores. Increased public awareness regarding the danger of ATVs in regions with lower index scores may prevent these injuries. Clear, targeted policies toward ATV usage in childhood are needed.

Introduction: The rapid assessment zone is a newer model for optimizing emergency department (ED) throughput. Similar models implemented in adult ED settings have shown improvements in throughput parameters. However, few studies have taken place in the pediatric ED setting. Our study objective was to assess the impact of implementing a rapid assessment zone on throughput in an urban pediatric ED. We hypothesized that length of stay (LOS), time to bed placement, and time to see a clinician would decrease after the intervention and remain sustainable over long-term follow-up.

Methods: This retrospective study assessed the effect of rapid implementation from May 2012–April 2018 on LOS for ED visits for three two-year time periods: pre- and post-rapid assessment zone and post-follow-up. Our primary outcome measures were LOS, time from registration to bed, and time from registration to first clinician evaluation. Secondary outcome measures were how LOS differed between high- and low-acuity visits. We analyzed data using Kruskal-Wallis for comparison of medians and Wilcoxon rank-sum tests with Bonferroni correction for pairwise comparisons.

Results: There were 304,318 unique ED visits from May 1, 2012–April 30, 2018, with an increase in volume over time (92,551 visits pre-rapid assessment zone and 106,530 visits post-follow-up). Overall median LOS decreased from pre- rapid assessment zone, post- rapid assessment zone, and post-follow-up, respectively (110 minutes versus 101 minutes vs 94 minutes; P < .001). When stratified by acuity level, low-acuity visit LOS decreased from pre- rapid assessment zone to post- rapid assessment zone to post-follow-up (85 min vs 77 min vs 70 min; P < .001), whereas LOS for higher-acuity levels was, on average, unchanged (144 min vs 149 min vs 143 min for pre-RAZ, post- rapid assessment zone, and post-follow-up, respectively; P < .001). The overall registration to clinician time decreased from 15 minutes to 13 minutes (P < .001) between pre-rapid assessment zone and postfollow-up, which is statistically but not clinically significant.

Conclusion: Implementation of a rapid assessment zone significantly decreased overall length of stay in our pediatric ED despite increased patient volume, especially for lower acuity patients. The rapid assessment zone model can be effective in preventing crowding in a pediatric ED with a large proportion of low-acuity visits.

Introduction: Pediatric emergency departments (PEDs) and general EDs in the United States (U.S.) do not consistently deliver sexually transmitted infection (STI) care that aligns with clinical guidelines. To inform the development of an implementation strategy plan aimed to improve STI care in a PED, we interviewed PED nurse and physician stakeholders to identify challenges and corresponding potential solutions aimed to improve STI care in a PED.

Methods: We conducted semi-structured interviews with 27 stakeholders consisting of emergency medicine (EM) residents, pediatrics residents, pediatric EM (PEM) fellows, attending pediatric emergency physicians, and PED nurses at an academic urban PED. Using the Tailored Implementation in Chronic Diseases (TICD) framework, we prepared semi-structured interview guides specific to stakeholder roles structured according to the usual six successive workflow stages of STI care in the PED (triage, history-taking, physical examination, testing, treatment, and follow-up). Questions concerned current practices on providing STI care, challenges encountered, and potential solutions. Interviews were transcribed and analyzed using rapid content analysis. Responses were coded independently by two reviewers and categorized by TICD determinant domain.

Results: Participants identified multilevel implementation challenges across the stages of STI care in the PED. Structural challenges included lack of privacy and limited private exam rooms, inadequate STI-related workflows, and inadequate waiting areas. Procedural challenges included the following: nonstandardized triage protocols; unclear role delineation; confusing sample collection procedures; insufficient training in STI examination, testing, and treatment procedures; variable documentation practices; and difficulty ensuring follow-up. Suggested solutions included development of role-specific STI protocols, smart phrases for documentation, improved sample-labeling procedures, prepackaged medications for empiric treatment, and embedded referral pathways to an adolescent care clinic.

Conclusion: Using the TICD framework, this study identified key challenges, such as gaps in training, protocols and transition of care, and corresponding stakeholder-informed solutions to improve adolescent care for STIs in a pediatric ED setting. These findings can guide efforts to implement evidence-based STI practice guidelines in PEDs and general EDs.

Introduction: Febrile infants ≤ 60 days of age are at increased risk for serious bacterial infections (SBIs), often necessitating extensive diagnostic evaluation and hospitalization. Although respiratory viral infections are common in this population and may influence the likelihood of concurrent bacterial infection, the relationship between respiratory viral panel (RVP) results and SBI risk remains an important consideration in clinical decision-making. The objective of this study was to evaluate the association between RVP results and the occurrence of SBIs among febrile infants ≤ 60 days of age.

Methods: In this single-center, retrospective study we analyzed data from infants ≤ 60 days of age who presented to the emergency department with fever (temperature > 100.4 °F/38 °C) between September 2020–May 2024. Infants were divided into two subgroups based on RVP results: positive or negative for any viral infections via a multiplex polymerase chain reaction panel. The overall rate of SBI, and the rates of individual SBIs (urinary tract infection [UTI], bacteremia, and bacterial meningitis), were compared between groups. The primary outcome was the rate of SBIs among infants with any positive RVP compared to those with a negative RVP.

Results: We analyzed 1,986 charts of febrile infants ≤ 60 days of age, of whom 485 (24.4%) met criteria. Of these, 309 (63.7%) had a positive RVP for at least one pathogen while 176 (36.3%) were all negative. Overall, the rate of serious bacterial infection in the RVP negative group was 35.8% (95% CI, 29%-43.1%) compared to 6.5% (95% CI, 4.1%-9.6%) in the RVP positive group (P < .001). Infants with a positive RVP had a significantly lower prevalence of serious bacterial infection (7.4%) and UTI (5.5%) compared to those with a negative RVP (P < .001). In the RVP positive group, 17 patients (5.5% [95% CI, 3.4%-8.5%]) had a UTI compared to 46 (26.1% [95% CI, 20.1%-33%]) in the RVP negative group. Notably, there were four cases of bacteremia (1.3% [95% CI, 0.4%-3%])  in the positive RVP group compared to 20 (11.4% [95% CI, 7.3%-16.7%]) in the negative RVP group. In the positive RVP group, there were 0 cases of meningitis (0% [95% CI, 0%-0.9%]) compared to 5 (2.8% [95% CI, 3.4%-85%]) in the RVP-negative group. The differences in bacteremia and meningitis rates between the two groups were statistically significant (P < .001).

Conclusion: Febrile infants ≤ 60 days of age with a positive RVP are associated with a significantly lower risk for SBI compared to those with a negative RVP, a 64% relative risk reduction. If validated with a prospective study, these findings could help guide clinical decision-making, potentially allowing for a more nuanced approach to the management and disposition of febrile infants, particularly the need for invasive workup and hospitalization.

Introduction: Historically, flumazenil was employed as both a diagnostic aid in unresponsive patients and as an antidote for suspected benzodiazepine overdose in both emergency departments and out-of-hospital settings. However, its prehospital application has been historically constrained by long-standing concerns regarding adverse events, leading many emergency medical service (EMS) systems to restrict or avoid its use. The use of flumazenil in the prehospital setting remains underreported in the literature, despite its inclusion in the treatment protocols of various EMS agencies. We conducted a descriptive analysis of the use of flumazenil by EMS in the out-of-hospital setting across the state of Kansas over a five-year period. We characterize the frequency, indications, patient outcomes, and associated adverse events of flumazenil administration, thereby contributing to a better understanding of its role, safety, and clinical relevance in prehospital care.

Methods: We performed a retrospective observational cohort design to evaluate the use of flumazenil by EMS clinicians in the state of Kansas from January 2015–August 2020. Patient care reports documenting prehospital administration of flumazenil were obtained from the Kansas Board of EMS. Data extracted included demographics, indications, initial and subsequent Glasgow Coma Scale (GCS) scores when available, clinical response, and the occurrence of adverse events. Our primary outcome measure was GCS improvement following administration, with secondary outcome measures including patterns and outcomes with flumazenil use in the prehospital setting, clinical response, and occurrence of adverse side effects.

Results: A total of 80 cases involving EMS administration of flumazenil were identified with 69 cases meeting inclusion criteria. No seizures or adverse events were associated with flumazenil use (0/69; 95% CI, 0–4.3%), even in administrations with possible contraindications. Of the 69 cases analyzed, 24 cases documented suspected benzodiazepine overdose, all of which documented neurologic improvement (24/24; 95% CI, 87.5–100%), with 17 receiving flumazenil alone and 7 with naloxone coadministration. 

Conclusion: In this small sample, no adverse events were noted with flumazenil administration in the prehospital setting. Flumazenil administration was commonly associated with documented improvement in GCS in suspected benzodiazepine overdose. These findings suggest that exclusion in EMS protocols based solely on concern for adverse events in the prehospital setting can be reconsidered. Further research is needed to better define its safety, efficacy, and clinical utility in this setting.

Background: In the Philadelphia region, there has been an increase in the potency of illicit opioids as well as the addition of nonopioid adulterants. Currently, medetomidine, a veterinary anesthetic that acts as an alpha-2-adrenergic agonist, is a common adulterant in the illicit opioid supply, causing both unique overdose and withdrawal syndromes. Although opioid withdrawal alone is not deadly, with added adulterants, especially medetomidine, this is no longer the case. Dexmedetomidine is an alpha-2-adrenergic agonist frequently used for sedation in the emergency department and intensive care unit. Dexmedetomidine is also used off-label to treat the life-threatening withdrawal from alpha-2-agonists.

Objective: This study describes the dosing and hemodynamic effects associated with the interfacility administration of dexmedetomidine in patients with alpha-2 adrenergic agonist withdrawal. Secondarily, we describe the safety of dexmedetomidine in this patient population.

Methods: We conducted a retrospective case review of patients receiving dexmedetomidine infusions in the interfacility setting for presumed alpha-2–adrenergic agonist withdrawal. Demographic data, dosing, and vital signs were analyzed descriptively.

Results: Over a six-month period, of 217 cases identified, 182 contained complete hemodynamic data. The average age was 39.5 years, and 67% were male. The average transport time was 15.7 minutes (range, 5-40 minutes). The mean dexmedetomidine infusion rate was 1.32 (0.31) mcg/kg/hr. The average mean arterial pressure decreased from 122.1 mm Hg (21.7) at the time of initial patient contact to 118.3 mm Hg (21.7) (mean difference, 3.80; 95% CI, 1.96-5.64) at final patient interaction. Heart rate also showed a minimal change from 104.9 (23.7) to 103.6 (21.8) beats/min (mean 1.3; 95% CI, -0.48 to 3.08). No cases of severe hypotension or clinically significant bradycardia requiring intervention were documented (one-sided 95% CI, 0-1.7%).

Conclusion: In this case series of patients, prehospital dexmedetomidine infusions to treat alpha-2-agonist withdrawal were associated with stable hemodynamics without significant bradycardia or hypotension. These findings support the safety of dexmedetomidine infusions for interfacility transport and provide a rationale for examining whether advanced life support clinicians can safely transport patients receiving dexmedetomidine infusions for this indication.

Introduction: High-quality cardiopulmonary resuscitation (CPR) is essential to improve survival in cases of cardiac arrest. However, skill acquisition based solely on instructor observation has proven to be limited. In this context, real-time feedback devices emerge as promising tools to optimize CPR training.
Objective: In this study our goal was to evaluate the effect of using a real-time feedback device on the quality of CPR performed by medical students at a public university in Colombia.

Methods: This was an experimental study with fourth-year medical students, randomly assigned to two groups. Both groups received the same initial theoretical and practical training in basic CPR. Subsequently, the intervention group practiced with a real-time feedback device, while the control group trained without technological feedback. The primary outcome measure was the target of chest compressions, simultaneously meeting both a rate of 100-120 compressions/minute and a depth of 5-6 cm (maximum value: 100%), as well as ventilations delivered within the 500-600 mL volume range. Secondary outcomes included isolated data on compression depth and rate during two simulated scenarios: hands-only CPR for two minutes and five cycles of 30 chest compressions and two ventilations.

Results: Of 106 eligible participants, 98 (92.5%) completed the test (46 intervention / 52 control). Regarding the primary outcome, the intervention group showed significantly higher compliance with the compression target compared to the control group (median values: intervention group 31% vs control group 0%, P < .001). In the hands-only CPR test, the intervention group achieved a higher compression target (72% [40.7-81] vs 3.4% [0-40]; P < .05) and better depth control (5.5 cm [5-5.6] vs 6 cm [5.6-6.1]); P < .05], with no differences in rate (P = .71). In the test with cycles of 30 chest compressions and two ventilations, the intervention group performed better, with a higher compression target (73% [5-83] vs 0.5% [0-19]), P< .05) and better depth control (5.5 cm [5-5.8] vs 6 cm [5.9-6.1], P < .05). No significant differences were observed in ventilation. Both groups had a median target completion of 0% with tidal volumes (intervention group, 265 mL; control group, 291 mL), accounting for failure at well below the recommended 500-600 mL.

Conclusion: Real-time feedback significantly improved chest compression quality in medical students, although ventilation difficulties persisted. Future research is needed to assess long-term skill retention and clinical application. 

Introduction: Chest pain patients presenting to the emergency department (ED) often require risk stratification through stress testing, which may necessitate hospitalization. This practice contributes to ED crowding by occupying beds with low-risk patients who may derive limited benefit from testing, thereby increasing bed occupancy, prolonging ED boarding times, amplifying crowding, and resource strain. Use of an artificial intelligence (AI)-driven clinical decision support tool improves the detection of obstructive coronary artery disease and focuses diagnostic testing on those most likely to benefit.

Methods: We created a Monte Carlo simulation informed by available published inputs and ran 1,000 trials to estimate the national impact of using an AI-driven decision-support tool to reduce avoidable downstream cardiac testing among eligible U.S. ED patients with chest pain. Model inputs included patient demographics, chest pain history, electrocardiogram (ECG) findings, medication use, and lab values (including some nonroutine tests). Our primary outcome was U.S. annual cost savings from reclassifying eligible ED patients using an AI-driven decision-support tool. Secondary outcomes included reductions in short-stay hospitalizations, cancer cases, and cancer deaths due to averted radiation exposure.

Results: Universal adoption of an AI-driven decision-support tool was estimated to save a mean (standard deviation) of $675 million ($340 million) by avoiding 688,000 (147,000) downstream cardiac diagnostic tests. This resulted in annual decreases of 537,000 (115,000) hospitalizations, 8.30 million (1.96 million) bed hours, 490 (150) new cancer diagnoses, and 250 (80) cancer deaths.

Conclusion: Assuming similar recategorization of patients seen in a European outpatient cohort, widespread adoption of an AI-driven clinical decision-support tool to evaluate U.S. ED patients with suspected obstructive coronary disease could yield substantial benefits by reducing avoidable downstream cardiac testing. By accurately identifying patients who do not require urgent diagnostics, this approach could help mitigate crowding, relieve resource strain, and improve patient flow—supporting a more efficient emergency care system. 

Introduction: Endotracheal intubation (ETI) is a life-saving procedure commonly performed in emergency departments (ED). Prior research has demonstrated significant variability in ETI experience, practices, and outcomes across EDs. Health systems often include a mix of ED environments, from large academic hospitals to community-based and freestanding EDs. However, little is known about how ETI experiences and outcomes vary within a single health system. Our objective in this study was to compare first-attempt success across three EDs representing different practice environments but within one health system.

Methods: This retrospective observational study used institutional data from 1,659 ETI events between November 2021–January 2025 to compare ETI-related outcomes across three EDs representing a spectrum of settings: an academic Level I trauma center (A); a community teaching hospital (B); and a nonteaching community site (C). Our primary outcome measure was first-attempt success. We also assessed adverse airway outcomes and ETI-related patient and procedural characteristics. Chi-square tests evaluated the association of ETI-related outcomes and hospital sites.

Results: Annual ED volumes were approximately 82,000 (A), 64,000 (B), and 49,000 (C), with respective ETI encounters per 1,000 patients of 5, 2, and 0.4. The community teaching hospital had the highest first-attempt success rate of 90.2% (B: 331/367; 95% CI, 87.2-93.2), followed by the academic center with 84.6% (A: 1038/1227, 95% CI, 82.6-86.6), and then by the nonteaching community site with 78.5% (C: 51/65; 95% CI, 68.5-88.5) (P = .01). Adverse airway outcomes occurred in 10.5% of ETIs and did not vary significantly between sites (A: 139/1,227 [11.3%]; B: 29/367 [7.9%]; C: 6/65 [9.2%], P = .16). The most common indication was airway protection, followed by altered mental status and cardiopulmonary arrest for all three sites. Trainees performed the majority of ETIs at hospital A (1,096/1,227; 89.3%), while attending physicians predominated at B (295/367; 80.4%) and C (64/65; 98.5%).

Conclusion: We found significant variation in first-attempt success between the three ED sites, although overall success and adverse airway outcomes were comparable. These findings suggest that first-attempt success may be impacted by factors such as patient differences, role and training level of laryngoscopists, and inherent site-level differences such as patient volume and acuity.

Introduction: The Emergency Severity Index (ESI) is a widely used triage tool in emergency departments (EDs) and is associated with adverse outcomes. Lactate has also been associated with mortality in various ED populations. This study evaluated whether lactate levels measured after triage at the treating physician’s discretion are associated with in-hospital mortality across ESI levels in admitted ED patients.

Methods: This study is a secondary analysis of prospectively collected data from adult patients presenting to the ED of a Swiss tertiary care center in 2013, 2015, 2017, and 2019. The study included admitted patients who underwent post-triage lactate measurement at the treating physician’s discretion. Only the first lactate value measured in the ED was analyzed and categorized as < 2.0, 2.0–3.9, and ≥ 4.0 mmol/L. The primary outcome was in-hospital mortality; secondary outcomes were 30-day mortality and intensive care unit (ICU) admission. Associations were assessed using multivariable logistic regression models adjusted for age and sex. Model discrimination was compared using receiver operating characteristic curve analysis.

Results: Among 3,909 patients admitted from the ED who had a lactate drawn (of 17,327 ED presentations during the study period; 22.6%), the median age was 72 years and 2,062 (52.8%) were male. In-hospital mortality occurred in 168 (4.3%), 30-day mortality in 258 (6.6%), and ICU admission in 698 (17.9%). In ESI levels 2 (n = 1,826) and 3 (n = 1,722), crude in-hospital mortality was similar (59 [3.2%] and 44 [2.6%], respectively), but varied after stratification by lactate level. In ESI level 2 patients, in-hospital mortality occurred in 24 (2.0%) among those with lactate < 2.0 mmol/L (n = 1,210) and in 18 (17.8%) among those with lactate ≥ 4.0 mmol/L (n = 101), corresponding to an age- and sex-adjusted absolute risk difference of 16.0% (95% CI, 8.8–23.3). In ESI level 3, in-hospital mortality occurred in 20 (1.6%) at lactate < 2.0 mmol/L (n = 1,254) and in 8 (15.1%) at lactate ≥ 4.0 mmol/L (n = 53), corresponding to a risk difference of 12.5% (95% CI, 3.7–21.3). Discrimination for in-hospital mortality was higher when lactate was considered alongside ESI (area under the curve [AUC] 0.844 versus 0.799; ΔAUC 0.045, 95% CI, 0.021–0.069), with smaller increases for 30-day mortality and ICU admission.

Conclusion: In admitted ED patients who had lactate measured after triage at physician discretion, higher lactate levels were associated with increased in-hospital mortality across ESI levels, particularly among patients triaged as ESI levels 2 and 3. 

Introduction: Adolescents frequently seek care in the emergency department (ED) for behavioral health emergencies. Due to national shortages in staffing, limited opportunities to begin treatment on site in most centers and, thus, the frequent default to elusive inpatient psychiatric beds as a means of stabilization, adolescents may spend prolonged amounts of time boarding in the ED, often without treatment. Ketamine is a rapid-acting antidepressant with emerging evidence in adults, but data are limited on its effectiveness in suicidal youth. We aimed to evaluate the effectiveness of a single dose of intravenous (IV) ketamine on depression and suicidality scores compared to placebo in adolescents with treatment-resistant depression presenting to the ED with suicidal ideation.

Methods: We conducted a two-arm randomized double-blind placebo controlled trial on a convenience sample of adolescents 12–17 years of age with treatment-resistant depression (trialed at least two antidepressants for at least four weeks each) who presented to the ED with suicidal ideation requiring psychiatric admission. Exclusion criteria included psychosis, substance abuse disorder, intoxication, developmental delay, aggressive behavior, and medical contraindications to ketamine. Subjects were randomized to receive a single dose of ketamine (0.2 mg/kg IV, maximum 35 mg) or saline placebo over two minutes. They completed the Beck Youth Inventory (BYI) and Suicidal Ideation Questionnaire (SIQ) at baseline and at 1 hour, 3 hours, 1 day, 3 days, and 7 days post-treatment. We compared groups with the Fisher exact and two-sided rank-sum tests. Our primary outcome measure was the proportion of subjects with a reduction of ≥ 50% on the BYI and SIQ within 3 hours after treatment.

Results: The 29 subjects (14 placebo, 15 ketamine) did not differ significantly in demographic and clinical characteristics. Despite reductions in BYI and SIQ in both groups, the proportions achieving ≥ 50% reductions did not differ significantly at 1 hour (SIQ: placebo, 0% vs ketamine 14.3 % [P = .48]; BYI Anxiety Inventory: placebo, 0% vs ketamine 21.4% [P = .22]; BYI Depression Inventory: placebo, 0% vs ketamine 15.4% [P = .22]). Differences at 3 hours were less pronounced. Adverse effects were more frequent in the ketamine group, most notably signs of dissociation (7% vs 60%, P = .004), with none after the 1-hour observation period.

Conclusion: The ED offers an opportunity to deliver rapid-acting antidepressant treatment for suicidal adolescents. Although low-dose ketamine was not associated with greater reductions in depression or suicidality than placebo, this study demonstrated feasibility and highlights the need for larger studies to determine optimal ketamine dosing, route of administration, and implementation strategies in the ED setting.

Introduction: Managing agitation in the emergency department (ED) is challenging and frequently involves decisions about physical restraints and emergent medications. While institutional protocols and behavioral response teams exist, little is known about how individual clinicians make decisions about restraint use—decisions with significant implications for safety, ethics, and equity. The objective of the study was to explore how emergency physicians, residents, and nurses make decisions about physical restraint and emergent medication use during episodes of patient agitation in the ED.

Methods: We conducted a qualitative study using semi-structured interviews with 35 emergency clinicians (18 attending physicians, 7 senior residents, and 10 nurses) at an urban academic ED. Interviews were transcribed and analyzed using inductive thematic analysis.

Results: Clinicians described three key factors informing restraint decision-making: (1) commitment to patient-centered care through noncoercive de-escalation; (2) real-time assessment of threats to staff and patient safety; and (3) team-based collaboration in both the restraint decision and implementation process. Participants shared a common mental model that prioritized verbal de-escalation before moving to pharmacologic or physical restraint. Clinicians acknowledged that unconscious bias and identity-based dynamics, including age, gender and race, may influence perceptions of threat and decision-making.

Conclusion: Emergency clinicians share a consistent framework for managing patient agitation, suggesting potential for a standardized, team-based algorithm. Future interventions should consider clinician and patient identities, aiming to reduce disparities and enhance safety while minimizing restraint use.

Introduction: Emergency departments (ED) have become important venues for hepatitis C (HCV) screening. Similarly, EDs have had increasing engagement in the management and treatment of opioid use disorder (OUD). Persons with OUD are at disproportionate risk for acquiring HCV. We sought to assess the intersection between OUD and HCV care through observing the uptake of HCV screening and subsequent steps in the HCV care cascade in an ED-OUD cohort.

Methods: This retrospective cohort study analyzed patients enrolled in an ED-OUD treatment program as a convenience sample subgroup of a larger institutional ED opt-out HCV screening program conducted at a single urban site in Alabama between July 2019–June 2022. Opt-out, nonfocused HCV screening provision was standardized at triage, excluding pregnant and incarcerated individuals. Descriptive analyses were conducted to ascertain screening uptake, positive screening, confirmatory testing, linkage to HCV treatment centers, and initiation of antiviral therapy. Additional patient level demographics considered included sex, race, age, insurance status, and domicile status.

Results: Of the approximately 75,000 patients screened annually across the study timeframe, July 2019–June 2022, 359 patients with OUD were enrolled; enrolled participants were more likely to be male (64.9%), white (77.4%), aged 25 to 44 (73.3%), uninsured (80.5%) and housed (80.5%). Only 99 (27.6%) received an HCV antibody (Ab) screening test, 52 (52.5%) of which were positive. Thirty-three patients (63.5%) of the Ab-positive cohort were confirmed HCV viremic or 9.2% of the entire OUD cohort. Three (9.1%) of those with active viremia had documented post-ED HCV-specific care and only one was initiated on direct-acting antiviral therapy. White patients were more likely to be Ab-positive as compared to Black patients (88.5% vs 9.6%); however, Black patients were more likely to have active viremia (15.2%). Antibody-positive females had higher rates of viremia (80.0%) compared to Ab-positive males (53.1%).

Conclusion: Screening capture, subsequent RNA-positive linkage to care, and medication initiation rates were suboptimal, revealing opportunities for improvement across the care continuum. Incidence of active HCV viremia in the ED-OUD patient cohort is nine times higher than that in the general population and three times higher than that of the local general ED cohort.

Introduction: Since 2019, transmission risk factors among patients diagnosed with HIV have changed, although the trends and reasons behind them have not been fully elucidated. The objective of this study was to assess changes in HIV transmission risk factors among patients newly diagnosed with HIV to inform future targeted HIV testing programs.

Methods: This study site is New England’s largest essential hospital and a major reporter of new HIV cases in Massachusetts. We performed a retrospective chart review of patients diagnosed with HIV infection at our medical center between January 2019 and December 2023. Demographic and clinical variables were collected and analyzed using descriptive and comparative statistics to evaluate trends in primary risk factor for HIV. Our primary outcome measure was incident HIV diagnosis with a primary risk factor of injection drug use (IDU), men who have sex with men (MSM), or heterosexual contact. A secondary outcome examined was CD4 count at the time of diagnosis.

Results: A total of 246 patients were newly diagnosed with HIV. Of these, 59% (n = 146) reported heterosexual contact as their most likely cause of transmission, 19% (n = 47) MSM, 19% IDU (n = 46), and 3% (n = 7) reported both MSM and IDU. Heterosexual contact increased as the predominant HIV transmission factor from 53% (24/45) in 2019 to 79% (37/47) in 2023 (risk difference, 25%; 95% CI, 6.7%-44.1%), and the percentage of diagnoses made in non-US-born patients increased from 60% (27/45) in 2019 to 83% (39/47) in 2023 (risk difference, 23%; 95% CI, 5.1%-41%). Non-US born patients had significantly lower CD4 counts at diagnosis (mean [SD] CD4 count 299 [241] cells/µL) compared to US-born counterparts (mean [SD] CD4 count 498 [309] cells/µL, P < .001), with a mean difference of -199 cells/µL (95% CI, -272 to -125).

Conclusion: The dominant risk factor for HIV transmission has changed from injection drug use/men who have sex with men to heterosexual contact in New England’s largest city. Our findings associate increased HIV incidence in non-US-born immigrants at an urban essential hospital, highlighting the importance of considering this group in targeted public health efforts to avoid missing cases of HIV in similar settings. 

Introduction: Patients with hepatic encephalopathy frequently visit the emergency department, and these visits are expected to rise in the coming years due to an increased prevalence of liver disease in the United States. Accordingly, we sought to define a comprehensive and efficient approach for emergency physicians to evaluate, treat, and determine the optimal disposition of patients presenting with possible or confirmed hepatic encephalopathy and its complications.

Methods: We reached consensus recommendations through a structured literature review and a modified Delphi technique, informing an expert panel of academic and community emergency physicians convened by the American College of Emergency Physicians.

Results: We created the assess, look, treat, evaluate risk, reassess, disposition (ALTERD) framework as a digital point-of-care tool to support clinicians in guiding key bedside steps involved in the diagnosis and care of patients across the spectrum of hepatic encephalopathy.

Conclusion: A collaborative expert panel process can create an emergency department-focused, easily accessible, and comprehensive digital tool to complement workflows and improve the care of a vulnerable and growing patient population.

Introduction: Acute cholecystitis is diagnosed based on clinical and diagnostic findings. Fever is commonly considered a sign of systemic inflammation in acute cholecystitis, although its diagnostic performance may vary depending on the timing of presentation. This study analyzed the prevalence of fever as a diagnostic parameter for acute cholecystitis, according to the symptom onset at the time of medical consultation (≤ 24 hours versus > 24 hours), and its potential association with both medical and surgical complications.

Methods: We conducted a retrospective cohort study in two urban, tertiary care emergency departments (ED) between March 2023 and June 2024. Adult patients (≥ 18 years) with clinically diagnosed acute cholecystitis were included. Presentations were categorized by time since symptom onset: early (≤ 24 hours) or late (> 24 hours). Fever was defined as axillary temperature > 37.5 °C at home or at ED arrival. The primary outcome was the sensitivity of fever for the diagnosis of acute cholecystitis, stratified by early versus late presentation. Secondary outcomes included the sensitivity of other inflammatory markers and the association between fever and medical or surgical complications. The association between fever and complications was evaluated using a penalized logistic regression model (Firth method) to account for the low number of outcome events.

Results: A total of 207 cases of acute cholecystitis were included in the analysis: 108 early presenters; and 99 late presenters. Fever was present in 4.6% (95% CI, 1.5–10.4) of early presenters and 20.2% (95% CI, 12.8–29.4) in late presenters, with an overall sensitivity of 12.1% (95% CI, 8.0–17.2). Medical and/or surgical complications were low in this cohort (n = 15, 7.2%), but more frequent in patients with fever, regardless of time onset of symptom (28% versus 4.5%, P < .001), yielding an adjusted odds ratio of 6.64 (95% CI, 1.42-31.21; P = .02) after adjusting for leukocyte count, C-reactive protein levels, and age.

Conclusion: Fever is an uncommon sign of acute cholecystitis, especially in early presentations, but may indicate a higher risk for complications when present. These findings underscore the need to reconsider the role of fever in current diagnostic criteria and suggest further validation of its use as a predictor of complications in prospective studies.

Introduction: Prehospital triage challenges often lead to suboptimal choices and delayed treatment for stroke patients. The objective of the study was to evaluate whether a decision-support interface to assist in stroke triage to an appropriate hospital could reduce emergency medical technicians’ (EMT) mental workload.

Methods: This randomized crossover study was conducted between February and March 2025. Each participant completed two 12-minute simulated trials in randomized order: current dispatch orders without decision support and a decision-support interface. We assessed mental workload—the mental effort required to make hospital transport decisions under time pressure during prehospital stroke triage—using heart rate variability (HRV) metrics and the National Aeronautics and Space Administration Task Load Index (NASA-TLX). System usability was assessed using the System Usability Scale. The primary outcome was the root mean square of successive differences for each participant after completing the two trials. The secondary outcomes included the differences of NASA-TLX, System Usability Scale, and other heart rate variability parameters, including mean R-R interval (meanRR), mean heart rate, percentage of successive R-R intervals that differ by more than 50 milliseconds, low-frequency power (LF), high-frequency (HF) power, and the LF/HF ratio. Subgroup analyses examined differences by sex, education, age, and years of service.

Results: A total of 35 emergency medical technician (EMT)-intermediate participants (mean age, 27.5 [5.3] years) completed the study. For the primary outcome, the root mean square of successive differences increased significantly (28.1 [13.0] vs 32.4 [13.6] milliseconds; mean difference, 4.3 milliseconds [95% CI, 1.57–6.99]; P < .01), indicating reduced mental workload when the participants used the decision-support interface. For the secondary outcomes, mean heart rate (77.5 [8.6] vs 73.8 [10.6], P < .01) decreased, mean R (784.2 [89.5] vs 808.9 [87.3], P < .01) increased, and HF power (370.1 [291.7] versus 482.6 [433.9], P = .02) increased, suggesting reduced mental workload when the participants used the decision-support interface. The mental demand scores in NASA-TLX decreased from 62.5 (14.6) to 35.5 (17.0). Emergency medical technicians with 1.0–1.5 years of service reported higher System Usability Scale scores than those with 1.5–3.0 years (84.4 versus 71.3, P = .02), and 82.9% of participants rated the system as acceptable (System Usability Scale score ≥ 70).

Conclusion: This study demonstrated that integrating a web-based decision-support interface effectively reduces mental workload and psychological stress among EMTs in stroke triage. 

Introduction: Headache is a common presentation to the emergency department (ED), requiring both accurate diagnosis and efficient management. Although consensus guidelines exist, real-world treatment practices and their associations with operational outcomes remain variable. We evaluated the association between acute headache management strategies—including medications, diagnostic imaging, and consultations—and ED length of stay (LOS), using both unadjusted and multivariable-adjusted analyses.

Methods: We conducted a multicenter retrospective observational study using data from 79,527 adult ED encounters for headache across 22 EDs in the southwestern and upper Midwestern United States between 2018 and 2024. The primary outcome was ED LOS. Secondary outcomes included LOS differences associated with medication classes, imaging modalities, procedures, and specialty consultations. Length of stay differences by treatment strategy were compared using Mann-Whitney U testing. We performed multivariable linear regression and quantile regression (median) adjusting for age, sex, Emergency Severity Index level, disposition, imaging, procedures, consultations, site, and year. Encounters were classified by headache type (primary, secondary, or unspecified) using discharge diagnosis codes, and stratified analyses were performed.

Results: Primary headache encounters comprised 19.4% of the cohort (n = 15,413), secondary headache 14.0% (n = 11,147), and unspecified headache 66.6% (n = 52,967). The overall median LOS was 183 minutes (interquartile range [IQR], 119–276). In unadjusted analyses, nonsteroidal anti-inflammatory drug (NSAID) (median 180 vs 185 minutes; P = .42) and triptan administration (177 vs 183 minutes; P = .49) were not associated with longer LOS. In contrast, antiseizure medications (+136 minutes; P < .001), intravenous magnesium (+101 minutes; P < .001), opioids (+89 minutes; P < .001), and benzodiazepines (+72 minutes; P < .001) were associated with the longest LOS. In multivariable-adjusted analysis (R² = .40), antiseizure medications (adjusted coefficient +85.1 min; 95% CI, 76.0–94.3), admission (+71.1 minutes; 95% CI, 68.3–73.8), and magnetic resonance imaging (+125.9 minutes; 95% CI, 119.8–131.9) were most strongly associated with longer LOS. Stratified analyses showed primary headaches had shorter median LOS (153 minutes; IQR, 105–224) than secondary (204 minutes; IQR, 126–317) or unspecified headaches (189 minutes; IQR, 123–282), with consistent medication–LOS associations across subgroups (Kruskal-Wallis H = 1,476.85, P < .001; all pairwise comparisons P < .001 after Bonferroni correction).

Conclusion: In this multicenter retrospective study, most pharmacologic and diagnostic interventions—aside from NSAIDs and triptans—were associated with longer ED LOS, even after adjusting for patient and clinical covariates. These associations likely reflect both direct treatment effects and confounding by indication. Prospective studies are needed to evaluate whether standardized protocols can improve ED throughput while maintaining care quality. 

Introduction: Central venous catheters are placed in the emergency department (ED) when difficult peripheral access limits care or when critical medications require central access because of their sclerotic nature or incompatibility with other drugs. Ultrasound-guided peripheral intravenous (IV) access offers a less invasive alternative. We evaluated whether implementation of a structured ultrasound-guided peripheral intravenous training program for ED nurses and technicians was associated with changes in ED central venous catheter use.

Methods: We performed a retrospective chart review at our 50-bed academic community ED, which holds a Level II trauma designation. This center has an ED census of 80,000 patients per year, a 4:1 nursing to patient ratio with an admission rate of 20-25% with expected monthly variation. A structured ultrasound-guided peripheral IV curriculum for nurses and technicians launched in November 2023. The primary endpoint was annual ED central venous catheter placement count, identified through procedure documentation in the electronic health record. Training that was conducted for nurses and clinical technicians consisted of three hours of didactic and hands-on training, followed by a period of procedural supervision. We compared the baseline year 2022 with the first two full post-implementation years, 2024 and 2025. The analysis was descriptive.

Results: Central venous catheter placements in the ED decreased from 387 in 2022 to 275 in 2024 and 218 in 2025, corresponding to absolute reductions of 112 placements (28.9%) and 169 placements (43.7%), respectively. By the end of 2025, 33 nurses and ED technicians had completed training and competency sign-off.

Conclusion: Implementation of a structured ultrasound-guided peripheral IV training program for nurses and technicians was associated with fewer ED central venous catheter placements at our institution. These findings support further multicenter evaluation using patient-level outcomes and visit-adjusted rates.

Introduction: Maintaining competence in high-acuity, low-occurrence (HALO) procedures poses a challenge for emergency physicians as they progress past residency training or practice in lower-acuity settings. Simulation-based deliberate practice offers a feasible method to sustain procedural competence. We developed and evaluated a blended, faculty development procedural curriculum designed to improve confidence and clinical application of HALO skills across a five-hospital emergency medicine (EM) network.

Methods: A faculty needs assessment and departmental quality data informed the creation of a 4-hour procedural curriculum course. The blended curriculum included asynchronous precourse procedural guides and videos followed by a 4-hour, in-person deliberate practice session led by peer EM faculty instructors. Year one procedures included cricothyroidotomy, transvenous pacing, catheter thoracostomy, neonatal resuscitation, and peritonsillar abscess drainage. Year two curriculum included fiberoptic nasotracheal intubation, pediatric airway management, ultrasound-guided pericardiocentesis, intraosseous access, lateral canthotomy, balloon tamponade of gastrointestinal hemorrhage, fascia iliaca nerve block, and orthopedic reduction/splinting. All stations used clinical equipment stocked across the enterprise. Anonymous pre- and post-course surveys measured self-reported procedural confidence and global course satisfaction. Procedure billing data and faculty self-report were used to evaluate clinical application.

Results: In year one, 62 of 90 (69%) participants completed surveys which demonstrated significant increases in confidence across all procedures (P < .01) with high satisfaction (median 5, IQR 5-5). Year two results were similar: 67 of 87 (77%) completed surveys, again showing significant confidence gains (P < .01) and high satisfaction (median 5, IQR 5–5). Seventy percent (47 of 67) of year two respondents were returning participants; among them, 68% reported performing at least one procedure reviewed in year one. All reported increased confidence during clinical performance. Peritonsillar abscess drainage increased from 14 procedures precourse to 133 in year one and 83 in year two, with 35% performed in regional hospitals. We observed no change in procedure-related quality incidents.

Conclusion: Our faculty procedural curriculum offers a framework that emergency departments can use to support faculty in increasing confidence in performing HALO and other low-frequency procedures. Future research should evaluate the durability of this educational approach, including how long the intervention preserves procedural confidence without decay. 

Introduction: People experiencing homelessness (PEH) frequently utilize the emergency department (ED) for acute and primary healthcare needs. Loyola Street Medicine is a multidisciplinary team comprised of physicians, students, and other professionals who provide weekly healthcare services to PEH at a train station in Chicago. The objective of the study was to identify the specific patient demographics, chief complaints, and clinical interventions associated with increased odds of these patients reporting that they would have sought care at an ED had Loyola Street Medicine been unavailable.

Methods: We conducted a retrospective review of patients seen by Loyola Street Medicine between September 2021 and September 2024, with 2,121 total encounters and a subset of 1,565 with identifying data. The primary outcome measure was whether the patient reported they would have gone to the ED for care, and the secondary outcome measures were patient demographics, chief complaints, and interventions provided. We estimated odds ratios with univariable logistic regression mixed models, with random intercept accounting for multiple patient visits in the subset of patients with identifiers.

Results: For 63% of all encounters (N = 1,293), people experiencing homelessness indicated they would have gone to the ED without street medicine, with the most common demographics including Black race (77%), male sex (80%), and a mean age of 46.7 years. Among patients who indicated they would have gone to the ED, the most prevalent chief complaints were wound check (22%), musculoskeletal issues (17%), and podiatry concerns (14%). Black and “other” race patients had decreased odds of indicating they would have gone to the ED compared to White patients (0.69 [95% CI, 0.49-0.97], P = .03 and 0.39 [95% CI, 0.22-0.69], P = .001, respectively). Patients with wound-related complaints and those needing wound care as an intervention had greater odds of indicating they would go to the ED versus any other location such as a clinic or a primary care physician (1.46 [95% CI, 1.07-1.99], P = .02 and 1.5 [95% CI, 1.11-2.03], P = .009, respectively).

Conclusion: The findings demonstrate that street medicine can play a vital role in addressing the complex needs of people experiencing homelessness. By providing consistent, low-barrier care, street medicine has the potential to reduce nonemergent ED use and improve continuity of care. 

Introduction: Congenital syphilis is rising in the United States, especially among infants born to women with limited prenatal care. Emergency departments (ED) offer opportunities for early detection, particularly among patients evaluated for urogenital sexually transmitted infection (STI) concerns. In October 2019, our health system implemented an ED STI order set that promoted HIV co-testing and included a preselected option for syphilis testing. In this study, we evaluated change in syphilis testing during the post-implementation period among ED encounters with both pregnancy and gonorrhea/chlamydia (GC/CT) testing.

Methods: We conducted a retrospective, quasi-experimental study across 20 EDs, using health record data from 2018 to 2023 for patients aged 15–44 years who received both pregnancy and GC/CT testing. We measured annual syphilis and HIV testing and positivity, stratified by pregnancy status. The primary study outcome was syphilis testing during the encounter; HIV testing and detection outcomes were secondary.

Results: Among 59,171 ED encounters with pregnancy and GC/CT testing, 5,178 (8.8%) involved pregnant patients, and 9,538 (16.1%) received syphilis testing. Syphilis testing among pregnant patients increased from .9% in 2018 to 46.1% in 2023 (+45.1 percentage points [95% CI, 40.4–49.6]). Testing among nonpregnant patients rose from 1.2% to 35.9% (+34.6 percentage points [95% CI, 33.3–35.9]). Overall, only 1,068 of 5,178 pregnant encounters received a syphilis test (20.6%). Among 1,068 syphilis-tested pregnant encounters, 15 (1.4%) were treponemal-positive and 9 (.8%; 843 per 100,000 tested) met the Centers for Disease Control and Prevention surveillance definition for active syphilis (approximately 1 per 119 tests). Using all pregnant encounters with GC/CT testing as the denominator, the encounter-based active syphilis rate was 173.8 per 100,000 (.17%). HIV testing increased similarly (pregnant: .4% in 2018 to 44.5% in 2023), while HIV positivity remained rare (2 pregnant; 13 overall).

Conclusion: Syphilis testing and case detection increased during the postimplementation period following introduction of a preselected STI order set in the electronic health record. Many encounters in the analytic cohort still did not include syphilis testing. These findings support the ED as an important setting for identifying syphilis in pregnancy while underscoring the need for further work to understand remaining testing gaps. 

Introduction: Ectopic pregnancy remains the leading cause of first-trimester maternal mortality. Delays in diagnosis and operative management increase morbidity and may be exacerbated by emergency department (ED) crowding. We evaluated whether integration of point-of-care ultrasound (POCUS) into the medical screening exam of pregnant patients—the obstetric medical screening exam—was associated with improved timeliness of care for patients with surgically managed ectopic pregnancy.

Methods: We conducted a single-center retrospective cohort study of adult patients undergoing operative management for ruptured ectopic pregnancy between January 1, 2019, and December 31, 2023, at a county safety-net hospital. The obstetric screening exam was implemented July 12, 2021, and incorporated focused transabdominal pelvic and right upper quadrant ultrasound into the initial ED evaluation, often prior to bed assignment. The primary outcome was time from ED arrival to operating room (OR). Secondary outcomes included time to obstetric consultation, time to hospital admission, ED length of stay (LOS), and POCUS use. Nonparametric testing was used for skewed time data. Logistic regression evaluated the odds of reaching the OR within four hours. Patient-level interrupted time series analysis assessed temporal trends.

Results: A total of 150 patients were included (87 pre- and 63 post-implementation). Median arrival-to-OR time decreased from 516 minutes (interquartile range [IQR] 324–709.5) to 391 minutes (IQR 220–619), a 125-minute reduction (P = .020; bootstrap 95% CI, 8–233). The proportion of patients reaching the OR within four hours increased from 16.1% to 31.8% (odds ratio 2.42; 95% CI, 1.11–5.29; P = .02). Time to obstetric consultation (210 vs 146 minutes; P = .003), time to hospital admission (345 vs 250 minutes; P = .005), and ED LOS (451 vs 367 minutes; P = .03) were all reduced. Point-of-care ultrasound use increased from 41.4% to 66.7% (P < .001), while the remainder underwent radiology ultrasound. Interrupted time series analysis demonstrated no significant immediate change after implementation (P = .790), but a significant postintervention trend toward reduced arrival-to-OR time (−0.45 minutes/day, P = .01).

Conclusion: Embedding POCUS into the medical screening examination in triage was associated with sustained improvement in operative timeliness for ruptured ectopic pregnancy. Early diagnostic integration within ED workflow may mitigate system-level delays in time-sensitive obstetric emergencies.

Introduction: Hip fractures are a common injury among the elderly and a substantial cause of morbidity and mortality worldwide. Pain management is an essential component of care for patients with hip fractures, particularly for improving patient outcomes. Ultrasound-guided nerve blocks such as the fascia iliaca block (FIB) are evidence-based means of providing perioperative analgesia and reducing opioid use. Newer nerve blocks, such as the pericapsular nerve group (PENG) block, may serve as alternatives to the FIB. The objective of this study was to retrospectively compare pain reduction following the PENG block and FIB in patients with hip fractures treated in our emergency department. Secondary objectives included block-related complications such as local anesthetic systemic toxicity (LAST), greater hospital length of stay, and increase in mortality.

Methods: The primary outcome measure was to investigate whether the PENG block is an effective alternative to FIB in achieving analgesia. Secondary objectives include data on rates of LAST, block complications, hospital length of stay, and mortality. We conducted a retrospective chart review on adult patients (≥18 years) with hip fractures who received either a FIB or PENG block between June 2021 and June 2023. Among the participants, pain scores (0–10 scale) were recorded before and after the block. Opioid use 24 hours postblock was also documented. We used generalized estimating equation modeling to compare pre-to-post block pain reduction between the FIB and PENG block groups.

Results: A total of 88 participants met inclusion criteria (73 FIB, 15 PENG). The mean (SD) preblock pain scores were 6.5 (2.1) for FIB and 7.9 (1.6) for PENG, improving to 4.4 (2.0) and 4.3 (2.1) postblock, respectively. Generalized estimating equation analysis revealed a statistically significant greater reduction in pain for the PENG group compared to FIB (mean difference = 1.42; 95% CI, 0.21–2.63; P = .02). In this study, there were no cases of local anesthetic systemic toxicity or other block-related complications observed (0%; 95% CI, 0%–3.4%).

Conclusion: Patients who received the PENG block achieved a greater reduction in pain scores compared to the FIB in this small retrospective cohort study. These findings suggest that the PENG block may be an effective alternative to FIB for analgesia in this setting. However, larger, prospective studies are needed to confirm these results. Given the study design and baseline differences in pain scores, these findings should be interpreted with caution.

Introduction: Abdominal pain is a common emergency department (ED) presentation, and virtual assessment of such complaints remains a challenge due to the limitations of remote physical examination. The standardized exam of the abdomen protocol (SEAP) was developed to guide patients in performing a self-abdominal examination during telemedicine consultations. We aimed to evaluate agreement between patient-performed abdominal self-examinations using the SEAP and physician-performed abdominal examinations.

Methods: We conducted a prospective, single-center study at the American University of Beirut Medical Center ED in Lebanon from August 2023–August 2024. Adult patients who presented with abdominal pain and met the inclusion criteria were enrolled. Each patient performed a video-guided abdominal self-examination by following a brief instructional video (SEAP). The SEAP was developed by an emergency medicine faculty at our institution using pre-established abdominal examination principles and clinical practice frameworks. The protocol was translated into a structured, two-minute instructional video. Blinded abdominal examinations were then performed by an emergency medicine resident and an attending physician. The primary outcome was agreement in abdominal tenderness across seven predefined regions, assessed using the Cohen kappa coefficient. Patient experience and feasibility measures were also collected.

Results: We included a total of 103 patients. Agreement between patient-performed and physician-performed examinations was slight to fair across six of the seven abdominal regions (κ range, .13–.41). The highest agreement was observed in the right lower quadrant, with fair agreement between patients and residents (κ = .47; 95% CI, 0.30-0.64) and patients and attending physicians (κ = .36; 95% CI, 0.18-0.53). Agreement in the remaining regions, including the upper quadrants and flanks, remained low; right upper quadrant (κ = .13), left upper quadrant (κ = .28), and flanks (κ range, -0.04 to .41). Most patients (97.9%; n = 94/96) rated the instructional video as clear and easy to follow.

Conclusion: Patient-performed abdominal self-examination using the SEAP demonstrated limited agreement with physician examinations across most abdominal regions. Agreement in the right lower quadrant was also fair. These findings indicate that patient-performed abdominal self-examination does not reliably reproduce physician assessment. However, they provide a foundation for further studies aimed at refining and better defining the role of patient-guided abdominal examinations in telemedicine settings.

Introduction: Emphasis on documentation challenges clinicians to strike a balance between efficiency and individualized care, often leading to the depersonalization of patient interactions. The Humanistic Charting Tool (HCT) addresses this by integrating the patient’s voice into the electronic medical record (EHR). The objective of this study was to examine whether use of the HCT during emergency department (ED) visits is feasible and improves key patient experience metrics.

Methods: The study took place in an urban, academic hospital. Patients in the ED completed the HCT while waiting to see a clinician. The patient’s responses were condensed into a two-page summary and uploaded into their EHR. Clinicians were asked whether they used the HCT for each patient at the end of the encounter, and patients completed precare and postcare surveys assessing key experience metrics. Our primary outcome measure was changes in patient experience metrics, including key Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) metrics. Our secondary outcome measure was subgroup analyses among patients facing barriers to care.

Results: Approximately 2.8% of the total ED patients were enrolled during the study period. Overall, 129 patients filled out the HCT, and 97 (74%) patients had complete survey data. A total of 65 clinicians participated in the study including 32 attending physicians, 23 resident physicians, and 10 advanced practice practitioners (APP). Clinicians used the HCT for 51 (53%) of these patients. Patients demonstrated significant improvements in feeling that clinicians listened carefully (79% to 92%; P < .001), took their preferences into account (61% to 74%; P = .01), treated them with courtesy and respect (85% to 94%; P < .001), and knew important information about them (43% to 52%; P = .01). Patients who did not have a regular clinician (n = 25 [26%]) had a significantly greater increase in feeling involved in their treatment discussion (36% to 60% vs 59% to 66%; P = .05). Patients who endorsed at least one social need (n = 15 [16%]) had a significantly greater increase in being listened to carefully (53% to 73% vs 84% to 95%; P = .01). No statistical significance was found between patients whose clinicians used the HCT versus not.

Conclusion: The Humanisticc Charting Tool demonstrated feasibility and was associated with improvements in patient experience within the ED. This tool has the potential for patients to share their narratives and enrich their own healthcare experience, which is invaluable in a high-stakes, time-sensitive environment. The results also highlight a novel finding that the HCT may help mitigate disparities in communication, trust, and engagement that disproportionately affect vulnerable populations. This study supports the further development of humanism-centered tools within healthcare systems.

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