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

Introduction: Penicillin allergy is one of the most reported drug allergies, but studies have shown that patients who report an allergy frequently do not have a significant reaction when challenged. Avoidance of penicillin or beta-lactam antibiotics in these patients results in increased hospitalization costs, suboptimal antibiotic therapy, and risk for subsequent infection with multidrug resistant organisms. 

Methods: This was a single-center, retrospective chart review that included patients ≥ 18 years of age with documented penicillin allergy who presented to the emergency department (ED) over a one-year period. Clinical pharmacy specialists in the ED reviewed and stratified patient allergy risk. Patients with low-risk allergy histories who were to be admitted and gave formal consent were given an oral amoxicillin challenge and then observed in the ED for at least one hour. Patients who were eligible for challenge but were to be discharged from the ED were given the option to be seen in the allergy clinic. The primary outcome was the incidence of adverse reactions related to the oral amoxicillin challenge for patients. An exploratory secondary outcome was the average length of stay (LOS) in the ED for oral amoxicillin-challenged patients compared to the average LOS for non-oral amoxicillin-challenged patients. We performed descriptive statistics on all variables. 

Results: A total of 144 patients received an allergy assessment in the ED, 20 who received an oral amoxicillin challenge and 124 who did not. Baseline characteristics were similar in both groups. The average total LOS in the oral amoxicillin-challenged patients was a non-significant 36 minutes longer compared to the non-challenged patients (P = 0.4). Of 144 patients, 71 (49%) had their penicillin allergy removed as a result of the challenge.. One patient experienced a mild and self-limited reaction to the oral amoxicillin challenge (0.7%; 95% CI, 0.02-3.8%). 

Conclusion: An ED pharmacist-led, penicillin de-labeling protocol was safe and feasible. A secondary exploratory analysis showed no significant difference in length of stay between patients who received the oral amoxicillin challenge in the ED vs those who did not. Performing a proper penicillin allergy evaluation in the ED can have lasting benefits for patients and antimicrobial stewardship.

Background: Intravenous (IV) fluids are commonly used in emergency departments (ED), but their supply can be vulnerable to national shortages. In September 2024, Tropical Storm Helene disrupted production at a major manufacturing facility, triggering a nationwide IV fluid shortage. In response, our ED implemented a multiphase intervention aimed at reducing non-essential fluid utilization. We aimed to reduce total IV fluid use in the ED by at least 25% through a staged, systems-based conservation strategy.

Methods: We conducted a single-center, retrospective, pre-post quality improvement initiative in a tertiary academic ED with approximately 57,000 annual visits. Interventions were deployed across three Plan–Do–Study–Act cycles: 1) clinician education on fluid stewardship (7 days); 2) protocol modifications to reduce routine IV placement (11 days); and 3) electronic health record (EHR) clinical decision support tools, including an interruptive alert and oral hydration order set (32 days). We analyzed daily fluid administration volumes, and ED census data from September 2024 (pre-intervention) and November 2024 (post-intervention). The primary outcome was total IV fluid usage per day; a secondary outcome was IV fluid volume per patient encounter. We compared mean daily utilization between periods using two-sample t-tests.

Results: Average daily IV fluid use declined from 56.3 to 24.8 liters, a 56.0% relative reduction (P < .001), while ED volume remained stable (155.4 vs 153.1 encounters/day pre- vs post-intervention). Normalized per-encounter IV fluid administration decreased from 0.36 to 0.16 liters per visit (P < .001), representing a 56% relative reduction. Assuming a pharmacy acquisition cost of approximately $2 per liter of crystalloid, the intervention was associated with an estimated reduction of $63 in IV fluid expenditures per day (31.5 liters), or $1,890 over the 30-day post-intervention period.

Conclusion: A structured intervention combining education, protocol changes, and EHR decision support significantly reduced IV fluid use in the ED without disrupting operations. This approach may serve as a scalable model for resource stewardship during future supply chain crises. The most substantial reductions occurred during the final intervention phase involving EHR-based decision support.

Background: Incidentalomas—unexpected neoplastic lesions discovered during imaging for unrelated complaints—represent a growing clinical and ethical challenge in emergency medicine. Their detection has increased due to widespread use of advanced imaging, particularly in patients who may otherwise escape thorough diagnostic evaluation.

Objective: We sought to determine the frequency, anatomical distribution, and clinical management gaps of neoplastic incidentalomas  observed in patients presenting with non-specific, low-severity complaints at the emergency department (ED). (In this paper, neoplastic incidentalomas include both lesions discovered incidentally during imaging for unrelated conditions and newly diagnosed malignancies plausibly related to the patient’s presenting symptoms,)

Methods: Data collection covered the period January 1–December 31, 2023. We conducted a retrospective observational study of all adult patients presenting to the ED of P.O. Anastasia Guerriero University Hospital in Marcianise, Italy. Incidentalomas were identified through discharge summaries and classified by imaging modality, anatomical site, and triage code. We analyzed data using descriptive and inferential statistics.

Results: Among 35,081 ED visits, 53 neoplastic incidentalomas were identified (1.52 per 1,000). The majority occurred in females (69%) and elderly (> 65 years) patients (61%), who often presented with minor complaints such as abdominal pain (38%) or anemia (15%). Most incidentalomas were gastrointestinal (31%) or pulmonary (23%) and primarily detected via computed tomography (51%). Notably, 100% of cases were triaged as non-urgent. Based on established guidelines, up to 20% of cases may represent potential overdiagnosis. The next most common modalities of detection were ultrasound (28%) and chest radiograph (22%).

Conclusion: Neoplastic incidentalomas are not rare in the ED setting, even among patients who present with low-severity symptoms. Our findings underscore the importance of structured follow-up protocols and integration of guideline-based reporting to avoid diagnostic delays, overdiagnosis, and unnecessary interventions. Emergency physicians should maintain diagnostic vigilance and consider incidental findings in clinical workflows.

Introduction: Our study objective was to share the experiences of four public emergency departments (ED) caring for patients with complications of gluteal autologous fat transfer (AFT), colloquially known as Brazilian butt lifts, to provide emergency physicians with a better understanding of these patients and potential complications associated with the procedure.

Methods: Jackson Health System in Miami, Florida, undertook an institutional initiative to prospectively collect data on patients presenting to any of the system’s EDs with gluteal AFT complications from October 2020–May 2023. We abstracted patient charts for demographics, disposition, lab values, diagnoses, and care-related charges to generate descriptive statistics. Our primary outcome measure was diagnostic code and diagnostic category. Secondary outcome measures were hemoglobin on presentation, units of blood transfused, admission level of care, hospital charge, length of stay, and mortality. 

Results: Of 234 potentially relevant patient charts identified by our hospital protocol, 157 patients met our criteria. All were female, with an average age of 33. A total of 123 patients were from out of state, and one was international. The most common diagnoses were anemia/bleeding (81 patients), followed by pain (65), cardiac (36) and hypovolemia/dehydration (32). Our analysis revealed that 86 patients presenting to the ED required admission (54.8%), with 12 patients requiring intensive care unit care (7.6%). There was one death (0.6%). Total hospital charges for this cohort equaled $2,822,540, averaging $17,977 per patient.

Conclusion: Gluteal AFT procedures are associated with a wide range of complications, morbidity, and mortality. These patients have a high admission rate and the potential to be critically ill. Patients travel from around the country to have these procedures performed, and it is crucial that EDs nationally are prepared to care for them.

Introduction: Alcohol use disorder (AUD) contributes to significant healthcare costs, disease, emergency department (ED) crowding, and recidivism. Naltrexone is a treatment for AUD that has been approved by the U.S. Food and Drug Administration and holds promise as a pharmacologic intervention for ED patients with AUD. We hypothesized that subjects who received naltrexone in the ED would have associated reduced recidivism in the 30 days after treatment.

Methods: This was a retrospective chart review of an AUD quality program comparing ED visits in the 30 days before with 30 days after initiation of naltrexone in the ED. We performed this study at two academic hospitals (one a Level I trauma center) and one community hospital.

Results: A total of 297 subjects (median age 43 years, 69.5% male) made 331 naltrexone index visits during the study period. There was no difference in the number of ED visits before versus after the index visit among all subjects (0 median visits before [interquartile range 0-1] versus 0 median after [0-1]). Subjects who were frequent ED users (defined as ≥ 4 ED visits in the 90 days preceding (N=56 [16.9%]) had a significant reduction in ED visits after administration of naltrexone (median of 5 visits [3-8] before versus 3 [2,6] after), with 36 of these subjects (64.3%) having reduced ED visits in the 30 days after naltrexone administration.

Conclusion: Naltrexone administered in the emergency department had no associated change on the study population’s rates of recidivism for alcohol use disorder, but it was associated with reduced ED recidivism in subjects with high ED use. 

Introduction: Hypoventilation and hypercapnia are the primary physiological indicators of opioid-induced respiratory depression (OIRD), while hypoxia is typically a later manifestation. However, use of pulse oximetry to measure oxygen saturation (SpO₂) level remains the most widely available and commonly used monitoring modality in both clinical and community settings, whereas capnography is not routinely accessible. Given this reality, it is important to evaluate hypoxia thresholds reported in the literature to inform practical detection and intervention strategies. Oxygen saturation monitoring may serve as a valuable support tool to help determine when individuals experiencing opioid toxicity require intervention; however, there is limited consensus on SpO₂ thresholds that indicate OIRD. Our objective in this study was to evaluate existing evidence on SpO₂ thresholds for OIRD as a physiological marker to incorporate with clinical assessment to potentially prevent opioid-related outcomes such as hypoxemia, hypoxic brain injury, cardiac arrhythmias, and mortality, and to inform monitoring and intervention strategies for future research.

Methods: We electronically searched Ovid MEDLINE, Ovid Embase, PubMed, and grey literature databases for qualitative and quantitative studies published from 2014–2024. We included studies published in English where participants with opioid use disorder (OUD) experienced opioid toxicity and continuous SpO₂ monitoring in medical settings. Quality was evaluated using the modified Downs and Black checklist. The primary outcome measure was the SpO₂ level used to quantify opioid-induced respiratory depression. 

Results: Of the 2,864 articles screened, 37 underwent full-text review, and 16 were included in data extraction and analysis (total patients, N = 12,887). Reported SpO₂ thresholds ranged from 85–95% (median 92, interquartile range 90–95). In three studies where patients experienced opioid-induced respiratory depression, SpO₂ levels dropped to a median value of 80%. 

Conclusion: Although hypoxia is a late indicator of opioid-induced respiratory depression, SpO₂ monitoring remains a widely deployed tool for detecting clinically significant deterioration. Reported SpO₂ thresholds for defining OIRD ranged from 90-95% across studies of “excellent” and “good” quality, underscoring the need for standardized, patient-centered thresholds to guide monitoring and intervention in future research.

Introduction: Understanding changes in opioid overdose-related emergency department (ED) visits and ED-based opioid use disorder (OUD) treatment post-coronavirus disease 2019 (COVID-19) pandemic can inform ongoing efforts to address the opioid crisis. We aimed to examine trends in opioid overdose-related ED visits, ED-based medication for OUD (MOUD) treatment, and appendicitis-related ED visits (as a control) before and after the initial COVID-19 peak in April 2020.

Methods: We conducted an interrupted time series analysis of monthly ED visits from January 2017–December 2022 at three hospitals in California. We modeled pre- and post-COVID-19 visit trends and the change in trend from pre- to post-COVID-19 peak using linear regression controlling for study site. Our primary outcome included monthly rates of opioid overdose-related ED visits, with monthly rates of ED visits with MOUD treatment as a secondary outcome. Appendicitis-related visits served as a control for temporal trends.  

Results: Of the 781,488 ED visits across the entire study period, there were 2,536 (0.32%) opioid overdose-related visits, 9,755 (1.25%) MOUD treatment visits, and 1,123 (0.14%) appendicitis-related visits. Pre-pandemic, monthly increases were observed in opioid overdose-related visits (6.7 visits/10,000 per month, 95% confidence interval [CI] 2.6-10.8, P = .001), MOUD-positive visits (34.9 visits/10,000 per month, 95% CI, 26.0-43.7, P < .001), and appendicitis visits (2.5 visits/10,000 per month, 95% CI, 1.2-3.9, P < .001). After April 2020, only MOUD-positive visits showed an immediate (level change) increase (49 visits/10,000 or 34% of April 2020 projected pre-COVID-19 visit rates, 95% CI, 26.1-71.9, P < .001), with opioid overdose-related visits subsequently declining (-4.6 visits/10,000 per month or -11% of April 2020 projected pre-COVID-19 visit rates, 95% CI, -7.2 to -2.0, P = .001). Across the entire pre- to post-COVID-19 period, significant decreases in overall visit trends were observed across all visit types, greatest for MOUD-positive visits (-39.2 visits/10,000 per month, or -27% of April 2020 projected pre-COVID-19 visit rates, 95% CI, -51.5 to -26.8, P < .001), followed by opioid overdose visits (-11.3 visits/10,000 per month, or -27% of April 2020 projected pre-COVID-19 visit rates, 95% CI, -16.1 to -6.5, P < .001) and appendicitis visits (-4.2 visits/10,000 per month, or -23% of April 2020 projected pre-COVID-19 visit rates, 95% CI, -7.2 to -1.2, P = .01).

Conclusion: From pre- to post-initial COVID-19 peak, absolute ED-based MOUD treatment trends declined over three times faster than those of opioid overdose-related ED visits (although percentage changes relative to expected April 2020 rates were both -27%). These findings may reflect reduced perceived urgency as overdose presentations decreased and a shift away from crisis-driven implementation, underscoring the need for intentional integration of MOUD into routine ED practice to sustain treatment capacity.

Introduction: We incorporated an 8-hour standardized substance use disorder (SUD) curriculum and X-waiver training into our emergency medicine (EM) residency. We sought to assess whether the implementation of the standardized SUD curriculum and X-waiver training affected graduated EM residents’ comfort with treating SUD and prescribing practices, as well as their view of their future career paths.

Methods: Physicians who completed their EM residency at our hospital from 2016-2022 were invited to complete the survey in 2023. The primary outcome measure was the proportion of surveyed graduates who reported comfort and confidence in treating patients with SUD, measured by affirmative responses to survey items. The secondary outcome measure was the proportion of surveyed graduates reporting that participation in the SUD curriculum and X-waiver training during residency influenced their career plans, measured by affirmative responses to career-related survey items. For each outcome measure, we compared percentages of affirmative responses between physicians who completed residency prior to and after the implementation of the SUD curriculum and X-waiver training.

Results: Among 81 graduated EM residents invited to complete the survey, 63 (78.8%) responded. We grouped them based on whether they had completed residency prior to the addition of the standardized SUD curriculum (pre-curriculum, 2016–2017) or after (post-curriculum, 2018–2022). Of the 63 participants, 17 were pre- and 46 were post-curriculum residents. Of the pre-curriculum residents, 58.8% prescribed buprenorphine in their practice after residency, compared to 76.1% of the post-curriculum residents (Fisher exact test, P = .22, odds ratio [OR] 0.46, 95% confidence interval, 0.12-1.76). Of the post-curriculum graduates, 93.5% noted that they were better prepared to treat patients with SUDs than their peers compared to 88.2% of the pre-curriculum graduates (Fisher exact test, P = .605, OR .529, 95% CI, 0.055-6.909), and 69.6% believed the training impacted their careers professionally and increased their interest in helping patients with opioid use disorder.

Conclusion: Overall, a greater proportion of EM graduates who had been X waiver-trained in a substance use disorder curriculm during residency training at our institution prescribed buprenorphine to their patients than those who had not undergone specific training. Although the X-waiver is no longer a requirement, our SUD curriculum and training remain relevant for buprenorphine prescribing and may offer some opportunities for EM residents to develop their careers. 

Introduction: Diagnostic efficiency in the emergency department (ED) is crucial for workflow. Among these, urinalysis (UA) is a key test for abdominopelvic complaints. Prolonged UA turnaround times can extend patient length of stay and reduce patient satisfaction, highlighting the need for improvement. In this study qw sought to measure the correlation between UA turnaround times and time to disposition.

Methods: We conducted a retrospective analysis of discharged ED patients with abdominopelvic complaints who had a UA ordered between January–August 2022. Electronic health records data included UA order-to-result time, urine human chorionic gonadotropin (hCG), time to disposition, and complete blood count (CBC) turnaround time as a venipuncture comparator. Spearman correlation coefficients assessed associations between lab processing times and time to disposition.

Results: Among 6,708 discharged patients included in the study, 3,795 presented with abdominopelvic complaints. In this subgroup, 3,688  UAs, 1,285 urine hCG tests, and 2,966 CBCs were obtained. Median times from UA order-to-specimen receipt and result were 65 (IQR 29-138) and 92 (53-168) minutes, respectively. A modest positive correlation was observed between UA order-to-result time and time to disposition (ρ = 0.46), relative to CBC order-to-result time (ρ = 0.29). The relationship was slightly weaker for urine hCG (ρ = 0.35). Laboratory turnaround times showed minimal correlation with ED time to disposition (UA ρ = 0.04; urine hCG ρ = 0.03; CBC ρ = 0.09).

Conclusion: Urinalysis acquisition and processing times are modestly correlated with time to disposition in patients with abdominopelvic complaints. Reducing collection time for UA and urine hCG tests may improve throughput for this patient cohort.

Introduction: Emergency departments (ED) are a primary site of blood culture collection in the United States. High rates of blood culture contamination, commonly seen in EDs, are associated with diagnostic inaccuracy, unnecessary antibiotic use, and increased costs. In this structured literature review, we evaluated the effectiveness of initial specimen diversion devices (ISSDs), which are attached to the needle tip and discard the initial 0.15-1.5 mL of blood. We paid particular attention to their applicability in reducing blood culture contamination in adult ED patients in rural healthcare settings. The average cost of an ISDD is $15–$30, and this upfront cost creates a significant barrier in rural EDs, which face resource scarcity.  

Methods: In this review of primary literature from 2021–2025, we evaluated the efficacy of ISDD in lowering blood culture contamination rates in adult patients in the ED. Our primary outcome was the change in contamination rates after introduction of the ISDD. Secondary outcomes included changes in vancomycin duration of therapy, hospital length of stay, and total hospital costs.  

Results: We screened 460 records across PubMed, EBSCO, and Embase. Eight papers were selected for full review, from 10 hospital systems. All studies demonstrated a decrease in the rates of blood culture contamination with the ISDD. Contamination rates were reduced by an average of 2.89% across all 10 study locations. Only three of 10 hospitals (30%) achieved a blood culture contamination rate below 1%. One rural community hospital saw an absolute reduction of BCCs from 3.94% to 1.05%. Another study reported a decrease in total yearly hospital costs from $1,120,000 to $383,690, and another reported a 31.4% reduction in mean duration of  vancomycin therapy.  

Conclusion: This review shows the clinical value of ISDDs to reduce blood culture contamination, and highlights the need for further research into scalable implementation strategies, especially in resource-constrained systems, like rural hospitals.

Introduction: Emergency department (ED) closures have become increasingly common across health systems worldwide, reflecting mounting pressures from staffing shortages, resource constraints, and rising patient demand. Closures, whether temporary or permanent, pose potential risks to timely access to emergency care and may significantly impact patient outcomes and healthcare system performance. Despite growing attention from policymakers and the public, academic evidence on real-world impacts of ED closures remains fragmented. In this scoping review we compiled and summarized the current literature directly addressing the impacts of ED closures.

Methods: Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews criteria, we conducted a search of PubMed.gov, the Cumulative Index to Nursing and Allied Health Literature, and Web of Science databases for papers published in English after the year 2000 that directly addressed ED closures. We screened these papers by title and abstract. This search yielded 15 studies for which we then conducted a forward and backward citation search, ultimately producing 22 unique papers. Data from these papers were initially extracted into a spreadsheet and then organized into thematic tables based on the impacts they discussed.

Results: Our search yielded 1,725 papers, and we ultimately included 22 of these (1.3%). Most studies were observational or quasi-experimental, covering 147 unique ED closures, with some analyzing all United States closures (thousands). We found that we could organize the papers into four themes determined by the impact of ED closures had on the following: 1) patient outcomes (eg, mortality, likelihood of acute myocardial infarction treatment) (n = 14); 2) equity-deserving populations (n = 6); 3) alternate EDs that remain open (n = 10); and 4) on healthcare networks as a whole, including emergency medical services (n = 5). Most of the papers were observational or quasi-experimental in design and drew data from a wide scale of closures, from single-site to national ED closures (> 500 sites). The largest proportion (40%) of studies were based in the U.S. 

Conclusion: The literature demonstrated mixed and context-dependent impacts of ED closures. The ED closures consistently adversely affected mortality rates of patients with time-sensitive conditions when travel times or distances exceeded certain thresholds. Closures also disproportionately affected equity-deserving populations. However, the negative impacts were often mitigated in the long term, and were less pronounced in well-resourced systems capable of adaptation. There are key gaps in the literature regarding impacts on conditions that are not time sensitive, on marginalized populations, and on broader system-level performance, which should guide future research.

Background: Asynchronous care has emerged as a promising approach to improving healthcare accessibility while potentially reducing costs, particularly for low-acuity conditions. Our objective was to describe the use patterns, patient characteristics, and short-term clinical outcomes of an emergency department (ED)–led asynchronous care platform managing low-acuity conditions in a large, academic health system.

Methods: We conducted a retrospective cohort study evaluating the Mount Sinai Health System asynchronous care platform for managing urinary tract infections, conjunctivitis, cold sores, vaginal candidiasis, emergency contraception, and oral contraceptive prescriptions between December 2023–October 2024 during an initial rollout period. Individual charts were reviewed by two trained abstractors and two emergency physicians. The primary outcome was any subsequent ED or clinic visit within seven days. Secondary outcomes included change in diagnosis and medication at relevant follow-up visits. We used descriptive statistics to characterize the cohort and outcomes. 

Results: During the study period, there were 19,204 ED encounters for conditions matching asynchronous care chief complaint categories, of which 343 encounters (1.8%) from 277 unique patients were managed via the asynchronous care platform. The median patient age was 32.6 years (interquartile range IQR 28.3–41.2), and 258 (93.1%) were female. Overall chief complaints included cystitis/urinary complaints in 157 (45.8%) encounters, conjunctivitis/eye complaints in 57 (16.6%), and vaginal/vulvar candidiasis in 96 (28.0%). At the encounter level, 18 (5.2%) were up-triaged from the asynchronous care platform to synchronous virtual urgent care or in-person evaluation after initial screening. We observed the primary outcome of a subsequent ED or clinic visit within seven days in 68 patients (24.5%). Five patients (1.5%; 95% CI, 0.5-3.5%) were identified with a change in diagnosis within the seven-day outcome window, with all diagnostic changes occurring within 1-3 days of the index asynchronous care encounter (median one day).

Conclusion: In this single-center study, an asynchronous care platform demonstrated a viable pathway for managing select low-acuity conditions in an urban academic health system. This structured platform, with appropriate triage pathways and low rates of diagnostic discordance, shows promise as a model to expand access to care for select low-acuity complaints.

Background: Emergency physicians frequently transfer patients with spine pathology to tertiary- care centers, although research suggests many are discharged without requiring a procedure or specialized imaging. Such transfers consume resources and remove patients from their families and communities. Better understanding these transfers might help identify which patients can receive care without transfer. 

Methods: This was a retrospective cohort study of transfers for spine evaluation to an urban, tertiary-care, Level I trauma center from October 1, 2017–October 1, 2022. Transfers were defined as necessary if the patient a) went to the operating room (OR) within 12 hours of arrival, b) had a neurologic magnetic resonance image (MRI), c) was admitted to an intensive care unit from the emergency department (ED), or d) was admitted to either neurology or a surgical service (including neurosurgery and orthopedics, which share spine coverage in the study hospital). 

Results: The study included 1,918 transfers with a spine evaluation, of which 617 (32.2%) were deemed potentially avoidable. Just 3.3% of all transfers went to the OR within 12 hours of receiving ED arrival, 45.7% had a neurologic MRI at the receiving hospital, and 36.6% were admitted to a neurology or a surgical service. For all transfers, 17.7% were discharged directly from the ED, 16.8% were placed in observation and then discharged, 6.8% were placed in observation and then admitted, and 58.7% were admitted to inpatient from the ED. The average ED length of stay for necessary spine transfers was 15.4 hours vs 16.6 hours for potentially avoidable transfers (P = .07). Compared to the overall rate of necessary transfers (67.8%), patients with the following conditions had a decreased incidence of necessary transfers: cervical spine fractures (62% necessary, P = .008), lumbar spine/sacrum/coccyx fractures (53.5% necessary, P < .001), and disc disorders (51.4% necessary, P = .003). Patients diagnosed with cervical spinal cord lesions (91.7% necessary, P = .01) had an increased incidence of necessary transfers.

Conclusion: Nearly one-third of spine evaluation transfers were potentially avoidable. Patients transferred for spine evaluation experienced prolonged ED stays, creating challenges for both receiving hospitals and patients. Further research is needed to prospectively identify patients who do not require tertiary care and to study methods for managing them in community settings.

Introduction: Despite expectations that emergency medical services (EMS) transport following a gunshot wound (GSW) would improve 30-day mortality compared to transport by private vehicle, the opposite has been found in several studies. In response, EMS has adopted interventions over the past decade to reduce patient mortality. We compared mortality of GSW patients transported by EMS versus private vehicle as these field practice advancements became widespread. 

Methods: We conducted a retrospective cohort study using data from the National Trauma Data Bank (NTDB) from 2007–2021. We included adults (≥ 16 years of age) with GSW injuries transported solely by ground EMS (≤ 2 hours) or by personal vehicle to a Level I or Level II trauma center. The primary outcome was 30-day in-hospital mortality. We also aimed to describe demographic changes over time in these patient populations. A multivariable logistic regression model was developed to estimate the adjusted odds ratio (aOR) of mortality, with demographic and clinical controls. To describe change over time, we performed the multivariable logistic regression model separately within three-year periods. To determine whether the change was significant, we performed the multivariable logistic regression model with the same controls and the addition of an interaction term for transport mode with year group.

Results: Of 355,913 patients, 83.7% were transported by EMS and 16.3% by private vehicle. Unadjusted mortality was consistently higher for EMS patients, ranging from 18.8% (vs 3.7% private vehicle) in 2007–2009 to 19.3% (vs 4.3% private vehicle) in 2019–2021. The aOR for mortality in the EMS cohort decreased from 2.2 (95% CI, 1.7–2.8) in 2007–2009 to 1.6 (95% CI, 1.3–1.8) in 2019–2021. However, this temporal trend was not statistically significant (P = .17).

Conclusion: Our analysis suggests EMS transport remains associated with higher odds of mortality compared to private vehicle transport for patients with gunshot wounds. This may suggest that improvements in EMS clinical and transport practices have not yet proved sufficient to reduce relative mortality, or that there may be differences in injury severity or type of injury that are not adequately accountable from the NTDB data.

Introduction: While computed tomography (CT) is invaluable for detecting life-threatening injuries in the emergency department (ED), the literature shows increasing use of head CT and cervical spine CT in low-risk trauma patients without a corresponding rise in injuries identified. These low-yield exams expose patients to avoidable radiation, increase costs, and contribute to inefficiencies in already overburdened EDs. In this study we evaluated the impact of a multimodal quality improvement (QI) campaign to reduce the use of head and cervical spine CT in low-risk trauma patients.

Methods: This prospective QI intervention involved two EDs within one healthcare network: an academic trauma center and a community hospital. We collected data on baseline CT use for six months, followed by a 23-month intervention period. Primary outcomes were monthly rates of low-risk trauma head and cervical spine CT per 100 ED patients; secondary outcome was the rate of all-cause CT use per 100 ED patients. We plotted rates over time using u-charts with mean-shift lines. Pre- and post-shift differences were summarized as rate ratios (RR) with 95% confidence intervals, compared using the Poisson test.

Results: Use of head CT for low-risk trauma decreased from 5.00 to 4.01 per 100 patients at the academic site (RR = 0.80, 95% CI, 0.75-0.86, P < .001) and from 6.64 to 5.12 per 100 patients at the community site (RR 0.77, 95% CI, 0.73-0.82, P < .001). Use of cervical spine CT for low-risk trauma decreased from 3.36 to 2.83 per 100 patients at the academic site (RR = 0.84, 95% CI, 0.78-0.91, P < .001) and from 4.31 to 3.49 at the community site (RR = 0.81, 95% CI, 0.75-0.87, P < .001). All-cause CT use decreased at the academic site from 53.06 to 47.91 CT exams per 100 patients [RR = 0.90, 95% CI, 0.89-0.92, P < .001] but remained unchanged at the community site.

Conclusion: A structured quality improvement campaign led to a significant reduction in the use of head and cervical spine CT in low-risk trauma patients. These findings provide a framework for promoting evidence-based imaging practice.

Introduction: During endotracheal intubation, equipment setup typically includes the patient monitor fixed at the head of the bed behind the back of the operator. Inability to directly visualize the patient monitor may result in delayed recognition of desaturation. Our primary aim in this study was to measure the association between patient monitor position and the time to recognition of a desaturation event during endotracheal intubation.

Methods: We performed a randomized crossover trial of emergency medicine residents across two Accreditation Council for Graduate Medical Education-accredited programs. Subjects were asked to perform direct and video-assisted laryngoscopy once on a difficult airway trainer in a simulation. The sequence of laryngoscopy modality (direct vs video-assisted) and monitor position (head vs left vs right of bed) were randomized prior to each attempt. The simulated patient’s peripheral capillary oxygen saturation (SpO2 ) was programmed to begin at 100% and decrease at a rate of 1% per second 10 seconds after the start of the subject’s attempt. The primary outcome measure was time to operator recognition of hypoxia defined as the observed period during which the simulated SpO2 was < 90%. Secondary outcomes were operator failure to visualize a desaturation event. We rendered Kaplan-Meier curves illustrating the time to visualization of hypoxia and performed a Cox regression adjusting for laryngoscopy modality and total number of previous intubations performed. Using multivariable linear regression, we modeled the association between time to recognition of hypoxia in seconds and patient monitor position with similar adjustments. To assess differences in the number of observed failure events between study arms, we used chi-squared or Fisher exact tests. The threshold for statistical significance was a two-sided P < 0.05.

Results: We observed 68 attempts by 34 subjects. Twenty-two (32.5%), 22 (32.5%), and 24 (35%) intubations were performed with the monitor positioned at the head, left, and right, respectively. The median times to recognition of hypoxia were 37 seconds [sec] (95% CI, 25-86 sec) for the head, 32 sec (95% CI, 18-50 sec) for the left, and 23 sec (95% CI, 19-34 sec) for the right groups, respectively. Cox regression demonstrated hazard ratios of 2.7 and 3.2 for the left and right groups when compared to the head group, and these findings were statistically significant (P = .04 and P = 0.03, respectively). We found no statistically significant associations between time to recognition of hypoxia and laryngoscopy modality or total number of previous intubations (P = .82 and .21, respectively). Failure rates across head, left, and right groups were similar, at 36%, 59%, and 50%, respectively (P = .30).

Conclusion: Positioning of the patient monitor at the head of the bed results in delayed visualization of desaturation events during simulated direct and video-assisted laryngoscopy across different levels of experience. Ideally, the patient monitor should be positioned on the side of the bed and within the operator’s direct line of sight. Further research is warranted to assess how equipment setup may impact procedural performance, operator ergonomics, and patient safety.

Introduction: Emergency front-of-neck access may serve as a life-saving intervention when facing patients with difficult airways. Cricothyrotomy consists of needle and surgical techniques and is performed in approximately 0.2-0.5% of all airway management attempts. Our primary aim in this study was to compare procedural completion time and first-pass success of needle and surgical approaches to cricothyrotomy by civilian and military practitioners using a human cadaver model.

Methods: Emergency medicine (EM) attendings and residents and U.S. Air Force Pararescue specialists were randomized to perform either a needle or surgical cricothyrotomy on an unfixed human cadaver a single time following a 30-minute didactic session about both procedure types. We recorded procedural completion time, first-pass success, frequency and type of observed complications, and subject level of training. Our primary outcome measure was procedural completion time. Secondary outcome measures included first-pass success and complication rates. We used a Wilcoxon signed-rank test to compare the difference in median completion times between needle and surgical groups. We performed a Cox regression analysis to evaluate the relationship between technique and procedural completion time while adjusting for subject level of training. Chi-squared or Fisher exact tests were used to compare unadjusted first-pass success and complication frequencies between needle and surgical groups. Multivariable logistic regression analysis modeling the association between technique and first-pass success and complication events while adjusting for subject level of training was performed.

Results: A total of 99 subjects were enrolled, and 19 (19%), 68 (69%), and 12 (12%) were classified as EM attending, EM resident, and Pararescue specialist, respectively; 51 (52%) and 48 (48%) were randomized into the needle and surgical groups, respectively. The median time to procedural completion was shorter in the needle group than the surgical group (56.5 seconds [sec], 95% confidence interval, 54-66 sec vs 65 sec, 95% CI, 59-73 sec, respectively). The difference in median completion times was 8 sec (95% CI, -1.0 to 17 sec, P = .08). The hazard ratio comparing completion time of surgical to needle cricothyrotomy while adjusting for level of training was 1.41 (95% CI, 0.93-2.13, P = .11). First-pass success and complication rates were similar between the needle and surgical groups (94% vs 94%, P = .32, and 27% vs 33%, P = .52, respectively). The adjusted odds ratios comparing the likelihoods of first-pass success and complication between surgical and needle groups while adjusting for level of training were 1.06 (95% CI, 0.20-5.54, P = .95) and 1.40 (95% CI, 0.55-3.56, P = .48), respectively.

Conclusion: In this study using unfixed human cadavers, needle and surgical cricothyrotomy demonstrated comparable performance regarding procedural completion time, first-pass success, and complication rates. The 8-second difference in median completion time between groups was not found to be statistically significant and is unlikely to be clinically significant given the typical oxygen reserves in an apneic patient. These findings suggest that for practitioners in civilian and military settings, both needle and surgical cricothyrotomy remain viable options for emergency front-of-neck access, assuming adequate operator-level procedural proficiency and access to necessary equipment. 

Introduction: Emergency department (ED) boarding of critically ill patients awaiting intensive care unit (ICU) admission has been associated with delays in time-sensitive interventions, prolonged lengths of stay (LOS), increased crowding, and higher incidence of morbidity and mortality. To address this, our institution implemented an ED critical care consult team in 2020 and established a resuscitation and emergency critical care fellowship in 2022. The critical care consult team, staffed by emergency physicians with additional resuscitation or critical care training, provides consultative support for resuscitations and the management of boarding critically ill patients 10 hours per day, with the dual goals of improving clinical care and optimizing patient flow. The primary outcome of this study was to evaluate the rate of patients downgraded from their initial admission level of care (ICU, Intermediate care) to a lesser intensity of care (intermediate, ward, home). Secondary outcomes included ED, ICU, and hospital LOS. 

Methods: We conducted a retrospective chart review of all patients ≥ 18 years old with ICU or intermediate care admission orders placed between November 1–30, 2024. Patients were sequentially identified via the electronic health record, and clinical and quality assurance data were collected in a REDCap database. 

Results: During the study period, the ED critical care consult team was active on 73% of days, staffed primarily by resuscitation and emergency critical care fellows. Of 372 eligible patients, 18% (68/372) were managed by the critical care consult team after initial assessment by primary emergency physician staff, while 82% (304/372) served as controls and did not have involvement with the critical care consult team. Patients evaluated by the team had higher acuity, with 30.9% presenting with an Emergency Severity Index (ESI) score 1 compared to 4.6% in the control group. Despite this, the downgrade rate was significantly higher in the ED3CT cohort (29.4% vs 11.8%, p=0.001). No differences were observed in ED (0.62 days vs 0.60 days, P = .80), ICU (5.1 days vs. 5.2 days, P = .93), or hospital LOS (9.7 days vs 10.8 days, P = .68).

Conclusion: These findings suggest that ED-based critical care physicians, including fellows in training, may facilitate earlier identification of patients suitable for lower levels of care despite initially higher acuity. While there was no change in ED, ICU, and hospital length of stay, it is possible that this is related to systemic problems with hospital bed availability. The high rate of downgrades highlights the benefits of ED-based critical care physicians advancing care of critically ill patients boarding in the ED.

Introduction: Intimate partner violence (IPV) represents a pervasive and costly public health issue. Many IPV victims seek care in the emergency department (ED) due to injuries or related medical complaints; yet a substantial number of cases remain undetected. The challenge lies in implementing effective screening tools within the demanding environment of an ED. In this study we aimed to assess the efficacy of two brief IPV screening tools— the single question, “Have you been hit, kicked, punched, or otherwise hurt by someone in the past year?” and the 4-item Ongoing Violence Assessment Tool—and to compare them to the more comprehensive Index of Spouse Abuse, a validated 30-item survey that is considered the gold standard for IPV assessment. Our objective was to identify improved strategies for IPV screening in the busy ED setting.

Methods: In this prospective study, every third English-speaking female patient 18-55 years of age presenting to our ED triage was invited to participate. Each participating patient was sequentially assigned to either the single question or the ongoing assessment screening group. Both groups completed feedback surveys about their experiences and the Index of Spouse Abuse survey. We used chi-square tests to compare categorical variables, and we used frequency tables to calculate the sensitivity, specificity, positive predictive value, and negative predictive value of each IPV screening tool. We compared test characteristics between the Ongoing Violence Asessment Tool or the single question screening tool to the Index of Spouse Abuse using the Fisher exact test. Mean duration was compared using two-tailed Student t-tests. The primary outcome was the sensitivity and specificity of the single question assessment. and the 4-item Ongoing Violence Assessment Tool, using the Index of Spouse Abuse as the gold standard for IPV screening. Secondary outcomes were to record the length of time needed to screen with the single question assessment and the Ongoing Violence Assessment Tool and to collect participant feedback on the two screening tools.

Results: A total of 400 participants were enrolled in the study and completed the designated surveys. Screening time was significantly shorter in the single question group (median 6 seconds) compared to the ongoing assessment group (median13 seconds; P < .001). Feedback surveys did not reveal significant differences between the two groups. When compared to the Index of Spouse Abuse, the single question tool exhibited sensitivity of 53.3% and specificity of 94.1%, while the ongoing assessment demonstrated slightly higher sensitivity levels of 75.0% and lower specificity of 92.8%. For the single question assesssment, the positive predictive value was 42.1% and negative predictive value was 96.1%. For the Ongoing Violence Assessment Tool, the positive predictive value was 40.1% and the negative predictive value was 98.2%.

Conclusion: The 7-second reduction in overall IPV screening time for the single question compared to the 4-item Ongoing Violence Assessment Tool likely has little clinical benefit, especially with its low sensitivity. Further studies are needed to identify the optimal screening tool for intimate partner violence in the emergency department.

Introduction: Emergency department (ED) encounters are common for pregnant individuals in the United States. Radiological imaging is frequently ordered for diagnostics in the ED but generally avoided during pregnancy. This study examines missed pregnancy documentation and the association of pregnancy documentation with radiological imaging among individuals who have an ED encounter while pregnant.

Methods: We used a retrospective cohort of pregnant individuals who had a live birth in an urban county in Indiana 2022–2023. We pulled all ED encounters occurring between 42-279 days of gestation (N = 4,597) that did not occur within five days of delivery. Our primary outcome measure was pregnancy documentation in the patient’s electronic health record and receipt of radiological imaging (radiograph and computed tomography) of the chest, abdomen or spine. We used descriptive statistics and logistic regressions for the analysis. 

Results: Pregnancy was not documented in 273 of the 4,597 encounters (5.9%). A larger percentage of encounters with missed pregnancy documentation occurred with non-Hispanic Black patients (162/273, 59.3%) compared to non-Hispanic White patients (75/273, 27.5%);  (odds ratio 1.70, 95% CI, 1.21-2.41) for non-Hispanic Blacks relative to non-Hispanic Whites. Radiological imaging occurred in 147 of the 4,324 encounters with a documented pregnancy (3.4%), compared with  30 of the 273 encounters where the pregnancy was not documented (11.0%). Missed pregnancy documentation was associated with 2.11 times (95%CI, 1.30-3.42) the odds of receiving radiological imaging when adjusted for confounders.

Conclusion: Missed pregnancy documentation occurred in 5.9% of emergency encounters with pregnant patients. While this is uncommon, it is still significantly associated with receipt of radiological imaging. Disparities in odds of pregnancy documentation in the ED may contribute to differences in maternal outcomes and highlights the necessity of ensuring equitable care for all pregnant individuals.

Introduction: Methamphetamine-associated heart failure with reduced ejection fraction is a serious consequence of methamphetamine use often underrecognized in the emergency department (ED). Point-of-care ultrasound (POCUS) offers rapid, non-invasive cardiac screening for high-risk populations. This study evaluated the diagnostic yield of POCUS for detecting methamphetamine-associated heart failure with reduced ejection fraction in ED patients who use methamphetamine.

Methods: We conducted this prospective cohort study between December 2020–February 2024 at an urban Level I trauma center ED. The primary outcome was diagnostic yield of cardiac POCUS for abnormal left ventricular ejection fraction (LVEF) and abnormal sex-specific left ventricular end-diastolic diameter in patients with methamphetamine use, with secondary analyses assessing associations with use duration and frequency. Diagnostic yield was calculated as the proportion of completed POCUS examinations identifying abnormalities. We used E-point septal separation to calculate LVEF; < 40% was abnormal. Left ventricular end-diastolic diameter abnormality (> 5.8 cm males, > 5.2 cm females) was categorized as mild, moderate, or severe (mild, 5.9-6.3/5.3-5.6; moderate, 6.4-6.8/5.7-6.1; severe, > 6.8/> 6.1 cm males/females). Physician-performed POCUS assessed LVEF and left ventricular end-diastolic diameter in patients with a methamphetamine use history and a comparison group of non-users.

Results: Of the 136 enrolled patients, 84 (61.8%) reported methamphetamine use. Among methamphetamine users, diagnostic yield of cardiac POCUS was as follows: reduced LVEF in 22 of 70 with measurable LVEF (31.4% [20.9–43.6%]); any sex-specific left ventricular end-diastolic diameter abnormality in 30 of 84 (35.7% [25.6–46.9%]); and severe sex-specific left ventricular end-diastolic diameter abnormality in 15 of 84 (17.9% [10.4–27.7%]). Corresponding values in non-users were 3 of 52 (5.8% [1.2–16.0%]; P < .001), 10 of 52 (19.2% [9.6–32.5%]; P = .05), and 3 of 52 (5.8% [1.2 - 16.0%]; P = .07), respectively. Longer duration (odds ratio [OR] 6.05, 95% confidence interval [CI] 1.46–25.10) and higher frequency (OR 5.93, 95% CI, 1.52–23.06) of methamphetamine use were associated with reduced LVEF. 

Conclusion: Cardiac point-of-care ultrasound demonstrated a clinically significant diagnostic yield in detecting methamphetamine-associated heart failure with reduced ejection fraction among methamphetamine users in the ED, suggesting POCUS could aid early detection in this population, potentially streamlining management before disease progression.

Introduction: Toxic alcohol poisoning (methanol or ethylene glycol) can cause severe metabolic disturbances, end-organ damage, and death. Timely diagnosis is paramount and predicated on history, lab markers, and confirmatory laboratory testing, which inform antidote use and/or hemodialysis. Confirmatory toxic alcohol testing capabilities and turnaround times vary by geographic region. Our objective in this study was to evaluate how differences in toxic alcohol testing turnaround times impact our primary outcome of hospital length of stay and secondary outcomes of antidote (fomepizole) administration and medical outcomes (including death, major, moderate, and minor effects) among patients with suspected toxic alcohol poisoning.

Methods: This is a retrospective cohort study of toxic alcohol poisoning cases reported to two U.S. poison centers, Michigan Poison and Drug Information Center (MiPDC) and Florida’s Poison Information Network (FPIN), from 2018–2022. Based on investigator experience with each center’s practice patterns, MiPDC had a toxic alcohol testing turnaround time of 12-24 hours, while FPIN had turnaround times averaging 5-7 days. We queried poison center databases for cases where fomepizole was recommended and/or administered. Medical outcomes were categorized using National Poison Database System definitions: minor effects (minimally bothersome symptoms); moderate effects (pronounced symptoms requiring treatment); major effects (life-threatening or significant disability); and death. We excluded cases if there was no concern for toxic alcohol poisoning or if fomepizole was administered for acetaminophen poisoning. 

Results: A total of 963 cases met inclusion criteria: (MiPDC, n = 590; and FPIN, n = 373). Patients reported to FPIN had a longer median hospital length of stay compared to MiPDC (65.0 versus 48.0 hours, P < .001). FPIN patients received more doses of fomepizole (2.0 versus 1.0 doses, P < .001). FPIN patients had 4.1 times the odds of major effect (95% CI, 1.3-13.3) (P = .02) and 4.7 times the odds of minor effect (95% CI, 1.4-15.8) (P = .01), without significant association for moderate effects or death.

Conclusion: Access to rapid confirmatory toxic alcohol testing was associated with shorter hospital length of stay, reduced antidote use, and improved medical outcomes in suspected toxic alcohol poisonings. Future studies are warranted to comprehensively characterize the variation in region-specific care and inform efforts to standardize confirmatory testing capabilities.

Introduction: It is not known whether skin color influences inclusion of substance use on medical students’ differential diagnoses for a simulated cardiac arrest. Our objective in this study was to investigate whether the presence of a dark-skinned or light-skinned manikin in the lab correlated with their decision to include substance use on the differential as a possible cause of cardiac arrest.

Methods: In this study at a single institution, all fourth-year medical students in an emergency medicine course participated in a manikin-based cardiac arrest simulation case. The simulation sessions alternated between the use of a light-skinned and a dark-skinned manikin. Both were adult sized. After the first shock was delivered, students individually documented their differential diagnosis for the cause of the cardiac arrest on deidentified, free-text research forms. We excluded forms if they were blank, had been completed by a non-medical student, or could not be associated with the skin color of the manikin used. The primary outcome measure was how often students included substance use as a cause of cardiac arrest anywhere in their differential diagnoses. We compared the relationship between manikin skin color and the students’ consideration of substance use as a cause of cardiac arrest, using the Fisher exact test. 

Results: Of 270 eligible participants, 271 surveys were returned; 75 (27.7%) were excluded. Of the remaining 196 surveys, 96 were associated with the light-skinned and 100 with the dark-skinned manikin. Among the 100 respondents using the dark-skinned manikin, one student (1%) listed substance use as the leading diagnosis, while none (0%) of the students using the light-skinned manikin listed substance use as the leading diagnosis. In each group, only 20% of students (n = 39 total) listed substance use anywhere on the differential diagnosis (P = 1.00). 

Conclusion: Among fourth-year medical students participating in a simulated cardiac arrest, we found no correlation between manikin skin color and the inclusion of substance use on their differential for cardiac arrest. Overall, their decision to include substance use in their differentials was low regardless of skin color, suggesting the need to improve their awareness of substance use as a potential cause of cardiac arrest.

Introduction: Emergency physicians frequently care for patients with serious or terminal illnesses, yet they often lack formal palliative care training. Our primary objective was to develop a structured, multimodal palliative care curriculum for emergency medicine (EM) residents and evaluate whether this curriculum improved residents’ knowledge, comfort level, and perceived application of skills to care for patients with chronic or terminal illness in the emergency department (ED). Our secondary objective was to determine whether EM residents found palliative care education important and to identify which educational modalities are most effective for acquiring palliative care knowledge and skills.

Methods: We implemented an eight-hour multimodal curriculum for EM residents at a single, large Level I trauma center (four hours of didactics, a three-hour simulated patient communication skills lab, and one hour of high-fidelity simulation). Our primary outcome was pre- and post-intervention surveys (12 questions) that assessed perceived knowledge, comfort, and skill application on five-point Likert scales. We analyzed paired responses using the Wilcoxon signed-rank test, with a P value of < .05 considered statistically significant. Effect size was calculated using Cohen d. Our secondary outcome measure was a post-intervention survey (six questions) that assessed participants’ opinions on the effectiveness of the different educational methods.

Results: There was a 100% response rate among 41 residents from all postgraduate years 1-3. Significant improvements (P < .001) were observed in residents’ self-reported abilities across all domains with large effect sizes. Median scores and interquartile ranges increased for conducting goals-of-care discussions (4 [3–4] vs 4 [4–5]), interpreting advance directives (3 [2–4] vs 4 [4–4]), managing end-of-life symptoms (3 [2–3] vs 4 [3–4]), communicating bad news (3 [2–4] vs 4 [4–4]), and coordinating with palliative or hospice teams (2 [2–3] v. 4 [4–4]). All educational modalities were rated effective, with simulation and small-group sessions preferred over lectures.

Conclusion: A structured, multimodal palliative care curriculum significantly enhanced EM residents’ perceived preparedness to manage patients with palliative care needs. Embedding didactic and simulation-based palliative training in EM residencies is both feasible and impactful, addressing critical gaps in palliative competencies and aligning with national best-practice guidelines.

Introduction: Point-of-care ultrasound (POCUS) can expedite patient diagnoses and improve procedural safety in emergency department (ED) patients. Nevertheless, clinical POCUS use lags in many ED sites nationwide, with only 40% of community physicians using POCUS according to a study from 2019-2021. We studied the impact of a multifaceted clinical POCUS intervention to address barriers and increase clinical POCUS use. 

Methods: We conducted a prospective cohort study at a single academic hospital that included ED attendings, residents, and advance practice clinicians (APC). A multifaceted four-week intervention for emergency clinicians from December 2023–January 2024 addressed barriers to POCUS use identified on a pre- and post-intervention survey. The intervention included POCUS education during clinical shifts by ultrasound faculty, clinical POCUS workflow demonstration during resident conference/faculty meetings, and QR code reference files on machines for a total of two hours of additional training per clinician. The primary outcome was the number of clinical ED POCUS performed during the 18 months pre-intervention and 12 months post-intervention. Secondary outcomes were POCUS workflow knowledge exam scores and POCUS revenue. We analyzed clinical POCUS numbers from July 2022–December 2024 using an interrupted time series model.

Results: Forty-two of 99 emergency clinicians (42.4%) responded to surveys pre-intervention and 28 post-intervention (28.3%). Fifty-six physicians/APCs (56.6%) participated in the in-person POCUS intervention (17 attendings, 34 residents, 5 APCs). The unadjusted number of POCUS exams performed increased from 6,708 pre-intervention (18 months) to 11,600 post-intervention (12 months). After controlling for the underlying secular trend, we saw no effect of the intervention with no significant increase in overall number of POCUS exams performed per 100 ED patients after the intervention (mean level change = -0.81, 95% CI, -2.43 to 0.82; P = .33). Neither was there an increase in the slope of the secular trend post-intervention (difference in slope, β = 0.00, 95% CI, -0.10 to 0.10; P = .98 for post-intervention, β = 0.02, 95% CI, -0.08 to 0.12 for sustainability period). Monthly POCUS revenue increased ~$55,000 in total billed and $10,000 reimbursed (~16% reimbursement). This was the professional component only that was billed by the physician and not the technical component covering equipment and maintenance. Post-intervention mean knowledge scores were 88% correct (standard deviation 12.0) with 16/22 participants (72.7%) passing the assessment (score > 90%).

Conclusion: A multifaceted intervention was not shown to improve clinical point-of-care ultrasound use and revenue when accounting for an underlying sustained secular upward trend in number of POCUS exams performed per 100 emergency department patients throughout the study period. Future interventions directed toward low POCUS users and identification of clinical POCUS champions may improve clinical POCUS use.

Introduction: Ultrasound-guided nerve blocks (UGNB) are an effective and safe method of pain control that are increasingly used for pain management in the emergency department (ED). However, performing these procedures is often time-intensive due to the need to locate and gather necessary supplies. Our ED recently implemented use of a nerve block cart, which contains all the supplies needed for performing a nerve block. Our objective in this quality improvement study was to assess whether the presence of an ED nerve block supply cart was associated with an increase in the number of UGNBs performed.

Methods: We conducted a retrospective review of point-of-care ultrasound examinations performed in a single academic quaternary-care community ED over 22 months, looking at 11-month time periods before and after implementation of an ED nerve block supply cart in March 2023. Our primary outcome measure was documentation of a UGNB, and our secondary outcome measure was the type of UGNB performed.

Results: We reviewed 14,321 ultrasound exams over 22 months—11 months pre-cart (6,853) and 11 months post-cart (7,468) implementation. We noted a statistically significant increase in the number of UGNBs, from 21 performed in the pre-cart period (0.31% of all ultrasound exams [95% CI, 0.17- 0.43%], to 50 UGNBs in the post-cart period (0.67% of all ultrasound exams [95% CI, 0.46- 0.86%], P < .01). The fascia iliaca block was the most common UGNB performed in both the pre- (52.4%) and post-cart (62.0%) periods.

Conclusion: We found that the deployment of an ED nerve block supply cart was associated with an increased number of ultrasound-guided nerve blocks performed by emergency clinicians in our hospital.

Introduction: Rural areas in the United States have higher mortality rates than urban regions, particularly from emergency care-sensitive conditions. Air medical ambulances (medevacs) are critical to emergency care access in the rural U.S., but limited data hinder the ability to study this critical system. In Alaska, medevac services often represent the sole method for connecting Alaska Native patients in remote clinics to physician emergency medical care. This study characterizes medevac use and timing between tribally administered village clinics and hospitals in Northwest Alaska. Our objective in this study was to describe the use and timing of medevacs and investigate how medevac decision-making impacts medevac transport times.

Methods: We conducted a retrospective cohort analysis of medevac transfers between 2020–2024 from 11 Alaskan village clinics within the Maniilaq Association, which serves ~8,000 people over 35,862 square miles.We included 1,579 medevacs representing 1,119 unique patients flying from remote clinics to a central critical access hospital hub.. Our primary outcome measure was the association between short medevac decision times (< 60 minutes), and short total medevac times (< 180 minutes). We measured “flight time,” “decision time,” and “ground time” (time spent waiting for an aircraft to become available) as key components of total medevac time.

Results: A total of 1,579 medevacs were deployed for predominantly Alaska Native (96.8%) patients, of whom 22.2% had traumatic injuries. Between 4.1-7.9% of community members in the region are transported by medevac each year. Median medevac time was 262 minutes (interquartile range [IQR] 196–402 [101–4,142]) from activation call to arrival at the critical access hospital. No medevacs were < 100 minutes. “Ground time” was the longest phase of medevac encounters overall (median ground time 105 minutes (IQR 81–187]) vs median decision time 75 minutes (IQR 42–130) or median flight time 44 minutes (IQR 35–77). We found no association between short medevac decision times and short medevac response time (P = .93). Medevac decision-making was the longest phase in only 6% of the shortest total medevacs (< 190 minutes), but it was the longest phase in 40% of the longest total medevacs ( > 400 minutes).

Conclusion: We found four key themes: 1) no medevacs were < 100 minutes. Independent of human or system factors,atients cannot be transferred from a village clinic to a critical access hospital within the “golden hour” of emergency care; 2) short medevac decision times were not significantly associated with short overall medevac times; 3) the longest phase in a medevac transfer was “ground time”; and 4) in the subset of the longest total medevacs, medevac decision-making was much more likely to be the longest phase than in the shortest total medevacs. This emergency transfer system is not responsive to patient condition and suggests that medevac decision support may help for a subset of encounters.

Introduction: The transition from resident to junior faculty in academic emergency medicine (EM) may be shaped not only by formal training and institutional policies but also by the “unwritten curriculum,” a set of norms and expectations embedded in institutional culture. However, the unwritten curriculum and its potential to impact junior faculty development remains largely unexplored. Little is known about how junior faculty perceive, experience, and navigate these informal expectations, or the formal and informal structures that influence this process. In this study we aimed to explore junior faculty members’ experiences with the unwritten curriculum in academic EM, with a focus on how they interpret and navigate institutional norms and identify supports and barriers encountered during their early faculty development.

Methods: Within their first five years, EM faculty at academic institutions distinct from their residency training sites completed an anonymous, iteratively developed survey designed to explore experiences with the unwritten curriculum, informed by Schlossberg’s transition theory framework. The primary analytic focus was identification of themes describing how junior faculty perceive and navigate implicit institutional norms. Open-ended responses underwent thematic analysis using a structured codebook, applied by two independent reviewers with consensus-based coding and adjudication by a third when disagreements arose. 

Results: A total of 35 junior faculty members completed the survey. All participants indicated influence of the unwritten curriculum on their professional development. Major themes identified include the unspoken importance of mentorship and peer guidance; implicit expectations and norms surrounding engagement, productivity, and visibility; work-life integration; cultural adjustment; scholarly output; and gaps in onboarding, feedback, and role clarity. Participants emphasized challenges in navigating departmental politics, understanding hierarchical nuances, and balancing unspoken expectations for committee involvement and informal social participation. Additionally, unclear feedback processes, inconsistent evaluation expectations, and cultural norms for active engagement were noted as barriers to integration and professional growth. 

Conclusion: Junior faculty in academic EM described the unwritten curriculum as a meaningful influence on their early faculty experience. Within this sample, participants highlighted mentorship, feedback transparency, and structured faculty development as potential mechanisms to support navigation of implicit expectations during the transition to junior faculty. These findings reflect individual perceptions rather than program characteristics and should be interpreted within the context of the study’s scope.

Introduction: Multi-day planned mass gatherings are prevalent in various forms of sports competitions, concerts, professional, political, and religious conferences. The largest, the World Cup competition, will be hosted by large cities of the United States, Canada, and Mexico in June and July, 2026. These can present risks to the health of spectators, participants, organizers, and host communities, which if discovered faster, facilitates more effective responses in preventing morbidity/mortality. This study demonstrates visually modeled 9-1-1 medical data that uniquely contributes to existing syndromic surveillance activities by its practicality and time sensitivity.
      
Objectives: Using data from the nine-day period of 2019 Super Bowl LIII festivities, this retrospective, quantitative, descriptive, population-based study was conducted to demonstrate how 9-1-1 emergency medical dispatch (EMD) data could be practically modeled to more rapidly detect changes from baseline host community 9-1-1 data. Our ultimate objective is to illustrate these visual models in the attempt to improve syndromic surveillance.   

Methods: All 9-1-1 medical calls from three host municipalities were processed and categorized at the Grady Emergency Medical Services (EMS) Communications Center during game day and eight preceding days of festivities (time frame-standardized to nine-day events period). This events period call volume was contrasted to that of the identical nine-day pre- and post-events periods. The mean 24 one-hour interval call volumes for each day of these three periods were analyzed.  Data visualization techniques (a data table, bar graphs, geo-, and heat-mapping) were constructed to illustrate differences in 9-1-1 call volumes of three categories (hypothermia, traffic injury incidents, and violence-induced injuries), for the three periods. The most similar previous such studies were reviewed and related to our study.

Results: The events period call volume (3,267) was less than that in pre- (3,356) and post-(3,460) events totals. Directional (increasing versus decreasing) patterns in hourly call frequencies were similar among all three periods. Cold exposure calls decreased across the three periods (successive period were 9, 7, and 4 respectively). Changes in traffic incidents were minimal (36, 39, and 38, respectively). Violent act injury calls increased during the post-events period (151, 150, and 166, respectively). 

Conclusion: Data from 9-1-1 calls could provide readily discoverable trends reflective of clinically significant syndromes threatening host community health status associated with planned mass gatherings. The study demonstrates practical data modeling to enhance syndromic surveillance.  Recommendations are offered for enhancing 9-1-1 data analysis in conducting syndromic surveillance.

Introduction: Video methods used in medicine have been described as the “gold standard” because they show events as they occurred and with a level of detail unattainable when events are reconstructed using other methods. In stimulated recall, video or pictures during interviews prompt discussion about participants’ thoughts or feelings when images were captured. Coupled with video, stimulated recall can deepen researchers’ understanding of a participant’s thinking at the time. However, conducting video-based stimulated recall interviews with participants is poorly described in the literature because of word count limits in today’s journals. In this paper we describe how we used video with stimulated recall interviews to learn how the diagnostic process evolves for emergency physicians. 

Methods: We used the theory of distributed cognition to describe how information processing develops over time and occurs across physicians, the technologies used, and social organization. We conducted a qualitative study, collecting data in pediatric and adult emergency departments (ED) of an academic Level I trauma center. Participants wore head-mounted video cameras for two hours while providing care to ED patients and revealed their thinking throughout the diagnostic process in subsequent stimulated recall interviews. We reviewed video recordings to identify situations related to the diagnostic process or to one of the concepts in distributed cognition. We identified short video clips from each session to display during interviews and prepared accompanying questions. Stimulated-recall interviews were conducted using video conferencing technology, audio recorded, transcribed, and verified for accuracy. We used content analysis to analyze results.

Results: Eleven attending physicians from February 2022–May 2023 (five from the pediatric ED and six from the adult ED) interacted with 52 patients over a total of 24.4 hours on video. We obtained patients’ permission to film encounters before a participating physician provided care, wearing the head-mounted camera. We conducted individual stimulated recall interviews (mean 53 minutes, range 33–63 minutes) with all 11 physicians, which uncovered perspectives beyond what was revealed on film. For example, the complexity of cognition resides in patients as well as physicians. Thus, physicians must exert great effort to elicit the patient story and make a likely diagnosis in the chaotic, noisy environment of the ED. 

Conclusion: Using innovative methods to uncover emergency physicians’ cognitive processes has the potential to advance our understanding in other settings. This methodology brings awareness to how one’s thoughts can become visible and, thus, amenable to reflection and change.

Background: Prevalence of heart failure is increasing, with an associated rise in emergency department (ED)-related care. Social determinants of health (SDoH) are associated with adverse health outcomes, but the extent to which they influence ED use for heart failure care is poorly understood. We sought to describe the relationship between community-level social vulnerability and ED revisits and hospital admissions for heart failure within a single health system.

Methods: We conducted a retrospective review of Social Deprivation Index (SDI) scores (higher score = more deprivation) by ZIP code paired with administrative clinical data. Zero-hurdle regression was used to model the relationship between SDI and ED revisits within 90 days of a prior ED visit for heart failure (logistic model for > 0 revisits; Poisson model for count of revisits). We used a mixed-effects logistic model—accounting for repeat visits—to test the association of SDI with hospital admission at any given ED visit.

Results: From January 2022–December 2023, there were 3,569 ED visits from 2,406 patients. Each standard deviation increase in SDI (30.3) was associated with increased odds of at least one 90-day revisit (OR, 1.53; 95% CI, 1.08-2.16). Higher SDI was also associated with more 90-day revisits, with varying magnitude by hospital. After adjusting for characteristics of prior ED visit, SDI was not associated with hospital admission.

Conclusion: Our results suggest that area-level social vulnerability influences the decision to seek heart failure-related care in the ED. Patients from more deprived areas may not have more severe clinical presentations, however, as evidenced by lack of association of SDI with hospital admission. 

Importance: Distal radius fractures and distal ulna fractures are common orthopedic injuries treated in emergency departments (ED). Our goal in this narrative review was to present emergency physicians with a single source that covers the evaluation and treatment of distal radius fractures and distal ulna fractures across the lifetime of our patients. There are differences in the treatment algorithms for distal radius fractures between pediatric, young adult, and geriatric patients.

Observations: Pediatric distal radius fractures are defined by their relation to the growth plate and are influenced by the gradual calcification of the developing bone. Some pediatric distal radius fractures can heal through significant displacement, while others require anatomical reduction to limit the risk of growth arrest. For adult patients with a distal radius fracture, there are established guidelines for both appropriate reduction goals and for when operative treatment is indicated. For geriatric patients, management strategies have evolved over the last decade after multiple studies demonstrated no functional difference between operative and nonoperative management. Given this, most geriatric distal radius fractures are managed nonsurgically, which makes effective reduction in the ED important to optimize long-term wrist function. 

Conclusion and Relevance: Emergency physicians need to be well versed at both identifying fracture patterns and be knowledgeable about radiographic fracture-reduction goals. This emergency medicine-focused and illustrated narrative review will assist physicians, nurse practitioners, and physician assistants in meeting those goals. We also summarize pain management, splint molding, possible complications and follow-up considerations for emergency physicians treating patients with  distal radius fractures.

Introduction: Collective leadership within healthcare is critical if we are to deliver on net zero targets and provide high-value, low-carbon care to our patients. However, driving change in systems under considerable strain from crowding, limited resources, and increasingly complex caseloads can be a daunting task and often feels out of reach. In July 2023, the Royal College of Emergency Medicine (RCEM) launched a sustainability initiative to support environmentally sustainable healthcare within emergency departments (ED). This 12-month support and accreditation scheme centers around a framework of 36 actions and has been designed to make sustainability interventions accessible to staff, enabling individuals, groups, and networks to become leaders within their own spheres of influence and elicit measurable changes. The objective of this study was to evaluate the impact of the accreditation scheme over a 2-year period.

Methods: The primary outcome measures were the financial and carbon savings made by participating sites. Secondary outcome measures were derived from a thematic analysis of written submissions, undertaken to identify co-benefits and generate qualitative insights into both barriers to, and enablers of, environmental sustainability interventions within EDs. 

Results: Five sites were successfully accredited for Bronze and Silver awards in 2024, and 10 sites for Bronze, Silver and Gold awards in 2025, with combined projected annual savings of £351,366 and 157,724 kg of carbon dioxide equivalent. 

Conclusion: To our knowledge, this is the first time that a collaborative, structured, dynamic, and scalable approach to sustainable healthcare in emergency medicine has been used worldwide.