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

With increasing emergency department (ED) boarding and crowding, EDs have introduced several novel care-delivery initiatives including split-flow models (e.g., fast tracks), non-linear patient flow models (e.g., protocol bays), nursing triage order sets, physician-in-triage, and the use of non-traditional care areas (e.g., ED hallways). One such emerging practice is the placement of orders for patients in the waiting room (WR) by physicians prior to in-person physician evaluation (e.g., based on triage documentation and the patient’s medical record). This paper describes key ethical obligations to WR patients that support this practice, as well as other considerations that must be balanced against these obligations, including potential risks. 

Introduction: Upright intubation is essential for managing difficult airways but can be challenging, especially for less experienced clinicians. Face-to-face intubation may lower first-pass success rates due to unfamiliar orientation. New videolaryngoscope devices have the potential to improve intubation success. We aimed to compare first-pass success rates, intubation duration, and glottic view between the right-rear and face-to-face approaches, using channeled videolaryngoscope, hyperangulated videolaryngoscope, and video stylet for upright intubation.

Methods: We conducted a cross-over manikin simulation study involving 30 participants—19 attending physicians, six residents, and five nurse practitioners—to compare the efficacy of these devices to a standard Macintosh videolaryngoscope, using both right-rear and face-to-face approaches.

Results: We used Cox regression analysis to calculate hazard ratios for the following variables: first-pass success rate; intubation time; glottic view quality (Cormack-Lehane grade [C-L]); and percentage of glottis opening score (POGO]. The right-rear approach demonstrated a substantial improvement in first-pass success rates compared to face-to-face, with rates of 93% vs 78% and a hazard ratio of 2.10 (95% confidence interval 1.58-2.80). Additionally, both the video stylet and channeled videolaryngoscope techniques further optimized first-pass success rates and enhanced glottic visualization, achieving a CL grade I view and POGO scores of 100%, even in the inverted face-to-face orientation. These devices outperformed the standard Macintosh and hyperangulated videolaryngoscopes.

Conclusion: The right-rear approach was associated with higher first-pass success rates and provided a more familiar orientation for operators during upright intubation. Video stylets and channeled videolaryngoscopes also contributed to improved success rates, shorter intubation times, and better glottic visualization.

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Introduction: Increasing patient utilization and overcapacity threaten efficiency of care provided and the teaching mission. This study investigates the influence of medical students (MS) involvement on ED throughput, resource utilization, clinical outcomes, and addresses gaps in existing literature that primarily focus on resident physicians and singular throughput metrics.

Methods: A retrospective observational analysis was conducted on 123,503 patient encounters with age >21 years at an urban tertiary care hospital, comparing cases with and without medical student participation. Continuous variables were compared using t-tests with bootstrap, and categorical variables by chi-square tests. Continuous variables were reported with mean and standard deviation (SD), and the 95% confidence interval (CI) of mean difference was reported.

Results: Across all encounters, door-to-provider time showed no significant difference between encounters with MS (28.07 minutes ± 38.61) and without MS (28.39 minutes ± 37.99; P = 0.435). However, door-to-triage time was significantly shorter with MS involvement (14.32 minutes ± 15.02 vs. 15.69 minutes ± 27.67; P < 0.01). Arrival-to-disposition time (292.55 minutes ± 193.66 vs. 270.39 minutes ± 532.80; P < 0.01) and doctor-to-disposition time (266.83 minutes ± 186.12 vs. 242.93 minutes ± 376.38; P < 0.01) were both significantly longer with MS involvement. Utilization measures per 100 visits showed significant differences in CT scans (45.17/100 visits with MS vs 40.96/100 without, P<0.01) and plain radiographs (47.12/100 visits with MS vs 44.70/100 visits with, P<0.01) but not in MRIs, ultrasounds, or portable chest radiographs.  Patient outcomes included higher admission rates (23.06% vs. 18.13%; P < 0.01) and higher AMA rates (1.65% vs. 1.12%; P < 0.01) for encounters with MS. However, the discharge rate was lower (56.63% vs. 66.66%; P < 0.01), with no significant difference in the rate of patients returning to the ED within 72 hours (6.27% vs. 6.42%; P = 0.55).

In subgroup analysis of high complexity encounters, MS patients experienced shorter door-to-provider times (26.59 vs. 28.22 minutes, P < 0.01), door-to-triage times (13.55 vs. 14.46 minutes, P = 0.03), arrival-to-disposition (301.13 vs. 307.74 minutes, P =0.02) and doctor-to-disposition times (275.19 vs. 281.34 minutes, P=0.02). Utilization of CT scans and MRIs showed no significant differences. Medical student covered patient admission rates were equivalent (34.35% vs 33.59%, P=0.22), while discharge rates were lower (45.42% vs. 48.44%, P < 0.01), with no significant differences in rates of leaving AMA or returning to the ED within 72 hour. 

Conclusion: Though medical student involvement is generally associated with longer patient stays in the ED, student involvement was shown to improve efficiency in the management of high-complexity cases. Increased rates of some diagnostic imaging and higher admission rates occurred with medical students. Limitations, including the retrospective nature and single-center design, highlight the need for multi-center validation of these findings to inform future resource allocation and educational strategies in the ED. 

Background: As of 2021, there were 47 million immigrants in the United States. Immigrant populations are uninsured at higher rates than US citizens, leading many to rely on emergency departments (ED) for their healthcare needs. However, emergency physicians (EP) often lack training on the unique challenges faced by this population, necessitating educational interventions. 

Methods: We implemented educational interventions for an urban emergency medicine residency program using Kern’s six-step approach for curriculum development to inform EPs of existing immigration-specific patient resources; teach social-medical-legal best practices with regard to asking, documenting, and sharing immigration-specific health information; and increase awareness of ED-relevant local policies. We developed three educational interventions.in collaboration with legal organizations, and community experts. To evaluate the success of these interventions we administered a pre- and post-survey to 64 EPs (36% of 178 targeted learners)

Results: We found a significant increase in confidence and knowledge, with an average 5-point Likert scale score improvement of 1.47 (P < .001) in all responses and 1.40 (P < .001) in paired responses, and an improvement in test scores on the three knowledge-based questions of 30.66% (P < .001) in all responses and 33% (P = .02) in paired responses. 

Conclusion: This study highlights a model for interprofessional collaboration in curriculum development and the importance of a multipronged educational approach to improve the care of immigrants in the ED. The curriculum offers a framework for other EDs aiming to address healthcare inequities for this population. Future research can explore long-term knowledge retention, detailed educational tool utilization, and the impact on patients.

Introduction: The demanding nature of emergency medicine (EM), requiring immediate responses to emergencies, and presents significant challenges, particularly for new trainess specialty. Our goal was to evaluate  levels of anxiety and depression among EM intern doctors, with focus on the impact of the COVID-19 pandemic.

Methods: We  conducted this study at Istanbul University-Cerrahpasa, Department of Emergency Medicine, from December 29, 2019–May 2, 2021. In Türkiye, the six year medical education program has the first three  years preclinical, the fourth and fifth years comprised of clerkships, and the sixth year is internship training. In this final year,  these intern doctors rotate through various departments, including an 8-week EM internship. A total of 203 medical interns participated in the study, 50.2% male. We assessed participants using the State-Trait Anxiety Inventory (STAI 1-2) and the Beck Depression Inventory, both prior to starting their EM internship and upon completion. Intern doctors were divided into two groups: 51 who completed their internship before the COVID-19 pandemic (December 29, 2019–March 11, 2020) and 152  during the pandemic (March 11, 2020–May 2, 2021). We compared pre- and post-internship scores within each group and between the two cohorts.

Results: Anxiety scores (STAI-1) increased significantly in both groups during the internship. In the pre-COVID-19 group, median STAI-1 scores rose from 47 (IQR: 38–53) to 51 (IQR: 45–56) (p<0.001), and in the COVID-19 group, from 41 (IQR: 35–48) to 47 (IQR: 42–52) (p<0.001). However, depression scores (BDI) showed a significant increase only in the pre-COVID-19 group: from 9 (IQR: 2–14) to 26 (IQR: 15–32) (p<0.001). In contrast, the COVID-19 group’s depression scores remained relatively stable, increasing only from 7 (IQR: 2–13) to 8 (IQR: 3–16) (p=0.345).There were no significant differences between the groups in trait anxiety (STAI-2) scores (p=0.221) or pre-internship BDI scores (p=0.408). However, post-internship BDI scores were significantly lower in the COVID-19 group compared to the pre-COVID-19 group (median: 8 vs. 26; p<0.001). 

Conclusion: The EM internship was associated with an increase in anxiety levels among intern doctors. Depression scores did not show a significant increase in the COVID-19 group, whereas depression scores significantly increased in the pre-COVID-19 group by the end of the internship. These findings suggest that, while anxiety increased across both groups, depression levels were more stable in the COVID-19 group, with lower post-internship scores compared to those in the pre-COVID-19 group.

Objectives: Emergency medicine (EM) scholarly tracks have been adopted for increased subspecialty exposure and training. However, current literature fails to elucidate the impact on faculty and resident careers and resident and faculty engagement opportunities or demonstrate barriers to continuation. The purpose of this study was to evaluate the perceived impact of EM scholarly tracks on participating faculty (eg, resident interaction/mentorship, career satisfaction, perceived barriers to implementation) and recent graduates (eg, faculty mentorship, reasons for track selection, perceived barriers to continuation).

Methods: This mixed-methods study includes a cross-sectional quantitative survey with 30 EM residents (who graduated between 2021–2023) and semi-structured, one-hour qualitative interviews with six faculty in a large, tertiary-care academic medical center with a university-based hospital and medical school. We conducted frequency analyses on demographics, timing of tracks, mentorship impact, and implementation barriers. Chi-square analyses were used to compare the most and least common reasons for track selection. We evaluated faculty data in a program evaluation framework, seeking commonalities and idiosyncratic experiences.

Results: Resident Data—Most participants pursued either academic or hybrid academic/community careers (18/30). Additionally, most participants reported a positive impact on mentorship (25/30). The most common reason for choosing a track was “area of clinical interest” (mean 2.93, P <.001). The least common reason was “lowest effort/amount of work” (mean 1.47, P<.05) when compared to half of the other choices. Most residents did not report barriers to track continuation. Faculty Data—Faculty frequently discussed how resident scholarly tracks led to increased one-on-one faculty: resident time. Additionally, they reported the opportunity for specialization of residents not seeking fellowships. A reported barrier to continuation of and resident engagement in tracks was the balance needed between teaching enough and over-teaching, which can discourage learner interest. 

Conclusion: Recent EM graduates and current faculty members participating in scholarly tracks reported a positive impact on engagement and mentorship with minimal reported barriers to implementation and continuation. Scholarly tracks may offer more than educational benefits to participants, including individualized mentorship and career guidance.

Introduction: The POWER study, published in 2009 using data from 2003 examined the workload of emergency physicians using the Canadian Triage and Acuity Scale (CTAS) as a surrogate marker.  Many hospitals use a case-mix formula incorporating annual census and POWER study data to determine staffing levels. However, significant changes in emergency medicine have occurred since its publication, including the implementation of electronic medical record systems, increased patient complexity, real-time dictation software, and human health resource challenges due to the COVID-19 pandemic. Our study aimed to quantify the time required to perform tasks in the care of ambulatory emergency department patients. Our secondary objective was to stratify these times based on CTAS and provider factors.

Methods: We conducted a prospective observational time-motion study in the ambulatory section of a tertiary care academic emergency department with 90,000 visits annually, 70% of which are ambulatory.  Research assistants shadowed physicians on two 8-hour shifts daily (8 AM to 12 AM) from July 12 to August 14, 2022, tracking the time taken by physicians to perform tasks. Aggregate task times were calculated per patient.

Results: We observed 1,204 patient encounters over 65 shifts by 37 unique physicians. The mean treatment time was 21.6 minutes (95% CI 19.9-23.3) for ambulatory CTAS 2 patients, 22.5 minutes (95% CI 21.2-23.6) for CTAS 3 patients, 19.7 minutes (95% CI 17.9-21.6) for CTAS 4 patients, and 17.4 minutes (95% CI 14.9-19.9) for CTAS 5 patients. Compared to the previous POWER study data from 2003, CTAS 4 and 5 patient assessment times took 31% and 58% longer, respectively. Total assessment time by CTAS was statistically significant only comparing CTAS 5 patients to all others (p = 0.022).  Physicians who dictated their charts spent 34% less time (2.1 minutes per patient) charting than those typing.

Conclusion: The average time to see an ambulatory ED patient was 21.7 minutes.  Low-acuity ambulatory patients take longer to assess now than twenty years ago.  CTAS alone is a poor marker of workload for ambulatory patients, necessitating a reassessment of staffing and compensation formulas.

Introduction: The patient satisfaction survey is a controversial fixture of modern emergency care. Patients who are satisfied are more likely to adhere to the treatment plan and less likely to pursue legal action. However, the current surveys are susceptible to recall bias. This study uses an analysis of data collected in a separate study to assess how patients rated their physicians’ care when asked key questions in person by a trained volunteer versus in the Doctors section of the Press Ganey (PG) survey.

Methods: This was an analysis of prospectively collected data obtained in a separate study evaluating how patients experience their emergency care when learners are present. Trained medical student volunteers administered the survey to a convenience sample of patients slated for discharge at a single, community, tertiary-care hospital emergency department (ED) for a total of 12 weeks between June–October 2022. We compared this with the hospital’s PG data for the questions on which the survey was based.

Results: A total of 625 patients were approached over the study period with 313 agreeing to participate (response rate 50.1%). There were 8,460 patients discharged from the ED during those times (overall rate 3.70%). During the contemporaneous PG study quarter, the ED received 266 responses during the shifts for which the study enrolled patients, of a total 8,460 discharged from the ED during those times (response rate 3.14%). All key questions favored the in-person survey vs mailed PG survey: “I felt informed” score 79.2 (262) vs 75.6 (265), P = .02; “I felt like my [doctor] took time to listen” 85.0 (261) vs 79.6 (266), P = .05; and “satisfaction with care team” 83.0 (263) vs 74.7 (265), P = .0013.

Conclusion: This study shows higher satisfaction scores with an in-person survey. There was also a dramatically improved response rate compared with mail in PG forms, suggesting less recall bias. An absolute 5-point difference in PG score could lead to a relative 30-point change in percentile rank. This was a limited, single-site study whose results are hypothesis-generating but suggest a new pursuit for administrations seeking to improve their scores and possibly better understand patients’ experience of their care.

Introduction: Past patient data from health information exchanges (HIE) can enhance physician-patient interactions, although how and how often is unclear. We sought to determine how and how often past medical records provided by an HIE impacts current decision-making by emergency physicians. 

Methods: We identified qualifying emergency department (ED) visits between September 24-26, 2022. The primary feature of a qualifying visit was a separate ED visit within three days prior at a separate hospital system. Fifty-five charts with essential details of each patient’s most recent visit were reviewed in duplicate by 22 emergency medicine residents. Reviewers accessed prior medical records for each patient via an HIE clinical viewer. The primary outcome was the influence of knowledge from prior records on interactions during the most recent visit, measured with 11 Likert-scale ratings. Reviewer agreement was used as an indicator of confidence. 

Results: Reviewers most frequently agreed that the information from the prior visit was valuable “a moderate amount” (25% of all reviewer pairs) and agreed that the information would cause them to change their approach (69%). They would adjust treatment protocols because of understanding what had been tried previously (67%) and ask the patient different questions (78%). There was also agreement that they would further compare laboratory tests or imaging between visits (67%) and better understand patient behavioral patterns (73%). 

Conclusion: Access to patients’ previous medical records (diagnoses, imaging reports, discharge reports, etc) via HIEs impacts how emergency physicians communicate with patients, evaluate cases, and make medical decisions. 

Introduction: The discharge process is a crucial component of the emergency department (ED) encounter, with poor discharge quality often leading to negative patient outcomes. While numerous interventions have been implemented to improve this process, a comprehensive review of these interventions has not been conducted. This study provides a scoping, summative review of adult ED discharge interventions to date, evaluating the literature for potential best practices and future directions.

Methods: We conducted a scoping review of published literature on MEDLINE ALL (Ovid), Embase (Ovid), the Cochrane Central Register of Controlled Trials (Wiley), and CINAHL (EBSCOhost) on February 7, 2023, for articles reporting on ED-based discharge interventions. We excluded the following: studies involving pediatric patient populations; discharge from non-ED settings; in-ED risk screening and/or case management as the primary intervention; interventions occurring mostly after the ED encounter (even if initiated at time of discharge); and studies not written in English.

Results: The initial electronic database search yielded 3,842 unique titles and abstracts. After applying inclusion/exclusion criteria at various screening stages, we included 100 papers and abstracts in the final review. These studies, published between 2003 – 2023, predominantly originated from the US (66%). Using narrative synthesis, we summarized ED discharge intervention themes to form seven concept subgroups by consensus: mode of discharge; additional resource provision; addition of a discharge coordinator; follow-up assistance; pharmaceutical intervention; patient-centered education; and clinician/discharger-centered education. Effective strategies included enhanced discharge discussions and education by dedicated personnel, structured discharge checklists, and delivery of instructions at an appropriate reading level. However, because few studies have examined long-term patient-centered outcomes, such as ED return visits, hospitalizations, and mortality, cost-benefit analysis for interventions is lacking. Furthermore, the experiences of vulnerable populations who have limited-English proficiency are under-represented in current attempts to innovate ED discharge.

Conclusion: We found that interventions aimed at improving patient comprehension of discharge instructions were the most frequently studied and had the greatest impact on patient outcomes. This review highlights promising directions for patient-centered innovation; it also underscores the need for more research to optimize the adult ED discharge process and warrants a call to action.

Objectives: Little is known about the effect of pain on the relationship between triage and patient outcomes in United States emergency departments (ED). In this study we aimed to describe pain-associated ED visits and to explore how pain modifies the ability of ED triage to predict patient outcomes (hospitalization and ED length of stay [EDLOS)].   

Methods: We obtained data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2010-2021. Adult ED visits without missing data on pain score or triage level were included. We assessed pain scores at triage using a numeric rating scale (NRS) of 0-10. We further categorized the NRS scores into no (0), mild (1-3), moderate (4-6), and severe (7-10) pain. The five-level Emergency Severity Index was used for ED triage. The primary outcomes were hospital admission during the ED visit and EDLOS. For the analyses we used descriptive statistics and multivariable regression accounting for NHAMCS’s complex survey design. 

Results: Over the 12-year study period, there were 132,308 adult ED visits (representing 773,000,000 ED visits nationwide). Approximately 50% were triaged to level 3, followed by 30% to level 4. Approximately 45% reported severe pain, 21% moderate pain, 9% mild pain, and 25% no pain. Triage level 1 was associated with the highest rate of hospitalization (35%), with a gradual decrease in hospitalization rate from levels 2 to 4. Triage level 2 was associated with the longest mean EDLOS (5.6 hours), with a gradual decrease in EDLOS from levels 3 to 5. When stratified by pain intensity, the pattern of hospitalization altered in the mild and moderate pain groups. In these two pain-intensity groups, triage level 1 was associated with lower-than-expected odds of hospitalization, a 31% reduction suggested by the interaction term (adjusted odds ratio 0.69; 95% confidence interval .51-.92, P = .01). By contrast, the pattern of EDLOS persisted across all pain-intensity groups. 

Conclusion: Mild and moderate levels of pain intensity appear to negatively impact the ability of triage to predict hospitalization, resulting in overtriage among patients in these two pain-intensity groups. Pain intensity in the ED should be carefully evaluated to avoid overtriage and ensure the appropriate allocation of resources. [West J Emerg Med. 2025;XX(X)XXX–XXX.]

Introduction: Increasing demand for emergency department (ED) services and strained specialty- care access requires referral precision and was the impetus for a collaborative redesign of referrals between the Department of Emergency Medicine and Department of Orthopaedic Surgery.

Methods: Guided by root cause analysis of delays in post-emergency department (ED) specialty follow-up in our academic health system, the intervention targeted the finding that all ED referrals were marked “urgent” without differentiation by acuity of orthopedic issues. After implementation, referrals were triaged into three tiers—immediate, urgent, and routine—with stipulated follow-up timeframes. We evaluated differences in completion of scheduling and realized visits, across five calendar months (July–November) pre- and post-implementation (2021 vs 2022). Logistic regression assessed the relationship between patient demographics and outcomes. We report medians and interquartile ranges.

Results: Compared to the 393 urgent referrals to the Department of Orthopaedic Surgery pre-implementation, there were 463 total referrals post-implementation as follows: 11/463 (2.4%) marked as immediate; 123/463 (26.6%) urgent; and 329/463 (71.1%) routine. Similar proportions successfully scheduled pre- and post-implementation (41.5% vs 45.1%; P = .28). On average, immediate referrals completed scheduling within 1.0 (0.0 - 1.0) day and were seen in 4.0 (2.0 - 8.0) days, urgent referrals completed scheduling within 2.0 (1.0 – 4.0) and 7.0 (5.0 - 15.0) days, and routine within 3.0 (1.0 - 6.0) and 12.0 (6.0 - 19.5) days. Race/ethnicity and insurance were related to odds of successful scheduling; Black patients had lower odds than all other groups (odds ratio [OR] 0.3 - 0.4). All insurance categories had higher odds of successful scheduling relative to Medicaid out-of-network (OR 3.5 - 7.2).

Conclusion: A three-tier ED-to-orthopedics referral triage system was quickly adopted and differentiated referrals by urgency but did not impact time to follow-up or loss to follow-up. Structural inequities in access to follow-up care remain

Background: Emergency department (ED) utilization for non-emergent issues has been a longstanding issue in the United States, especially in service areas with high Medicaid enrollment. The Medical Home and Specialty Care Connection Program (MHSCC) at University of Chicago Medicine (UCM) supports patients recently seen in the ED with follow-up care by assisting patients with follow-up appointments, establishing a medical “home” and providing education on primary care utilization via working with a patient advocate. These types of programs have inconsistent results throughout the literature and a dearth of study periods. We conducted a program evaluation to assess the association of the MHSCC in reducing low-acuity ED utilization for program patients.

Methods: This program evaluation used retrospective data from the MHSCC program dataset from 2012–2020 and matched with electronic health records of low-acuity ED visits at UCM ED from 2010–2022 for each patient. Pre- and post-low-acuity ED visit rates were calculated based on the patients first program enrollment and compared using the Wilcoxon signed-rank test. 

Results: In total 5,482 ED patients enrolled in the program were included in the sample, 537 of whom were enrolled more than once. These patients had 41,530 low-acuity ED visits. The rate of low-acuity ED visits after the program enrollment was significantly lower than before with a mean of 2.5 visits per year before program intervention to 1.38 after, a 45% decrease (P<.0001). This resulted in an estimated 9,487 fewer low acuity ED visits over nine years. Patients with multiple enrollments (up to four) further resulted in a slightly lower ED visit rates. Patients who benefitted the most in both proportion and mean analyses were of low acuity. 

Conclusion: We found a significant reduction in program patient’s ED visit rates for low-acuity needs. Further evaluation on the outcomes of the program, mechanisms of physician referrals and attributes of the patient population are recommended to understand what drives these findings.

Introduction: Rates of sexually transmitted infections (STI), remain high in Hillsborough County, FL. As the emergency department (ED) is frequently used for STI diagnosis and treatment, a local hospital ED implemented a linkage-to-care program using a callback system to ensure that patients with chlamydia, gonorrhea, and/or syphilis received treatment. Our primary aim in this paper was to evaluate implementation of an ED-based STI treatment program by describing empiric, follow-up, and overall treatment rates in STI-positive patients by disease and sex. A secondary aim was to evaluate reasons for undertreatment during the acute-care encounter. 

Methods: We conducted this quality assurance project, including a retrospective chart review of electronic health records from 2019–2022, at an urban ED in Hillsborough County, Florida. During this period, we reviewed all records reflecting positive results for chlamydia, gonorrhea and/or syphilis to determine whether empiric treatment was administered in the ED or the patient required coordination for follow-up care. Patients who received empiric treatment or successful follow-up treatment were classified as treated, while those who did not receive successful follow-up treatment were classified as untreated. 

Results: A total of 1,170 patients were diagnosed with an STI at an urban, quaternary-care hospital in the county. Of these, 689 (58.9%) had chlamydia, 324 (27.7%) had gonorrhea, 133 (11.4%) had dual gonorrhea-chlamydia, and 24 (2.1%) had syphilis. Rates of STI empiric, follow-up, and overall treatment were 47.1%, 86.1%, and 92.6%, respectively. Empiric and overall treatment rates were highest for male patients (72.3% male, 33.4% female) and patients presenting with gonorrhea (67.6% gonorrhea, 63.9% chlamydia). Follow-up treatment rates were highest for female patients (87.1%) and patients presenting with gonorrhea (87.6%). 

Conclusion: Our findings emphasize both the successes and opportunities for improvement of a linkage-to-care protocol to provide treatment access for patients in the ED who test positive for sexually transmitted infections. Given the significant strain on the public health infrastructure in the United States and on our local Department of Health, ED-based linkage programs fill an important gap in healthcare delivery. Going forward, improving overall treatment rates in females and patients with chlamydia or syphilis is warranted.

Introduction: To better understand the impact of the COVID-19 pandemic on emergency department (ED) utilization, we examined two years of Veterans Health Administration (VHA) ED visits. Emergent and non-emergent ED visits were examined separately to understand the impact of systems-level changes in healthcare delivery. 

Methods: In this retrospective, observational cohort study we examined ED visits in 111 EDs within the VHA from March 2018–February 2022. Primary outcome was the count of emergent and non-emergent ED visits, using incident rate ratios (IRR) with 95% confidence intervals (CI) to examine ED visits during the first two years of the COVID-19 pandemic in eight separate quarters, compared to two years of seasonally equivalent quarters before COVID-19.

Results: Over the four-year period, US veterans made 8,057,011 ED visits, with 54.7% in the eight pre-COVID-19 quarters, and 45.3% in the first eight quarters during the COVID-19 pandemic. Both emergent and non-emergent visit counts decreased in each of the first eight quarters during COVID-19 when compared to their respective pre-COVID-19 baseline. The change in emergent visits ranged between -26.9% (March-May 2020; IRR 0.73, 95% CI 0.72-0.74) and -7.0% (June-August 2021; IRR 0.93, 95% CI 0.92-0.94). The change in non-emergent visits ranged between -33.0% (March-May 2020; IRR 0.67, 95% CI 0.67-0.67) and -5.7% (June-August 2021; IRR 0.94, 95% CI 0.94-0.95). After the first six months of the pandemic, emergent ED visits had a sustained greater decrease compared to non-emergent visits.

Conclusion: As of 2022, ED visits had not returned to pre-pandemic baselines, and our results suggest that emergent visits have sustained a greater decrease even in the second year of the pandemic compared to their respective, seasonally equivalent pre-pandemic quarters from March 2018–February 2020. The finding that emergent visits decreased more than non-emergent is notable given that system-level changes in care delivery, particularly a shift toward use of telehealth, would be expected to have a greater impact on non-emergent care. More work is needed to understand whether acute care is being forgone altogether, as well as the subsequent impact.

Introduction: The Tijuana River, which affects southern San Diego Beaches, is severely contaminated with untreated sewage. Exposure to pathogens can lead to various health problems, commonly gastrointestinal (GI) illnesses. We aimed to look for any relationship between Tijuana River flow rates and ocean pollution levels and levels of diarrhea at a nearby Emergency Department (ED).

Methods: In this retrospective study that spanned the 2023 dry season and included Hurricane Hillary, we compared Tijuana River flow rates and fecal bacterial counts on the southern San Diego County coastline to the number of visits to a nearby ED, specifically a 225-patient sample size, with the chief complaint of diarrhea, a potential waterborne illness. 

Results: In late August of 2023, after Hurricane Hillary made landfall as a tropical storm in Baja California, Mexico, there was a large increase in the Tijuana River flow rate and a correspondingly significant increase in diarrhea cases at 3.25 times the mean, from a mean of 4.25 cases per week to 14 cases the week of Hurricane Hillary.

Conclusion: We found a significant correlation between Tijuana River transboundary flow rates and Emergency Department case levels of diarrhea, a known waterborne illness, in the summer of 2023.

Objectives: Sepsis is a common presentation to the emergency department (ED) and represents a life-threatening syndrome with high mortality rates. The existing literature has conflicting findings regarding outcomes between sexes. Our goal in this study was to investigate the clinical presentation, interventions, and outcomes based on sex for sepsis in the ED. 

Methods: We conducted a retrospective cohort study to identify patients presenting with sepsis to the ED. We employed the Global Collaborative Network from 119 international healthcare organizations in the TriNetX Research Network. Sepsis was defined according to International Classification of Diseases, 10th Rev, codes. To evaluate sex differences in sepsis presentation, we collected data on age, comorbidities, sex, vital signs, laboratory values, medications, intensive care unit (ICU) admission, mechanical ventilation, and mortality at 30 days, 90 days, and one year. We used a 1:1 propensity score matching by age, race, comorbidities, and infection source to identify and balance potential risk factors across the study groups to investigate mortality, interventions, and intensive care unit admission trends. Data abstraction and analysis were conducted in the TriNetX platform. 

Results: In total, 920,160 patients were included in this study. The most common infection source for both females and males was respiratory, accounting for 40% and 46.2% of sepsis cases, respectively. After adjusting for urinary tract infection as an infection source, females were less likely to receive piperacillin-tazobactam (21% vs 23.6%; odds ratio [OR] 0.76; 95% confidence interval [CI] 0.75 - 0.77), vancomycin (32.9% vs 36%; OR, 0.87; 95% CI 0.86 - 0.88), and vasopressors (16.5% vs 17.6%; OR, 0.92; 95% CI 0.91 - 0.93). Females had a lower all-cause mortality at 30 days (12.1% vs 13%; OR 0.91; 95% CI 0.90 - 0.92), 90 days (17.1% vs 18.7%; OR 0.91; 95% CI 0.90 - 0.92), and one year (21.5% vs 23.3%; OR 0.90; 95% CI 0.89 - 0.91).

Conclusion: Females demonstrated 10% lower odds of mortality from sepsis at 30 days, 90 days, and one year (absolute difference: 0.9%, 1.6%, 1.8%, respectively). Females were less likely to receive vasopressors, vancomycin, or piperacillin-tazobactam, even after accounting for urinary tract infection as the sepsis source. [West J Emerg Med. 2025;XX(X)XXX–XXX.]

Introduction: Extended-release buprenorphine (XR-BUP) is a long-acting injectable medication used for the treatment of opioid use disorder (OUD). It is currently approved for use in patients who have been administered at least seven days of sublingual  buprenorphine (SL-BUP). For patients with OUD who are unstable (ie, not at treatment goal, with active opioid use) or not yet on medication for OUD (MOUD) such as SL-BUP, the emergency department (ED) setting is an essential location for access to treatment. There is, as yet, no research on the utility of on-demand XR-BUP administration in the ED.

Methods: We performed a retrospective cohort study of individuals with OUD who received XR-BUP in the ED through our novel reallocation pathway. We reviewed charts from an addiction medicine specialty outpatient clinic to determine retention in treatment, continuation on XR-BUP, and reported quantitative analysis. Our primary outcome was retention in treatment, measured by subsequent XR-BUP injection after initial ED XR-BUP administration. The secondary outcome was the reason for ED administration of XR-BUP (as opposed to administration in the clinic setting).

Results: Our study population included 69 patients (68.2% male). Our primary outcome showed that 51 (73.9%) patients who had their first injection in the ED received a second XR-BUP injection and 40 (58%) received their third XR-BUP injection. Our secondary outcome showed that 7.2% had barriers with access to treatment; however, most of the patients received the injection due to instability of the treatment of the OUD (69.6%). These patients were either unable to adhere to MOUD, reported issues with the prescription, or were still using substances while on MOUD. For 52 (75%) patients, the index ED injection was their first ever XR-BUP injection. Logistical regression analyses demonstrated that clinical and demographic factors did not lead to increased attrition, while patients with other co-occurring substance use disorders were more likely to present for follow-up treatment.

Conclusion: In our retrospective study, patients who received ED-initiated extended-release 
buprenorphine had a strong retention rate compared to previous studies evaluating ED-initiated sublingual BUP (retention rates ranging from 16.7-60%). The ED provided a convenient healthcare access point for XR-BUP initiation. The XR-BUP is a helpful tool for achieving induction after failed SL-BUP initiation and may have further implications in minimizing treatment gaps after discharge and improving OUD treatment retention. 

Introduction: Comorbid psychological conditions have an impact on opioid use disorder (OUD). We measured multiple psychological tests in OUD patients who entered an emergency department (ED)-based medication for opioid use disorder (MOUD) program to determine whether any test correlated with six-month retention in the MOUD treatment program. 

Methods: Patients with OUD who were enrolled in an ED-based MOUD program over a 12-month period were eligible to participate. We surveyed enrollees using nine validated tools to assess depression, anxiety, and traumatic stress within 24 hours of their ED presentation and then at one and six months. The primary outcome was program retention rates at one and six months. Secondary outcomes were levels of clinical symptoms, substance use, and quality of life.  

Results: Of 143 patients enrolled in the MOUD program, 64 (44.8%) participated during the 12-month study. The mean age was 33 years, with 65% male and 35% female. Baseline surveys indicated moderate symptom severity for depression and anxiety. The Post-Traumatic Stress Disorder Checklist (PCL-5) scores showed significant traumatic stress. Retention rates were 47% at one month and 25% at six months. General well-being improved from 40% at baseline to 56% at six months. Average income correlated (0.51) with six-month retention, suggesting that those with financial means were more likely to remain in treatment. The Life Events Checklist (LEC-5) correlated (0.41) with six-month retention. This indicates that the more trauma an individual experienced, the less likely the person would remain in treatment. 

Conclusion: Higher income and lower post-traumatic stress disorder scores had higher retention rates in a medication-based opioid use disorder program. Psychological surveys of patients entering a MOUD program may help predict treatment retention. There will likely be challenges in keeping patients with extensive trauma histories retained in treatment.

Introduction: Patients who frequently use the emergency department (ED) make up 8% of ED patients annually but account for up to 28% of all ED visits. Frequent ED utilization has been associated with mental health disorders. However, the association between social determinants of health (SDoH) and frequent ED use is not as well understood. Our objective was to identify associations between frequent ED use and mental health disorders and SDoH among patients visiting 19 Upper Midwest EDs in an integrated health system.  

Methods: We conducted a cross-sectional analysis of adult patients presenting to the 19 EDs from July 1, 2020–June 30, 2021. Using odds ratios (OR) and 95% confidence intervals obtained from multivariable logistic regression models, we characterized associations between mental health disorders (based on ICD-10 groupings) and 10 SDoH with frequent ED utilization (defined as ≥6 ED visits per year).  

Results: A total of 228,814 visits among 134,452 patients were eligible for inclusion. After accounting for clinical features and mental health risk factors, the following had the strongest association with frequent ED use: unmet transportation needs (OR 1.73); high risk for financial resources (OR 1.52); food insecurity (OR 1.58); smoking tobacco (OR 1.31); and physical inactivity (OR 1.23). The top mental health risk factors for frequent ED utilization were adult personality and behavioral disorders (OR 4.0) and anxiety, stress and non-psychotic disorders (OR 3.35). 

Conclusion: We found strong associations between mental illness and SDoH and frequent ED use.  The strongest SDoH risk factors included unmet transportation needs, financial resource risk, and food insecurity. The top two mental health risk factors were adult personality and behavioral disorders as well as anxiety and stress disorders, with differences that persisted when analyzed independently as well as when adjusting for other mental health risk factors. By understanding the interaction between social determinants of health and mental health disorders researchers can better address root causes and improve health outcomes among this vulnerable population.

Introduction: Incarcerated individuals represent a vulnerable sector of society, with a disproportionate burden of substance use, mental health problems, and chronic illness. The purpe of this study was to perform a descriptive analysis of emergency medical services (EMS) response to detention facilities.

Methods: We conducted a retrospective review of Mayo Clinic Ambulance Service ground EMS emergency (9-1-1) calls for service to nine detention centers within the service area occurring between January 1, 2002–December 31,2021. We excluded calls to a 10th detention center, the Federal Medical Center – Rochester, due to the unique nature of this facility. Additional exclusion criteria included non-emergency calls and lack of patient care narratives within the patient care report. We analyzed data using descriptive statistics, chi-square, and the Student t-test. This study was reviewed and approved by the Mayo Clinic Institutional Review Board.

Results: During the study period, 3,114/1,231,853 (0.25%) service requests to detention facilities occurred. After accounting for exclusion criteria, the final sample size consisted of 2,034 patients. Average patient age was 40.2 ± 13.3 years of age, compared with 54.0 ± 25.9 years of age for non-detention center calls (P < 0.001). The majority (80.8%) of patients were male. Mean scene time was 14:13 ± 7:49 minutes, compared with 12:04 ± 12:27 minutes (P < 0.01) for non-detention center calls. The most common complaints were medical, behavioral emergencies, cardiac, and trauma. Obstetrics requests accounted for 5.8% of calls for female patients. Most calls (91.3%) to detention centers involved incarcerated individuals, with the remainder representing facility staff (1.5%), visitors (0.5%), and undetermined (6.7%). Nearly 4% of patients refused treatment; 48.9% of these patients were still transported. Consent for treatment/transport by the patient was documented in 6.1% of charts. 

Conclusion: Recognizing the retrospective, single-agency nature of this study, we found that calls to detention facilities within our 9-1-1 service area predominantly involved incarcerated individuals. Consent for treatment/transport was not documented in most EMS encounters. Further study is needed to better understand the healthcare needs of these patients, including ability to consent.

Background: Patients with ST-elevation myocardial infarction (STEMI) cared for by rural emergency medical services (EMS) agencies commonly do not have first medical contact-to-percutaneous coronary intervention (PCI) time within the recommended goal of 90 minutes. In this study we identify factors associated with performance variation among rural EMS agencies in first medical contact-to-PCI time. 

Methods: In this explanatory, sequential, mixed-methods study, we ranked eight rural county EMS agencies by continuous first medical contact-to-PCI time, accounting for loaded mileage, using data from a regional STEMI registry (2016–2019). A qualitative researcher conducted 28, one-hour, semi-structured interviews from January– March 2021 with the EMS director, training officer, medical director, and four paramedics at the top two high- and bottom two low-performing rural EMS agencies. Key informants were blinded to agency STEMI performance. Interviews were structured to identify positive deviance by exploring agencies’ clinical approach to patients with chest pain, their organizational culture, structure, and quality improvement (QI) activities regarding STEMI care, and recommendations for improving STEMI performance. Interviews were digitally recorded and transcribed verbatim by a professional transcription service. We established a codebook and performed a thematic analysis using an inductive approach. We summarized and compared data across agencies to identify commonalities and differences between high- and low-performing agencies. Findings were reviewed and validated by an expert panel. 

Results: The top two highest-performing EMS agencies had a median first medical contact-to-PCI time of 79 minutes (interquartile range [IQR] 65-91) minutes vs 98 minutes (IQR 82-120) among the bottom two lowest-performing agencies, P<.001. Both high- and low-performing agencies identified issues with electrocardiogram (ECG) transmitting technology and cumbersome hospital activation communications. However, top-performing agencies shared a culture that encourages early EMS activation of the cardiac catheterization lab after STEMI recognition. Top-performing agencies also placed a higher value on QI and training. These agencies prioritized mission and chain of command over staff relationships/interpersonal bonds; have stable, strong leadership; provide opportunities for career advancement; and collaborate with community leaders. 

Conclusion: Top-performing rural EMS agencies for STEMI care promote early activation, have a strong chain of command, are mission focused, and have a greater focus on quality improvement and training.

Introduction: Prolonged emergency department (ED) waiting times for STAT spine magnetic resonance imaging (MRI) in the ED can expose patients to hospital-acquired infections and increase the workload in the ED, further impacting healthcare quality. In this study we aimed to characterize emergent spine MRI frequency and positivity in the ED, and its impact on ED length of stay (LOS), admission rates, and the necessity for surgical interventions.

Methods: We performed a retrospective chart review of a consecutive group of patients who had emergent spine MRI (cervical, thoracic, lumbar) ordered from the EDs at four hospitals from January 1, 2017-December 31,2022 were included for traumatic and atraumatic patients. We recorded patient demographics, time metrics, discharge status, and surgical interventions within seven days (for those who were hospitalized during the ED encounter). Spine MRI reports were reviewed and categorized, with positive cases defined as severe spinal canal stenosis regardless of cause and/or fracture. We used descriptive statistics to assess the positivity rate for emergent spine MRIs as well as the LOS, rate of surgery, and rate of admission for patients getting emergent spine MRIs.

Results: A total of 689 spine MRI of 889,527 ED visits (0.1%) were included. Patients’ mean age was 51.3 ±17.1 years, and 59.5% were female. Discharge rate was 93.9%, 3.3% were admitted, 1.7% left against medical advice, and 1.0% were transferred to other facilities. The overall spine MRI positivity rate was 18.9% (130). Moreover, the median (IQR) time from imaging order placement to imaging completion was 2.6 (1.8 - 3.7) hours, while the time from imaging completion to final report availability was 1.5 (0.4 - 13.9) hours. The median ED LOS was 7.4 (5.7 - 9.5) hours. Of 23 hospitalized patients, 17 (73.9%) required surgical intervention. Positive cases had significantly higher ED LOS compared to negative cases (8.1 vs 7.2, respectively; P < .001).

Conclusion: The positivity rate for ED spine MRI in this study was 18.9%. Of the positive cases, 17.7% underwent hospitalization, with 13.1% requiring emergent surgery. Considering high costs in both time and resource utilization, further research is needed to optimize the triage process for patients requiring emergent spine MRI.

Introduction: Stroke mimics comprise a significant proportion of cases presenting with neurological deficits and can be difficult to differentiate from true stroke cases. Our aim in this study was to assess the frequency and etiologies of stroke mimics presenting to our emergency department (ED).

Methods: We conducted a retrospective review of the charts of patients presenting to the ED of a tertiary- care center between November 2018–August 2023 and on whom the stroke code was activated. The cases were categorized into real strokes or stroke mimics based on patients’ discharge diagnoses. 

Results: Stroke code activation was implemented on 584 patients during the study period. These patients received full service and a final discharge diagnosis. Of these, 349 (59.8%) received a diagnosis of a true stroke, whether ischemic, hemorrhagic, or transient ischemic attack. The remaining 235 (40.2%) were classified as stroke mimics, with functional (12.8%) and medical (87.2%) etiologies. Medical stroke mimics were further categorized into non-cerebrovascular neurologic (59.5%), infection or allergic reaction (17.1%), cardiovascular (11.7%), metabolic or drug-induced (8.3%), and other (3.4%). Factors found to favor stroke mimics were history of neurological (adjusted odds ratio [aOR] 4.98; 95% confidence interval [CI] 2.89 - 8.57) or psychiatric disorders (aOR 2.88; 95% CI 1.29 - 6.41) and patients presenting with altered mental status (aOR 1.70; 95% CI 1.04 - 2.80) or generalized weakness (aOR 2.38; 95% CI1.12 - 5.03). Conversely, factors that favored true strokes (with OR <1 for mimics), were patients aged >65 years (aOR 0.61; 95% CI 0.38-0.96), history of hypertension (aOR 0.61; 95% CI 0.38 - 0.97) or atrial fibrillation (aOR 0.39; 95% CI 0.21 - 0.72), and presenting with speech disturbance (aOR 0.56; 95% CI 0.37-0.83) or extremity weakness (aOR: 0.22; 95% CI 0.15- 0.38).

Conclusion: Approximately 40% of cases presenting to our ED with stroke code activation were found to be mimics. The high ratio warrants the establishment and adoption of a more specific triaging algorithm for stroke code activation to minimize the pressure on an already overburdened healthcare sector.

Introduction: Emergency department (ED) use varies by age, sex, race, ethnicity, language preference, and payor type. Most studies comparing ED use by patients with English vs non-English preference (ELP/NELP) have used racially aggregated data, potentially masking differences across population subgroups. In this study we aimed to disaggregate the associations of race, ethnicity, language preference, and Medicaid coverage with ED utilization.

Methods: We used cross-sectional study electronic health record data for 2,047,105 Kaiser Permanente Northern California members who were 25 - 85 years of age in January 2019 and had been continuous health plan members during 2018 - 2019. We tabulated the percentages of adults in seven racial and ethnic groups (White, Black, Hispanic, Chinese, Filipino, Vietnamese, South Asian) within three age groups (25 - 44, 45 - 64, 65 - 85) who had ≥1 ED visit in 2019. Modified log-Poisson regression was used to examine racial, ethnic, and language preference differences after adjusting for demographic and Medicaid status covariates.

Results: The study population was 51.8% White, 53.2% female, 9.6% NELP, and 6.2% Medicaid-insured. Overall, 18% had ≥ 1 ED visit. Compared with White adults, Black and Hispanic adults were more likely and Chinese, Vietnamese, and South Asian adults were less likely to have ≥ 1 ED visit. After adjusting for all covariates, NELP adults 25 - 64 years of age were 10% less likely to have had an ED visit. However, while NELP was associated with a 10-20% lower ED visit prevalence among Hispanic, Filipino, Chinese, and Vietnamese adults 25 - 64, the prevalence was 10% higher among White and South Asian adults 45 - 64 and Filipino and South Asian adults aged 65 - 85. Adults with Medicaid coverage aged 25 - 64 were twice as likely and adults aged 65 - 85 were 50% more likely to have had ≥ 1 ED visit. 

Conclusion: This study of a US adult health-plan membership found several significant differences in ED use across racial, ethnic, and language subgroups and a higher prevalence of ED use by Medicaid-covered adults ≤ 65 years of age in most racial and ethnic groups. Our findings highlight the importance of using disaggregated data, particularly for Asian ethnic groups, when comparing ED use in different populations. Further research is needed to identify similarities and differences in social, personal, and policy factors driving ED use in diverse adult populations to better inform population-specific health interventions.

Background: The COVID-19 pandemic had a disproportionate impact on minority communities, including patients who identify as having a preferred language other than English (PLOE). Our primary goal in this study was to evaluate the effect of the COVID-19 pandemic on patients with a PLOE in the emergency department (ED), and the use of interpreter services. Secondary outcomes evaluated were measures of patient care, including length of stay, number of studies performed, and unplanned return visits to the ED. 

Methods: We performed an interrupted time series study of prospectively collected electronic health record (EHR) adult ED and language services data from an urban, safety-net hospital. 

Results: The total number of patients presenting to the ED went down in the early peak of the pandemic; however, the percentage of patients with a PLOE went up compared with previous years (19% vs 16%) and, despite making up only 19% of total patients, comprised 44% of total COVID-19 positive patients. In-person interpreter use decreased (prevalence ratio 0.49, 95% confidence Interval [CI] 0.43-0.56) while telephonic and video interpretation increased (prevalence ratio 3.97, 95% CI 3.56-4.43). Baseline testing was unchanged. All groups experienced a decrease in median LOS in 2020, but this was only found to be significant for patients who speak a language other than English or Spanish (P<0.001). None of the patient groups experienced a significant increase in unscheduled returns in 2020.

Conclusion: Our data confirms that COVID-19 disproportionately affected patients with a PLOE, with patients with a PLOE 2.9 times more likely to test positive for COVID-19 than their English-speaking counterparts. Efforts should be made to mitigate this effect via language-concordant care, professional interpreters, and culturally appropriate interaction and information dissemination, not only as it relates to planning for public health crises, but in the day-to-day function of the healthcare system at large. Continued research into the factors driving these inequities and ways to mitigate them is warranted.

Introduction: Prehospital emergency care is critical to saving lives. Facilitating bystander involvement and increasing the likelihood that people will provide first aid can reduce the time to treatment and increase the chances of survival and recovery. One possible solution to increasing people's willingness to provide first aid is to identify the barriers that may prevent them from doing so. One such barrier could be Blood Injury Injection (BII) phobia, which is a very common condition with up to 20% of people experiencing mild to severe fear and 3-5% experiencing phobic levels of fear.

Methods: In the absence of a psychometrically sound measure of the probability of giving first aid, we developed a brief six-item questionnaire (Probability of Giving First-aid Scale; PGFAS) and tested its performance with the Polytomous Rasch Model. We demonstrated that the questionnaire had adequate reliability and validity. We then used the PGFAS measure to test how anxiety and disgust sensitivity related to BII phobia may act as barriers to providing medical assistance.

Results: Our results show that fear of injection and blood draw, blood and mutilation significantly reduced the likelihood of giving first aid. In contrast, fear of sharp objects, medical examinations, people showing symptoms of illnesses and disgust sensitivity, and fear of contamination did not have a significant effect.

Conclusion: In conclusion, the PGFAS could be a useful as a screening tool to identify people who are less likely to help. It may also be used to assess the effectiveness of first aid training, but this was not addressed in this study. Our results emphasize the importance of preparing the person who is to give first aid, and of incorporating activities that support helper identity into training that teaches technical knowledge.

Introduction: Toxicologists use a universal threshold to determine QRS and QTc prolongation in poisoned patients. Further understanding of the biologic variance of these intervals may allow for a more personalized approach to assessing the clinical significance of electrocardiogram (ECG) changes in these patients. 

Methods: We recruited six male and six female healthy subjects. Standard 12-lead ECGs were performed in duplicate once per week for four consecutive weeks. We calculated the mean and standard deviation, the coefficient of variance (CV) for replicate readings (CVA), and within (CVI) and between individuals (CVG) using analysis of variance for all subjects and separately for males and females. From these measured parameters, we determined the index of individuality (II), the reference change value (RCV), and number of readings needed to maintain a homeostatic setpoint. 

Results: The median QRS interval for healthy males (103.4 milliseconds [ms]) was statistically higher than that for females (88.6 ms) in our study (P < .05). The CVA and CVI for the QRS interval for the total cohort were relatively low at 3.0 and 2.2, respectively. The CVG for the QRS interval was relatively high at 12.9. There was no difference in the QTcorrected (QTc) interval between gender (404 vs 415 msec, respectively). The II was 0.29 for QRS and 0.74 for QTc in pooled subjects. The RCV was 10.3 and 7.1 msec, respectively, for QRS and QTc for all subjects. The number of samples needed to establish a homeostatic set point was 1 for all analyses at a closeness of 10% with a 95% probability (P = .05). 

Conclusion: We demonstrated a significant difference in QRS duration between healthy males and females as well as a low II, particularly for the QRS interval, indicating that the CVG is greater than the CVI among these ECG intervals. In this study we also determined that one ECG is needed to establish a homeostatic set point for patients. If a baseline ECG is available, medical toxicologists would benefit from using the baseline tracing as an internal reference for determining QRS and QTc prolongation in the individual patient rather than a predetermined universal threshold for managing poisoned patients. 

Introduction: Various variables of weather are hypothesized to exert a small but measurable, significant influence on the development of cerebral infarctions (strokes). Improved characterization of this relationship would enhance understanding of the impact of climate change on healthcare demand. However, current data are conflicting regarding the exact nature of the direction and magnitude of the relationship between weather variables and stroke incidence.

Methods: We conducted a retrospective analysis using patient data from 2019 across the contiguous United States obtained from the TriNetX global research data network and weather data from the National Oceanic and Atmospheric Administration database. Data from hospitalized patients who had a diagnosis of cerebral infarction, as defined from International Classification of Diseases, 10th Rev, diagnosis codes, were used for analysis. Negative binomial regression calculated the incidence rate ratio (IRR) between stroke and various weather variables: temperature (°C), change in temperature, pressure, change in pressure, and precipitation.

Results: Our study included 92,422 patients across 92 healthcare systems. Regression analysis revealed a small but statistically significant association between stroke and change in temperature (IRR 1.0047, confidence interval 1.0012 - 1.0083, P = .010). The remaining variables in our model did not have a statistically significant effect on incidence of stroke.

Conclusion: The data suggest that one aspect of weather, specifically day-to-day increases of ambient temperature, has a measurable small magnitude but statistically significant impact on local stroke patterns. 

Background: Delivery of emergency surgical care remains a challenge in much of Sub-Saharan Africa, with physician shortages in Uganda resulting in only one surgeon per 100,000 people. Emergency units in Uganda receive emergency surgical patients, but it is unknown how great of a burden these emergency surgical patients represent in terms of total number, care required, or outcomes.

Methods: We performed a retrospective review of a quality assurance database for all patients treated at two emergency units in Uganda from 2009–2019. Patients were defined as “surgical” if they were admitted directly to the operating theatre, received a surgical diagnosis, or received an emergency surgical procedure as identified by the Disease Control Priorities 3 (DCP3) group. We generated descriptive statistics.

Results: Of the 109,999 total patients seen, 24,745 (22.5%) were emergency surgical patients. Surgical patients were predominantly male (71.7%) with a mean age of 34.9 years. Most surgical patients (57.0%) were admitted to the hospital, while 38.9% were discharged, and only 1.7% were sent directly to the operating theatre. In total, 12.1% of all patients seen in the emergency unit received a surgical procedure from a non-physician clinician while in the unit. Of the surgical procedures, the most common were suturing of lacerations (51.8%), urinary catheterization (24.5%), fracture management (16.5%), and incision and drainage of abscesses (6.0%). Among surgical patients, the most common surgical diagnoses were for fractures (30.9%), lacerations (29.6%), and abscesses (8.8%). The overall three-day mortality for emergency surgical patients was 2.8%.

Conclusion: Emergency surgical patients are common in Ugandan emergency units, where emergent surgical procedures are commonly performed by non-physician clinicians. Strengthening system capacity for emergency surgical patients should also consider emergency unit resources.

Introduction: Greece is a high-income country and a member of the European Union. Emergency Departments (EDs) continue to be staffed by physicians with training in other medical specialties. This study aims to evaluate the perceived level of competency and preparedness of physicians who work exclusively in EDs in Greece. It also sought to identify gaps in EM expertise, opinions on the need for EM residency training in Greece, and job satisfaction of physicians practicing in Greek EDs.  

Methods: We performed a mixed method, cross-sectional, nationally representative survey of physicians working in EDs across all health districts in Greece. The survey was administered in Greek and anonymously conducted online. Quantitative data was extracted from Qualtrics (Qualtrics, Provo, UT, USA) to Microsoft Excel (Microsoft Corporation, Redmond, WA, USA) and qualitative data was uploaded to NVivo (NVivo 14, Lumivero, Denver, CO, USA). The study received institutional review board approval, and all participants signed an online consent form.

Results: 171 out of 263 (65%) of ED physicians based in 52 EDs across Greece responded to the survey. 62% of respondents were not EM-certified: most were trained in Internal Medicine or General Practice. Nearly 30% reported discomfort taking care of critically ill patients, and more than 50% reported discomfort taking care of trauma or pediatric patients. Fifty seven percent acknowledged that an EM residency is needed in Greece. Key themes identified in the qualitative analysis include a lack of skills and confidence, and a need for structured training in EM.

Conclusion: The current emergency care model in Greece prohibits the development of the full spectrum of EM services to meet healthcare personnel expectations and population health needs. This survey represents the first assessment of attitudes, clinical preparedness, and perceived need for EM residency training among emergency care physicians working across all health districts in Greece. The majority did not feel comfortable caring for critically ill, trauma or pediatric patients, and expressed the need for EM residency training. Critical next steps should include training on targeted aspects of emergency care for existing ED physicians and continued efforts to establish EM residency training in Greece.

Introduction: Psychiatric conditions are common presentations to the emergency department, and their prevalence has been steadily increasing. Part of this spectrum of presentations is self-directed violence. Self-directed violence involves suicidal acts and non-suicidal self-injuries that can result in serious morbidity and mortality. This study examines characteristics and outcomes of patients who presented to US trauma centers with self-inflicted injuries and identifies factors associated with survival to hospital discharge in this patient population.

Methods: We extracted data in a retrospective, observational manner from the 2020 National Trauma Data Bank (NTDB) 2020. The NTDB includes data from over 900 trauma centers (900/2,294 total trauma centers in the United States, 39.2%). We performed a descriptive analysis of characteristics, injury patterns and outcomes. All variables were tabulated by outcome (died: yes/no). We then conducted a multivariable logistic regression using a stepwise technique to identify factors associated with the patients’ survival to hospital discharge.

Results: A total of 12,824 patients with self-inflicted injuries were included in this analysis. Their median age was 35 years (interquartile range 25-50), and they were mostly males (74.7%) and White (69.6%). Patients were mostly transported by ground ambulance (78.9%) to Level I (60.6%) and Level II (33.5%) trauma centers. Most patients had a pre-existing condition (70.2%). These included mental/personality disorder (48.2%), alcohol use disorder (11.5%), and substance use disorder (17.7%). The most common mechanism of injury was penetrating trauma (71.6%), followed by blunt trauma (18.0%) and burns (1%). Cutting/piercing was the most common penetrating mechanism (60%) compared with firearm-related trauma (40%). Severe injury (Injury Severity Score ≥ 16) was present in 32.8% of patients. A positive alcohol screen and/or a positive drug screen were reported in 30.2% and 31.2% of patients, respectively. Most patients were admitted to hospital (86%). Overall mortality rate at hospital discharge was 21.7%. We identified Important factors associated with survival to hospital discharge in this patient population.

Conclusion: Patients with self-inflicted injuries treated at US trauma centers have high rates of injury severity and a high mortality rate. This study sheds light on the complex and resource- intensive care needed for this vulnerable patient population.

Introduction: Inconsistent and ever-changing state abortion laws across the United States raise the possibility of deviation from established standards of emergency care. Yet the experiences of emergency physicians in this era have not been captured. We sought to examine the experiences of US emergency physicians in the management of presumed ectopic pregnancy since the Dobbs Supreme Court ruling and passage of new abortion restrictions affecting clinical decision-making around pregnancy termination. 

Methods: This was a cross-sectional survey of US emergency physicians administered online between April 1–15, 2024. The survey was completed by 150 board-certified US emergency physicians—50 physicians each from states categorized as abortion restrictive, semi-restrictive, or permissive—who were queried about any reported delays in or adaptations to the assessment and/or management of patients with known or suspected ectopic pregnancy.

Results: We found that 24% of physicians in restrictive or semi-restrictive states reported delays in the management of patients with suspected or confirmed ectopic pregnancy, and 54% of physicians reported adaptations to care of these patients including repeat testing and arranging alternative care in cases where they might previously have delivered definitive care in the emergency department.

Conclusion: In a post-Dobbs practice environment, emergency physicians across the United States, practicing in states with various abortion restrictions, reported delays and adaptations of care for patients with presumed or suspected ectopic pregnancy including deviations from standard of care in emergency medicine.

Introduction: Patients with pulmonary embolism (PE) often present with non-specific signs and symptoms mimicking other conditions and complicating diagnosis. In this study we aimed to evaluate the performance of an artificial-intelligence tool, Microsoft Copilot, in the diagnostic process of PE, using clinical data including demographics, complaints, and vital signs.

Methods: We conducted this study using 140 clinical vignettes, including 70 patients with and 70 patients without PE. The vignettes were derived from published case reports within the last 10 years. We used Copilot for its free GPT-4 integration to analyze clinical data and answer two questions after each vignette. We compared Copilot’s ability to identify PE within the top 10 differential diagnoses, and its ability to predict the risk of PE when compared to the use of the Wells score by two independent investigators.

Results: Copilot correctly included PE in the differential diagnosis in 94.3% of cases by listing it within the top 10 conditions. Risk assessment by Copilot yielded significantly higher levels in patients with PE (P<.05). No statistically significant difference was found in the Wells scores between patients with PE and without PE  (P>.05). Copilot demonstrated better discriminatory power than the Wells score in risk assessment of PE (area under the curve 0.713 vs 0.583), with statistical significance (P<0.001 vs P=.091). Sensitivity, specificity, positive predictive value, and negative predictive value for discriminating between the combination of low- and intermediate- vs high-risk categories were 34%, 97.1%, 92.3%, and 59.6%, respectively.

Conclusion: This study explores the potential of Copilot as a tool in clinical decision-making, demonstrating a high rate of correctly identifying PE and improved performance over the Wells score. However, further validation in larger populations and real-world settings is crucial to fully realize its potential. 

Introduction: Palliative care consultation teams provide significant advantages for patients, healthcare professionals, and hospitals, particularly in pain management, family support, and clinician satisfaction. Numerous studies show that inpatient palliative care services yield benefits regardless of the timing of initiation, contributing to shortened hospital stays and cost savings. Recent studies have focused on the timing and setting of palliative care, especially in emergency departments (ED), highlighting improved patient outcomes when initiated early. This study explores the potential of embedding hybrid physicians (double-boarded physicians in palliative and emergency medicine) in the ED to further enhance patient care and reduce hospital resources.

Methods: This small pilot case-control study included a subset of all patients referred by emergency physicians and hospitalists for palliative care within 24 hours of registration, physically present in the ED. Cases consisted of all the patients seen by hybrid physicians embedded in the ED. Matched controls were seen by palliative care-boarded clinicians (various other primary specialties) during palliative care rounds in the hospital. Matches were based on diagnosis, comorbidities, and referral date. Outcomes measured included hospital length of stay, total charges, discharge disposition, code status changes, and ED visits not resulting in admission. Statistical analyses used chi-square tests for categorical data and Wilcoxon rank-sum test for continuous data.

Results: In a four-year period, 68 cases were attended by hybrid physicians over 57 disparate days. These cases had significantly shorter hospital stays (median 2.1 days) compared to controls (6.5 days, P<.001). Total charges were also lower for cases ($37,800) than for controls ($78,000, P<.001). A notable secondary outcome was that 26.5% of ED visits in the case group did not result in hospital admission, compared to 100% of controls (P<.001). In addition, more cases than controls had a code status of comfort care at discharge (P=.07)

Conclusion: Embedding hybrid physicians in the ED significantly shortened hospital stays and reduced charges for seriously ill patients. These findings support the further exploration of integrating such physicians into ED settings to enhance patient care and optimize hospital resources. [West J Emerg Med. 2025;XX(X)XXX–XXX.]

Introduction: Undocumented immigrant patients with end stage kidney disease (ESKD) who do not have access to standard dialysis often rely on emergency-only dialysis (EOD) through the emergency department (ED). EOD is provided to patients who present with a critical dialysis need, which includes life threatening hyperkalemia, hypoxemia, uremia, and metabolic acidosis. Compared to standard dialysis, emergency-only dialysis leads to worse patient outcomes, higher hospitalization rates, hospital days, and mortality. The objective of this study was to examine hospitalization rates and hospital days after transitioning undocumented patients with ESKD from EOD to scheduled dialysis through the emergency department and subsequently from scheduled emergency department dialysis to standard dialysis (three day a week dialysis).

Methods: This was a retrospective study using data from one academic teaching hospital over the course of 10 years (2014-2023). All patients over the age of 18 who received dialysis primarily through the emergency department for more than one year were included in the study. Data from two cohorts was collected. Cohort 1 consisted of undocumented individuals who initially were receiving EOD and later transitioned to twice-weekly dialysis through the ED. Cohort 2 was composed of undocumented patients who transitioned from twice-weekly dialysis through the ED to a standard outpatient dialysis schedule. Patients who only received dialysis during one time period (no comparison time period) were excluded from the analysis.  The primary outcome studied was hospitalization rate and hospital days. 

Results: Overall, there were 7 patients in cohort 1 (mean age = 39, 86% female) and 20 patients in cohort 2 (mean age= 44, 50% female). Analysis of hospitalization rates and hospital days was performed using the Wilcoxon signed-rank test. Analysis demonstrated that transitioning from EOD dialysis to twice-weekly dialysis was associated with lower hospitalization rates (1.44 vs. 0.26, p < 0.05) and decreased total hospital days per month (2.18 vs. 1.20, p < 0.05). Switching from twice-weekly dialysis to standard outpatient dialysis was associated with significantly fewer hospitalizations per month (0.10 vs. 0.02, p < 0.01) and lower hospital days per month compared to the twice-weekly dialysis regimen (0.31 vs. 0.08, p < 0.01).

Conclusion: Introducing  scheduled twice weekly dialysis sessions for undocumented patients with end stage kidney disease through the emergency department was associated with lower overall hospitalization rates and hospital days. Moving to the standard thrice weekly dialysis was associated with even lower hospitalizations and hospital days.

Introduction: Emergency physicians (EP) are uniquely positioned to benefit from a deeper understanding of cognitive bias, particularly in the context of limited processing time. The framing effect—the tendency to evaluate identical information inconsistently given varying methods of presentation— presents a particular challenge within emergency medicine (EM). Understanding how the presentation of clinical information affects medical decision-making is paramount, given variability in how information is received. In this study we aimed to assess whether the imposition of a cognitive frame and time pressure affected participants’ differential diagnoses.

Methods: We recruited attending physicians in emergency medicine (EM) and third-year EM residents via email from our university hospital. They were asked to review two case vignettes: one consistent with pulmonary embolism (PE), the other with interstitial lung disease. Each vignette had two versions, one emphasizing features consistent with the respective diagnoses. Each pair of vignettes contained objectively identical clinical information. Subjects were randomly assigned to one of four conditions based on 1) the specific or non-specific-frame version of each case and 2) the inclusion or exclusion of time pressure. Subjects provided their top three differential diagnoses for each case. Our primary outcome measure was identification of intended diagnosis.

Results: A total of 39 subjects completed the study. Two-sided Fisher exact tests showed that varying cognitive frames affected the likelihood of EPs identifying PE as a diagnosis of interest (P = .01). Among EPs who identified PE, the likelihood of this diagnosis leading their differential diagnosis was also related to frame (P = .01). 

Conclusion: The results of this work reveal that cognitive frame and time pressure may independently influence diagnostic reasoning among emergency physicians, bearing implications for medical education. [West J Emerg Med. 2025;XX(X)XXX–XXX.]

Objectives: Copperhead envenomations are the most common snakebite in the United States, and the majority are categorized as mild-moderate severity. The need for prolonged observation to monitor for signs of envenomation supports observation in a clinical decision unit (CDU). To our knowledge, no articles to date have reported on the clinical outcomes of patients managed in a snakebite CDU protocol. 

Methods: We performed a five-year structured, retrospective cohort study of adult patients managed in a single-center CDU, compared to a 10-year period of historical cohort managed inpatient at the same institution. Several clinical parameters were abstracted for comparison. The primary outcome was effective management in CDU observation as measured by length of stay (LOS), disposition, and documented return for care within the hospital system. Secondary outcomes were management comparisons between groups, as measured by LOS, frequency of antivenom use and vials administered, and surgical interventions. 

Results: The two cohorts included 59 patients on CDU observation protocol compared to 36 patients as historical inpatient management. Fifty-four patients (92%) were discharged from observation. Five patients converted to inpatient admission, mostly secondary to uncontrolled pain. After discharge, six patients in the CDU cohort (10.2%) returned for care within the network for wound checks and/or concern for extremity swelling; all were discharged. Compared to the inpatient cohort, patients managed in CDU observation had shorter LOS, less antivenom administered, and fewer surgical interventions. 

Conclusion: Copperhead snakebites can be managed effectively in clinical decision unit observation. The majority of patients were discharged from observation with few return visits. Few patients required admission; those who did were secondary to pain control issues. Anticipated gains of CDU observation are shortened length of stay and lower resource utilization.

Introduction: Resuscitative transesophageal echo (rTEE) is a promising adjunct to cardiac arrest resuscitation. However, it is a high-acuity diagnostic tool that is rarely used in this setting and its safety establishment is limited because of low occurrence. High-acuity, low occurrence skills such as rTEE during cardiac arrest inevitably decay. In this study we examined the content and percentage of rTEE skill decay following simulation-based education (SBE). 

Methods: Resuscitative TEE-naïve emergency physicians (EP) were trained using a combination of clinical exposure, web-based didactics, and monthly hands-on sessions with a high-fidelity rTEE simulator for four months. The COVID-19 pandemic created a natural wash-out phase where EPs did not perform any actual or SBE for six months after initial training. Unadvertised assessment of rTEE skill occurred at month 6 after rTEE training to test skill decay and at month 7 to determine the effect of spaced repetition. One year later, the EPs completed a questionnaire assessing rTEE comfort. Statistical measures were used to measure skill decay.

Results: Seven EPs were individually evaluated in four domains: name recall; probe manipulation (rotation); probe manipulation (omniplane); and image acquisition adequacy. At the end of training, all participants reached a full proficiency score of 32. At month 6, the mean score was 19 of 32 (SD ±7), reflecting a 41% decay (95% confidence interval (CI) -54%, -27%; P < .001) for eight standard rTEE views. Following spaced repetition at month 7, the median score improved to 26 (IQR 23-30), representing a 19% decay (95% CI -35%, -4%; P < .02). For the three guideline-recommended views, the overall decay percentage was 26% (95% CI -36%, -16%; P < .001), although image acquisition skills did not show significant decay. Spaced repetition resulted in a 23% increase in mean scores (95% CI 9-37%), and the average time to obtain all eight rTEE views decreased from 7.3 minutes at month 6 to 5.7 minutes at month 7.

Conclusion: After focused, proficiency-based SBE in rTEE, hands-on image acquisition skills showed the least decay compared to name recall and probe manipulation. Spaced repetition mitigated decay over one month, although not back to baseline.

Objectives: To evaluate the prognostic capability of the Neurological Pupil Index (NPI) in predicting patient disposition from within the emergency department (ED).

Method: This prospective observational study followed fifty comatose patients (Glasgow Coma Scale score < 9) treated in the ED at a Level 1 Trauma Center and public safety net hospital located in San Francisco, CA. NPI scores were calculated using the NPi®-200 pupillometer. Data on patient demographics, clinical characteristics, and outcomes were collected. NPI scores were categorized into three groups: 0 (very poor), 0.1-3.0 (poor to moderate), and 3.1-5.0 (good). ANOVA, Pearson’s Chi-squared test, Wilcoxon rank sum test, and Fisher’s exact test, were used to assess the association between NPI scores and discharge status. Results were reported as odds ratios with 95% confidence intervals, with a p-value < 0.05 considered statistically significant. 

Results: The median age of patients in this study was 58 years (IQR: 42-74), and 66% were male. Higher NPI scores (3.1-5) were significantly associated with an increased likelihood of ED discharge (81%), while lower NPI scores (0) were predominantly associated with hospital admission (92%) (p < 0.001). Significant predictors of discharge status included patient age, GCS scores, and coma etiology.

Conclusions: This study highlights the utility of the NPI, a reliable and objective measure, in predicting patient disposition from within the ED. Higher NPI scores were strongly associated with an increased likelihood of ED discharge. These findings support the idea that NPI has the potential to enhance the accuracy of prognostic assessments, in comparison to subjective characterizations of pupil activity. Additional research with larger, multicenter cohorts is recommended to confirm these results and establish standardized protocols for integration of NPI in ED workflow. 

Background: Situated in the western Pacific Ocean, Taiwan has faced a diverse array of natural and man-made disasters. Since 2000, disaster medicine education has been progressively integrated into various medical professions, with a focus on training disaster medical assistance teams, managing chemical and radiological emergencies, and enhancing prehospital and hospital emergency management capabilities. Despite the key roles of emergency physicians (EP) as primary responders and crucial managerial personnel during disasters, a comprehensive assessment of the disaster medicine core competencies (DMCC) required for emergency medicine (EM) residency training might serve as a blueprint for Taiwan’s EM residency core curriculum. We sought to survey the most critical DMCCs, prioritize them, and determine their appropriateness for the EM residency training program. We also compare dthe prioritization of DMCCs between Taiwan and the United States.

Methods: To accomplish these objectives, we employed a modified Delphi method over three rounds. Initially, three EPs developed a draft of DMCCs for Taiwan. This draft, including 42 DMCCs, was subsequently reviewed by a task force comprising 22 leaders in disaster medicine from EM residency training hospitals across Taiwan. The Delphi method facilitated consensus on the DMCCs through three iterative rounds of polling, with each round evaluating the appropriateness of the proposed competencies. The study also compared the prioritized DMCCs proposed in both Taiwan and the US.

Results: The following 15 DMCCs were rated as highly appropriate with high consensus agreement: personal protective equipment (PPE); decontamination; incident command systems; mass casualty incidents; basic concepts and nomenclature of disaster medicine; medical response to chemical emergencies; triage; identification, notification, activation, and information collection; medical response to radiation emergencies; medical response to bioterrorism and biological emergencies; mental health; disaster exercises; prehospital disaster management; communication and information management; and health consequences of different disasters. A comparison with DMCCs in the US revealed shared prioritization for PPE and decontamination competencies. However, Taiwan placed greater emphasis on prehospital disaster operation management, mental health implications, and health consequences across different disasters, while the US focused more extensively on emergency management within hospitals.

Conclusion: The expert-consensus-driven ranking of DMCCs in the study showed noteworthy agreement with the US. However, the roles of EPs, experience of previous disasters, and government policies may influence specific competencies. This underscores the importance of incorporating local context into disaster medicine training.

Introduction: Despite prior efforts to improve well-being in emergency medicine, clinician burnout in the specialty is rising. In this study we examined the acceptability and feasibility of using a method called “experience sampling” to explore factors important to clinician experience in emergency departments (ED). Experience sampling enables the measuring of work experience in real time, with more granular detail than in usual burnout surveys. The approach may reveal new opportunities for improving work experience in emergency medicine at a critical time.

Methods: We conducted this pilot study in a large, urban, academic, quaternary care ED. Iterative multidisciplinary focus groups were used to generate a brief, experience-sampling tool that was comprised of three different surveys to assess emergency clinician experience before, during, and after shifts. These were deployed using a smartphone application to a convenience sample of 11 clinicians (three attending physicians, two residents, five physician assistants, and one registered nurse) during four shifts each. A post-pilot survey was also sent to all participants to evaluate their experience of using the tool. Our primary outcome measures were feasibility, assessed by the survey response rates during the pilot, and acceptability, assessed by participant sentiment as expressed in the post-pilot surveys. Secondary outcomes were quantitative- and qualitative- experience data collected using the tool.

Results: The overall response rates for pre-shift, on-shift, and post-shift surveys were 79%, 73%, and 91%, respectively. All participants responded to the post-pilot survey and indicated they would be willing to use the experience-sampling tool again in the future. Many participants noted that the simple and open-ended on-shift questions were relatively easy to complete; some also said on-shift survey questions could present added difficulty during busy shifts. Four participants said the exercise of completing surveys itself improved on-shift experience by prompting reflection. Common themes associated with positive experiences included manageable patient volumes, excellent teamwork, interesting cases, adequate staffing, and feeling able to provide adequate care. Common themes associated with negative experiences included crowding, inadequate staffing, feeling overwhelmed, complex patient cases, difficult disposition plans, and feeling unable to provide adequate care.

Conclusion: Experience sampling is an acceptable and feasible method for measuring clinician experience in a busy academic ED. Further studies could potentially use this approach to identify targets for reducing burnout in emergency medicine. 

Introduction: Acute musculoskeletal back pain is a frequent cause of emergency department (ED) visits, often with suboptimal relief from standard treatments. Recent evidence suggests listening to music may modulate pain and anxiety. In this pilot randomized controlled trial, we evaluated the impact of a brief session of patient-selected music vs noise cancellation on pain severity and anxiety in patients presenting to the ED with back pain.

Methods: Patients with acute back pain completed a baseline survey to assess demographics, medication information, and psychosocial factors. The ED patients were randomized to listen to self-selected music or to noise cancellation (control). Patients rated their pain and anxiety (0-10) before and immediately after the intervention. We used analyses of covariance to examine whether post-intervention pain and anxiety differed between the groups, while controlling for baseline trait pain catastrophizing. A mediation analysis was conducted to explore the role of post-intervention anxiety as a mediator of the group difference in post-intervention pain.

Results: Forty patients were enrolled with an average age of 47.2 years (range 21 - 81). and 27 patients (68%) were female. At baseline, patients in the music group reported higher pain catastrophizing compared to patients in the noise cancellation group. There were no other group differences in baseline characteristics. Post-intervention, patients in the music group reported significantly lower anxiety (3.0 ± 0.7 vs 5.5 ± 0.7, P = 0.016) and pain severity (6.1 ± 0.4 vs.7.5 ± 0.4, P = 0.037) compared to the noise cancellation group. A mediation analysis showed that post-intervention anxiety partially mediated the association between intervention group (music vs noise cancellation) and post-intervention pain.

Conclusion: A brief session of self-selected music resulted in lower pain and anxiety scores than noise cancellation among patients with musculoskeletal back pain in the ED. Patients who listened to music reported lower post-intervention anxiety, which partially contributed to lower post-intervention pain severity.