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

Introduction: Violence-related injuries (VRI) such as interpersonal violence, intimate-partner violence, and self-harm injuries present a significant public health challenge in the United States. We aimed to explore interpersonal-violence and self-harm injuries, focusing on demographic disparities (age and sex) and mechanisms of injury, including firearm-related violence.

Methods: We conducted a retrospective study of VRIs among the US civilian population between 2017-2021. Data were extracted from the American College of Surgeons (ACS) Trauma Quality Programs Participant Use Files. We identified VRIs using the International Classification of Diseases, 10th Rev, with Australian modification E-code series. The dataset was categorized and compared by age, sex, ethnicity, violence intent, and mechanism of injury. This study was a secondary data analysis reporting interpersonal-violence and self-harm injuries among trauma cases from the national trauma database.

Results: The total number of trauma patients in the ACS database was 5,483,016 between 2017– 2021 (1.1 million/year). The final analysis included 584,417 (11%) patients with VRIs (interpersonal violence and self-harm), with a mean age of 35 years; 82% were male, 45% White, and 42% Black. Interpersonal violence accounted for 88% of injuries, while 12% were self-harm, with firearm-related violence the most common mechanism of injury (35%). Firearm-related interpersonal violence was common among younger individuals (19-39 years), while non-weaponized interpersonal violence was prevalent among older individuals (≥ 60 years). Blacks had a higher rate of firearm-related interpersonal violence (51%), and Whites had a greater frequency of non-weaponized interpersonal violence. There were 43,089 deaths (7.4%), with 68% resulting from interpersonal-violence and 32% from self-harm injuries. Firearm-related injuries (interpersonal violence and self-harm combined) accounted for 78% of all VRI-related deaths. Mortality was higher in males (7.7%) than in females (5.9%) (P < .001).

Conclusion: There is a significant burden of violence-rated injuries in the US, particularly affecting males, racial minorities, and vulnerable age groups. Firearm-related injuries are the leading cause of death in both interpersonal-violence and self-harm cases. The increase in VRIs during the COVID-19 pandemic highlights the urgent need for targeted public health interventions focused on firearm safety, violence prevention, and mental health support.

Improving resident teaching skills is an expectation of training. Despite the recognized importance of resident-as-teacher (RaT) curricula, variability indicates the need for evidence-based guidelines to inform best practices. This paper outlines expert guidelines for the development, implementation, and evaluation of RaT curricula from the members of the Council of Residency Directors in Emergency Medicine Best Practices Subcommittee, based on a critical review of the literature. It is important to perform a needs assessment prior to creating and implementing a RaT curriculum. The RaT curricula should include instruction on adult learning theory, feedback, and classroom and bedside teaching techniques. Outcomes of RaT curricula should be assessed using multiple sources including direct observation and incorporate both knowledge and skill retention, as well as acquisition.

Introduction: Future large-scale combat operations (LSCO) with adversaries such as Russia or China are predicted to present unique challenges for medical personnel, including high casualty rates, limited resources, and austere environments. While traditionally associated with military conflict, the anticipated scale of future LSCO may overwhelm military medical systems, requiring civilian physicians to support wartime care or manage surges in casualties on the home front. Effective training early on is, therefore, critical to prepare both military and civilian physicians for these unique and demanding conditions.

Methods: We used interpretive phenomenological analysis in this qualitative study to explore key competencies needed for LSCO medical readiness. The first and seniors author interviewed 27 military physicians (active duty, retired, and reservists) and one military chaplain with extensive operational medical experience in the fall of 2023 and fall of 2024. We analyzed transcripts to identify recurring themes. Data analysis was conducted by a diverse and experienced research team.

Results: Five key themes emerged as essential for LSCO-focused medical training: 1) problem-solving in resource-limited environments, emphasizing critical thinking and improvisation; 2) ethical and emotional resilience, addressing psychological and moral challenges; 3) adaptive leadership, highlighting decision-making in high-stress settings; 4) mastery of core medical skills, ensuring competency in essential procedures; and 5) cultural competence and interoperability, supporting effective collaboration across military-civilian teams.

Conclusion: The competencies identified in this study are relevant to both military and civilian physicians who may be called upon to provide care during large-scale combat operations. Medical education must proactively incorporate these themes to ensure readiness across both sectors. Strengthening military-civilian collaboration in training and curriculum development will enhance national preparedness for future conflicts.

Introduction: Applying to emergency medicine (EM) residency programs is costly. In the past several years, the EM residency application process has undergone multiple changes in recommendations regarding away rotations and interview format, primarily but not solely driven by COVID-19 restrictions. To date, little is known about the financial impact of these changes on EM applicants. This study assesses recent trends and changes in the costs of the EM residency application.

Methods: We analyzed EM applicant survey data from the Texas STAR (Seeking Transparency in Application to Residency) database from 2019–2024. Application cycles were grouped into three time periods: pre-pandemic (2019–2020), pandemic (2021–2022), and post-pandemic (2023–2024). Applicants’ self-reported data for application fees, away rotation costs, interview costs, and total expenses were analyzed. We conducted Kruskal-Wallis testing to evaluate differences in expense-related variables across the three time periods. We performed post-hoc analysis using the Dunn test if significant differences were detected.

Results: This study included 3,495 EM applicants, which represents 8.4% of the total 41,497 Texas STAR survey respondents from 2019–2024. Average per-applicant total costs were $5,412, $2,076, and $3,156 in the pre-, during-, and post-pandemic application cycles. Self-reported total applicant expenses decreased between the pre- and pandemic period and increased from the pandemic and post-pandemic period (P < .01). Applicants had the lowest overall costs in 2021. Away rotation, second look, application costs, interview travel and lodging, and virtual interview costs all reached their lowest levels during the pandemic period (P < .01). In the post-pandemic period, travel and lodging costs were higher than pre- and during pandemic levels, while interview costs remained lower due to the continued use of virtual interviews (P < .01). Applicants from the Western Region of the US saw the highest total costs compared to the Northeast, which saw the lowest.

Conclusion: The total expenses reported by medical students applying to EM residency programs were significantly reduced during the pandemic, compared to other years. Some expenses, notably away rotation and second look and application costs, have risen post-pandemic. To help reduce the financial burden of the EM residency process, the continued use of virtual interviews is an opportunity for cost savings.

Introduction: Core faculty are key to supporting the educational mission in emergency medicine (EM). Changes in the Accreditation Council for Graduate Medical Education (ACGME) requirements for minimum protected time for core faculty may no longer guarantee adequate support. We sought to assess EM core faculty characteristics, support, and the impact of the 2019 revisions to ACGME regulations. We explored the influence of individual and institutional characteristics on support and the impact of the regulatory changes.

Methods: This was a cross-sectional survey study of a convenience sample of EM core faculty. Participants completed an online survey of multiple-choice and completion items between April–June 2022. We calculated descriptive and comparative statistics to assess associations between individual (e.g., sociodemographics, rank) and institutional (e.g., region, program type) factors on resources and impact of ACGME revisions.

Results: A total of 596 individuals (57% male) from 116 residency programs participated, including 15 (3%) instructors/lecturers, 280 (47%) assistant professors, 182 (31%) associate professors, and 80 (13%) professors. Most (64%) were 36-50 years of age; 246 (41%) had completed a fellowship. Despite the change to the ACGME requirements in 2019, 417 (70%) reported no modification to their clinical work hours, and 420 (71%) reported no modification to their non-clinical responsibilities. There were statistically significant associations between number of residents per class (P < .001), duration of training program (P < .001), and type of institution (P < .001) with the number of administrative personnel. We also observed statistically significant associations between academic rank (P = .02), region (P =.01), number of residents per class (P = 0.02), and type of site (P = .01) with change to clinical work hours after changes to ACGME requirements.

Conclusion: A minority of participants reported a change to their clinical and non-clinical expectations after revisions to the ACGME regulations with disproportionate impact across faculty and program type.

Introduction: Throughout graduate medical education (GME), it is crucial for learners to not only develop the skills necessary to manage a wide variety of medical conditions, but also to foster personal development and to gain a deeper understanding of the complex and multifaceted needs of our patients. We often refer patients to community sites to address needs such as homelessness, hunger, and domestic violence; however, we frequently make these referrals with only a superficial understanding of what each resource entails.

Methods: To address this issue, our department integrated a two-day Community Engagement Retreat into our curriculum. Twenty-two first-year residents participated in small group visits to three or four community organizations. There, residents engaged with community workers and the public to learn about the services each program offers. This was followed by a session of focused reflection and discussion on how to integrate this new knowledge into our care for patients in the emergency department. At the conclusion of the experience, residents completed an anonymous survey with a response rate of 77.3%.

Results: The results suggest that participants found the sessions highly useful, with 98.6% of residents reporting that they “agreed” or “strongly agreed” that the experiences at the community sites would better allow them to care for patients. They further stated that the program was one of the most impactful elements of their training and highly recommended it to future learners.

Conclusion: This initiative demonstrates the importance and utility of a novel, structured community engagement to begin to address this deficiency in GME and improve patient care.

Introduction: Emergency department (ED) flow could be improved with quicker disposition decisions. One possible way to expedite decisions is for triage nurses to make predictions about whether patients require admission to hospital. The information contained in these predictions could be useful for disposition planning and for physician decision-making. Previous studies made use of prospective designs that introduced Hawthorne effects and have demonstrated mixed evidence on whether triage nurse predictions are accurate. We examined the accuracy of triage nurse predictions for patient admission in an ED in southeastern Ontario.

Methods: We examined a retrospective sample of 134,891 visits to an ED in Ontario from March 2019 – July 2024. Triage nurses made predictions about admission to hospital for these visits, from which we estimated measures of specificity, sensitivity, positive predictive value, negative predictive value, accuracy, and F1 scores.

Results: Of 134,891 visits, 13.7% resulted in hospital admission. We found the accuracy of the nurses in predicting admission to be 85.8% (95% confidence interval [CI] 85.7 - 86.1), while overall sensitivity was 36.6% (95% CI 35.9 - 37.3) and specificity was 93.7% (95% CI 93.5 - 93.8). The positive predictive value of admission was 47.9% (95% CI 47.1 - 48.7), and the negative predictive value of admission was 90.3% (95% CI 90.1 - 90.5). F1 scores were 0.415. These results were relatively stable over time, although there was notable variation in prediction ability between nurses. We also report that some presenting conditions lead to relatively higher prediction accuracy than others and that as overall case severity increases, sensitivity increases and specificity decreases.

Conclusion: These results suggest that although nursing staff predictions are insufficient to streamline disposition decisions completely, they could be useful in expediting certain decisions related to hospital admission and resource requirement, thereby improving flow in EDs.

Introduction: The key role of emergency departments (ED) is to treat severe and life-threatening cases. A rise in ED visits, particularly for low-acuity conditions, places a burden on resources which may hinder efficient care for high-acuity conditions. We investigated the association between previous outpatient healthcare services use and low-acuity visits in EDs in Germany. 

Methods: We analyzed data from the Initiative for Emergency Department Evaluation and Data Collection project, with 454,747 ED visits by 353,926 patients collected from 16 EDs in Germany in 2016. We included a subset of 228,753 (64.6%) patients with 299,914 (66.0%) visits from 12 of the participating EDs for which outpatient care data was available. We categorized ED presentations into low- or high-acuity based on transportation to the ED, triage category, hospital admission status, and intrahospital mortality. By merging patient hospital records with outpatient billing information, we assessed outpatient care utilization prior to ED visits. Using a generalized mixed-effects model, we investigated the relationship between acuity level and outpatient care utilization, adjusting for age, sex, and  type of residential area. 

Results: Low-acuity patients were considerably younger than high-acuity (mean age ± standard deviation: 45 ±19 vs 58 ±21 years) and used outpatient services less often within 10 days prior to their ED visit: 40.6% vs 49.5%. Key associations for low-acuity ED visits included younger age (per 10-year categories: adjusted odds ratios 0.72, 95% confidence interval 0.72-0.73), urban residence (1.17; 1.13-1.22), and timing of the last outpatient contact. Longer durations since the last outpatient contact were associated with a higher likelihood of presenting to the ED with low-acuity symptoms. Compared to patients who visited their primary care physician (PCP) shortly before their ED visit, those with PCP contact 1-6 months (1.22; 1.19-1.25) and over six months prior (1.33; 1.26-1.41) were more likely to present with low-acuity conditions. 

Conclusion: While almost half of both low- and high-acuity patient groups utilized outpatient services prior to the ED visit, low-acuity patients were generally younger and had fewer such contacts. The majority had accessed both primary care and the ED, challenging the assumption that low-acuity patients routinely bypass outpatient care before seeking emergency services. This raises the question of what limitations or unaddressed needs in outpatient care drive these patients to seek subsequent care in the ED. More research is needed to explore the structural and systemic factors influencing low-acuity ED visits. 

Introduction: Emergency department-based intensive care units (ED-ICU) address the increasing demand for critical care services and represent a transformative approach to the specialty’s management of critically ill patients within emergency medicine. However, data on their financial impact and operational effects remain limited.

Methods: We conducted a retrospective, quasi-experimental study at an urban, academic ED with approximately 90,000 annual visits. In July 2019, a nine-bed ED-ICU model, referred to as “Next Pod,” was implemented. We analyzed Current Procedural Terminology (CPT) coding data and professional revenue (charges billed and payments received) for 35 weeks before and after the intervention (November 2018–March 2020). The intervention involved repurposing a nine-bed ED area and adjusting physician and nursing staffing models. We compared critical and non-critical care CPT coding proportions and professional revenue using the Student t-test.
Results: During the study period, there were 38,283 ED visits pre-implementation and 36,424 visits post-implementation. Across the entire ED, critical care coding significantly increased following implementation (CPT 99291: 6.2 - 8.8% [total percentage increase of 41.94%]; 99292: 0.5 - 1.0% [total percentage increase of 100%]). Encounters where 99292 was billed multiple times increased by 128.1% (32 vs 73). Non-critical care coding (99282, 99283) decreased 23% (9.1% vs 7.0%, P< .001) / 29.6% (16.2 vs 11.4, P < .001), respectively. There was a non-statistically significant increase in 99284. Higher acuity codes (99285) increased by 10% (31.7% vs. 34.9%, P < .001). Average ED charges per visit increased by $40 (95% CI $37.2 – $45.5) post-implementation.

Conclusion: The implementation of an ED-ICU was associated with significant increases in critical care and high-acuity coding, as well as enhanced professional revenue. These findings suggest that ED-ICU models can improve both fiscal performance and operational efficiency. Further research is needed to explore the contributions of resource allocation, documentation improvements, and care practices to these outcomes.

Introduction: Our Emergency Department (ED) and Population Health Services Organization developed a telehealth ED-transition of care program (TOC) for patients insured through value-based contracts. This study’s goal was to determine the association of our ED-TOC on ED revisits. We hypothesized that the ED-TOC would decrease ED revisits.

Methods: This was a retrospective cohort study conducted between August 1, 2021 and July 31, 2023 at two EDs where an ED-TOC is available. Included were ED visits among discharged Medicare beneficiaries that occurred one year before and after the launch of the ED-TOC program.  ED visits involving Medicaid beneficiaries served as the control.  A difference-in-differences (DID) strategy was used to compare Medicare and Medicaid visits. The primary outcome measure was the association of the program with 14- and 30- day ED revisit rates. Secondary outcomes were the association of the ED-TOC with post-discharge PCP visits and hospitalizations and estimated cost-savings associated with the program.

Results: Our sample size was 23,696 ED encounters (13,553 treatment group and 10,143 control group).  At 14-days after ED discharge, Medicare beneficiaries were associated with a 1.77% decrease in the rate of ED revisits in the year after the ED-TOC launch relative to the control (p=0.03) or a 15.8% reduction relative to baseline (11.2% to 9.4%).  At 14-days after ED discharge, PCP visits were associated with a 1.51% increase in the year after program launch relative to the control (p=0.03) or a 10.3% increase relative to baseline (14.6% to 16.1%).  No difference was associated with Medicare beneficiaries’ ED revisits or hospitalizations at 30-days. PCP visits were associated with a significant increase at 30-days (p=0.005).

Conclusion: An ED-TOC is associated with a reduction in Medicare ED revisits during days 8-14 after an index ED visit but not during days 1-7 days or at 30-days.   Cost savings over a 24-week period are conservatively calculated to be $215,779.

Introduction: The emergency department (ED) serves as an entry point to the healthcare system for many patients, and the increased use of advanced imaging has resulted in identification of masses of unclear significance. We describe patients presenting to an ED who were referred to an undiagnosed mass clinic (UMC).

Methods: We performed a retrospective observational cohort study of patients ≥16 years of age presenting to Mayo Clinic in Jacksonville, Florida, from October 31, 2018–March 31, 2023, who were referred to the UMC.

Results: There were 116 patients referred to the UMC with a median of 3.5 days from ED encounter to clinic date and a median of 14.5 days from ED encounter to biopsy. Using an analytic tool in the electronic health record, we estimated that of 16,872 patients, 116 (0.69%) Mayo Clinic Florida (MCF) ED patients ≥18 years of age who received computed tomography and were discharged from the ED were referred to the UMC. Ultimately, 35 of 65 patients (53.8%) seen in the UMC received a cancer diagnosis.

Conclusion: Our study shows a viable care path from ED encounter to undiagnosed mass clinic. Further research is needed to ensure timely transitions of care for patients who are uninsured or out of network.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic significantly altered emergency department (ED) utilization patterns. This study quantifies the statistics at a Level I trauma center in Southern California from 14 months before to nine months after the start of the pandemic (January 2019–December 2020). We hypothesized that during the COVID-19 pandemic, changes in ED use patterns impacted patient acuity, as measured by admission rate, mortality rate, ED volume, Emergency Severity Index (ESI), and female:male ratio, even when controlling for COVID-19 cases.

Methods: In this study we examined 97,793 ED visits from January 2019–December 2020 at the University of California, Irvine Medical Center in Orange, CA, via an administrative database comprised of anonymized datapoints from the electronic health record. We included all months from January 2019–December 2020 to account for potential secular trends by calendar month. Primary outcome measures were hospital admission rate and all-causes mortality rate among non-COVID-19 patients who presented to the ED. Secondary outcome measures included the mean number of ED visits per month, mean ESI, and female:male ratio among non-COVID-19 patients. Statistical analyses were performed.

Results: We found an increase in the mortality rate per ED visit of 0.8859% before the pandemic to 1.2706% (P < .001) during the pandemic. After excluding COVID-19 cases, the mortality rate per ED visit remained elevated at 1.1746% (P < .001), a relative increase of 32.6%. Hospital admission rate increased from 26.0% before the pandemic to 32.3% during the pandemic (P < .001). The mean number of ED visits per month decreased from 4,271.2 ± 193.1 before the pandemic to 3,558.7 ± 437.1 per month during the pandemic (P < .001), a relative decrease of 16.7% when excluding COVID-19 cases. The mean ESI of non-COVID-19 related cases during the pandemic decreased from 2.85 pre-pandemic to 2.84 during the pandemic (P = .03). The female:male ratio decreased from 1.003 pre-pandemic to 
0.885 during the pandemic (P < .001).

Conclusion: This study reveals a decrease in patient volume with an increase in mortality and admission rate, demonstrating an association between shifts in ED utilization patterns and increased patient acuity during the pandemic. Understanding patients’ emergency care-seeking behavior during this period is essential for preparing for future large-scale public health crises and optimizing ED resource allocation and mobilization based on lessons learned from COVID-19. Overall, these findings highlight the need for further research into the development of strategies to address changes in care-seeking behavior during access-limiting scenarios.

Introduction: Advanced practice clinician (APC) presence has increased in emergency departments (ED), leading to increased exposure to higher acuity patient conditions. Relatively few APCs have completed formalized postgraduate emergency medicine (EM)-specific training, creating uncertainty around how well prepared APCs are in identifying and treating life-threatening conditions. Foundations of Emergency Medicine (FoEM) offers free open-access curricula, including Foundations I (F1), a flipped-classroom course targeting fundamental knowledge for resident physicians. We sought to use F1 for APC learners to improve their knowledge in identifying and treating emergent conditions.

Methods: In our single-center study, 23 APC postgraduate learners (17 nurse practitioners and 6 physician assistants) completed the F1 course between 2020-2021. The F1 course consisted of 23 virtual meetings led by faculty and senior residents, each lasting one hour. The APCs were asked to review vetted asynchronous resources for a recommended two hours before participating in small group, case-based learning sessions involving real-time feedback, curated teaching points, and 
paired online assessments. Immediately before and following F1 course implementation, participants completed a 50-question multiple-choice test and attitudes survey to quantify knowledge acquisition and evaluate the course. We evaluated change in knowledge scores using a Friedman test. Changes in self-assessed knowledge were evaluated using mixed-effects ordinal logistic regression.

Results: Knowledge assessments showed APCs universally improved from the pre-course test (median score 23, 46%, IQR 20-26) to the post-course test (median score 33, 66%, IQR 31-37; adjusted P < .001). The APC self-assessments revealed improved overall EM knowledge (adjusted P = .02), yet respondents also reported an increased likelihood of seeking attending physician help (adjusted P < .001). Overall, 96% were satisfied with the course, 100% agreed that the course difficulty was appropriate, and 79% believed the course improved their performance in a clinical setting.

Conclusion: Implementation of the Foundations of Emergency Medicine, Foundations 1, curriculum was associated with increased classroom knowledge and self-assessed overall knowledge in EM among advanced practice clinicians, with high learner satisfaction in the course. Along with knowledge improvement, APCs also reported increased likelihood to seek guidance from an attending physician. These data form the basis for the use of FoEM in the APC learner population.

Introduction: Black and Hispanic patients, and patients with a preferred language other than English experience longer emergency department (ED) wait times and delays in treatment. We aimed to evaluate racial, ethnic, and language-based differences in wait times to see a physician and get a disposition, as well as in the rates of objective vs subjective urgent evaluations.

Methods: This was a retrospective study of all ED visits in our tertiary-care, academic medical center from July 2021–June 2023. Using electronic health record data, we compared time-to- physician, physician-to-decision times, and frequency of triggers (urgent evaluations based on objective criteria) and priority assessments (urgent evaluations that can be based on subjective perception of patient acuity) by race, ethnicity, and preferred language. We used logistic regression, controlling for age, Emergency Severity Index, and sex to compare differences in trigger rates.

Results: We included 93,728 patient encounters in this study. Black patients had a median time-to-physician of 31 minutes compared to 24 minutes for White patients (adjusted median difference (aMD) 3.2, 95% CI 2.4-3.9]) and a median physician-to-decision time of 228 minutes compared to 213 for White patients (aMD 15.0, 95% CI 12.0-17.9). Hispanic patients had a median time to physician of 31 (aMD compared to White patients = 3.4, 95% CI 2.4-3.9) and a median physician-to-decision time of 233 minutes (aMD compared to White patients 21.3, 95% CI 17.5-25.2). Patients with a preferred language other than English had a median time-to-physician of 33 minutes compared to 25 in English-preferring patients (aMD 4.6, 95% CI 3.7-5.6) and a median physician-to-decision time of 234 compared to 214 minutes for English-preferring patients (aMD 17.1, 95% CI 13.6-20.7). Black patients were less likely to have a trigger activated relative to White patients (adjusted odds ratio [aOR] 0.88, 95% CI 0.82-0.95). Black patients (aOR 0.72, 95% CI 0.67-0.77), Hispanic/Latino patients (aOR 0.78, 95% CI 0.71-0.86), and non-English-preferring patients (aOR 0.85, 95%CI 0.78-0.92) were less likely to have a priority assessment called compared to White patients.

Conclusion: Black, Hispanic, and patients who prefer non-English language experience delays in time-to-physician and physician-to-decision time. Black patients are less likely to have triggers activated. Black, Hispanic, and patients who prefer non-English language are less likely to have priority assessments activated compared to White patients. These findings underscore the need to develop additional mechanisms for mitigating biases in the triage process.

Introduction: Urgent care centers (UC) play an important role in addressing non-emergent health concerns, offering a convenient alternative to emergency departments (ED). However, accessibility to UCs can vary based on transportation availability and socioeconomic factors. In this study we evaluated the geospatial accessibility of UCs and EDs in Milwaukee County, Wisconsin, and sought to characterize the relationship between transit options, socioeconomic vulnerability, and access to care.

Methods: We included 13 EDs and 13 UCs in the study. Public and private transit times between census tracts in Milwaukee County and the nearest UC or ED were calculated using an application programming interface that recorded data from Google Maps. We employed socioeconomic vulnerability index (SEVI) scores to define community vulnerability. Statistical analyses, including Mann-Whitney U tests and Pearson correlation coefficients, were used to determine differences in commute times and their relationship with socioeconomic status.

Results: Private transit times were shorter than public transit times when commuting to the nearest ED (7 minutes vs 22 minutes, P <.001) and the nearest UC (9 minutes vs 31 minutes, P < .001). The EDs were generally more accessible than UCs, with shorter transit (22 vs 31 minutes, P < .001) and walk times (11 vs 14 minutes, P <.001). Socioeconomically disadvantaged communities with higher SEVI scores had longer private transit times to UCs (r = 0.17, P = .003) while having shorter public transit times to EDs (r = -.21, P < .001).

Conclusion: Access to urgent care centers and EDs in Milwaukee County is influenced
by socioeconomic factors and transportation modes. While EDs are more accessible to socioeconomically vulnerable communities, UCs are less accessible, which may contribute to higher ED utilization for non-emergent needs. These findings highlight the need to address transportation limitations as a social determinant of health that can impact how disadvantaged populations seek care and the implications for non-emergent ED use and ED crowding.

Introduction: The National Clinical Assessment Tool for Emergency Medicine (NCAT-EM) was designed to standardize medical student assessments during emergency medicine clinical rotations. While multiple assessment tools implemented in medical education have been prone to inequities, it remains unknown how student and rater demographics impact NCAT-EM scores. In this study we examined how a student’s gender and status as under-represented in medicine (URM) affected NCAT-EM scores.

Methods: This was a retrospective cohort study of all NCAT-EM assessments of clerkship medical students at a single institution in 2022. We performed mixed-effect ordinal logistic regression analyses to determine the association between the seven NCAT-EM domains (history/physical, prioritized differential, formulation of plans, observation/monitoring, emergency management, communication, and global assessment) and student gender, as well as the NCAT-EM domains and students’ URM status (specifically in domains of race and ethnicity). We adjusted our analyses for the site of rotation, time, the rater’s role (attending or resident), and rater demographics (gender, URM status). We then evaluated the interaction in gender concordance and URM-status concordance on outcomes.

Results: A total of 1,881 NCAT-EM assessment forms were submitted on 142 students completed by 266 raters. There were no significant associations between student gender and NCAT-EM ratings across the seven domains. W  found an association between URM students and lower scores in multiple NCAT-EM domains, including global assessment (odds ratio [OR] 0.50, CI 0.25-0.99, P = .01); history/physical (OR 0.38, CI 0.19-0.77, P = .01); and prioritized differential (OR 0.47, CI 0.26-0.88, P = .02). This effect was moderated by a significant positive interaction effect with URM concordance between raters and students in the prioritized differential and observation/monitoring domains.

Conclusion: This is the first study to highlight differences in both gender and status as underrepresented in medicine within the nationally implemented NCAT-EM assessment tool. Women students were overall rated similarly across the NCAT-EM domains compared to men, with no association of gender on ratings. However, students’ URM status was associated with lower scores in multiple NCAT-EM domains. This finding was mitigated by URM concordance between faculty and resident raters. Our findings support the need for additional studies to understand bias and inequities in the application of the NCAT-EM tool nationally.

Introduction: Over 20% of the United States population speaks a language other than English, and many use the emergency department (ED) to access healthcare. However, there remains concern that patients preferring languages other than English are under-represented in clinical research. Thus, our goal was to assess the proportion of ED studies that excluded patients for recruitment due to language.

Methods: We conducted a narrative review using seven search engines for 2018–2023. We included studies if they mentioned language of participants and prospectively enrolled patients in an ED or prehospital setting. We excluded studies if they only included patients <18 years and/or were conducted exclusively outside the US. Two independent reviewers reviewed studies. Analyses included descriptive statistics.

Results: Of the 10,513 studies we identified, 281 were eligible for review; 163 (58%) excluded non?English language preferred (NELP) patients. Among the 107 interventional studies, 69% excluded NELP patients. Of the 135 studies focused on health equity/social emergency medicine, 47% excluded NELP patients.

Conclusion: We found 163 (58%) studies conducted in the ED that mention language and excluded NELP patients. Additional work is needed to encourage and support inclusive study designs.

Introduction: Clear communication is essential for emergency medical services (EMS) clinicians to assess a situation and make appropriate transport decisions. When barriers are present that impede communication between emergency responders and patients, EMS clinicians report difficulty navigating these encounters. As communication barriers potentially delay definitive care, it remains unclear the amount of time that EMS clinicians spend on scene during these encounters and how often they result in non-transport. In this study we sought to characterize the association between the presence of communication barriers, time spent on scene, and non-transport.

Methods: We conducted an observational analysis using 2022 data from the ESO Data Collaborative, a deidentified national prehospital electronic health record dataset. Encounters were restricted to 9-1-1 responses in which the responding ambulance was first on scene, the patient was alive,  ≥ 18 year of age,  and able to refuse transport. The primary outcomes were time on scene and non-transport. We used logistic regression models to estimate non-transport by communication barrier (including non-English language preference, speech disability, deaf or hard of hearing, and blind or low vision) and control for key patient and encounter characteristics.

Results: Of 3,477,008 EMS responses, 233,084 (6.7%) resulted in non-transport and 99,263 (2.9%) had a communication barrier identified. Among encounters with a communication barrier identified, EMS clinicians spent more time on scene with patients who were not transported (21.0 minutes) compared to patients who were transported for definitive care (15.9 minutes). Compared to those without an identified barrier, encounters with a patient who had a non-English language preference (odds ratio [OR] 0.51, confidence interval [CI] 0.49-0.53, P < .001), patients who had a speech disability (OR 0.36, CI 0.33-0.40, P < .001), were deaf or hard of hearing (OR 0.71, CI 0.66-0.76, P < .001), or were blind or had low vision (OR 0.80, CI 0.69-0.92, P < .001) were less likely to result in non-transport, with non-transport rates of 3.6%, 1.9%, 4.0%, and 4.4% respectively. 

Conclusion: Encounters with communication barriers were less likely to end in non-transport. When communication barriers were identified, EMS clinicians spent 32% (5.1 minutes) longer on scene on encounters that resulted in non-transport, showing that EMS clinicians may be dedicating additional time and resources caring for this population.

Introduction: Prehospital information is valuable but often under-used by physicians. In both the emergency and inpatient settings, information about a patient’s condition prior to their arrival is important to provide optimal care. Historically, prehospital responders’ electronic patient care reports (ePCR) have not been integrated with the hospital’s electronic health record (EHR). In this study, we aimed to assess physician attitudes towards the ePCR and patient care decisions before and after integration of prehospital ePCR and hospital EHR systems. We hypothesized that this would increase accessibility and use of prehospital ePCR in patient care decisions.

Methods: In 2023, our local academic health center implemented software that made prehospital documentation available to hospital staff within 30 minutes of patient arrival to the emergency department (ED). Before this, we surveyed attendings, fellows, and residents from both the ED and internal medicine (IM) department on their attitudes and behaviors regarding ePCR and clinical practice. We administered the same survey six months after implementation, and compared responses with a Wilcoxon signed-rank test.

Results: Sixty-six physicians responded to the pre survey, including 39 (59.1%) from the ED and 27 (40.9%) from the IM department. Fifty-two completed the post survey, including 33 (63.5%) emergency physicians and 19 (36.5%) IM physicians. The pre- survey response rates were 92.9% and 54% for the ED and IM groups, respectively, while the post-survey response rates were 84.6% and 70.4%. Change in rank was significant (P < .01) for the following categories: knowledge;, ability; ease of use; time to access; and frequency of accessing the ePCR. Change in rank was not significant for the importance of ePCR in patient care and medical decision-making, and whether the ePCR would be used more frequently if it were easier to access.

Conclusion: Pre- and post-survey responses regarding accessibility showed a significant change in rank, while the importance of the ePCR on clinical decision-making did not. This suggests that while system integration increased accessibility to prehospital information, it did not significantly alter patient care decision-making.

Introduction: Ambulances are often left to idle, which may contribute to maintenance costs, environmental harm, and resource inefficiencies. Engine idling affects the health of first responders due to the consequences of exhaust. Our study objective was to gain understanding of current emergency medical services (EMS) policies and perspectives on ambulance engine idling.

Methods: We designed an anonymous, 48-question survey that was distributed to all levels of EMS clinicians. There were 684 total survey responses from 11 states. We excluded those that only included demographics, yielding 507 responses. The response rate was 10.8%. The questions surveyed demographics, service characteristics, and current policies and perspectives on idling. We used multiple question types, including some that asked participants to rate their level of concern on a five-point Likert scale. “Strongly disagree” was coded as 1, and “strongly agree” was coded as 5. “Neither agree or disagree” was considered a neutral response and was coded as 3. Additionally, we conducted a thematic analysis on data derived from the free-text responses to identify themes.

Results: Few (12%) respondents reported written policies on idling. The biggest concerns regarding idling involved the following (reported as median (IQR, 25th and 75th percentiles): patient comfort (4, IQR 4-5); EMS clinician comfort (4, IQR 4-5), and medication compromise (4, IQR 4-5). There was a neutral level of concern regarding equipment failure (3, IQR 3-4) and response delays (3, IQR 3-5). There was a less than neutral level of concern regarding engine failure (2, IQR 2-4); vehicle theft (2, IQR 2-4), air quality (2, IQR 2-3); increased fuel usage (2, IQR 2-3); and carbon emissions (2, IQR 2-3). Six themes emerged: fear of harming patient; safety; effects on air quality; habits and indifference; cost of idling; and frustration.

Conclusion: Emergency medical services clinicians mainly hesitate to turn off their engines out of concern for patient/personnel harm and potential equipment failure. The theme of frustration, noted in free-text responses, describes EMS clinicians’ feelings of suspicion and concern for an ulterior motive behind the study, which highlights the need for a collaborative effort at addressing this collective issue.

Introduction: Lift assistance represents a high proportion of emergency medical services (EMS) calls, yet data is limited regarding the long-term outcomes of these patients who subsequently refuse transport. In this study, our objective was to examine the outcomes of patients who require lift assistance but refuse transport and to determine factors associated with repeated EMS utilization.

Methods: We conducted a retrospective, observational cohort study of EMS calls in southern New Jersey in patients ≥18 years of age who declined EMS transport after a fall between July 1, 2021–July 1, 2022. Repeat callers were defined as making one additional call within 30 days, and we defined super-users as those making ≥four calls within six months. The primary outcome was repeat emergency department (ED) visits within 30 days from the initial transport refusal visit. 

Results: We analyzed 116 of 203 (57%) patients. The mean patient age was 66.3 years, and 53.6% were female. Forty-seven (37.9%) patients were repeat callers, and 27 (21.8%) were super-users. Repeat callers and super-users had increased odds of 30-day ED visits (odds ratio [OR] 17.2, 95% confidence interval [CI] 6.4-47.6, and OR 8.8, 95% CI 3.3-23.7, respectively), and six-month ED visits (OR 4.9, 95% CI 2.2-11.2, and OR 12.9, 95% CI 3.9-56.5). Similarly, there were increased odds of 30-day admission for repeat and super-user callers (OR 6.6, 95% CI 2.5-18.2, and OR 10.8, 95% CI 4.0-29.8, respectively), and six-month admissions (OR 3.0, 95% CI 1.4-6.5,and  OR 6.8, 95% CI 2.6-19.9, respectively). No differences in death at one year were observed in either group (repeat callers OR 1.4, 95% CI 0.4-4.5; super-users OR 1.1, 95% CI 0.2-4.1) Repeat callers had higher proportions of anticoagulation/antiplatelet therapy and non-ambulatory status (42.9% vs 61.7%, P=.046 and 29.0% vs 56.8%, P=.006, respectively). 

Conclusion: Repeat EMS calls for lift assistance may be used to identify patients at high risk for ED visits and hospitalizations. As patients decline transport, EMS may be their sole healthcare encounter. Future directions would entail training EMS personnel in screening or referring patients for more intensive outpatient interventions.

Introduction: Hypertension and diabetes are common cardiovascular disease risk factors among emergency department observation unit (EDOU) patients evaluated for acute coronary syndrome (ACS). Our primary aim was to determine rates of untreated hypertension and diabetes in the EDOU. Our secondary aim was to identify rates of glycemic control assessment among patients with diabetes.

Methods: We conducted a retrospective, observational cohort study of patients ≥ 18 years old evaluated for ACS in a tertiary care center EDOU from March 3, 2019–February 28, 2020. Known diagnoses prior to EDOU encounter and new outpatient diagnoses within one year for hypertension and diabetes were identified by health record data. We defined untreated hypertension and diabetes as no antihypertensive or antihyperglycemic prescriptions or diabetes counseling within one year. We calculated treatment rates with exact 95% confidence intervals (CI). Multivariable logistic regression adjusting for age, sex, and race compared treatment rates among men vs women and White vs non-White patients. Rates of glycemic control assessment were defined by the proportion of patients with known diabetes who received hemoglobin A1c (HbA1c) measurement within one year.

Results: Among 649 EDOU patients, 59.5% (386/649) were female and 43.8% (284/649) were non?White with a mean age of 59 ± 12 years. Of these, 76.9%(499/649) had known hypertension and 31.3% (203/649) had known diabetes. Within one year, 3.1% (20/649) had newly diagnosed hypertension and 3.2% (21/649) had newly diagnosed diabetes. Among those with known or newly diagnosed hypertension, untreated hypertension occurred in 36.4% (189/519; 95% CI 32.3 - 40.7). Hypertension treatment rates were similar in men vs women (aOR [adjusted odds ratio] 0.82, 95% CI 0.57 - 1.19) and White vs non?White patients (aOR 0.95, 95% CI 0.66 - 1.38). Among those with known or newly diagnosed diabetes, untreated diabetes occurred in 25.0% (56/224; 95% CI 18.5 - 31.2). Diabetes treatment rates were similar in men vs women (aOR 1.41, 95% CI 0.72 - 2.74) and White vs. non-White patients (aOR 1.05, 95% CI 0.56 - 1.97). At one year, just 32.0% (65/203) of patients with diabetes had HbA1c testing.

Conclusion: Given that many patients evaluated for acute coronary syndrome in the ED observation unit do not receive treatment for hypertension and diabetes within one year of presentation, clinicians should consider initiating EDOU-based preventive cardiovascular care for these conditions.

Introduction: Syncope is a common emergency department (ED) presentation and frequently results in low-yield hospitalizations. The Canadian Syncope Risk Score (CSRS) is a validated risk stratification score that identifies 30-day risk of serious adverse events for patients presenting with syncope. In this retrospective, cross-sectional study we aimed to evaluate syncope admissions with the CSRS to determine potentially unnecessary hospitalizations.

Methods: We identified patient visits for syncope at 11 EDs from February 2019–January 2020. We excluded patients with additional serious diagnoses that would have independently required admission and those who were discharged. We then randomly sampled the remaining charts until finding 200 that met study inclusion criteria on full chart review. We retrospectively calculated CSRS via manual chart review and identified the proportion of patients with low-risk CSRS. We compared demographic characteristics between those with low- vs medium- and high-risk CSRS.

Results: We identified 5,718 adult patients hospitalized for syncope. Of these patient visits 3,999 were initially excluded, 336 were sampled, and 200 included for analysis. Of these, 39% (77/200, 95% CI 32-46%]) were low risk (CSRS < 1). Patients with low-risk CSRSs were younger (61.2 years vs 70.6 years of age; absolute difference [AD] 9.4 years; 95% CI 4.8-13.9), less likely to have heart disease (1.3% vs 61.8%; AD 60.5%, 95% CI -69.4% to -51.5%), and more likely to have substance use disorder (14.3% vs 4.9%; AD 9.4%, 95% CI 0.7-18.1%).

Conclusion: In this sample of patients hospitalized for syncope, 39% had low-risk Canadian Syncope Risk Score. Had the CSRS been used, these patients could have been safely discharged, as their estimated 30-day serious adverse event rate was < 1%. Wider adoption of the CSRS could potentially reduce unnecessary hospitalizations for patients with syncope.

Introduction: Recent evidence suggests that survival to hospital discharge in patients with out-of-hospital cardiac arrest (OHCA) is similar among patients receiving a single dose epinephrine protocol compared to a multi-dose epinephrine protocol. However, it is unknown whether survival to hospital rates differ for single dose vs. multi-dose epinephrine within sex and race subgroups. Our objective in this study was to determine whether survival to hospital discharge rates varied for single dose vs. multi-dose epinephine protocols among men, women, White, and non-White patients.

Methods: We conducted a pre-post Single Dose Epinephrine Implementation Study from November 1,2016 – October 29, 2019 at five North Carolina emergency medical services (EMS) systems, involving patients ≥ 18 years old with non-traumatic OHCA. Data on race, sex, and the primary outcome of survival to hospital discharge were determined from the Cardiac Arrest Registry to Enhance Survival and from EMS records. We performed intention-to-treat analysis. We compared survival to hospital discharge rates between single dose vs multi-dose epinephrine protocols within sex and race subgroups using generalized estimating equations with a logit link to account for clustering among EMS agencies and to adjust for age, witnessed arrest, automated external defibrillator availability, EMS response interval, the presence of a shockable rhythm, receiving bystander cardiopulmonary resuscitation, and sex or race. In the model, we evaluated interactions between epinephrine protocol and race and sex. 

Results: Of the 1,690 patients included, (899 multi-dose, 791 single dose), 38.7% (657/1,690) were female and 74.7% (1,262/1,690) were White. Survival to hospital discharge occurred in 13.6% (122/899) of patients in the multi-dose group and 15.4% (122/791) in the single dose epinephrine group (OR 1.19, 95%CI 0.89-1.59). Single dose epinephrine was associated with increased survival to hospital discharge rates in White patients (adjusted odds ratio [aOR] 1.17, 95% confidence interval [CI] 1.05-1.30). However, the rates were similar for single dose vs. multi-dose epinephrine among men (aOR 1.03, 95% CI 0.93-1.14), women (aOR 1.23, 95% CI 0.97-1.56), and non-White patients (aOR 1.08, 95% CI 0.78-1.51). Interactions between epinephrine protocol and subgroups were not significant.

Conclusion: Rates of survival to hospital discharge were similar in the single dose and multi-dose epinephrine strategies regardless of sex. Single dose epinephrine was associated with increased survival to hospital discharge among White patients but not in non-White patients, which may be due to unmeasured confounding or inadequate power.

Introduction: Out-of-hospital cardiac arrest remains a leading cause of death and significantly impacts global health outcomes. International guidelines emphasize the importance of high-quality CPR (cardiopulmonary resuscitation).

Objectives: Our goal was to compare CPR efficiency using the criteria recommended by international guidelines between two out-of-hospital cardiac arrest intervention scenarios: CPR at the incident site; and CPR during patient transport to the hospital by emergency medical services.

Methods: In each of the two scenarios, five full two-minute cycles of cardiac compression were applied to a manikin according to international guidelines. The CPR quality parameters were chest compression rate, chest compression depth recorded by the manikin, and investigator-evaluated correct hand placement on the manikin.

Results: We analyzed data from 240 CPR cycles provided by 24 healthcare professionals. The mean chest compression rate was higher (120.5±10.9/minutes vs 125.3±14.7/min, P = .001) and the mean chest compression depth was shallower (43.9±6.6 millimeters [mm] vs 37.9±7.2 mm, P = .001) in the on-the-move group. The two groups’ appropriate hand placement rates were similar (92.1±5.4% vs 92.2±4.5%, P = .48).

Conclusion: In this study, the moving ambulance simulation demonstrated that chest compressions were administered at a rate exceeding recommended guidelines and at a shallower depth than recommended, while the frequency of correct hand placement remained comparable. If the patient requires transportation from the scene of the incident, the healthcare team must be aware of the potential adverse effects on the chest compression quality.

Introduction: Climate change has significantly impacted human health worldwide, contributing to the rise of emerging infectious diseases, allergies, pollution, natural disasters, non-communicable diseases, and malnutrition. One crucial but often overlooked area where climate change has had a notable effect is upon interpersonal violence.

Methods: Following PRISMA guidelines, we searched PubMed and Epistemonikos for studies measuring the effect of temperature on violence. Inclusion criteria encompassed peer-reviewed, English-language articles reporting an association between temperature and violence. Data extraction focused on various forms of violence including homicides, assaults, sexual assaults, suicides, intimate partner violence, riots, and civil wars, and we assessed article quality using Joanna Briggs Institute criteria.

Results: We included a total of 37 studies from 11 countries, three subcontinental regions, and two global-level analyses in this review. Of these, 46% originated from the United States. Rising ambient temperatures were significantly associated with increases in homicides (10 studies), assaults (15 studies), sexual assaults (8 studies), firearm violence (5 studies), intimate partner violence (9 studies), and suicides involving violent methods (9 studies). Conversely, no association was found between temperature and non-violent crimes. Civil wars and riots were also linked to temperature increases in all relevant studies. A meta-analysis of eight studies on violence showed that each 1°C increase in ambient temperature results in 1.64% (95% CI 1.23-2.19%) increase in violence (P<.01).

Conclusion: This review demonstrates a significant association between rising temperatures and increased worldwide incidents of violence and self-harm. These findings underscore the urgent need for public health strategies and interventions to mitigate the societal and health impacts of climate change-induced temperature increases.

Introduction: Heatwaves are becoming more frequent and severe globally. Heat is associated with increases in emergency department (ED) volumes and higher morbidity for a range of chronic conditions. We describe how temperature impacts ED arrivals at different acuity levels.

Methods: We obtained time-series records for daily ED arrivals stratified by Emergency Severity Index (ESI) from 2010 – 2019 from hospital records. Wet-bulb temperature was the exposure of interest; analysis was controlled for precipitation, snow, wind speed, day of week, and federal holidays. We fitted a Poisson model for each ESI category and estimated the association between temperature and ED arrival acuity with a distributed lag non-linear model with three days of lag to account for delayed health effects of temperature.

Results: We analyzed data for 3,652 days totaling 556,663 arrivals between 2010 – 2019. At lag 0, lower temperatures were associated with a reduced relative risk of arrival to the ED for ESI 2, ESI 3, and total arrivals. At higher temperatures, ESI 2 and ESI 3 showed an increased relative risk of arrival (wet-bulb exposure of 25°C at 0-day lag: ESI 2 RR = 1.06 [1.02–1.10]; ESI 3 RR = 1.04 [1.01-1.07]). While not statistically significant, ESI 1 exhibited a subtle increase in arrivals at the highest temperatures while ESI 4 & 5 displayed a subtle decrease in relative risk of arrivals under these conditions.

Conclusion: Extremes of temperature, particularly heat, appear to affect ED arrivals differently across different acuity levels. Medium- to higher-acuity presentations appear to be more responsive to heat, with a statistically significant increase in ED presentations on days with the highest heat burden. The highest acuity presentations became numerically but not statistically more frequent on days with the highest heat burden, while the lowest acuity presentations decreased numerically but not statistically in these conditions.

Introduction: The global incidence and severity of severe heat illness is on the rise. The increasing number of summer heatwaves in Phoenix, Arizona, gave us a distinctive opportunity to better understand the impact on the clinical presentation and management of acute heatstroke. Our primary objective in this study was to describe the prehospital and emergency department (ED) clinical presentation, treatment, and outcomes of patients with acute heatstroke at a single hospital system during the summers of 2021 and 2022 in Phoenix.

Methods: This was a descriptive, retrospective observational study of heatstroke-associated adult ED presentations occurring from June 1 – August 31, 2021 and June 1 – August 31, 2022, to a single hospital system in Maricopa County.

Results: We identified 60 ED heatstroke encounters. The median environmental daily maximum (Tmax) and minimum (Tmin) were 106.0° Fahrenheit (interquartile range [IQR]) 102.0 - 109.0°F) and 84.0°F (IQR 79.0 - 88.0°F), respectively. The patients were commonly male (42, 70.0%, 95% CI 56.8 - 81.2%), White (26, 43.3%, 95% CI 30.6 - 56.8%), middle-aged (mean 52.7 years, 95% CI 48.4 - 56.9), Medicaid-insured (37, 61.7%, 95% CI 48.2 - 73.9%), and presenting via emergency medical services (60, 100%). Patients were commonly of high acuity (median Emergency Severity Index 1, IQR 1.0 - 2.0), and intubated (45, 75.0%, 95% CI 62.1-85.3%). Forty-seven (78.3%, 95% CI 65.8 - 87.9%) patients were found unresponsive outside with associated substance use (methamphetamines 22, 46.8%, 95% CI 32.1 - 61.9%; and fentanyl 14, 29.8%, 95% CI 17.3 - 44.9%). The average patient Tmax at ED presentation was 41.9°C (IQR 41.1 - 42.2). Forty-one patients (68.3%, 95% CI 55.0 - 79.7%) survived to hospital discharge or transfer, of whom 32 (82.1%, 95% CI 66.5 - 92.5%) were neurologically intact.

Conclusion: During the summers of 2021 and 2022, a significant number of heatstroke presentations were treated in a single healthcare system in Maricopa County, Arizona. A substantial number were successfully treated with cold water immersion and discharged neurologically intact. In this urban population, extreme weather exposure and associated substance use appeared to play significant roles.

Introduction: On August 3, 2019, a mass casualty incident (MCI)/active shooter event in El Paso, TX, left 21 people dead on scene and 27 transported. Our main objective in this article was to describe trauma center responses to a sudden patient influx after a MCI/active shooter event. We hypothesized that a triage practice in which two physicians providing care while simultaneously triaging would be equivalent to triage with a single physician providing triage only. The secondary objective was to describe patient injuries and treatment. Our third objective was to describe how a large, multidisciplinary team of hospital personnel were rapidly notified and arrived at the trauma center. Finally, we describe how the problems identified in a review of hospital response led to better results after implementing new practices in a 2023 MCI/active shooter event. 

Methods: We conducted a retrospective cohort/medical record review and departmental survey. We performed the Fisher exact test using survival as an outcome to compare the two centers’ triage methods.

Results: A total of 15 patients arrived at the University Medical Center of El Paso, 14 of them within 35 minutes and one in a later transfer; 14 survived at 24 hours. Total patients included 10 females and 5 males, mean age 40.6 (1-88) years. Mean hospital length of stay (LOS) was 13 ± 16.4 days. For the six intensive care unit (ICU) patients the mean LOS was 5.7 (1-11) days. In comparing day 1 survival between the center where a surgeon and an emergency physician triaged patients while also providing care and the center where a sole triage physician was on duty, survival rates were equivalent (P = .56). Six surgeries occurred on day 1 with four laparotomies performed within 43 minutes. The trauma team expanded rapidly as 132 persons from 16 departments, notified by phone calls and text, arrived, improving communication and patient registration in two 2023 MCI responses.

Conclusion: The survival rate of victims of a mass casualty incident brought to a Level I trauma center and triaged by a surgeon and an emergency physician who simultaneously provided care did not differ significantly from the survival rate at a Level II trauma center with a single triage physician on duty. The rapid arrival of multiple specialists resulted in 14 patients treated within an hour.

Introduction: Rib fractures are common in patients with blunt thoracic trauma, and their associated pain causes significant morbidity and mortality. Adequate analgesia is crucial to prevent rib fracture-associated pulmonary complications. However, current analgesic modalities have drawbacks, and the optimal analgesia protocol remains elusive. Intravenous (IV) lidocaine infusions have a well-established safety profile and efficacy in other patient populations and may benefit patients with traumatic rib fractures. To better understand current practices and to inform the design of a multi-centre trial, we believe that a study to determine Canadian trauma centres’ current analgesic practices is warranted. This study describes the current familiarity and use of IV lidocaine infusions for management of rib fracture pain. Secondary outcomes included the identification of common Canadian analgesic protocols for rib fractures and willingness to participate in a future multi-centre trial of lidocaine for these traumatic injuries.

Methods: We distributed an online survey to 14 Canadian trauma centres. Study questions were designed to address four themes: trauma centre characteristics; pain management strategies; current use of IV lidocaine infusions; and interest in future study participation. The analysis included a frequencies analysis and a thematic analysis of descriptions. 

Results: The medical directors of 12 trauma centres (85%) responded. Six of those centres (50%) experience > 450 annual trauma admissions with Injury Severity Scores > 12. Six sites (50% of respondents) have a rib-fracture analgesic protocol. Four centres (33% of respondents) frequently use IV lidocaine for rib fractures, and 10 (83% of respondents) believe further research with IV lidocaine is needed.

Conclusion: Canadian trauma centres’ current practices for rib-fracture pain management are variable. Prospective work is needed to evaluate IV lidocaine as an analgesic for traumatic rib fractures.

Introduction: Patients with respiratory distress are frequently encountered in the emergency department (ED). Efforts to assess, initiate treatments, and stabilize these patients require a systematic and rapid response. Emergency physicians need a comprehensive and efficient approach for evaluating, treating, and managing patients presenting to the ED with moderate respiratory distress.

Methods: The American College of Emergency Physicians convened an expert panel of academic and community emergency physicians, critical care specialists, respiratory therapists, hospitalists, and pharmacists to develop and subsequently disseminate consensus recommendations regarding the diagnosis and treatment of patients with moderate respiratory distress presenting to the ED.

Results: A digital tool using a consensus-based framework was developed to aid emergency clinicians in diagnosing and caring for patients with moderate respiratory distress. The tool can be employed at each step in the diagnostic and treatment process.

Conclusion: The evidence-based tool is a practical and freely available bedside instrument for emergency clinicians to diagnose and treat patients with moderate respiratory distress. Further studies are needed to examine the effectiveness of this approach.

Introduction: Emergent endotracheal intubation is common in critically ill patients. Underlying pathophysiologic derangements puts these patients at increased risk of peri-intubation major adverse events (MAE) and have been associated with higher morbidity and mortality. Investigating the impact of interventions in the peri-intubation period on the rate of peri-intubation hypoxemia and hypotension can help improve management of emergent airways.

Methods: We searched PubMed, Embase, and Scopus databases from their beginning through April 2024 to identify randomized controlled trials (RCT) evaluating interventions to prevent peri-intubation hypoxemia and hypotension. Random-effects meta-analysis was used for the outcomes of peri-intubation hypoxemia and hypotension. We used the Cochrane risk-of-bias tool and Cochrane Q-statistic and I2 to assess the quality and heterogeneity of the included studies, respectively.

Results: We included 16 RCTs included in our analysis with a total of 7,778 patients. All studies reported incidences of peri-intubation hypoxemia, and 11 studies reported rates of hypotension. One study had some concern of bias; otherwise all others were found to have low risk of bias. The examined interventions were associated with a 25% reduction in rates of hypoxemia (OR 0.748, 95% CI 0.566 - 0.988, P = .04). The subgroup of preoxygenation techniques showed a 63% reduction in rates of hypoxemia (OR 0.37, 95% CI 0.23 - 0.61, P < .001). Interventions to prevent hypotension were not associated with a significant decrease in rates of peri-intubation hypotension (OR 0.848, CI 0.676 - 1.063, P = .15).

Conclusion: Preoxygenation interventions, in the form of noninvasive ventilation, are associated with lower odds of hypoxemia in the peri-intubation period. More research is needed to determine whether interventions can be successful at preventing cardiovascular collapse.

Introduction: Effective airway management is critical for optimal patient outcomes in the emergency department (ED). Additionally, airway management is significantly influenced by the clinician’s selection of equipment, specifically the choice of intubating stylet. Also of note, the duration of intubation (time to intubate) impacts overall success. The choice of intubation device may influence first-pass success and intubation times. In this study we evaluated equipment trends for first-pass success and intubation duration. We collected data by reviewing a video database of recorded airways. Three commonly used intubating stylets were reviewed: the hyperangulated stylet; bougie (Eschmann stylet); and malleable stylet.

Methods: In this retrospective observational study, we reviewed 615 intubation videos. These videos were recorded via video laryngoscopy at the University of Kansas Medical Center and The University of Kansas Health System between February 2019–January 2022. We recorded device type, number of intubation attempts, and time to successful intubation (time from entry of laryngoscope blade to passage of endotracheal tube through vocal cords). We included and analyzed 575 intubations for first-pass success, while a random subset of 70 intubations was used to evaluate intubation times. We also conducted a survey to query current faculty and resident physicians regarding their preference for intubation modality.

Results: Among 575 intubations, the bougie (Eschmann stylet) was used in 47.1% of cases, the malleable stylet in 27.3%, and the hyperangulated (also known as “rigid” or “angular”) stylet in 25.6%. Overall first-pass success was 91.3%. The malleable stylet showed the highest success rate (94.9%), followed by the hyperangulated stylet (93.2%), and the bougie (88.2%) (χ² = 6.53, P = .04). In a separate analysis of 70 cases, the median intubation time was 35.5 seconds. For intubation time, we found a significant difference between the three modalities (χ² = 8.2019, P = .02), with pairwise differences between bougie vs malleable stylet (P = .01) and bougie vs hyperangulated stylet (P = .02), but not between hyperangulated and malleable stylets (P = .62). Bougie-assisted intubations had the highest median time of 40.5 seconds (mean 49.15 +/- 23.1) compared to malleable stylet 31 seconds (mean 33.8 +/- 16.4) and hyperangulated 31 seconds (mean 33.6 +/- 11). A survey of 52 physicians showed that 55.8% preferred the malleable stylet, 19.2% preferred the hyperangulated stylet, and 25% preferred the bougie.

Conclusion: The malleable stylet demonstrated the highest first-pass success rate and the most consistent intubation times, while the bougie had the longest times and lowest success rate in our ED. Physician preferences also favored the malleable stylet. First-pass success rates and intubation times vary depending on an institution’s familiarity with specific devices and the clinician’s preference. These factors should be considered when selecting intubation equipment to optimize airway management outcomes or facilitate training.

Introduction: We assessed the prevalence of burnout syndrome among emergency physicians and advanced practice practitioners (APP) in an academic emergency department (ED) to identify demographic and lifestyle factors associated with burnout.

Methods: We administered a cross-sectional survey including the Maslach Burnout Inventory (MBI) with a demographic/lifestyle component to emergency physicians, residents, and APPs at an academic ED. We reported descriptive data and performed chi-square analysis to identify significant variables, followed by logistic regression to quantify their effects. A factor count was performed to assess for additive effects of burnout risk factors.

Results: We collected 55 surveys (60% response rate) yielding an overall burnout prevalence of 52.7%. The following had a significant association with burnout: 0-6 days off per month; fewer than two major hobbies; thoughts of quitting one’s job “at least some of the time”; and spending less than four hours outdoors per week. Zero to six days off per month was associated with 4.70 times more burnout compared to ≥7 days off per month (95% confidence interval [CI] 1.24-17.82). Participants who met 3-4 vs 0-2 of the previously mentioned conditions had a 6.87 times increased burnout prevalence (95% CI 2.01-23.52).

Conclusion: This preliminary study highlights four unique factors associated with burnout. It also demonstrates that a specific number of days off may reduce burnout prevalence. Emergency department wellness efforts should consider focusing on strategically scheduling time off each month while encouraging individual habit generation and time spent outdoors to maximize burnout protection. Further research is needed to evaluate the efficacy of the proposed interventions.

Introduction: Topical salicylates are commonly found in over-the-counter medications and are applied for pain relief or to treat dermatologic conditions. While generally considered safe, they can cause systemic toxicity under certain conditions. We conducted a systematic review of topical salicylate toxicity. This comprehensive review of previously reported cases highlights the risks, clinical presentations, and management considerations of systemic toxicity from topical salicylates.

Methods: We present a new case of topical salicylate toxicity and conducted a comprehensive systematic literature search from 1952-2024 using PubMed, Google, and Google Scholar. Our search was supplemented by cross-referencing previous studies to identify cases and reviews of topical salicylate toxicity. We then performed a descriptive analysis of the cases, summarizing key information such as clinical presentation, blood levels, and outcomes. Findings were used to contextualize the risks and clinical manifestations of topical salicylate toxicity. 

Results: A total of 44 cases of topical salicylate toxicity, including our index case, were identified and included in our analysis. Most cases involved patients > 40 years of age, but all age ranges were represented, including neonates. The most frequently reported symptoms included tachypnea (32.5%) and vomiting (25.5%). The new case was an elderly male with further altered mental status from baseline dementia and elevated anion gap. 

Conclusion: Both the new case and the literature review emphasize the continued potential systemic risks of topical salicylates among a broad demographic. Given the variable presentations, clinicians should maintain a high index of suspicion for salicylate toxicity in patients with unexplained altered metabolic and/or mental status. Early consideration, recognition, and intervention of topical salicylates-induced toxicity is essential for good outcomes. As many of these products are heavily advertised, patient education on the appropriate use of topical salicylates may be crucial to prevent inadvertent toxicity. 

Introduction: Geriatric emergency medicine (GEM) has emerged as a subspecialty of emergency medicine (EM) with seven fellowships available throughout North America and opportunities for career development in administration, clinical leadership, education, and research. Our objective in this study was to ascertain the perspectives and understanding of the subspecialty among EM trainees.

Methods: We recruited participants from four geographically diverse institutions. Three institutions were academic and had GEM faculty or divisions, and the fourth institution was a community site without geriatric-specific faculty. We conducted semi-structured interviews, adapted from a prior protocol, via teleconferencing and subsequently transcribed them. Codes were generated by two investigators and categorized into themes derived from the data.

Results: Seventeen trainees with an average age of 32.1 years across four institutions participated in the study. Three themes emerged, demonstrating that trainees’ perceptions of GEM were affected by 1) education and exposure; 2) perception of geriatrics; and 3) future career considerations. Trainees with exposure to GEM had greater appreciation for the specialty, but their understanding of career opportunities was mixed. Participants acknowledged broader clinical and social considerations for older adults and in general felt that specialty training would benefit older patients. However, most participants had no personal interest in pursuing GEM, with reasons for disinterest including belief that they would only see older patients, dislike of geriatric complexity, and uncertainty about GEM as a career. Many 
participants identified educational opportunities for GEM, including noting that curricula include dedicated time for other subspecialties such as pediatrics but not geriatrics. Fellowship decisions were influenced by duration of training, salary, job opportunities, practice settings, and career goals.

Conclusion: Emergency medicine trainees who participated in semi-structured interviews overall viewed geriatrics as an important aspect of EM with perceptions formed from exposure and education at both the institutional and individual level, perceptions of treating older adults, and future career considerations. However, interest in pursuing GEM was overall low, and participants expressed uncertainty about the subspecialty and career options, indicating opportunity for increased awareness, education, and mentorship. 

Introduction: Pharmacogenomic-assisted prescribing of medications uses individual genetic information to identify drug-gene interactions. We aimed to assess potential pharmacogenomic drug-gene interactions in geriatric emergency department (ED) patients who sustained a fall.

Methods: This was a prospective study involving 25 older adult ED patients with fall-related injury. Data collected included current medications, demographics, and mechanism of injury. All patients provided a DNA sample, which underwent pharmacogenomic testing by an accredited genetics lab, Each patient’s medications were reviewed against their pharmacogenomic report and categorized as Green (continue to use), Yellow (use with caution) or Red (stop use) based on their genetic information and published interactions by the Clinical Pharmacogenetics Implementation Consortium, Dutch Pharmacogenetics Working Group, and US Food and Drug Administration-approved drug label information. The main study outcome was pharmacogenomic drug-gene interactions.

Results: Of the 25 patients enrolled (median age, 81 years, IQR 76-85), 68% were female. Patients were taking a median of eight medications (IQR 5-11). The most common types were antihypertensives, statins, anticoagulants, and anti-platelet medications. Significant drug-gene interactions (Yellow or Red) were identified in 14/25 patients (56%; 95% CI 35-76%). Further, 6/25 (24%; 95% CI 9-45%) had one or more potentially serious (Red) interactions identified.

Conclusion: We found that in geriatric ED patients with a fall-related injury, most had a significant pharmacogenomic drug-gene interaction. DNA testing identifies these interactions and can assist with pharmacogenomic-guided medication prescribing, which may decrease adverse drug events and improve clinical outcomes.

Introduction: Demographic inequities in cardiovascular care have been well established, with evidence of effects from sex, age, and body mass index (BMI). For instance, women are less likely to receive guideline-based care for acute myocardial Infarction, bystander cardiopulmonary resuscitation, or recognition of cardiac arrest. We investigated the impact of patient sex, along with other patient demographics such as age and BMI, on the quality of focused cardiac ultrasounds (FOCUS). We hypothesized that females would have lower overall FOCUS quality and more frequently omitted apical four-chamber (A4C) views due to breast tissue. Secondary objectives included evaluating differences in image quality and omission rates by BMI, and by age and sonographer sex and training level.

Methods: In this multicenter, retrospective study we investigated 1,200 total adult patients (100 females and 100 males per site) at six participating sites. The FOCUS quality was determined by two blinded experts per site using a 1-5 ordinal scale per view (parasternal long, parasternal short, A4C, and subxiphoid). The primary outcome, overall quality, was the summed score of the four views, with a maximum score of 20. This scale was then collapsed into three categories for the individual FOCUS views: images inadequate to support diagnosis; images meeting the minimum to support diagnosis; and images supporting the diagnosis well. Secondary outcomes were A4C quality and omission rate. We evaluated associations between sex and FOCUS overall quality using unadjusted mixed-effects models followed by multivariable mixed-effects models adjusted for patient age, BMI, operator sex, and operator experience level. 

Results: The A4C images of female patients were of significantly lower quality (P < .001) and had been omitted more frequently (P < .001); male patients had > 60% higher odds of a diagnostic A4C view (95% CI 1.3 - 2.0). Overall FOCUS quality decreased as BMI deviated from normal and as age increased. There was no significant difference in overall FOCUS quality between female and male patients. 

Conclusion: We did not find sex-based differences in overall FOCUS quality; however, we did find that females received lower quality apical four-chamber views and had this view omitted more frequently. Additionally, overall quality declined as BMI deviated from normal, and as age advanced. Future research should elucidate the clinical implications of these differences in quality and the explanation behind not obtaining high-quality views in older patients, in individuals whose BMI deviated from normal toward either underweight or overweight, or in female patients.

Introduction: Although ultrasound is readily available to emergency physicians and known to be very accurate for diagnosing rotator cuff tears, it is rarely used for this purpose. Our goal in this study was to develop and preliminarily assess the accuracy of a simplified shoulder ultrasound protocol (the “supra-short” protocol), designed to be used by emergency physicians for diagnosis of supraspinatus tears.

Methods: We performed a pilot diagnostic accuracy study in which we assessed the accuracy of the supra-short protocol as performed by minimally trained emergency physicians for identifying supraspinatus tears in volunteers. As a criterion standard, a sports medicine physician also performed a complete shoulder ultrasound on each volunteer. We determined the test characteristics of the supra-short protocol for supraspinatus tears, as well as the median time to complete a scan and the percentage of images deemed adequate by expert review.

Results: Nine emergency physicians performed a total of 40 bilateral supra-short scans on six volunteers (two of whom were known to have shoulder pathology and four of whom had normal shoulders). Of the 80 shoulders scanned, there were 18 cases in which complete ultrasound performed by the sports medicine physician revealed a supraspinatus tear; 12 (66.7%) of those were identified by the novice sonographers using the supra-short protocol. Overall, the sensitivity of the supra-short protocol was 66.7% (95% CI 29.9-92.5%) and the specificity was 87.1% (95% CI 70.2-96.4%). The median time to completion of each shoulder was 133 seconds (interquartile range 88-182). Upon expert image review, 80.0% of the images were deemed adequate.

Conclusion: After minimal training, emergency physicians were able to quickly perform the supra-short US protocol but were only able to identify supraspinatus tears with moderate accuracy, suggesting the need for more extensive training before clinical use.

Introduction: There is limited data comparing pediatric return visits between pediatric emergency departments (PED) and general EDs. We hypothesized that the 72-hour return rate is higher for patients discharged from general EDs than from PEDs.

Methods: We analyzed all PED visits in a large, national emergency medical group that had a repeat ED visit to the same site within 72 hours between 2016–2019. Associated visit- and facility?level characteristics analyzed in the model included patient age, Emergency Severity Index and triage level, sex, insurance type, categorized reason for visit, facility type, facility size, trauma status, teaching status, year, and month. Diagnostic categories were defined using the Agency for Healthcare Research and Quality clinical classification software for diagnosis codes. The outcome variable was 72-hour returns. We analyzed returns at the visit-level using descriptive statistics and at the facility-month level using logistic regression to adjust for potential confounders.

Results: A total of 2,588,680 pediatric visits were included: 1,821,800 from 137 general EDs and 766,880 from 7 PEDs. The proportion of children returning to a PED within 72 hours was 1.1 percentage points higher than at a general ED (3.5% vs. 2.4%). The adjusted odds ratio for a 72-hour return visit was 1.3 (confidence interval 1.15-1.38) in PEDs compared to general EDs.

Conclusion: Pediatric patients discharged from PEDs had a higher rate of 72-hour return visits than those discharged from general EDs. These findings merit further investigation into factors driving these differences to identify best practices and optimize care across ED settings.

Introduction: Neuroleptic malignant syndrome (NMS), comprising typical and atypical presentations, is a rare but life-threatening reaction to antipsychotic medications. While typical NMS is characterized by fever, rigidity, and autonomic instability, atypical NMS often lacks these hallmark features, complicating timely diagnosis in the emergency department (ED).

Methods: We conducted a systematic review of PubMed and citation databases (1988–2024) using the keywords “Neuroleptic Malignant Syndrome” and “Lorazepam.” Case reports were screened using strict inclusion criteria and appraised with the Joanna Briggs Institute Checklist.

Results: Lorazepam led to clinical improvement in 5 of 6 atypical and 7 of 9 typical NMS cases. Among five atypical cases, four demonstrated improvements in altered mental status (AMS), resolution of agitation, and reduction in neuromuscular symptoms within 72 hours, including two within 24 hours, compared to the usual 5-10 day recovery with supportive care alone. One atypical case presenting to the ED showed rapid improvement in AMS following early lorazepam administration, although catatonia ultimately necessitated electroconvulsive therapy. These findings highlight lorazepam’s potential benefit in both timely symptom control and diagnostic clarity in atypical NMS.

Conclusion: Lorazepam shows rapid efficacy in atypical NMS, with most cases improving within 72 hours. Yet its subtle presentation often delays diagnosis in the ED, reducing early treatment opportunities. Typical NMS cases demonstrated slower response. Emergency physicians should maintain a high index of suspicion for atypical NMS and consider empiric lorazepam therapy alongside antipsychotic discontinuation and supportive care. Prospective studies are needed to refine ED management strategies.

Introduction: Alcohol intoxication is a common patient presentation to urban emergency departments (ED). There is limited data on the healthcare financial impact of caring for alcohol-intoxicated patients in the ED. In this study we examined the facility-based financial billings and collections related to ED visits for alcohol intoxication. 

Methods: Using a retrospective cohort analysis of two large, urban EDs, with a combined yearly census of approximately 150,000 patient visits, we included all encounters between June 2018–December 2021 with a discharge diagnosis consistent with acute alcohol intoxication. We reviewed records of patient encounters with a final diagnosis consistent with acute alcohol intoxication who only had minimal or no interventions performed, implying the visit was solely consistent with acute alcohol intoxication. We reviewed the facility charges of these patients, along with insurance status and average payment by status to understand the financial impact. 

Results: Of 495,436 patient presentations to the EDs during the study period, 13,454 met study criteria (2.7% of total patients). Patient length of stay in the ED had an average of 254 minutes and median of 240 minutes. In total, this cohort of patients occupied ED beds for 56,505 hours cumulatively, or an average of 43.2 bed hours per day for alcohol intoxication-related visits, representing 3.14% of all ED bed hours across both sites. The majority of patient encounters were billed as a level 3 facility code 
(76%). Facility charges for the cohort totaled $22,590,000. The estimated reimbursement based on the percentage reimbursed by payor mix was $1.7 million (7.5%), or an average of $126 per patient visit—less than one quarter of the general average visit collection. 

Conclusion: Patients with acute alcohol intoxication and no other complaints are a minority of 
ED patients, yet their care results in substantial charges and ED resources. Based on the known facility collection rates per insurer, the weighted prevalence of insurers among this cohort yields 
an estimated collection rate of 7.5%. Opportunities to provide proven alcohol-related interventions should consider the unreimbursed costs of these visits when determining cost effectiveness.

Introduction: Hip fractures are a common reason for presentation to the emergency department (ED) and are associated with significant morbidity. Nerve blocks have emerged as a safe and effective tool to treat pain associated with hip fractures. In this study, we aimed to measure the frequency with which nerve blocks were performed for ED patients with hip fractures. Our secondary aims were to study the demographic and clinical characteristics of patients who received and did not 
receive a nerve block.

Methods: We performed a retrospective study at a single-center, urban, academic, Level I trauma center. We measured the frequency with which patients received a nerve block. We measured other demographics (age, ethnicity, insurance) and clinical data (comorbidities, Emergency Severity Index, National Emergency Department Overcrowding Scale, and hip fracture type). Lastly, we measured the types of nerve block performed, who performed the nerve block, and any associated complications.

Results: Overall, 17% (36/209) of the studied patients and 14% (36/257) of all patients with an acute hip fracture received a nerve block. Patients who were cared for by ultrasound (US) fellowship-trained physicians were more likely to receive a nerve block compared to patients cared for by non-US fellowship-trained physicians (20/35 vs 16/174; P-value < .001).

Conclusions: Nerve blocks were performed for a minority of patients presenting with an acute hip fracture. Patients who are cared for by ultrasound fellowship-trained physicians may be more likely to receive a nerve block than patients cared for by non-ultrasound fellowship-trained physicians in 
the emergency department.