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

Introduction: In early 2025, the Accreditation Council for Graduate Medical Education (ACGME) announced proposed revisions to emergency medicine (EM) residency training to include substantial changes to the length of training programs, required rotations, and structured experiences. To date, no published national survey has sought to determine how these changes would impact individual programs. 

Methods: Over a three-week period in April 2025, we anonymously surveyed program directors or their designees online through the Council of Residency Directors in Emergency Medicine listserv. Survey respondents were asked about the impact the changes would have on their programs and their overall opinions of the proposed 48-month minimum requirement. 

Results: A total of 86 program directors responded to the survey (response rate of 29.9%) with representative samples from current three-year (83.7%, 72/86) and four-year (16.3%, 14/86) programs. Most program directors reported that they would have to make significant revisions in either structured experiences, required rotations, or both. Most survey respondents from three-year programs (52/72) do not support the proposed changes, whereas all respondents from four-year programs (14/14) do support the changes (P<.001). 

Conclusion: Proposed program requirements may require modifications in both three- and four-year programs; 33 of the 86 program directors surveyed reported that would need more than one year to meet the requirements, if adopted. This raises the concern that programs may not be prepared to implement the revisions within the proposed timeline, potentially impacting resident education and the future EM workforce. The ACGME should consider a staged rollout of requirements to allow them to be thoughtfully implemented in a meaningful way. 

Introduction: Deimplementation is the process through which an existing practice, procedure, or protocol is discontinued. Past deimplementation efforts in emergency medical services (EMS), such as reduction of liberal oxygen administration, backboard use, and lights and sirens responses, have been slow in rates of change and had varying levels of adoption. Our objective in this study was to analyze the deimplementation of albuterol administration in the beginning of the 2019 novel coronavirus (COVID-19) pandemic for the adoption of deimplementation guidelines, rate of change, and factors leading to this change in EMS practice.

Methods: Using the 2020 National Emergency Medical Services Information System (NEMSIS) dataset, we analyzed the change in EMS calls with albuterol administration following the US Centers for Disease Control and Prevention (CDC) advisory recommending limiting aerosol-generating procedures in response to the COVID-19 pandemic.

Results: The 2020 NEMSIS dataset included 43,488,767 total records, and 449,290 (1.0%) records included at least one albuterol administration. Calls with albuterol administration dropped 61.7% in a near-linear fashion in the six weeks following the publication of the CDC’s guidance (from March 8–April 18, 10,426 absolute reduction; from 16,891 to 6,465, in average calls per week with albuterol administration). In the period before the guidance, there were on average 16,891 calls with albuterol administration of 640,597 (2.6%) calls per week. In the period after the guidance, there were, on average, 6,465 calls with albuterol administration of 601,943 (1.1%) calls per week. Therefore, while total EMS calls declined by 6% during the transition period, the proportion of albuterol calls within this decline went down by 1.5% (2.6% to 1.1%), reflecting rapid deimplementation.

Conclusion: Deimplementation of albuterol administration in the beginning of the COVID-19 pandemic was significant in its rate and success in adherence to guidelines when compared to other changes in EMS policies, procedures, and protocols. A better understanding of deimplementation can guide future EMS efforts to phase out ineffective practices while minimizing disruption to care.

Introduction: Residents and medical students spend thousands of hours of medical education learning the physician’s perspective but rarely find themselves on the other side of the stethoscope. In this study we evaluated whether a brief, novel curriculum of simulating the patient experience could improve medical learners’ reported empathy for patients and ability to explain medical interventions.

Curricular Design: Fifty-eight medical learners (medical students and resident physicians) participated in a 50-minute didactic session where learners simulated patient experiences such as wearing a patient gown and cervical collar, walking with crutches, and tasting potassium chloride and thickened water. Learners evaluated their perceptions of the curriculum with a survey.

Impact/Effectiveness: Participants reported limited experience as patients, with 66.7% never having been hospitalized and 50% not taking any daily medications. Learners rated the curriculum highly on a seven-point Likert scale with 98% expressing it helped them to empathize with patients (90% either agreed or strongly agreed) and 95% expressing that it would help them explain interventions (81% either agreed or strongly agreed). There was no difference between medical students and residents regarding reported effect on empathy (M 6.24 vs 6.44; P = .30) or effect on ability to explain the intervention (M 6.06 vs 6.24; P = .43). This brief curriculum simulating the patient experience was well-received by medical student and resident learners, who overwhelmingly felt it improved their empathy for patients and explanations of common interventions. This approach to fostering empathy could help both medical student and resident learners, many of whom may have limited experience as a patient.

Thirty years ago, education leaders in emergency medicine (EM) developed a standardized letter of recommendation to address limitations of narrative letters of recommendation in the residency selection process. Since then, multiple iterations and improvements with specialty-wide adoption have led to this letter being cited as one of the most essential pieces of a residency application. Based on the experience and success in EM, many other specialties have also now adopted standardized letters of their own. In this paper, we detail the 30-year history of the EM standardized letter including form changes and technological innovations, research and validity evidence, and discussion of research and administrative priorities for the future.

Introduction: Vagal maneuvers are first-line therapy for hemodynamically stable supraventricular tachycardia (SVT), yet the relative efficacy of the standard Valsalva Maneuver (SVM), modified Valsalva maneuver (MVM), carotid-sinus massage (CSM), and head-down deep breathing (HDDB)  remains uncertain. We undertook a network meta-analysis (NMA) to define the optimal technique and explore age- and sex-related effect modification.

Methods: We searched nine databases from inception to January 2025 for randomized controlled trials involving adults (≥ 18 years of age) with stable SVT treated with at least two of the four maneuvers. Primary outcomes were conversion to sinus rhythm after a single attempt after multiple attempts, and by the end of the trial. Secondary outcomes were the need for rescue intravenous (IV) antiarrhythmic drugs and maneuver-related adverse events (AEs). Bayesian random-effects NMA generated risk ratios (RR) with 95% credible intervals (CrIs); surface under the cumulative ranking curve (SUCRA) quantified hierarchy. We performed consistency, publication bias, and sensitivity analyses, and network meta-regression for mean age and female proportion.

Results: Nineteen trials (n = 2,545) formed a connected network. The MVM was more than doubly effective for single-attempt conversion relative to the SVM (RR 2.71, 95% CrI, 2.26-3.31) and outperformed CSM (RR 6.57, 3.33-14.94) and HDDB (RR 1.30, 0.35-4.66); SUCRA = 88.7%. At the end of the trial, the MVM retained superiority over the SVM (RR 1.25, 1.03-1.56) and ranked the highest success rate (SUCRA = 81.3%). The MVM also reduced IV drug use vs the SVM (RR 0.64, 0.55-0.73) and CSM (RR 0.59, 0.37-0.90). No maneuver differed in multiple-attempt success or AEs. The HDDB technique was ranked highest in safety (SUCRA = 82.4%) but was supported only by a single, small study. Meta-regression showed no age or sex interaction. Inconsistency was minimal; the Egger test suggested small-study effects only for the IV-drug endpoint (P = .03).

Conclusion: The MVM provides the greatest likelihood of rapid sinus rhythm restoration and the least need for rescue pharmacotherapy without increasing AEs, supporting its adoption as the default vagal strategy for SVT. Larger, standardized trials are warranted to confirm safety differentials and long-term outcomes.

Introduction: Hemorrhagic shock is a life-threatening condition and remains a leading cause of death worldwide. Current European guidelines lack recommendations for one fluid type over another in the management of hemorrhagic shock. This study explores the effectiveness and safety of colloids and crystalloids in resuscitation of hemorrhagic shock patients.

Methods: We conducted a systematic search in PubMed, Cochrane Cenral Register of Controlled Trials (CENTRAL), Scopus, Web of Science, ProQuest, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) up to January 3, 2024. We performed data analyses using Rstudio v.4.4.1 in Frequentist network meta-analysis with DerSimonian-Laird random-effects model. Subgroup and network meta-regression analyses was also performed in Bayesian methods. We analyzed safety aspects using meta-proportions with generalized linear mixed models models.

Results: A total of 3,693 patients from 23 randomized controlled trials were included in this study. Synthetic colloid demonstrated the lowest mortality rate (odds ratio 0.37, 95% CI, 0.15-0.93; P-score = .94) with the lowest fluid input requirement (mean difference -1.02; 95% CI, -1.62 to -0.41; P-score = .75). Subgroup and network meta-regression analysis revealed none of the covariates significantly influenced these two outcomes. Regarding safety aspects, isotonic crystalloid caused the most diverse adverse events, with acute respiratory distress syndrome (prop = 0.067) and overload syndrome (prop = 0.063) being the most common adverse events.

Conclusion: This study provides robust evidence favoring the initial use of synthetic colloid in the management of patients with hemorrhagic shock.

Introduction: Resuscitation of critically injured patients requires effective team leadership. Poor communication is the leading cause of sentinel events. Closed-loop communication reduces error during trauma resuscitations. Nonetheless, previous studies show few verbal orders are audible. Verbal orders during trauma resuscitations have not been studied for completeness. In this project we aimed to assess whether verbal orders for medications and blood products during trauma resuscitations were complete, audible, and used closed-loop communication.

Methods: This was an observational assessment of a convenience sample of verbal orders that trauma captains gave for medications and blood products during the primary and secondary survey. It was conducted in an academic emergency department (ED) at an adult Level 1 trauma center. We assessed medication orders for the presence or absence of medication name, dose, and route. Blood orders were evaluated for the presence or absence of blood product (packed cells or whole blood) and type (O- or O+). We recorded orders as audible or inaudible. Closed-loop communication was recorded as present or absent. Orders were considered complete if they included all elements. We used descriptive statistics to analyze data.

Results: There were 186 verbal orders enrolled: 165 (88.7%) for medications and 21 (11.3% for blood products. For medication verbal orders, 77.9% (n=127) were audible, 73.6% (n=120) included the name, 62.0% (n=101) included the dose, 17.8% (n=29) included the route, and 73.5% (n=111) used closed-loop communication. Overall, 23 (14.1%) medication verbal orders were complete. Regarding verbal orders for blood, 16 (76.2%) were audible, three (14.3%) included the blood product, seven (33.3%) included the blood type, and 13 (61.9%) used closed-loop communication. Overall, 0% (n=0) of the blood product verbal orders were complete.

Conclusion: Audible, complete verbal orders, and closed-loop communication were underused during trauma resuscitations. Interventions to improve communication of verbal orders warrant evaluation in the ED.

Introduction: Timely documentation of a patient encounter is a necessary component for delivering high-quality healthcare as it has direct impacts on continuity of care. The use of voice recognition software has been integrated into the electronic health record (EHR) to increase efficiency of documentation. We aimed to investigate the impact of dictation use on emergency medicine (EM) residents’ time to note completion. 

Methods: We conducted this study in a three-year EM residency program at an academic emergency department. Notes written in the EHR by EM residents were included for analysis. We split notes into two cohorts based on academic year: 2018-19 academic year (AY18-19); and 2021-22 academic year (AY21-22). We analyzed approximately 37,000 notes per cohort. Dictation was available to all residents in each cohort. The length of the note (measured by character count) and time to note completion (less than or greater than 24 hours) was analyzed. 

Results: For both the AY18-19 and AY21-22, the rate of note completion within 24 hours was higher when using dictation compared to typing (odds ratio [OR] 1.3 and OR 2.9, respectively). Aggregated data of both cohorts showed 77.9% of dictated notes were completed within 24 hours compared to 70.9% of typed notes (P < .001). In both cohorts, the average number of characters per note was larger if the note was dictated. For AY18-19, the average was 6,628 characters for dictated notes vs 6,136 for typed notes (P < .05). Similarly, for AY21-22, the average was 6,531 vs 6,347 (P < .05).  

Conclusion: The use of dictation by EM residents for note completion resulted in a higher likelihood of the note being completed within 24 hours.

Introduction: Discrimination and bias based on race/ethnicity permeate the medical education system. Racial disparities in assessment measures can ultimately impact applicants’ Match results. Few studies to date have examined the narrative portion of the emergency medicine (EM) Standardized Letter of Evaluation (SLOE) for language differences by race. In this study we aimed to determine whether there were language differences by race in the narrative portion of the EM SLOE.

Methods: This study is an analysis of word category frequencies in the narrative portion of the SLOE for applicants applying to EM residency. The sample was drawn from the students who applied to the study institution in 2022. The narrative portion of the SLOE and other applicant factors were collected from the Electronic Residency Application Service (ERAS) applications and de?identified. We compared the number of SLOEs containing predefined keywords by race using chi2 analysis. Keywords were identified in six thematic word categories: agency; standout traits; ability; grindstone habits; achievement; and compassion. We performed logistic regression to determine whether any differences remained after controlling for other factors in the application. 

Results: Of 1,104 applicants to the institution, 2,288 SLOEs with self-identified race/ethnicity were available for analysis. Black and Hispanic applicants had higher proportions of SLOEs that contained a compassion word than White applicants (24.9% and 22.4% vs 16.9%, respectively). This finding persisted after controlling for other factors in the application for Black applicants (odds ratio 1.61, 95% CI 1.1-2.36]). There was no evidence of difference in word use by race across other thematic categories.

Conclusion: We found differences in the proportion of SLOEs containing compassion words in the narrative portion of the EM SLOE between Black and White applicants, with Black applicants being described with compassion language more frequently. However, we found no difference in any other word category, indicating less overall disparity than other narrative assessment studies.

Background: Emergency medicine (EM) physicians commonly use the National Institutes of Health Stroke Scale (NIHSS) to assess acute ischemic strokes in community settings. However, this assessment is often led by neurology residents in academic teaching hospitals. We implemented a quality improvement intervention to improve EM resident comfort with the NIHSS and to assess if EM resident-led NIHSS evaluation prolonged key stroke metrics, such as door-to-CT (DTCT), door-to-needle (DTN), or door-to-groin puncture (DTGP) times, which may affect stroke outcomes. 

Methods: This prospective observational comparison analyzed all patients with acute ischemic strokes at the Zuckerberg San Francisco General Hospital, a Level I trauma center from April 2021–October 2022. We implemented the intervention from April 2022 –October 2022 which included NIHSS certification for all residents and attendings. Both EM and neurology residents recorded NIHSS scores separately for each patient and scores were revealed to each resident during patient care once completed. We then compared stroke metrics between pre- and post-intervention periods.

Results: There were 247 and 122 strokes included in our analysis, pre- and post-intervention, respectively. Overall, 58% (n=213) of all patients were female, 33% were Asian (n=123), and Cantonese was the second most common language after English (15%, n=54). Mean overall NIHSS scores were similar between EM and neurology residents, 6.6 (IQR=2, 10) and 6.7 (IQR=1, 10), (p<0.001), respectively, with substantial agreement between groups (84.4%, κ=0.63). Median DTCT times were 25 and 28 minutes (p=0.2), DTN times were 38 and 35 minutes (p=0.7), and DTGP times were 94 and 110 minutes (p=0.1) for pre- and post-intervention groups, respectively.

Conclusion: The NIHSS is one element of stroke evaluation and management that can impact stroke metrics. Our intervention found that EM resident-led NIHSS assessment did not prolong DTCT, DTN, and DTGP times and met nationally established goals.

Introduction: Intraosseous (IO) vascular access is commonly used when critically ill patients require rapid indirect venous access for the infusion of fluids and medications. The proximal tibia (PT) IO insertion site has been shown to be associated with the highest first-attempt placement success rates. However, inadequate catheter length continues to contribute to failure of IO line placement. In this study, we compared patient characteristics to the depth of soft tissue at the PT insertion site, to determine whether any specific patient subgroup may be at high risk for excessive pre-tibial soft tissue depth.

Methods: Patients were enrolled retrospectively from the medical records of adult (≥ 18 years old) subjects who had undergone computed tomography (CT) imaging of the lower extremity. We calculated the pre-tibial soft tissue depth according to a predefined method using CT images. Data were abstracted into a standardized data collection form prior to analysis. Variables including side, age, sex, body mass index (BMI) and comorbidities (i.e., hypertension, diabetes mellitus, atherosclerosis, coronary artery disease, osteoarthritis) were collected and analyzed.

Results: A total of 368 patients were included in the final data analysis. Increased BMI, height and weight had a statistically significant increase in pre-tibial soft tissue depth. Analyzing patients within groups based on this tissue depth (>40 mm, 20-40 mm, <20 mm) showed that height was the only quantitative variable to have a significant association with pre-tibial soft tissue depth measurements between the >40 mm and 20- 40 mm groups with a negative correlation. While female sex was associated with a statistically significant increase in pre-tibial soft tissue depth, no such effect was seen with any of the recorded comorbidities.

Conclusions: Female sex, short height, and high weight / BMI appear to be correlated with increased soft tissue thickness at the proximal tibial intraosseous insertion site. Longer catheter sizes may be required for proximal tibial intraosseous cannulation in obese patients, and for female patients when compared to male patients with the same BMI.

Introduction: Firearm injuries have become increasingly more common in the pediatric population; however, there is a paucity of literature examining the management of these pediatric firearm-related injuries (FRI) specifically as they affect the upper extremity. This study identifies demographic and environmental risk factors in pediatric upper extremity FRIs and evaluates the severity of injury, concomitant injuries, and rates of surgical intervention in pediatric patients treated at a Level I pediatric trauma center over 20 years.

Methods: We completed a retrospective analysis on 540 patients <18 years of age with FRIs at a single institution from 2001 – 2020. Of these, 72 (13%) had FRIs involving the upper extremity. The patients were stratified into groups based on whether they had received operative intervention or a bedside procedure for their injury and on their year of presentation between two decades (2001 – 2010 vs. 2011 – 2020). We obtained upper extremity injury-specific variables along with hospital demographics. The primary outcomes in this study included hospital length of stay, number of bullet wounds, motor and sensory deficits, and amputation.

Results: In the last 10 years, the rate of upper extremity FRIs observed in the pediatric population has increased by 380% at our institution (15 vs. 57, P < .001). After 2010, cases were more likely to present with an increased number of gunshot wounds per patient (1.14 vs. 1.98, 95% confidence interval [CI] -0.94 - 0.24, P = .03) but were less likely to require admission to the intensive care unit (19% vs. 67%, P < .001). When stratifying by intervention, both the operative intervention and bedside procedure groups had a similar number of gunshot wounds (1.86 vs 1.76, 95% CI -0.52 - 0.43, P = .86). The operative intervention group was more likely to have had a soft tissue injury (68% vs. 35%, P = .005) and motor deficit at follow-up (45% vs.15%, P =.02). Patients in the operative intervention group had longer lengths of stay (9.66 vs. 2.25 days, 95% CI -1.16 - -0.21, P < .01) and more morbid injuries despite similar patient demographics.

Conclusion: In the last decade, an increased frequency of pediatric upper extremity firearm- related injuries was noted despite a stagnant state population. Emphasis should continue to be placed on education and improving firearm safety in settings in which children are present.

Introduction: Emergency departments (ED) have increasingly engaged in screening and treatment initiation for patients with opioid use disorder (OUD). Patients with OUD, however, may also be impacted by significant social need, including housing insecurity. We sought to consider the incidence of homelessness and housing insecurity in patients engaged in an ED-initiated medication for opioid use disorder (MOUD) program.

Methods: We performed a secondary analysis, with specific consideration of housing status, on data obtained from a prospective, ED-initiated MOUD study conducted at an urban, academic hospital, inclusive of enrollments from July 2019–February 2022. We obtained data from participant interviews conducted at study intake and at three months to include the question: “In the past 30 days, where have you been living most of the time?” We used descriptive statistics and Pearson chi-square analyses to assess the data.

Results: Of 315 participants, most were White (79.4 %), male (64.4 %), and between the ages of 25-44 (74.6%). At intake, 66 (20.9%) reported active homelessness, including 44 (14.0%) unsheltered. An additional 157 (49.8%) met criteria for housing insecurity. Men were more likely to be experiencing homelessness (25.1% men reported homelessness vs 13.4% women, P = .01). In contrast, women trended toward housing insecurity more than their male counterparts (45.8% men with housing insecurity vs 57.1% women, P = .05). At three-month follow-up, 141 were able to be reached, with a predominance of housed individuals (118 housed; 46.8%); in contrast only 34.8% of persons experiencing homelessness) (23 participants) were able to follow up at three months (P = .07). Significant differences between sexes noted at intake resolved. No significant differences were found at intake or three months when considering race or age comparisons. 

Conclusion: Patients in the ED who are engaged in care for OUD are disproportionately (70.8%) impacted by homelessness and housing insecurity; further, sex may play an exacerbating role. Emergency department-initiated MOUD treatment may have a positive impact on housing status, suggested by this study; however, the study was limited due to large loss to follow-up, especially among those with housing insecurity.

Introduction: Many states have legalized the use of cannabis for medical or recreational purposes. Cannabis is commonly used both recreationally and medicinally, with therapeutic applications for conditions including chronic pain, seizure disorders, multiple sclerosis, anxiety, and depression. The purpose of this study was to compare emergency department (ED) patient knowledge of the short- and long-term effects of cannabis between users and non-users, and to understand perspectives and knowledge of cannabis use, to assist in development of public health interventions.

Methods: We conducted this prospective survey study at Penn State Health – Milton S. Hershey Medical Center. Inclusion criteria included adult ED patients, ≥ 18 years of age, who had used cannabis in the most recent 30 days, between May to August 2024. The control group consisted of adult ED patients, ≥ 18 years of age, who had not used cannabis in the most recent 30 days. We conducted thematic analysis to identify subjects’ knowledge of positive and negative effects of cannabis use. 

Results: Of 258 eligible subjects, 169 consented to participate (65.5%). Most identified as female (54.4%) and White (68.1%), with a mean age of 40 years. Most participants reported cannabis use in their lifetime (75.7%). Participants reported a myriad of reasons for using cannabis, including to treat anxiety (N = 67; 40%); pain (N = 65; 38%); recreational use (N = 62; 37%); sleep (N = 48; 28%); and depression (N = 34; 20%). Commonly perceived positive effects of cannabis use included relaxation (18%), pain relief (16%), and improved mental health symptoms (13%). Commonly perceived negative effects of cannabis use included cognitive impairment (11%), addictive potential (7%), pulmonary effects (8%), and worsened mental health symptoms (6%). Cannabis users were less likely to correctly identify negative short-term and long-term consequences of cannabis use, compared to non-users. Cannabis users scored mean 2.51/5 (95% CI 2.11-2.92) for correctness of negative short-term effects, compared to 3.28/5 (95% CI 2.96-3.6) for non-users (P = .004). Cannabis users scored mean 1.78/5 (95% CI 1.44-2.12) for correctness of negative long-term effects, compared to 2.38/5 (95% CI 2-2.76) for non-users (P = .002).

Conclusion: Among ED patients who reported using cannabis, reasons cited for its use included recreation, anxiety, pain, depression, and sleep. Emergency department patients had significant knowledge gaps regarding the effects of cannabis use, and these knowledge gaps were higher among cannabis users. Cannabis users were less likely to correctly identify negative short-term and long-term consequences of cannabis use, compared to non-users.

Introduction: Take-home naloxone (THN) programs in emergency departments (ED) can reduce opioid overdose deaths by providing naloxone directly to at-risk patients before discharge. However, sustainable models that integrate reimbursement and workflow alignment remain limited.

Methods: A reimbursable ED-led THN program was developed across a large regional health system. The program used electronic health record (EHR)–integrated ordering, on-site kit dispensing, and third-party insurance billing when available. Kits were stocked in automated medication dispensing systems and supplemented by city-provided stock for uninsured patients. Pilot outcomes included kits dispensed and reimbursement rates across eight participating EDs.

Results: A total of 2,520 naloxone kits were dispensed across eight EDs between January 2019–December 2024, with a total of 6,551 encounters with decision support prompting naloxone ordering (31.6% of eligible). The proportion of kits reimbursed by insurance rose from 46% in 2019 to 95% by 2025. In total, 89.9% of kits were reimbursed either by insurance or public supply (the rest paid by the hospital system). Kit distribution grew from 99 in 2019 to 702 in 2024, reflecting expanded site participation, improved workflows, and greater staff engagement.

Conclusion: A reimbursable ED-led naloxone program can increase access to life-saving medication for patients at risk of opioid overdose. Integrating take-home naloxone distribution into EHR workflows, leveraging insurance billing, and partnering with public health agencies offers a sustainable, low-barrier model that other health systems can adopt.

Introduction: Most patients with acute coronary syndrome (ACS) die before hospitalization. Early diagnosis and effective interventions can prevent the disease from worsening. In this single-center, retrospective study we aimed to investigate the appropriateness of the pretreatment of patients referred to the emergency department of our hospital, a percutaneous cardiac intervention (PCI) center, with a prediagnosis of ACS under the previously published European Society of Cardiology guidelines (2017 and 2020) and the new guidelines published in 2023.

Methods: Based on the date of publication of the European Society of Cardiology’s most recent ACS guidelines (August 25, 2023), we divided patients admitted between August 25, 2022–August 24, 2024, into two groups: patients who were evaluated and received pretreatment under the previous guidelines; and patients who were evaluated and received pretreatment under the new guidelines.

Results: Of 1,675 patients screened for enrollment who were referred to our PCI center with prediagnosis of ACS, after exclusion criteria, we report on 1,450 (86.6%). Pretreatment (before PCI) compliance rate with all aspects of the previous and new guidelines was low, at 9.8%. Study patients were 69.9% (n = 1,013) male with mean age of 63.9 ± 13.0 years. Comparing the compliance rate between the new versus previous guidelines, for individual components, we found better compliance for aspirin administration (72.6 vs. 66.2%) and anticoagulants (40.3 vs. 22.7%), while for P2Y12 inhibitors, we found lower compliance (58.9 vs. 70.0%, all p< .001). For the subset of patients with ST-elevation myocardial infarction, P2Y12 inhibitors were used less appropriately under the new vs. previous guidelines (31.4 vs. 55.0%, p < .001).

Conclusion: The compliance rates with the previous and new guidelines for ACS pretreatment by physicians working in hospitals without PCI centers were low. Pretreatment compliance during the new guideline period was lower than compliance during the prior guideline period.

Introduction: Infestation with Pediculus species, or common lice, is frequently diagnosed in the emergency department (ED). Because lice ingest human blood, prolonged and heavy infestation can plausibly lead to iron deficiency anemia. Severe anemia attributable to lice infestation has infrequently been reported to date. Our objective in this study was to retrospectively review cases of lice-related anemia at a single public hospital to identify risk factors and associated demographic and clinical features of this disease process.

Methods: We screened the medical records for patients presenting to the ED of an urban public hospital between 2016–2024 for the diagnoses of lice infestation and severe anemia (hemoglobin < 7 grams per deciliter (g/dL). Cases were reviewed for clinical and demographic characteristics.

Results: A total of 932 patients were diagnosed with pediculosis infestation in the ED during the study period; 332 (35.6%) of those patients had a complete blood count obtained by the treating team. Thirty-seven cases of severe anemia were identified (3.9% of total pediculosis cases, 11.1% of those for whom a complete blood count was obtained); 84% were microcytic, indicating iron deficiency anemia. Twenty-five patients (68%) were undomiciled, and nine patients (24%) were shelter domiciled. Twenty-three patients (62%) had comorbid psychiatric diagnoses, and 21 (51%) had substance use disorders. The median hemoglobin was 4.4 g/dL (range 2.4-6.9 g/dL). Thirty patients (81%) were admitted to a medical floor and seven patients (19%) to an intensive care unit, each with a comorbid primary condition.

Conclusion: In this cohort, anemia secondary to lice infestation was seen in patients with unstable housing, substance use disorders, and psychiatric disease. Most patients were hemodynamically stable, consistent with the proposed mechanism of chronic blood loss. The prevalence of this condition may be higher than previously noted among this vulnerable population. Emergency physicians should be aware of this rare but potentially serious disease process.

Introduction: Workplace violence (WPV) is a significant occupational hazard in healthcare, with emergency departments (EDs) recognized as high-risk environments. Although globally significant, data from Latin America remain scarce. In this study we aimed to evaluate the prevalence and effects of WPV on healthcare workers in Brazilian EDs.

Methods: We conducted a cross-sectional survey of healthcare workers in Brazilian EDs. Respondents indicated verbal and physical violence experienced within the preceding six months, along with associated psychological and occupational impacts. Univariable models identified significant associated factors, followed by multivariable models to determine independent associated factors of WPV. We reported results as adjusted odds ratios (aOR) with 95% confidence intervals. Statistical analyses were performed in R v4.4.1, and significance was defined as P < .05.

Results: The response rate was 19.1% (1,255/6,570), Of those responses, 61.3% (769/1,255) met the inclusion criteria and were included in the analysis. Of all respondents, 84.0% were physicians. Respondents indicated 79.6% (612/769) occurrence of WPV, including verbal abuse (79.5%) and physical assault (12.1%). Physical assaults against co-workers were witnessed by 40.3% of respondents. Perpetrators included visitors (85.3%), patients (80.7%), and co-workers (35.8%). The absence of institutional preventive measures was associated with increased WPV (aOR, 2.47; 95% CI, 1.71-3.57; P < .001), while the presence of security staff reduced WPV (aOR, 0.61; 95% CI, 0.42–0.89; P = .01). Indicated impact included post-traumatic stress symptoms (88.4%), considering leaving their job (49.5%), impaired workplace performance (75.2%), and time off work (10%), including 11.5% permanently leaving.

Conclusion: Workplace violence is highly prevalent in Brazilian EDs, with substantial psychological and occupational consequences. The absence of protocols or preventive measures may increase WPV risk, emphasizing the urgent need for public policies to protect healthcare workers in emergency settings.

Introduction: Using simulation-based medical education has proven to be an effective instructional strategy both procedurally and clinically. Emergency medicine (EM) residency programs use simulation in a variety of ways and settings. Given the ongoing development of the field and the recent expansion of EM training programs, our objective was to assess the current state of simulation use in Accreditation Council for Graduate Medical Education (ACGME)-approved EM residency programs in the United States.

Methods: We performed this cross-sectional national survey from July–September 2022. The survey was sent to the residency program directors of all 277 ACGME-accredited EM residency programs in the US. The survey focused on simulation use, technology, types of simulation (procedural vs case-based), barriers to growth, and overall sentiments regarding simulation in EM.

Results: We attempted to contact 277 programs, successfully reaching 244. We received a total of 100 responses (36%). Nearly all responding programs reported access to a dedicated sim center (95.8%), with available high-fidelity manikin simulators (93%) and task trainers (90%). Most programs engage in simulation didactics monthly (50%), followed by more than monthly (22%) and quarterly (19%). Barriers to simulation implementation included funding, simulation lab availability, and equipment. Programs frequently used simulation to perform the majority of rare but required procedures, and about half of the programs responding reported simulation fellowship-trained faculty on staff.

Conclusion: Simulation education is an important aspect of EM residency and training. Most residency programs reported dedication and resources to developing and integrating simulation into their curriculum. There is likely room for its further use in residency program training in the coming years as residency programs continue to expand.

Introduction: Frequent users are a small but important group of patients in the emergency department (ED). This group is often the target of interventions that redirect visits to other areas of the healthcare system under the premise that some of these visits could be best managed elsewhere. Most existing interventions do not consider sociodemographic factors when targeting specific populations, while larger scale policy initiatives often do not reach those who would most benefit from alternative points of healthcare access. In this study we use population-level survey data linked to health administrative data to describe frequent ED users and those 
whose visits are potentially avoidable and could benefit from additional points of healthcare access.

Methods: This was a population-based cohort study of responses from 18-74 year-old Ontario residents to the Canadian Community Health Survey from 2001–2014, which we linked to administrative health data for one-year following survey completion. We categorized participants according to the frequency of their ED use in the year following survey date and whether any of their visits were potentially avoidable. Associations between category of ED use and various sociodemographic, health, and behavioural factors were examined with multinomial logistic regression.

Results: A total of 181,369 eligible respondents were included in this study. Of these, 1,460 (0.8%) were frequent users (four or more visits) with one or more potentially avoidable visits in the year following survey date. Compared to non-ED users, frequent users with avoidable visits were associated with the lowest quintile 
of household income (aOR: 1.91, 95% CI: 1.37, 2.65), rural-dwelling (aOR: 1.44, 95% CI: 1.18, 1.77), and the highest quintile of material resource deprived neighbourhoods (aOR: 2.23, 95% CI: 1.47, 3.36). They were more likely to have poor self-reported physical (17.2% vs 9.0%) and mental health (4.1% vs 2.7%) compared to total cohort, and more likely to have comorbidities (63.3% vs 48.7%), but less likely to access a usual provider of care for their healthcare needs (33.3% vs 28.2% without a usual provider of care).

Conclusion: This study provides a novel description of frequent ED users for whom some of their visits were potentially avoidable. As efforts are made to redesign access to primary and community care, and with increasing emphasis on virtual care and other initiatives to reduce avoidable ED use, the healthcare system should ensure that these interventions are responsive to the needs of the people at higher likelihood of needing them.

Introduction: Emergency departments (ED) present unique challenges for elderly patients who often experience higher revisit rates, increased number of complications, and worse health outcomes. This study examines the impact of implementing a combined automated screening callback and Geriatric Emergency Nurse Initiative Expert (GENIE)-led callback system on reducing ED revisit rates among elderly patients.

Methods: We conducted a retrospective analysis that compared revisit rates before and after the implementation of a GENIE callback system in the ED of a large, Level 1 trauma academic center. The study cohort included 23,664 patients, and the primary outcome was revisits at three, seven, and 30 days post-discharge from the ED. Data were adjusted for the Emergency Severity Index (ESI), age group, and sex. The cost of this initiative came from a three-year grant of $650,000 from the Gary and Mary West Foundation, which included the salary for a GENIE nurse. 

Results: Revisit ratios in the pre-intervention period were 4.8%, 8.9%, and 17.2% at three, seven, and 30 days after discharge, respectively. Following implementation of the callback system, those ratios decreased to 3.9%, 7.6%, and 15.2% at the corresponding time points. All reductions were statistically significant (P < .001) and remained significant after adjusting for ESI, age group, and sex.

Conclusion: The GENIE callback system effectively reduced ED revisits among elderly patients, highlighting the importance of structured follow-up communication and care. These findings support the expansion of such programs to improve patient outcomes and reduce healthcare costs.

Introduction: Although humility is a key leadership trait linked to collaboration and trust, current residency application processes lack methods to identify it. By examining whether themes of humility appear in the Standardized Letters of Evaluation (SLOE) of medical students who later became emergency medicine (EM) chief residents, we sought to determine the presence of humility-related traits in SLOEs and explore their potential to inform the identification of applicants with leadership potential during residency selection. 

Methods: Two independent reviewers examined 104 SLOEs (52 chief, 52 non-chief) from 2015–2021, representing 43 students (21 who later assumed chief resident positions and 22 who did not) between 2018–2024 at a single academic EM residency program. A third reviewer resolved all coding disagreements. Reviewers deductively analyzed all written comments, targeting elements associated with humility as conceptualized by Tangney (2000) and Gruppen (2015). A SLOE was categorized as containing elements of humility if at least one clearly defined construct (such as openness to feedback, recognition of limitations, or concern for others) was identified. Sections of the data displaying the most convergence of humility elements underwent open coding, revealing emerging themes.

Results: Nineteen of 21 (90.5%) chief residents had letters encompassing elements of humility compared to only 10 of 22 (45.5%) non-chief residents (P < .01). Openness was the most prominent element noted, followed by the need to make changes in performance, concern for others, and confidence. Further analysis of comments that highlighted humility uncovered several other themes including commitment and advocacy, eagerness to learn and improve, and maturity and responsibility.

Conclusion: This study highlights specific humility-related traits noted in the Standard Letters of Evaluation of fourth-year medical students who later became chief residents in emergency medicine, offering preliminary insights into how qualitative evaluation tools may capture characteristics associated with future leadership roles. 

Introduction: Poisoning-induced out-of-hospital cardiac arrest (P-OHCA) is a leading mortality cause; however, no specific prognostic model exists for P-OHCA. In this study we aimed to develop and validate a novel scoring system, the WAIVOR score, which identifies factors associated with survival to hospital discharge in patients with P-OHCA, including the nature of the toxic agent.

Methods: In this retrospective nationwide observational study we analyzed 4,252 South Korean adult P-OHCA cases from 2013–2023. The study population was randomly stratified into derivation (n = 2,834) and validation (n = 1,418) cohorts. Independent factors associated with survival to hospital discharge were identified through multivariable logistic regression analysis, yielding adjusted odds ratios (aOR) and 95% confidence intervals (CI). We assessed the scoring system’s discriminative performance using the receiver operating characteristic curve and area under the curve (AUC) analysis, with optimal threshold determination via the Youden index.

Results: Among all patients, 291 (6.8%) survived to hospital discharge. The most frequent poisoning substances were gases/vapors (45.3%), pesticides (31.5%), and medically prescribed drugs (12.0%). Six independent factors associated with survival to hospital discharge were incorporated into the WAIVOR score (maximum 11 points): pre-hospital return of spontaneous circulation, four points (aOR 16.11, 95% CI 10.16-25.64); witnessed arrest, two points (aOR 3.86, 95% CI 2.61-5.71); age < 65 years, two points (aOR 3.34, 95% CI 2.20-5.15); female sex, one point (aOR 1.54, 95% CI 1.09-2.16); and arrest-to-emergency department intervals ≤ 30 minutes, two points (aOR 3.44, 95% CI 2.00-6.09; 31-60 minutes, one point (aOR 1.77, 95% CI 1.08-3.02); and poisoning by non-gas/non-vapor substances, one point (aOR 0.54, 95% CI 0.33-0.89). The WAIVOR score demonstrated robust discriminative performance (AUC: 0.823 and 0.739 in derivation and validation cohorts, respectively). At the optimal threshold of five points, the score demonstrated 53.6% sensitivity, 84.4% specificity, 19.8% positive predictive value, and 96.2% negative predictive value (NPV).

Conclusion: The WAIVOR score represents a practical tool whose associated factors may help assess potential for survival to hospital discharge in patients with P-OHCA. Its high NPV renders it valuable for identifying poor prognostic outcomes. However, further external validation studies are required before this score can be broadly used in decisions regarding resuscitation termination in clinical practice.

Introduction: Our goal was to assess the impact of emergency department (ED) clinician category on length of stay (LOS) and resource utilization in children presenting with abdominal pain.

Methods: We conducted a retrospective chart review of all subjects 4-18 years of age at a quaternary-care pediatric ED between May 2021–April 2022 presenting with a chief complaint of abdominal pain. Collected data included demographics, LOS, disposition, 72-hour return visits, lab tests and radiology studies, consults, and emergency clinician category. We defined clinician categories as attending only, advanced practice clinician (APC) only, or supervised resident encounters. Medically complex and high-acuity cases were excluded. We performed statistical comparisons with ANOVA, chi-squared, and Kruskall-Wallis tests. Binomial logistic regression addressed the effects of the covariates age, sex, race, and acuity level. 

Results: We included 3,874 episodes. Of these, 622 (16%) visits were seen by an attending only, 1,018 (26%) by APCs, and 2,234 (58%) by supervised residents. Controlling for covariates, the average APC encounter lasted 17 minutes longer than the average attending encounter (293 minutes vs 276 minutes, P < .005, 95% CI -29.9, -4.0) and 21 minutes longer than the average resident encounter (293 minutes vs 272 minutes, P <.001, 95% CI 11.4-30.6). There were no significant differences in admission rates (attending: 128/622 [20.6%]; APC: 226/1,018 [22.2%]; resident: 477/2,234 [21.4%]; P = .63), or 72-hour return rates (attending: 30/622 [4.8%]; APC: 41/1,018 [4.0%]; resident: 99/2,234 [4.4%]; P = .61). Compared to attending-only encounters, APC encounters were more likely to include a consult (127/622 [20.4%] vs 292/1,018 [28.7%]; adjusted odds ratio (aOR) 1.51, 95% CI 1.18-1.93); less likely to include a computed tomography (CT) (13/622 [2.1%] vs 7/1,018 [0.7%]; aOR 0.31, 95% CI 0.12-0.79); more likely to include a radiology study (484/622 [77.8%] vs 873/1,018 [85.8%], aOR 1.64, 95% CI 1.26-2.14); and more likely to include lab testing (329/622 [52.9%] vs 669/1,018 [65.7%], aOR 1.62, 95% CI 1.30-2.00). Compared to supervised resident encounters, APC encounters were more likely to include a consult (518/2,234 [23.2%] vs 292/1,018 [28.7%], aOR 1.35, 95% CI 1.14-1.61); less likely to include a CT (36/2,234 [1.6%] vs 7/1,018 [0.7%], aOR 0.43, 95% CI 0.19-0.98); more likely to include a radiology study (1603/2,234 [71.8%] vs 873/1,018 [85.8%], aOR 2.41, 95% CI 1.97-2.96); and more likely to include lab testing (1,230/2,234 [55.1%] vs 669/1,018 [65.7%], aOR 1.63, 95% CI 1.39-1.92). Attending-only encounters were more likely to include radiology studies compared to resident encounters (484/622 [77.8%] vs 1,603/2,234 [71.8%], aOR 1.47, 95% CI 1.18-1.83), but they were otherwise similar in diagnostic utilization.

Conclusion: In our study of pediatric patients with abdominal pain, APC encounters had longer length of stay and were more likely to include lab testing, radiology studies, and consults than resident or attending-only encounters. This suggests that emergency clinician category may be associated with resource utilization, and further research could help optimize healthcare utilization.

Introduction: Transfers between emergency departments (ED) can have an important impact on patient care and experience. We examined interfacility transfers from an academic ED due to insurance status to determine whether they disproportionately affected minority demographics.

Objective: Our objective was to determine whether interfacility transfers for non-contracted insurance status disproportionately affected minority patients in our hospital ED.

Methods: We extracted data from the hospital’s electronic health record system. Records for patients who underwent facility transfer were reviewed to determine which transfers were due to insurance contracting status. We compared the number of patients transferred for insurance incompatibility with the number admitted to the same hospital as initially seen in the ED, either to observation or inpatient status, for groups with socioeconomic minority status including Hispanic, Hispanic non-White, Black, Native American, and non-English speaking.

Results: We identified 2,031 total interfacility transfers. Of these, 735 (36.2%) met inclusion criteria, and 49.7 % (366/735) of these transfers were due to insurance incompatibility. The total transfer rate for all patients was .93% (366/39,299). Increased transfer rates due to insurance incompatibility were observed for all minority demographics queried. The most severe disparity in effect size was for non-English speakers (2.06% compared to 0.90% for English-speakers; 2.32 odds ratio [OR], P < .001). Patients with Hispanic ethnicity experience insurance transfer in 1.31% of cases compared to 0.87% for non-Hispanic whites (OR 1.52, P < .001). The insurance transfer rate for all non-White patients was elevated at 1.11%, but this did not rise to the level of statistical significance (OR 1.28, P = .06).

Conclusion: In our single-center ED study, minority patient populations were disproportionately impacted by interfacility transfers for non-contracted insurance status. We found increased transfer rates due to insurance incompatibility for all minority demographics queried. The most severe disparity was found for non-English speakers and patients with Hispanic ethnicity.

Introduction: The guaiac fecal occult blood test, originally designed for colorectal cancer screening, is frequently used in emergency departments (ED) to detect occult gastrointestinal (GI) bleeding. However, the test has low sensitivity and specificity, leading to potential false positives and negatives. This study evaluates the current practices and perceptions of emergency physicians and hospitalists regarding the utility of the guaiac test in the setting of suspected GI bleeding in the ED.

Objective: Our primary aim in this study was to evaluate the current practice and views of emergency physicians and hospitalists on the utility of the stool guaiac test in the ED.

Methods: We conducted a multicenter survey from January 3–April 3, 2024, across four hospital systems, targeting attending physicians in the ED and hospitalists. Participants were asked to rate their agreement with statements about the stool guaiac test on a scale of 1 (strongly disagree) to 5 (strongly agree).

Results: Response rates were 47/93 (50.5%) for emergency attendings and 9/18 (50%) for hospitalists. Emergency attendings were significantly less likely than hospitalists to agree that stool guaiac testing is important for evaluating GI bleeding (31% vs 67%, P < .001). More than half of emergency attendings (55%) reported often performing the test, while 44% of hospitalists reported frequently requesting it before accepting a patient. Although 70% of emergency attendings believed that guaiac results influence hospitalists’ admission decisions (P = .02), 67% of hospitalists stated they would accept a patient with suspected GI bleeding even without a result. Despite rating the test as important, only 33% of hospitalists felt that stool guaiac testing frequently changes management during hospitalization. Overall, the groups showed distinct attitudes regarding the utility and impact of stool guaiac testing.

Conclusion: The guaiac fecal occult blood test remains widely used despite skepticism among emergency attendings regarding its importance. Hospitalists were more likely to request the test but acknowledged it rarely changes patient management. These findings highlight the need for re-evaluation of guaiac testing in acute care settings and improved communication between ED and inpatient teams. Further research should explore the clinical impact of removing routine stool guaiac testing

Introduction: Emergency department (ED) boarding negatively affects patient outcomes, increasing length of stay, hallway care, and mortality. Prior research found disparities in capacity metrics like hallway care based on patient race and ethnicity. However, whether boarding differs by demographics is not well characterized. We examined boarding variation by sociodemographic factors in a hospital with a standardized bed-prioritization process. We hypothesized that a structured inpatient assignment method may be associated with reduced boarding inequity.

Methods: This single-center, retrospective, cohort study included adult patients boarding in the ED after admission to the non-intensive care inpatient medicine service between February 2020– February 2023 at an urban, academic, tertiary-care hospital with > 110,000 annual ED visits. Primary outcome was time from admission order to inpatient bed transport. Patient demographics (age, sex, race/ethnicity, language,  insurance, and housing status), visit characteristics (Emergency Severity Index, time, and day), and bed request features (telemetry, sitter need, and isolation precaution) were obtained via the medical record. We assessed for bivariate relationships between boarding time and demographics with descriptive statistics and analysis of variance using adjusted and unadjusted regression analyses with generalized estimating equations to account for patient-level correlation.

Results: In total, 22,291 encounters were included. Average age was 64 (SD ± 19) years, and 47% were female. Approximately 12% identified as Hispanic, 70% as non-Hispanic White, and 10% as non-Hispanic Black. Most (97%) boarded ≥ 120 minutes. In adjusted analyses, patients with Medicaid waited an additional 85 minutes (95% CI 49-121), and patients with Medicare waited an additional 67 minutes (95% CI 32-103) compared to those with commercial coverage (both P < .001, respectively). Non?Hispanic Black patients boarded 14 minutes longer (95% CI 22-51), and non-English primary language speakers boarded 15 minutes longer (95% CI 17-47) than non-Hispanic White patients and English primary language speakers, respectively, although these two findings were not statistically significant. 

Conclusion: Among adult patients admitted to the inpatient medicine service, non-commercial insurance such as Medicaid and Medicare was significantly associated with longer ED boarding, whereas race/ethnicity and primary language were not. Further study should determine whether these findings are replicated elsewhere, how this impacts patients, and whether targeted intervention can reduce inequities.  

Introduction: While research has begun to understand emergency department-based cardiac arrest (EDCA), consensus on what exactly constitutes EDCA remains unknown. In this study we aimed to explore the grouping of EDCA by using an unsupervised machine-learning algorithm and to investigate how these underlying clusters related to patient outcomes.

Methods: We retrieved electronic health record data from an ED in a tertiary medical center. The EDCAs were identified via the cardiopulmonary resuscitation log. We used k-means cluster analysis to group EDCAs and t-distributed stochastic neighbor embedding (t-SNE) for visualization. Primary outcomes were ED mortality and ED length of stay (LOS). The analyses were repeated using an independent ED data set, the Medical Information Mart for Intensive Care IV Emergency Department (MIMIC-IV-ED) dataset.

Results: From 2019 to 2022, there were 366 EDCA events. Cluster analysis identified three distinct clusters (Cluster 1 or immediate risk, n=54 [15%]; Cluster 2 or early risk, n=274 [75%]; Cluster 3 or late risk, n=38 [10%]). Cluster 1 patients had the shortest median time to EDCA (< 1 hour), followed by Cluster 2 (3 hours) and Cluster 3 (81 hours). Near cardiac arrest at triage was the most common cause of EDCA in Cluster 1, while respiratory illnesses and sepsis were more common in Cluster 3. The causes of EDCA in Cluster 2 were diverse, with predominantly cardiovascular and neurologic emergencies. The t-SNE revealed farther distances from Cluster 1 to the other two clusters, suggesting its most critical nature. Cluster 3 had the highest mortality (58%), followed by Clusters 1 (48%) and 2 (35%) (P = .01). Cluster 1 had the shortest median LOS (median, 4 hours), while Cluster 3 had the longest LOS (81 hours) (P < .001). In the independent data set, Cluster 1 remained, but Clusters 2 and 3 appeared to merge due to a shorter ED LOS overall.

Conclusion: We identified three novel clusters (immediate, early, and late risk) with distinct patterns in clinical presentation, putative causes of ED-based cardiac arrest, and ED outcomes. Understanding these clinical phenotypes may help develop cluster-specific interventions to prevent EDCA or intervene most appropriately. Cluster 1 patients may benefit from resuscitation efforts, and Clusters 2 or 3 patients can benefit from timely interventions for cardiac, respiratory, and neurologic emergencies. In addition, for patients with prolonged ED boarding, periodic monitoring with an early warning system may prevent a cardiac arrest event.

Introduction: Septic thrombophlebitis of the internal jugular vein (STIJV), or Lemierre syndrome, is a rare, life-threatening condition. Anticoagulant use for managing STIJV remains unclear due to ambiguous diagnostic criteria and a lack of robust evidence. We evaluated the clinical benefits and risks of anticoagulants in patients with STIJV.

Methods: In this retrospective study we used data from over 1,700 hospitals, retrieved from a nationwide Japanese database. We used multivariate logistic regression and propensity score matching to adjust for confounding variables (age, sex, Charlson Comorbidity Index, level of consciousness, use of mechanical ventilation, use of disseminated intravascular coagulation, admission to intensive care unit, history of diabetes, use of noradrenaline, diagnosis of acute renal failure, and diagnosis of cerebral infarction). We also conducted instrumental variable estimation to account for the impact of unmeasured covariates. The primary outcome was in-hospital mortality; the secondary outcomes were 90-day mortality, major bleeding events, and length of stay (LOS) in hospital.

Results: Among the 523 patients diagnosed with STIJV between April 1, 2014–March 31, 2022, 343 (65.6%) were excluded due to lack of appropriate treatment initiation for STIJV. Overall, 180 patients (34.4%) met the inclusion criteria; the data of 156 patients (31.1%) were ultimately analysed. Of these, 86 (55.1%) received anticoagulants, which neither significantly improved nor worsened survival outcomes. The in-hospital mortality was 3.39% and 1.69% and 90-day mortality was 2.54% and 1.69%, respectively, in patients who did and did not receive therapy, (P = .56 and .99, respectively). The adjusted odds ratio (AOR) for in-hospital and 90-day mortality was 0.858 (95% CI, 0.126-5.826, P = .88) and .991 (95% CI, .932-1.055, P = .79), respectively. The LOS was longer in those receiving anticoagulants (mean, 29.2 vs 21.8 days, AOR 11.7 days longer, 95% CI, 4.11-19.20, P < .01), potentially due to dose adjustment or clinical decision-making. Subgroup analysis comparing unfractionated heparin and direct Xa inhibitors showed similar in-hospital mortality outcomes: 4.54% in the unfractionated heparin group (AOR 2.361, 95% CI, 0.32-17.40; P = .40) and 3.03% in the direct Xa inhibitor group (AOR 0.444, 95% CI, 0.032-6.23; P = .55), respectively.

Conclusion: In the largest study of septic thrombophlebitis of the internal jugular vein to date, we found that early initiation of anticoagulation treatment was not statistically associated with survival. Therefore, anticoagulant use should be determined based on individual patient characteristics. Further research is warranted to improve the quality of evidence for this rare disease. 

Introduction: Biliary tract disease is a frequent cause of abdominal pain among emergency department (ED) patients and accounts for a significant portion of hospital admissions and return visits. Our objective was to compare ED outcomes for patients ultimately diagnosed with biliary tract disease based on the use of point-of-care ultrasound (POCUS) during their initial visit. We specifically analyzed patients admitted after an unscheduled return visit within 72 hours vs those admitted directly from the ED.

Methods: In this retrospective cohort study we used propensity score weighting and included 1,228 adults admitted for biliary tract disease, either during their initial ED visit (n = 1,120, 91.2%) or following an unscheduled return visit within 72 hours (n = 108, 8.8%) at a tertiary center in Taiwan between 2021–2023. Outcomes included ED length of stay (LOS), costs, hospital LOS, intensive care unit (ICU) admission, and in-hospital mortality. We used multivariable regression models with inverse probability of treatment weighting adjustment to account for baseline differences.

Results: Initial discharge followed by admission after an unscheduled return visit was not associated with worse clinical outcomes compared to direct admission. There were no significant differences in in-hospital mortality (0.93% vs 1.16%; odds ratio [OR] 0.59, P = .56) or ICU admission (0.93% vs 0.71%; OR 1.78, P = .61). While the initial ED LOS was shorter (mean: 4 hours vs 15.6 hours; regression-adjusted difference -6.66 hours, P < .001) and the initial ED costs were lower (mean: NT5477 vs NT$16,269, a 66% savings; regression-adjusted difference: -NT$6,548, P < .001), this reflects an expected early discharge. Among patients ultimately requiring admission after an unscheduled return visit, those who received POCUS at their index visit had a significantly shorter initial ED LOS (mean: 2.97 hours vs 4.78 hours; regression-adjusted difference -1.42 hours, P = .006) and lower initial ED costs (mean: NT$3,248 vs NT$7,149; a 55% saving; regression-adjusted difference -NT$3,271, P < .001) compared to those who did not. This initial POCUS use did not increase adverse events; only one of the 108 patients in the unscheduled return visit group required ICU admission (0.9%, 95% CI, 0.02-5.1%), and no deaths occurred (0%, 95% CI, 0-2.78%).

Conclusion: Initial discharge following ED assessment appears safe for many low-risk patients ultimately diagnosed with biliary tract disease on repeat visit within 72 hours. Incorporating POCUS during the initial evaluation may shorten ED LOS and reduce costs for patients who later require admission, without apparent measurable negative effects on mortality, hospital, or ICU length of stay.

Introduction: Fever as an indicator of infection is frequently used as an aid in triggering concern for sepsis in the emergency department (ED). Adults with sepsis presenting to the ED with a normal temperature have been shown to have delays in treatment and greater mortality. The association between temperature and timeliness of sepsis-related care in the ED remains poorly characterized in children. Our objective in this study was to measure the association between body temperature at the physiologic onset of sepsis and the time to initiation of antibiotic treatment and fluid bolus among children with clinically defined sepsis.

Methods: We conducted a retrospective, cohort study of pediatric patients with sepsis presenting to the ED. Data collected from an existing quality improvement database were supplemented via chart extraction. We assessed body temperature at physiologic onset of sepsis (PO-S), the date and time when a patient first met clinical criteria for sepsis as defined by Goldstein et al.1 Our primary outcomes were time from PO-S and administration of antibiotics and fluid bolus. Secondary outcomes included maximum vasoactive-inotropic scores, need for extracorporeal membrane oxygenation (ECMO) within 30 days of presentation, presence and type of organ dysfunction, 30-day hospital- and intensive care unit (ICU)-free days, and mortality. We summarized and compared data  by temperature group. Multivariable quantile regression was used to evaluate adjusted associations between body temperature and time to initiation of antibiotic treatment and fluid bolus.

Results: Of 928 patients screened, 385 (41%) met inclusion criteria. Median time to antibiotic treatment did not differ between temperature groups at PO-S—≤ 36.0 °C: median (IQR) 48.5, (41.3-104.8); 36.1-37.9 oC: median, 95.5, (41.3-104.8;), and ≥ 38.0 oC: median 84, 45-151; (P = .24). Median time to fluid bolus administration also did not differ between temperature groups at PO-S—≤ 36.0 °C: median 39, (20.8-65.8); 36.1-37.9 oC: median, 42.5 (21.3-86.3); and ≥ 38.0 oC: median, 54 (29-84); (P =.07). In addition, mortality differed by temperature at PO-S (≤ 36.0 °C: 1/22 (4.5%); 36.1-37.9 oC: 4/80 (5.0%); and ≥. 38.0 oC: 3/283 (1.1%), (P = .04); as did organ dysfunction at 72 hours: ≤. 36.0 °C: 15/22 (68.2%); 36.1-37.9 oC: 43/80 (53.8%), ≥ 38.0 oC: 74/283 (26.1%); (P < .001) and median (IQR) 30-day ICU- and hospital-free days—≤ 36.0 °C: median, 24, (20,-26.8); 36.1-37.9 oC: median, 28 (24.8-30), ≥ 38.0 oC: median, 30 (27-30), (P < .001); and at ≤. 36.0°C: median, 22, (17-25); 36.1-37.9 oC: median, 24 (17.8-27); ≥ 38.0 oC: median, 25 (20, 27), (P = .04), respectively. We did not observe an association between temperature and median time to antibiotic administration (β: 2.5, 95% CI, -4.2 to 9.1, P = .50) or first fluid bolus administration (β: 1.7, 95% CI, -1.4 to 4.8, P = .30).

Conclusion: Time to fluid bolus administration and time to antibiotic administration did not differ statistically by temperature from physiological onset of sepsis. Children presenting with hypothermia (≤ 36.0 °C) had worse outcomes.

Introduction: We evaluated the relationship between inpatient boarding, measured as functional bed capacity, and left-without-being-seen (LWBS) rates. Functional bed capacity is defined as the mean percentage of ED beds available for new and existing patients over a 24-hour period.

Methods: We performed quantile regression models examining the association between LWBS and terciles (low, medium, and high) of functional bed capacity, as well as median admit-to-departure times, controlling for other daily operational metrics. We additionally performed an encounter-level analysis to assess the relationship between functional bed capacity at the time of a patient’s arrival and their likelihood of LWBS. Study sites included one academic, one community, and one pediatric ED in a single, urban medical system.

Results: Our study included 373,388 visits. In the adjusted regression at the daily level, low functional bed capacity was associated with an increase of 1.59% in LWBS compared to high functional bed capacity, which represented a 26.5% relative increase (about three patients) compared to median LWBS of 6.0% (P < .001). Larger daily census (+ 0.07% for each additional patient, P <.001), resulted in two additional patients LWBS for every 15-patient increase in daily census from the median. Additionally, longer length of stay of discharged patients (+ 0.05% for each minute increase, P < .001), resulted in two additional patients LWBS for every 20-minute increase in length of stay from the median. Weekdays relative to weekend days were associated with a 1.28% decrease in LWBS (P < .001) (approximately three fewer patients who left without being seen relative to the median LWBS of 6.0%). At the encounter level, functional bed capacity in the low and middle tercile was significantly associated with an increased probability of a patient LWBS (91% and 40% increases, respectively, P < .001). Of the patients who LWBS, 9.3% were high acuity, 59.5% medium acuity, and 31.2% low acuity.

Conclusion: Functional bed capacity is a new and pragmatic operational metric strongly associated with left-without-being-seen rates and provides an improved way to measure, study, and communicate the impact of inpatient boarding. We propose using functional bed capacity as a metric in future studies of ED operations. Additional studies that incorporate staffing levels to more accurately approximate functional bed capacity and better characterize its true impact on LWBS rates are needed.

Introduction: Pneumonia is the most common cause of pediatric death worldwide. We sought to determine whether the rate of hospital admission of pediatric patients diagnosed with pneumonia at a dedicated pediatric -emergency department (PED) is different than the rate at a community emergency department (CED). This comparison may provide insight into decision-making and factors associated with admission.

Methods: In this retrospective cohort study we reviewed patient records from January 1, 2017–December 31, 2019 for pediatric patients diagnosed with pneumonia. We excluded patients who were not prescribed antibiotics, those who did not receive a chest radiograph or had no radiologic signs of pneumonia. In addition, we excluded patients with comorbid conditions such as tracheostomy, supplemental oxygen requirement at baseline, chronic lung disease other than asthma or reactive airway disease, any cancer diagnosis, cystic fibrosis, or congenital heart disease. The primary outcome was the proportion of pneumonia diagnoses that resulted in admission from the PED vs CED. We used logistic regression analyses to evaluate which clinical factors were associated with hospital admission. Significance levels were determined by chi-square test or the Fisher exact test and Cochran-Mantel-Haenszel statistic.

Results: We identified 400 pediatric patients with pneumonia, 182 from the PED and 218 from the CED. There was a significant difference in admission rates between the two hospitals: 53 of 182 patients in the PED were admitted (29.1%) vs 27 of 218 patients in the CED (12.4%, P < .001). Patients in the PED were, therefore, 2.35 times more likely to be admitted than those at the CED (odds ratio 5.1, 95% CI, 2.5-10.4). Patients presenting to the PED were more likely to arrive via ambulance (10.7% vs 3.1%, P = .04) and to be hypoxic upon arrival (13.2% vs 3.2%, P < .001). The median age of patients in the PED was significantly higher than the CED (6.0 years vs 2.0 years, P < .001). A significantly greater proportion of patients in the CED identified as Hispanic or Latino (68.6% vs 20.3%, P < .001). Patients in the CED were more likely to be insured (11.0% vs 19.9%, P = .01). There was no significant difference in immunization status between the two groups.

Conclusion: Patients presenting to a dedicated pediatric ED had a higher admission rate than did those at a community ED. Patients in the PED were more likely to arrive by ambulance and less likely to have active health insurance coverage. Patients at the PED were more likely to be hypoxic than patients at the CED. These findings highlight important practice differences between PEDs and CEDs that may inform strategies to improve patient outcomes, reduce costs, and promote more effective, evidence-based care. Future studies should further investigate the drivers of these variations and evaluate targeted interventions to optimize care across settings.

Introduction: In the emergency care setting, implementation of infection prevention and control (IPC) practices can be challenging due to numerous factors including emergency department (ED) crowding and boarding of patients, high staff-turnover rates, and acuity of patient needs. Understanding how the unique nature of the ED environment impacts IPC implementation is essential to reducing healthcare-associated infections and to improving patient safety. In this study we aimed to assess ED leaders’ perceptions of IPC practices to identify areas for potential intervention and inform targeted process improvement initiatives.

Methods: Between January–July 2023, ED leaders across the United States were queried about their IPC practices using the National Emergency Department Inventories (NEDI)-USA survey, which is administered annually to all EDs in the US. An expanded survey was administered in a subset of EDs to assess healthcare personnel training for IPC, reported adherence to recommended practices and policies related to disinfection of reusable medical equipment and environment, use of personal protective equipment, hand hygiene practices, patient care space cleaning and disinfection, use of transmission-based precautions signage, risk perceptions of how healthcare personnel practice contributes to healthcare-associated infections and barriers to appropriate room cleaning.

Results: Of the 289 facilities surveyed, 159 (55%) responded, and among responding EDs, 67 (42%) reported seeing ≥ 40,000 patients in the prior year. Regarding healthcare personnel training, 84% (131/156) of ED leaders reported that ≥80% of their ED healthcare personnel were correctly trained in IPC procedures according to their hospital’s policies. Perception of healthcare personnel compliance with IPC practices, however, was lower. Although 75% (118/157) of EDs reported > 80% compliance with correct N95 respirator use, compliance with transmission-based precaution signage was identified as a significant gap, with 30% (47/159) of EDs reporting that they never, rarely, or only sometimes posted signs for patients who required them. Further, 69% (61/89) of EDs reported that they never, rarely, or only sometimes posted transmission-based precaution signs for patients in hallways or overflow treatment spaces.

Conclusion: This national survey found that ED leaders perceive that their healthcare personnel have a high level of knowledge of IPC policies and compliance with some, but not all, IPC policies in the ED. The overall high perceptions of compliance stand in contrast to prior published observations of poor IPC practice in ED settings, suggesting complex relationships between perception and practice that may impact patient safety outcomes. These findings can guide future targeted interventions to improve IPC compliance, reduce healthcare-associated infections, and improve patient safety in emergency settings.

Introduction: The COVID-19 pandemic and related anti-Asian political rhetoric had a detrimental impact on the mental health of Asian American and Pacific Islander (AAPI) youth in the United States. Our objective was to quantify trends in suicide-related emergency department (ED) encounters among AAPI youth before and during the COVID-19 pandemic, using an intersectional lens of race and sex and to contextualize these trends on a timeline of political and social events (such as anti-Asian hate crimes) occurring during the same period in California.

Methods: Using data from the California State Emergency Department Database (SEDD) from 2018–2021, we evaluated changes in quarterly proportions of suicide-related ED encounters by age, race, and sex subgroups by comparing mean percentage change in proportions before and during the pandemic among patients 8-21 years of age. We evaluated changes in quarterly proportions of suicide-related ED encounters by age, race, and sex subgroups by comparing mean percentage changes as they related to events around the pandemic and spikes in anti-Asian hate crimes. To compare relative disparities during the periods, we used stratified adjusted mixed multilevel logistic regression, with White males as the reference group.

Results: The overall increase in suicide-related ED visits for all youth during this period was 49.5% (95% CI 46.7-52.2%), representing 2,637 more suicide-related ED visits in 2021 than 2018. The graphical observational analysis of changes in quarterly proportions of suicide-related ED visits showed some temporal correlation between spikes in rates among AAPI and American Indian and Alaska Native (AI/AN) females and specific events, such as anti-Asian hate crimes and school closings. The largest percentage increase was seen among females of all races, and in particular, AI/AN females (+58.1%, representing 471 more suicide-related ED visits in 2021 than 2018) and AAPI females (+57.5%, representing 1,545 more suicide-related ED visits in 2021 than 2018). During the pandemic, the adjusted odds of a suicide-related ED visit among AAPI females 13-17 years of age compared to White males was 2.01 (95% CI, 1.91-2.13). A total of 131 in-ED deaths occurred during the study period, with no significant year-to-year variation in the number of deaths.

Conclusion: Suicide-related ED visits increased for all youth during COVID-19, with the sharpest rise among AAPI and AI/AN females. Asian American and Pacific Islander females 8-12 and 13-17 years of age showed especially large increases. While causality cannot be inferred, patterns aligned with pandemic disruptions and anti-Asian hate crimes. Findings highlight the value of intersectional analysis to identify disproportionately impacted subgroups and inform future, culturally responsive suicide prevention efforts. 

Introduction: Delirium is a critical neuropsychiatric condition that surged among older adults during the coronavirus disease 2019 (COVID-19) pandemic, likely due to social isolation resulting from distancing measures. In this study we examined trends in delirium-related emergency department (ED) visits before and during the pandemic using nationwide data from South Korea, with a focus on different phases of social distancing, to inform healthcare strategies for older adults during public health crises.

Methods: We obtained data from the National Emergency Department Information System (2017-2022). Changes in ED visits were assessed across pre-pandemic (January 2017–January 2020), early pandemic (February 2020–March 2022), and late pandemic (April 2022–December 2022) phases using interrupted time series analysis.

Results: A total of 80,442 delirium-related ED visits among adults ≥ 65 years of age were recorded. The interrupted time series analysis showed a significant step increase in ED visits during the early pandemic phase (relative risk [RR] 1.290, 95% CI 1.201-1.386; 29.0% increase), followed by a decrease in the late pandemic phase (RR 0.922, 95% CI 0.868-0.981; 7.8% decrease). The most substantial increase was for individuals 65-74 year of age during the early pandemic period (RR 1.406, 95% CI 1.264-1.564) reflecting a 40.6% increase in visits to the ED. Indirect ED visits, such as institutional referrals, also notably increased (RR 1.275, 95% CI 1.184-1.373) reflecting a 27.5% increase.

Conclusion: Delirium-related ED visits among older adults showed a notable 7.8% decrease during the late pandemic period, with key risk groups identified, particularly adults 65-74 of age (40.6% increase) and those referred from institutions (27.5% increase) during the early pandemic period. These findings may help inform targeted interventions and public health responses in similar healthcare settings. Despite limitations including reliance on diagnostic codes, lack of subgroup analysis by COVID-19 status, potential duplicate visit counts, and limited regional granularity this study offers important insight into delirium care needs during crisis periods. Further research should further explore causal mechanisms and the specific impact of COVID-19 infection on delirium incidence.

Introduction: As emergency medicine (EM) residents prepare for the transition into unsupervised practice, their focus shifts from demonstrating competencies within familiar training environments to anticipating their new roles and responsibilities as attending physicians, often in unfamiliar settings. Using the self-regulated learning framework, we explored how senior EM residents proactively identify goals and enact learning strategies leading up to the transition from residency into unsupervised practice.

Methods: In this study we used a constructivist grounded theory approach, interviewing EM residents in their final year of training at two residency programs. Using the self-regulated learning framework as a sensitizing concept for analysis, we conducted inductive, line-by-line coding of interview transcripts and grouped codes into categories. Theoretical sufficiency was reached after 12 interviews, with four subsequent interviews producing no divergent or disconfirming examples. 

Results: We interviewed16 senior residents about their self-regulated learning approaches to preparing for unsupervised practice. Participants identified two types of gaps that they sought to address prior to entering practice: knowledge/skill gaps, and autonomy gaps. We employed specific workplace learning strategies to address each type of gap, which we have termed cherry-picking, case-based hypotheticals, parachuting, and making the call, and reflection on both internal and external sources of feedback to assess the effectiveness of these learning strategies. This study presents participants’ identification of gaps in their residency training, their learning strategies, and reflections as cyclical processes of self-regulated learning. 

Conclusion: In their final months of training EM residents strategically leverage learning strategies to bridge gaps between their self-assessed capabilities and those they anticipate needing to succeed in unsupervised practice. These findings show that trainees have agency in how they use goal setting, strategic actions, and ongoing reflection to prepare themselves for unsupervised practice. Our findings also suggest tailored approaches whereby programs can support learning experiences that foster senior residents’ agency when preparing for the challenges of future practice.