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

Introduction: California has one of the highest rates of homelessness in the United States. Unhoused individuals often have complex medical and behavioral health disorders, frequently complicated by substance use disorders. They have a significant risk of sustaining traumatic injuries. This report compares unhoused and domiciled patients treated at our Northern California trauma center.

Methods: In this retrospective analysis of trauma patients we used data extracted from our institution’s Trauma Quality Improvement Program Trauma Registry for January 1, 2019–April 22, 2022 and compared characteristics of unhoused and domiciled individuals. All unhoused patients in the registry were included in the analysis, as well as an equal number of domiciled patients who were randomly selected during the same time frame. We described and compared demographic and clinical characteristics.

Results: Of 8,529 patients in the registry, 181 (2.1%) were unhoused, and we selected 181 domiciled patients to compare. Unhoused patients were more likely male (83% vs. 61%, P < .001) and younger (48.8 ± 12.3 vs. 55. 8 ± 23.7 years, P <.001). Both cohorts had similar Injury Severity Scores. However, unhoused patients had a higher rate of hospital admissions (76.8% vs. 61.9%, P <.001) and longer hospital stays than domiciled patients (4.0 [IQR 2.0-9.0] days vs. 3.0 [IQR 1.0-6.0] days, respectively; P = .02). A higher proportion of unhoused patients received alcohol- (85.6% vs. 74.6%, P = .01) and drug screening (56.4% vs. 30.4%, P < .001) than domiciled patients. Of those screened for urine drugs, unhoused patients had a higher positive rate (76.5% vs. 50.9%, P < .001). Unhoused patients were more frequently injured by assault (30.4% vs. 8.8%, P < .001) or pedestrian strike (21.5% vs. 3.3%, P < .001), whereas more domiciled patients were injured in falls (46.4% vs. 21.5%, P < .001) and motor vehicle accidents (29.8% vs. 8.3%, P < .001). Falls were most common in the oldest quartile for both groups. In both cohorts, a “sharp object” was the most common mechanism of assault injury (40.0% vs. 37.5%, respectively). Assault by firearm occurred in 14.5% of unhoused and 18.8% of domiciled patients. Overall mortality was 2.2%, with no significant difference between groups (1.7 vs. 2.8%, P = .70). 

Conclusion: Unhoused patients were predominantly younger males with a higher incidence of substance use disorder and greater likelihood of injuries  from assault and pedestrian strikes. Falls and assault with a sharp object were common in both cohorts. Unhoused patients  were admitted more often  and stayed longer  in the hospital. Understanding the complexities of these patients can guide local and regional prevention and treatment measures.

Introduction: Over 350,000 out-of-hospital cardiac arrests occur annually in the United States, with neurologically intact survival below 10%. Recent literature demonstrates that survival is lower in communities of color and non-English speakers. Social determinants of health, such as healthcare access, language, and literacy, may serve as barriers to receiving cardiopulmonary resuscitation (CPR) education and using the skills learned. Current research is sparse on identifying barriers contributing to the lack of CPR education and use in non-English speaking communities. We hypothesized that barriers to CPR education and use differ between English- and Spanish-speaking learners. This study provides insights into how classes could be tailored to address disparities in CPR education and use.

Methods: In this cross-sectional study we used survey-based research to assess the knowledge, comfort, and perceived barriers to activating the 9-1-1 system and performing bystander CPR. Participants were recruited using convenience sampling at community-based events in Roanoke, Virginia. We directly compared responses between language groups using Fisher tests within R, adjusting for various demographic factors.

Results: We collected 367 surveys from the 550 participants (estimated 50 attendees each for 11 events) for a response rate of 66.7%. Of the surveys collected, 231 (63%) were in English and 136 (37%) in Spanish. Spanish-speakers were more concerned with immigration status (7% vs 1%), doing something wrong (14% vs 7%), and language barrier (31% vs 1%) compared to English-speakers when asked why they may not call 9-1-1. We found that 72% of English-speakers would have no problem calling 9-1-1, compared to only 16% of Spanish-speakers. Regardless of language, the most prevalent barrier to initiating CPR was the “fear of doing something wrong” with 49% of Spanish-speakers and 28% of English-speakers endorsing this as a barrier. Only 10% of Spanish speakers would have no concerns starting CPR, compared to 54% of English-speakers. Language was reported by 21% of Spanish-speakers vs 2% of English-speakers as a barrier to administering CPR.

Conclusion: Results of this pilot study highlight that Spanish-speaking respondents were less comfortable calling 9-1-1 and initiating CPR compared to English-speaking respondents. While there were some shared barriers between the groups, Spanish-speaking respondents were more likely to identify a barrier overall. These results suggest that marginalized communities would benefit from tailored educational models that address their unique challenges. Further research is necessary to better understand how social determinants of health serve as barriers to CPR education/use in specific communities.

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Introduction: Timely evaluation in the emergency department (ED) is critical for patients with cardiac chest pain. Although racial disparities in ED wait times have been reported, few studies have focused specifically on cardiac-related presentations. In this study we assessed racial and ethnic disparities in ED door-to-clinician time for cardiac chest pain.

Methods: We conducted a retrospective analysis of adult ED visits for cardiac chest pain (2019–2025) at a tertiary-care academic hospital. Patients ≥ 18 years of age were included. Race/ethnicity was categorized as White, Hispanic/Latino, Black, Native American, Asian, or other/unknown. Multivariable generalized linear modeling assessed the association between race/ethnicity and door-to-clinician time, adjusting for demographics and clinical variables. 

Results: The study included 3,925 patients. The overall median door-to-clinician time was 15.9 minutes (interquartile range 8.0-36.0). In unadjusted bivariate analyses, significant differences were observed across racial and ethnic groups (P < .001). Native American patients experienced the longest delays (23.8 minutes [13.9-49.8]), followed by Asian (18.6 minutes [8.4-36.5]) and Hispanic/Latino patients (17.1 minutes [9.3-43.7]). In contrast, White and Black patients had shorter median wait times of 14.9 minutes [7.1-33.9] and 15.0 minutes [8.8-38.7], respectively. After adjustment for age, sex, triage acuity, clinician type, and initial vital signs, Hispanic/Latino patients waited 18.2 minutes vs 14.9 minutes for White patients (absolute +3.3 minutes; 22% longer; relative risk 1.22, 95% CI, 1.09-1.36, P < .001). Adjusted times were also higher for Black (16.5 minutes), Native American (17.7 minutes), and Asian patients (15.1 minutes), but differences were not statistically significant. 

Conclusion: Hispanic/Latino patients with cardiac chest pain experienced a 22% longer ED wait time than White patients. Our findings highlight the need for targeted interventions and multisite research to ensure equitable, timely care for all patients with acute cardiac conditions.

Introduction: Free Open Access Medical Education (FOAMed) has emerged as a prominent component of online medical communication, with X (formerly Twitter) serving as an active hub for professional exchange among clinicians. Despite its reach and influence, few longitudinal studies have examined how FOAMed content and engagement patterns evolve over time. In this study we aimed to analyze thematic shifts and user interaction trends in #FOAMed tweets over a five-year period.

Methods: We conducted a retrospective bibliometric and natural language processing (NLP) study of 6,000 high-engagement, English-language tweets tagged with #FOAMed, posted between January 1, 2020–December 31, 2024. Each month, the 100 tweets were selected from Twitter’s “Top” tab and manually curated. We used latent Dirichlet allocation (LDA) to identify thematic clusters. Hashtag usage and engagement metrics were assessed using descriptive statistics and linear regression.

Results: We identified 10 distinct topics were identified through LDA modeling: point-of-care ultrasound (POCUS) education; neuro-radiology, cardiology-electrocardiogram (ECG); nephrology; and intensive care unit; ultrasound; prehospital/policy; webinars and learning; resuscitation scenarios; pediatric imaging; medical student education; and critical care and publications. Topic prevalence shifted over time: Early tweets focused on COVID-19 and critical care, while later years showed increasing attention to prehospital care, diagnostics, and POCUS. Mean tweet engagement peaked in 2023 (236.9 ± 914.6). Notably, hashtags such as #POCUS and #MedEd showed substantial increases in both usage and engagement, with #MedEd reaching a peak mean engagement of 287.7. In contrast, COVID-19 declined steadily, both in frequency (from 126 tweets in 2020 to just six in 2023) and in engagement (mean: 67.1 → 18.5). Spearman correlation analysis revealed that hashtag count had a weak but statistically significant correlation with engagement (ρ = 0.047, P < .001), suggesting that content quality, rather than volume, was the primary driver of visibility.

Conclusion: FOAMed discourse on Twitter/X remains dynamic, responsive to clinical priorities and shaped by peer interaction. Natural language processing and topic modeling are valuable tools to uncover longitudinal trends in digital medical education, reinforcing Twitter/X’s role in informal, real-time learning communities.

Introduction: Effective resuscitation leadership is a critical competency for emergency physicians, with evidence correlating strong leadership with improved team performance and patient outcomes during resuscitations. Despite its importance, the extent and nature of structured resuscitation leadership education in emergency medicine (EM) residency training remains unclear.

Methods: We conducted a voluntary, anonymous, needs assessment survey of United States (US) EM residency programs between August–October 2021. The survey assessed for the presence, content, and methods of formal resuscitation leadership curricula within these programs. We used descriptive statistics to analyze responses.

Results: Of the 261 US EM residency programs invited to participate, 80 responded (30.7%). Nineteen programs (23.8%) reported offering resuscitation leadership training through formal curricula, with considerable variation in both educational methods and content. Additionally, 68.4% of responding programs offered external generalized leadership development opportunities through partnerships with hospitals, universities, community organizations, and research entities.

Conclusion: A minority of surveyed US EM residency programs incorporate formal resuscitation leadership training into their curricula with significant variance in curricular content and educational methods. Given the critical role of resuscitation leadership in EM, our findings highlight the need for further research to evaluate the effectiveness of existing curricula and educational approaches.

Introduction: In 2024, the American Board of Emergency Medicine (ABEM) announced the launch of a new certifying exam that emergency medicine (EM) residency graduates must pass to achieve specialty certification. To date, there are no comprehensive curricula published in the available literature to aid residents in exam preparation.

Methods: In this pre-post pilot study, 44% (24/55) of postgraduate year 1 (PGY-1) through PGY-4 EM residents at a single site participated in a four-hour simulated certifying exam curriculum. Learners were asked to complete a four-point Likert scale survey rating self-reported preparedness (very unlikely – very likely) to take the ABEM Certifying Exam, as well as comfort with the ABEM tested competencies, preceding and following the simulation session.

Results: Survey respondents (n = 21; 87.5%) reported an improvement in overall preparedness to take the ABEM Certifying Exam, yielding a pre-post mean difference score of +1.2 (1.9 [unlikely] pre to 3.1 [likely] post, P < .001). Additionally, there was an improvement in all ABEM-tested competencies; pre-post mean difference score ranged from +0.5 (3.0 pre to 3.5 post) for patient-centered communication to +1.1 (2.2 pre to 3.3 post) for clinical decision-making (P < .001 for all competencies).

Conclusion: Given the critical need, and self-reported improvement in preparedness, EM training programs nationwide could consider incorporating a similar simulation curriculum into their didactic experience to help better prepare their learners for the new ABEM Certifying Exam. 

Introduction: Patients with acute stroke may occasionally present as trauma activations, particularly after being found down or sustaining falls. This atypical presentation can delay diagnosis and treatment. Our objective in this study was to compare time to brain imaging, use of reperfusion therapies, and clinical outcomes, including discharge disposition and mortality, between patients with acute stroke presenting as code trauma activations and those presenting as code stroke activations.

Methods: We conducted a retrospective review of all trauma activations at our Level I trauma center from January 2018-December 2024. Patients diagnosed with acute stroke on initial trauma imaging after trauma evaluation formed the code trauma activation (CTA) group. These patients were compared to all patients diagnosed with acute stroke after a code stroke activation (CSA) in 2024. The primary outcome was door-to-imaging time; secondary outcomes included door-to-intervention time, discharge disposition, and mortality. 

Results: There were 208 CSA patients and 198 CTA patients. The CTA patients were older (75.3 vs 70.3 years of age, P < .001) and had a higher percentage of hemorrhagic stroke (43.9% vs 14.4%, P < .001). The CTA patients had a higher National Institutes of Health Stroke Scale score (14.44 vs 9.67, P < .001). Despite minimal injuries (mean Injury Severity Score 3.3), CTA patients experienced longer times to initial brain imaging (47.4 vs 24.8 minutes, P < .001). Mean door-to-thrombolysis (50.3 vs 43.7 minutes, P = .19) and door-to-puncture time (98 vs 82 minutes, P =.18) did not differ significantly. The CTA patients had lower rates of discharge home (23.2% vs 42.8%, P < .001) and higher mortality (24.2% vs 12%, P < .001). On multivariate analysis, trauma activation itself was not independently associated with mortality (OR 1.57, CI, 0.53-4.27, P =.42). Age, stroke severity scores, hemorrhagic stroke, and early imaging were independently associated with mortality after acute stroke. 

Conclusion: Acute stroke patients presenting as trauma activations face significant delays in imaging and lower rates of thrombolytic treatment, despite low injury burden. While trauma activation designation was not independently associated with mortality, delays in imaging and higher hemorrhage prevalence were strongly linked to worse outcomes. These findings highlight modifiable workflow opportunities, particularly streamlined imaging and early stroke recognition in low-impact trauma presentations, to improve delivery of care.

Introduction: Functional vertigo is commonly missed in the emergency department (ED) and often misdiagnosed as other peripheral vestibular disorders. It is strongly associated with anxiety and depression, yet standardized diagnostic criteria are lacking in the ED setting, leading to unnecessary tests and misdiagnosis. We aimed to assess the diagnostic accuracy of the Vertigo Symptom Scale -  Short Form - Autonomic (VSS-SF-A) and the Hospital Anxiety and Depression Scale – Anxiety (HADS-A) and – Depression (HADS-D) for distinguishing functional vertigo from other peripheral vertigos in the ED and  to determine its prevalence.  

Methods: This was a prospective, cross-sectional, observational studey of  adult patients of a tertiary-care ED with dizziness.. We included patients who received an initial peripheral vertigo diagnosis from attending emergency physicians. Blinded otolaryngologists (ENT) verified all final diagnoses through standardized evaluation methods performed on the same day as the ED visit. We excluded patients with central, metabolic, cardiovascular conditions. Study participants received thorough vestibular evaluations while a separate physician, also blinded to diagnostic outcomes, administered the VSS and HADS tests, which typically require 15-20 minutes to complete. The final ENT evaluation served as the criterion reference for the diagnosis of functional vertigo. We evaluated the diagnostic accuracy of the scales through receiver operating characteristic (ROC) analysis.

Results: During the study period, 694 patients presented to the ED with dizziness-related complaints, of whom 69 (9.9%) met the inclusion criteria and were enrolled in the study. Of 69 patients initially diagnosed with peripheral vertigo in the ED, ENT specialists confirmed functional vertigo in 25 (36.2%) and peripheral vertigo in 44 (63.8%). Functional vertigo patients were significantly younger (43.4 ± 16.9 vs 60.1 ± 14.9 years of age, P < .001). In patients with functional vertigo, the mean VSS-SF-A, HADS-A, and HADS-D scores were 9.04, 9.28, and 7.52, respectively, compared to 3.80, 4.18, and 2.91 in peripheral vertigo cases. Conversely, the VSS-SF subscale—Vestibular-Balance (VSS-SF-V)—scores were higher in peripheral vertigo patients (13.05 vs 6.56), all P < .001. The ROC analysis showed that VSS-SF-A (cutoff ≥ 8, area under the curve [AUC] 0.85, 95% CI, 0.76-0.94) had the highest accuracy for diagnosing functional vertigo, with a sensitivity of 72% and specificity of 84.1%, followed by the HADS-A (cutoff ≥ 8, AUC = 0.81, 95% CI, 0.70-0.91), which had a sensitivity of 68% and specificity of 88.6%, while HADS-D (cutoff ≥ 4, AUC = 0.80 95% CI, 0.60-0.90) showed 76% sensitivity and 75% specificity.

Conclusion: Functional vertigo is an underdiagnosed condition that produces dizziness in patients. The Vertigo Symptom Scale and Hospital Anxiety and Depression Scale show promise for enhancing early diagnosis while reducing unnecessary imaging and improving patient care. Future research is needed to confirm these findings through larger multicenter cohorts. 

Introduction: Seizures are one of the most common neurological presentations to an emergency department (ED), often as a first seizure of life or a breakthrough seizure. There is practice variation regarding the diagnostic workup and management for these patient populations. A standardized pathway for emergent evaluation of first seizure of life or breakthrough seizure currently does not exist, resulting in variability in evaluation and timing of outpatient care.

Methods: We created standardized pathways for evaluation and management of patients presenting to the ED with a first seizure of life or breakthrough seizure. These pathways, implemented at a large, quaternary-care hospital system, were utilized on 130 patients presenting with a seizure and compared with all patients with seizure on whom the pathway was not used, between May 2022–October 2023. Outcomes of interest included ED length of stay (LOS), proportion of patients admitted, time to outpatient follow-up, and difference in resource utilization. We compared categorical variables using chi-square test and continuous variables using the Wilcoxon rank-sum test. Equality of variance between the two cohorts was tested using the Levene test.

Results: There was no statistically significant difference between the percentage of male and female patients evaluated via standard-of-care model (45.6% and 49.5%) and those on the pathway (56.9% and 43.1%). The average age of patients was similar between standard-of-care and pathway groups (41 and 39 years, respectively). Median ED LOS was 5.0 (Interquartile range [IQR] 2.9-9.4) hours for standard of care and 4.8 (IQR 3.1-7.0) hours for pathway (P = .34), with a significant difference in variability in time for pathway group (P < .001). Fewer patients were admitted or observed with pathway use (P < .02). Median time to outpatient follow-up was 41.0 days (IQR 17.0-93.0) with standard of care and 23.5 days (IQR 8.0-57.0) with pathway use (P < .001). More urinalyses (P < .001), drug screens (P < .001), alcohol levels (P < .001) and computed tomography for first seizures (P < .001) were ordered for the pathway group. Fewer magnetic resonance imaging studies were ordered for patients in the breakthrough seizures group using the pathway (P < .001).

Conclusion: Standardized pathways to approach seizure presentation in the ED can reduce variability in care, improve time to outpatient neurologic care, and standardize seizure-safety counseling. 

Introduction: Following the 2022 Dobbs Supreme Court decision, emergency department (ED) use for early pregnancy complications (EPC), such as miscarriage and ectopic pregnancy, may increase in states that enacted severely restrictive abortion policies. Patients may increasingly seek EPC-related care in the ED due to delays in treatment resulting in greater symptom severity or reduced access to usual settings of obstetric and family planning care. Our objective in this study was to examine the association between severely restrictive abortion policies and post-Dobbs EPC-related ED visits.

Methods: This retrospective, cross-sectional study used data from the 2016-2022 National Hospital Ambulatory Medical Care Survey. Our primary outcome measure was ED visits among female patients 15-49 years of age for EPC-related care, defined using encounter diagnosis code or chief complaint. We used multivariable logistic regression to examine the association between US region and post-Dobbs, EPC-related visits, as the number of states with severely restrictive abortion policies (bans from conception to six weeks) varied by region, from zero (Northeast) to 10 of 17 states in the South. 

Results: We identified 7,872,445 weighted EPC-related visits (unweighted n = 1,008) among 266,222,232 weighted (unweighted n = 32,841) encounters for female patients 15-49 years of age (3.0%). The median age was 28 (IQR 23-32). The proportion of pre- vs post-Dobbs EPC-related visits was 3.1% vs 2.5% in the Northeast (P = .72); 3.2% vs 3.5% in the West (P = .80); 2.4% vs 3.1% in the Midwest (P = .36); and 2.9% vs 3.7% in the South (P = .50). Compared to the Northeast, the adjusted odds of post-Dobbs EPC-related visits were 1.4 in the West (95% CI, 0.4-5.2), 1.4 in the Midwest (95% CI, 0.4-4.6), and 1.3 in the South (95% CI, 0.4-4.7). 

Conclusion: This preliminary study did not find a statistically significant association between US region and post-Dobbs ED visits for early pregnancy complications. However, given the increasing restrictions surrounding reproductive healthcare access, the ED represents an important setting for the delivery of this care. Further investigations using more robust data sources are needed to understand the effect of prohibitive abortion laws on the ED use and the management of early obstetric complications.

Introduction: Prior research demonstrates that emergency department (ED) patients with suicidal ideation (SI), substance use (SUD), and/or intimate partner violence (IPV) have disproportionate adverse outcomes for both women and infants. The 2013 Hague Protocol suggested that children with caregivers with the above characteristics are also more likely to suffer from child maltreatment. Of all pregnancies in this group, as many as 90% are unintended. We hypothesized that women with SI/SUD/IPV have gaps in care access, high levels of unscheduled care use, and reduced ED contraceptive inquiry, which if addressed could potentially improve outcomes.

Methods: We conducted a chart review of 62,284 ED visits from 2018–2021 from a suburban four-hospital system in the Southern United States. We compared women of reproductive age (15-44) with SI/SUD/IPV (4,776) against controls (57,508). The exposures were defined as women with SI, SUD, and/or IPV. We analyzed results using the chi-square test (χ²) with Bonferroni adjustment to test for independence and logistic regression.

Results: Women suffering from SI/SUD/IPV who present to the ED have contraceptive status less frequently documented compared to controls without these factors (39.5 vs 51.7%, RR 0.77, CI, 0.74-0.79, P < .001). They also have reduced access to care, with higher rates of uninsurance (32.7 vs 26.1%, P < .001), more care in the acute care environment, longer ED length of stay (LOS) (mean was 10.38 vs 3.87 hours, P < .001), higher hospitalization rates (61.0 vs 8.7%, P < .001), and higher 30-day ED revisits (11.8 vs 8.8%, P < .001), even after adjusting for the Social Vulnerability Index, acuity, age, and obesity (adjusted odds ratio 1.52 95% CI 1.36-1.70 P < .001).

Conclusion: Despite significant morbidity coupled with reduced access to ambulatory care and disproportionately increased ED use, little ED contraceptive documentation exists. This practice contributes to inequity, given the increased number of unintended pregnancies and greater need of contraceptives in women with suicidal ideation/substance use disorder/intimate partner violence.

Introduction: Patients who report sexual assault in the emergency department (ED) have a legal right to a forensic exam. Emergency departments that do not provide such exams must offer transfer to a forensic site. Little is known about the factors influencing whether patients are offered a forensic exam and complete the transfer. In this study we aimed to identify patient characteristics associated with being offered a forensic exam in an ED that does not perform them on site.

Methods: We conducted a retrospective chart review of adult patients presenting to a single, urban, academic ED between January 2017–December 2019. The ED receives over 75,000 visits annually and refers patients to an external site for forensic exams. Using keywords “sexual assault” or “rape” we identified charts that included whether the visit involved an initial report of sexual assault. Charts were abstracted for demographics, insurance status, psychiatric history, clinician concern for acute mental illness or substance use, and mode of arrival. The primary outcome was whether a forensic exam was offered. Statistical analyses included chi-square tests and penalized logistic regression.

Results: Of 167 charts reviewed, 108 met inclusion criteria. Of these, 94 patients (87.0%) were offered a forensic exam and 14 (64.8%) accepted transfer. Patients who were offered exams were younger (mean age 29.9 vs 36.8 years, P = .05), more likely to arrive ambulatory (69.1 vs 42.9%, P = .02), and less likely to have a psychiatric history (31.9 vs 71.4%, P = .01). Clinician concern for acute psychiatric illness or substance use was significantly associated with not offering a forensic exam (64.3 vs 16.0%, P < .001). In regression analysis, this concern was the only independent association of not being offered a forensic exam (adjusted odds ratio 0.16, 95% CI, 0.03-0.76, P = .02). Additionally, 23.1% of patients were uninsured, significantly higher than the local rate of 2.7%.

Conclusion: Patients in the ED who report sexual assault are less likely to be offered a forensic exam if they present with signs of acute mental illness or substance use disorder. These findings highlight the need for standardized protocols and advocacy to ensure equitable access to forensic exams, especially for patients with behavioral health needs or without insurance.

Introduction: In North America, suicide ranks among the top causes of death in individuals 15-60 years of age. In this study we aimed to determine whether an emergency department (ED) presentation for suicidal behaviors accompanied by acute alcohol intoxication was associated with increased six-month suicide or all-cause mortality compared to non-intoxicated presentations of suicidal behaviors.

Methods: We performed a retrospective cohort study of adults (≥ 18 years) presenting to 16 EDs in Alberta, Canada, between April 2011–March 2021. Suicidal attempt or self-harm was identified via International Classification of Diseases codes, 10th Rev, Canadian Enhancement (ICD-10-CA). Patients were classified as acutely intoxicated if they had relevant ICD-10-CA codes or a blood alcohol concentration ≥ 2 millimoles per liter (9.2 milligrams per deciliter). We excluded patients who died on arrival, were transferred, or were non-residents. The primary outcome was suicide-specific mortality at six months; secondary outcomes included all-cause mortality, use of involuntary holds, psychiatric consultations, admissions, and ED return visits. Median differences with 95% confidence intervals and unadjusted odds ratio (OR) with 95% CI were reported for continuous and categorical variables, respectively. 

Results: Among 58,051 suicidal or self-harm patients, 17,488 (30%) were classified as intoxicated. Six-month suicide mortality was similar between intoxicated and non-intoxicated groups (0.3% each; adjusted sub-distribution hazard ratio = 0.98 [95% CI, 0.73-1.38]), indicating no significant association between alcohol intoxication and suicide-specific death. Intoxicated patients were more often male (58% vs 52%; OR 1.26 [1.22-1.31]), arrived by ambulance (70% vs 50%; OR 2.32 [2.23-2.41]), and were more frequently placed on involuntary holds (26% vs 16%; OR 1.92 [1.83-2.00]). They had fewer hospital admissions (10.8% vs 15.4%; OR 0.63 [0.60-0.67]), longer ED stays (411 vs 277 minutes; median difference = 134 minutes [127.7-140.3]), and higher ED return rates at 30 days (19.8% vs 18.3%; OR 1.10 [1.05-1.15]) and six months (45.8% vs 42.1%; OR 1.16 [1.12-1.20]).

Conclusion: Acute alcohol intoxication among ED patients presenting with suicidal behaviors was not independently associated with higher six-month suicide mortality. Patients with acute alcohol intoxication had increased use of involuntary holds, longer lengths of stay, and more frequent ED return visits. Future work should explore other psychosocial and clinical factors, including substance use and psychiatric comorbidities, that may influence outcomes beyond the acute setting. 

Introduction: As part of a quality improvement initiative, our emergency department (ED) implemented a community advisory council consisting of leaders from five community-based organizations (CBO) that provide services for survivors of intimate partner violence. We used qualitative interviews with participants from the organizations to evaluate the council by identifying factors that promoted and hindered their engagement in this partnership between the community and the ED as well as best practices for future collaborations

Methods: We conducted five, 30-minute semi-structured interviews, one for each CBO representative on the council. Interview questions were based on validated toolkits for evaluating community-based participatory research. We conducted thematic analysis using a barriers and facilitators framework.

Results: Our focus on building relationships within the community advisory council facilitated collaboration between the ED and the CBOs. We identified structural barriers to and facilitators of the relationship-building process, as well as four behaviors that promoted relationship-building within the council. These behaviors included a joint problem-solving orientation, a culture of curiosity, shared empathy between emergency clinicians and CBO members, and a deeper understanding of barriers to caring for survivors of intimate partner violence in the ED. Themes regarding the impact of the council included the results of tangible projects as well as cultural shifts in the ED as perceived by leaders of the CBOs.

Conclusion: We share a case study of a collaboration between the ED and community-based organizations that illustrates barriers to and facilitators of engagement by leaders of these organizations in community-healthcare partnerships. The ED is a short but meaningful stop in recovery for many survivors, and a warm handoff to a CBO can be an essential next step in their care. When rooted in mutually respectful, trusting relationships, ED-CBO partnerships have the potential to enable survivor-centered, quality improvement efforts that work to improve the continuum of care between the ED and the community.

Introduction: Timely identification of critically ill or injured children in prehospital and emergency settings remains a persistent challenge due to developmental variability, low case volumes in emergency medical services (EMS), and contextual limitations during field assessments. Existing frameworks to identify at-risk children often fail to capture the nuances of pediatric presentations, particularly in resource-limited or mass casualty settings. We aimed to explore prehospital and hospital-based clinician perspectives to inform a Delphi survey for the development of a consensus-driven definition of pediatric critical illness and injury.

Methods: We conducted a qualitative study using one semi-structured interview and two focus groups with participants with expertise in pediatric prehospital and hospital acute care. Participants were presented with a list of tools commonly used to assess the severity of illness in children in the emergency department and hospital-based settings. Interviews were conducted virtually, transcribed, coded using an iterative process, and thematically analyzed. We used key themes to inform the structure and priorities for a future Delphi survey.

Results: Six of the 12 invited participants took part in the study. Five major themes emerged: 1) prehospital indicators of critical illness (e.g., seizure, intravenous  placement, cardiopulmonary resuscitation; 2) in-hospital markers of severity (e.g., air medical transport, intubation, diagnostic findings); 3) perceptions of existing triage tools (e.g., limited awareness or utility among paramedics); 4) differences in assessment approaches across roles and settings; and 5) specific triage challenges during mass casualty or disaster scenarios. Paramedics emphasized clinical actions as indicators of acuity, while physicians cited diagnostic findings and broader contextual indicators. Across roles, there was more agreement on the limitations of current triage and illness severity tools than on their utility.

Conclusion: We gained insights into key gaps in current pediatric triage systems, including limited applicability of existing tools in prehospital settings, variability in comfort with pediatric interventions, and the lack of alignment between paramedic action-based indicators and physician reliance on diagnostic findings. Role-specific experiences influence how critical status is assessed and highlight the value of integrating multidisciplinary insight. These findings inform future work focused on the development of consensus-based outcome measures that align with decision-making across prehospital and hospital environments.

Introduction: The COVID-19 pandemic disrupted care-seeking and respiratory disease epidemiology across healthcare settings, notably for emergency department (ED) care. The scope of this disruption and whether patterns of ED visits have returned to predictable seasonal patterns is of interest in planning ED staffing and resource availability for future illness surges, pandemic or not. We evaluated ED visits for acute respiratory illness among children in a large, integrated healthcare delivery system to describe illness and patient characteristics in the years before, during, and after the pandemic peak. 

Methods: We conducted a cross-sectional study of ED visits among patients 0-17 years of age to the 21 EDs of Kaiser Permanente Northern California, from January 1, 2018–December 31, 2019, pre-pandemic; January 1, 2020–December 31, 2021, pandemic; and January 1, 2022–March 31, 2024, post-vaccine (vaccines for children > 5 years of age approved and available). We electronically extracted eligible ED visits with acute respiratory infection diagnoses and a range of sociodemographic, medical comorbidity, and utilization characteristics. 

Results: We observed 151,983 pediatric ED visits with eligible respiratory infection diagnoses, 49,912 (32.8%) visits pre-pandemic, 27,109 (17.8%) visits during the pandemic, and 74,962 (49.3%) visits post-vaccine. Eligible visits dropped every month from 6,361 in February 2020, just prior to the pandemic onset, to their lowest volume (243) in June 2020. In the post-vaccine period, visits peaked at 10,638 in November 2022, the highest of any month during the study period. Sex, race/ethnicity, and tobacco exposure were comparable over time, but the proportion of visits by patients with under-immunized diagnosis trended upward over time. Upper respiratory infection (30% pre-pandemic, 32% pandemic, and 33% post-vaccine periods), asthma (15% pre-pandemic, 12% pandemic, and 12% post-vaccine periods), and cough (9.9% pre-pandemic, 12% pandemic, and 12% post-vaccine periods), were the top three diagnoses across all periods. 

Conclusion: In this cross-sectional study of acute respiratory illness-related ED visits in an integrated healthcare system, from 2022 onward seasonal variation in respiratory illness ED visits rebounded, with notable and unseasonal peaks in late 2022. COVID-19 appears to be a minor contributor to ED visits for pediatric respiratory illness. However, an increased overall and seasonal burden of ED visits has implications for surge planning and mitigation, with COVID-19 now being endemic and typical respiratory pathogens having resurfaced

Introduction: Pulmonary embolism (PE) is common with potential for morbidity and mortality. Several PE risk-stratification tools exist; however, more granular and patient-specific indicators of potential decompensation or short-term mortality that can be easily obtained are needed for the bedside clinician to further sub-stratify risk and inform management decisions. We sought to determine the association of early emergency department (ED) measurement of the shock index (SI) and SI variants (modified SI, SI to peripheral oxygen saturation ratio, age-adjusted SI, respiratory-adjusted SI, and double product) and mortality among patients with acute PE. 

Methods: This was an observational case-control study of adult patients who presented to the ED at a single health system (January 2021–April 2023) and had PE response team (PERT) activation for newly diagnosed acute PE. We evaluated the association of 30-day in-hospital mortality with the SI (heart rate/systolic blood pressure) and variants of the SI—modified SI = heart rate/mean arterial pressure; SI to peripheral oxygen saturation ratio = SI/peripheral oxygen saturation; age-adjusted SI = age x SI; respiratory-adjusted SI = SI x (respiratory rate/10); double product = systolic blood pressure x heart rate—in addition to the Simplified Pulmonary Embolism Severity Index (sPESI) and European Society of Cardiology (ESC) risk schema. We used the area under the receiver operating characteristic curve (AUC) to assess discriminatory efficiency of the SI and each variant with the primary outcome. Multivariable logistic regression measured the association between SI and variants with 30-day mortality. 

Results: Of 121 patients included in the study, 12 (9.9%) died. The SI and variants were all significantly different between survivors and non-survivors (P < .05), while the sPESI was not different (P = .30). The age-adjusted SI had the highest discriminatory efficiency for mortality (AUC 0.82; 95% CI, 0.71-0.93), followed by the SI (AUC 0.78; 0.67-0.89), the SI/peripheral oxygen saturation (AUC 0.77; 0.65-0.90), double product (AUC 0.76; 0.61-0.91), modified SI (AUC 0.75; 0.61-0.90), ESC risk schema (AUC 0.71; 0.52-0.90), and the respiratory-adjusted SI (AUC 0.70; 0.54-0.87).

Conclusion: Among patients presenting to the ED who had a PERT activation for acute PE, the age-adjusted SI had the highest discriminatory efficiency for mortality, followed by the SI and its other variants. Further investigation regarding use of the age-adjusted  SI for prognostication of acute PE and implications on PE management is warranted.

Introduction: Despite numerous randomized controlled trials, lung protective ventilation and prone positioning remain the only therapies shown to have a survival benefit in acute respiratory distress syndrome (ARDS). A National Heart, Lung, and Blood Institute workshop on the future of clinical research in ARDS suggested that identification of at-risk patients earlier in their clinical course would allow implementation of prevention strategies and facilitate study of these interventions. To this end, the Lung Injury Prevention Score (LIPS) was derived and validated to identify patients at risk of developing ARDS upon hospital admission, and the Emergency Department Lung Injury Prevention Score (EDLIPS) was subsequently derived and internally validated. For this study, we sought to externally validate EDLIPS.

Methods: We performed a validation study of EDLIPS, using data from a large, multicenter trial— the Vitamin D to Improve Outcomes by Leveraging Early Treatment (VIOLET) trial. After identifying patients who met VIOLET inclusion criteria while in the ED, variables comprising EDLIPS were extracted for each patient. We calculated area under the receiver operating characteristic curves (AUC) of EDLIPS for the VIOLET dataset.

Results: We identified a total of 1,270 patients. The mean age was 56, and 55% were male. The incidence of ARDS was 8.1%. EDLIPS discriminated patients who developed ARDS from those who did not with an AUC of 0.786 (95% CI, 0.740-0.832), nearly identical to its performance in the original study, which yielded an AUC of 0.784 (95% CI, 0.748-0.820).

Conclusion: We successfully validated a risk-prediction model for the identification of ED patients at risk for ARDS in a large cohort of critically ill patients. The development of ARDS prevention trials will involve collaboration with other clinical groups, such as emergency physicians, to enroll patients as early as possible in their clinical course. EDLIPS is the first tool of its kind to undergo external validation, and it can aid in the identification of ED patients at risk for the development of ARDS.

Introduction: Patients leaving without being seen is a critical quality metric for emergency department (ED) performance and is associated with negative patient outcomes and operational inefficiencies. In this study we aimed to systematically assess patient- and system-level factors influencing leaving-without-being-seen behavior.

Methods: We conducted a retrospective cohort study at The Ottawa Hospital, a tertiary-care ED with 85,000 annual ED visits in Ottawa, Canada. We analyzed all patient encounters for two years from May 2022–April 2024. Variables included demographics characteristics (age, sex), visit specifics (arrival day and time, Canadian Triage and Acuity Scale [CTAS] scores, presenting complaints), and operational metrics (ED occupancy metrics). Multivariate logistic regression analyses evaluated the influence of these factors on rates of leaving without being seen.

Results: Of 170,536 ED visits, 15,473 (9.1%) patients left without being seen, and 2,716 (1.6%) left before triage. Each additional 10 years of age reduced the adjusted odds of leaving without being seen by 20.2% (older patients left less frequently). Male patients had 9.4% higher adjusted odds of leaving without being seen compared to females. For every five patients waiting to be seen, the adjusted odds of leaving increased by 16.9% for a newly arriving patient. For every five patients already seen but awaiting disposition, the adjusted odds of leaving increased by 9.6% for a newly arriving patient. Compared to CTAS 2 patients (high acuity), CTAS 3 patients had 67.1% higher adjusted odds of leaving, CTAS 4 patients had 134% higher adjusted odds, and CTAS 5 patients (lowest acuity) had 176% higher adjusted odds of leaving.

Conclusion: Younger age, male sex, lower acuity, and ED crowding independently and significantly increase rates of leaving without being seen. Importantly, both crowding and volume of patients waiting impact left-without-being-seen behaviour. Optimizing patient flow through strategic movement within the ED may enhance the perception of progress, encouraging patients to remain for care.

Introduction: The emergency department (ED) is a setting where communication occurs often and with potential consequences for patient care. In this study we sought to determine nurse and physician perspectives on the nature and implications of effective and ineffective communication in the ED.

Methods: We used a mixed-methods design, including an online survey followed by in-person focus groups with emergency nurses (EN) and emergency physicians (EP). Participants were recruited through email listserves to emergency staff at four hospitals. We integrated quantitative survey results with focus-group themes.

Results: A total of 115 eligible ENs and EPs completed the initial questionnaire (50% response rate from ENs, 65% response rate from EPs). Responses from nurses and physicians were similar; both noted that poor communication is frequent, adversely affects patient care and ED function, affects trust, particularly between individuals, and that non- verbal communication behaviors affect team communication. In the focus groups (consisting of 18 EPs and 17 ENs), six themes emerged: 1) Situations, built physical environment, and medium of communications all impact quality of communication; 2) core elements of desired professional communication include respect and attention, often conveyed through non-verbal behaviors; 3) poor communication begets poor communication and influences interpersonal relationships; 4) effective communication is seen as fundamental to patient care but also has impacts beyond patient care; 5) clinician gender and gender dyads influence communication dynamics; and 6) participants were able to identify learning activities and techniques for effective communication.

Conclusion: Emergency nurses and physicians across four EDs described failures of communication as both frequent and significant to patient care. This study identified characteristics of effective communication, complex factors influencing communication, and emphasized the whole-team impact of communication quality.

Introduction: Viewing a solar eclipse without proper eye protection can lead to ocular injuries such as solar retinopathy or photokeratitis. The April 8, 2024, solar eclipse in the southern and eastern United States presented a rare opportunity to assess the public health impact of such events on eye-related emergency department (ED) visits.

Methods: We identified a total of 1,774 ED visits for eye injuries across both periods. There were 853 visits before the eclipse and 921 visits after, showing no statistically significant difference (X² = 1.432, P > .05) between the two time periods.

Results: We identified a total of 1,774 ED visits for eye injuries across both periods. There were 853 visits before the eclipse and 921 visits after. The chi-square statistic (X² = 1.432, degree of freedom = 1, P > .05) indicated no statistically significant difference in the incidence of eye injuries between the two time periods.

Conclusion: Despite concerns regarding eclipse-related eye injuries, we found no statistically significant increase in ED visits for ocular pain or photokeratitis following the April 8, 2024, solar eclipse. These results suggest that public education campaigns promoting safe eclipse viewing may have been effective. Ongoing efforts are warranted to continue promoting ocular safety during future eclipses

Introduction: Acute long bone fractures, such as femur and humerus fractures, frequently lead to emergency department (ED) visits and require timely pain management. However, disparities in analgesia administration persist across age and sex. This study investigates how these intersecting patient characteristics affect the timing and receipt of analgesia in both prehospital and ED settings.

Methods: We conducted a retrospective cohort study of adults (≥ 18 years of age) presenting to a Level I trauma center ED in 2022 with femur or humerus fractures. Demographics, analgesia timing, and receipt in both prehospital and ED settings were extracted from medical records. Our analysis included all forms of initial analgesic administration, including both narcotic and non-narcotic medications. We further categorized treatments to distinguish between any analgesia and narcotic analgesia. Multivariable Poisson and logistic regression models were used to assess disparities, adjusting for triage acuity, arrival method, initial pain score, and prehospital analgesia.

Results: Among 553 patients, 75% were ≥ 65 of age and 63% were female. Older adults experienced significantly longer delays to ED analgesia compared to younger adults (median 81 vs 44 minutes; +54.9% adjusted delay; P < .001) and were less likely to receive prehospital analgesia (44% vs 66%; odds ratio 2.52; P < .001). Sex-based disparities were also evident: females waited longer than males for ED analgesia (median 76 vs 57 minutes; +12.9% adjusted delay; P < .001). Among those who received prehospital analgesia, females waited 43% longer than males for subsequent ED pain treatment (median 72 vs 30 minutes; P <.001).

Conclusion: Age and sex disparities exist in both prehospital and ED pain management for long bone fractures. Older adults were less likely to receive prehospital analgesia and experienced prolonged delays in the ED. Female patients had longer ED wait times for analgesia, especially following prehospital treatment administered by emergency medical services responders.

Introduction: The coral snake is the only native elapid in North America. Their venom contains potent neurotoxins. Historically, all confirmed/presumed bites were treated with antivenom whether or not symptoms were present. Production of antivenom ceased in 2003. The resultant national shortage prompted clinicians to investigate alternative treatment strategies such as a wait-and-see approach where antivenom is held until signs of systemic toxicity manifest. Now that production has resumed there is limited research available comparing these two treatment paradigms, empiric administration vs the wait-and-see approach. Our objective in this study was to compare outcomes of the two treatment paradigms to determine whether one is associated with better patient outcomes.

Methods: This was a retrospective analysis of coral snakebite cases reported to the Florida Poison Information Center Network from January 1, 1998–December 31, 2021. We collected demographic, clinical, and outcome variables. Patients were stratified into two groups, empiric antivenom administration vs the wait-and-see approach in patients who were asymptomatic in terms of systemic symptoms at the time of initial presentation to the emergency department. We used multivariable logistic regression models, controlling for whether the bite occurred during the North American Coral Snake Antivenin (NACSA) shortage period (yes/no), age, sex, and whether systemic effects developed (yes/no), to determine differences between study groups in the incidence of the main outcomes: intensive care unit (ICU) admission; intubation; and death, as well as ICU and hospital length of stay.

Results: We analyzed 301 cases: 171 (56.8%) empiric; and 130 (43.2%) wait-and-see. Patients in the empiric treatment group had approximately three times higher likelihood of ICU admission (empiric 121 [75.2%] and wait-and-see 71 [56.8%]), odds ratio [OR} 3.047, P = .05). There was no difference in the incidence of intubation (empiric 2 [1.2%] and wait-and-see 1 [<1%]), OR 2.486, P = .63) or in ICU length of stay (OR 0.485, P = .08). Of the patients treated with NACSA (191), adverse reactions to the antivenom occurred in 38 (19.9%) patients—35 patients in the empiric group and three in the wait-and-see group who later received antivenom. Of these 38 patients, eight (21.1%) experienced an anaphylactic reaction.

Conclusion: Empiric North American Coral Snake Antivenin administration was associated with higher ICU admissions and with a considerably higher risk of adverse reactions, which may serve to impose caution when treating empirically.

Introduction: Mass shooting incidents (MSI) are single events injuring four or more victims, and they occur in the United States on average every 12.5 days. Studies have examined the psychological impact of MSIs on witnesses and surviving victims. However, the mental health of healthcare workers involved in the care of MSI victims requires further examination. We explored the association between work-related stress and symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD) in healthcare workers involved in the 2017 Las Vegas mass shooting.

Methods: Surveys were distributed to 170 healthcare workers involved in the care of victims of the largest MSI in US history, the 2017 Las Vegas Route 91 Harvest Festival (58 people killed, 413 wounded bv gunshot or shrapnel). Fifty healthcare workers (29.4% response rate; 68% female), 29–71 years of age, responded to demographic questions followed by the Beck Anxiety Inventory, Beck Depression Inventory-II (BDI-II), Patient Health Questionnaire-9 (PHQ-9), PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders, 5th Ed, and the Health & Safety Executive Management Standards Indicator Tool, between October 15, 2022–March 15, 2023. 

Results: Results showed that work-related stress was significantly associated with symptoms of depression (BDI-II: P < .001, 22.9% variance; PHQ-9: P < .05, 20.5% variance) and PTSD (P < .001, 26.8% variance). No significant differences in symptom severity (work-related stress, anxiety, depression, and PTSD) were found between participants involved in critical care and non-critical care (P > .05). In addition, healthcare workers reported higher symptoms of depression (5.18 vs 2.91, P < .001), and lower symptoms of anxiety (8.84 vs 22.35, P < .05) than normative data of the general population.

Conclusion: Healthcare workers reporting a higher risk of work-related stress were more likely to report more symptoms of depression and PTSD. Healthcare workers involved in critical and non-critical care reported similar symptoms of anxiety, depression, PTSD, and work-related stress. Moreover, healthcare workers involved in the care of the Las Vegas mass shooting victims were more likely to report more symptoms of depression and fewer symptoms of anxiety than samples of the general population. Given the novelty of this study, the unpredictability of MSIs, and the current limitations, we offer recommendations for future studies.

Background: Immediate care clinics (ICC) account for a significant portion of acute, low-severity visits that preclude the use of resources from an emergency department (ED). Given the chronic issue of ED crowding and its detrimental effects on quality of care and health system efficiency, understanding and optimizing the use of ICCs for non-emergent visits could significantly alleviate pressures faced by EDs and improve patient satisfaction, as well as control the overall cost of care. This study describes the application of the Billings/Ballard severity algorithm to ICC visits over a seven-year period and compares the findings to previously published ED literature.

Methods: We obtained data from ICC visits within a large, academic health system. The analytical sample included 306,395 visits from 125,063 unique patients. We describe ICC patient characteristics and the Billings/Ballard severity classification. We used negative binomial regression analysis to evaluate the associations between patient characteristics and total visits to ICCs and primary care physician (PCP), and multivariate regression analysis to assess the relationship between ICC visit severity and patient characteristics, controlling for multiple visits per patient. The algorithm was also used to identify and classify the most common International Classification of Diseases, 9th and 10th modifications (ICD-9/10) diagnosis codes by severity.

Results: In total, 9.17% of ICC visits were classified as emergent, 81.25% as non-emergent, 0.79% as indeterminate, and 8.79% as unclassified, compared to literature-reported ED distributions of 37.90% emergent, 45.08% non-emergent, 11.32% indeterminate, and 5.70% unclassified. The ICC visits included a greater proportion of non-emergent presentations. The ICD-9/10 diagnosis distribution revealed a distinct ICC environment compared with that of the ED. The most frequent diagnoses among emergent ICC visits included chest pain, asthma exacerbation, and shortness of breath, while non-emergent visits were predominantly for upper respiratory tract infections. Within one year at the same healthcare system, 47% of patients had repeat ICC visits and 41% had primary care follow-up.

Conclusion: These results demonstrate that immediate care clinics deliver predominantly non-emergent care as intended (81% vs 45% in the ED), potentially reducing ED crowding and validating current clinician- and patient-initiated referral practices. High rates of repeat ICC visits (47%) and follow-up with primary care physicians (41%) within the same healthcare system suggest these facilities foster care continuity while providing accessible, non-emergent care alternatives. However, user disparities persist as self-pay and uninsured patients show lower overall ICC use, while uninsured and publicly insured individuals present with emergent conditions more frequently than privately insured patients. These findings inform care-seeking education and health service delivery while highlighting the need to improve ICC accessibility across insurance types to optimize efficiency and patient outcomes. 

Introduction: ChatGPT and other large language models (LLM) have increased in popularity. Despite the rapid rise in the implementation of such technologies, frameworks for implementing appropriate prompting techniques in medical applications are limited. In this paper we establish the nomenclature of “variable” and “clause” in the prompting of a LLM, while providing example interviews that outline the utility of such an approach in medical applications. 

Methods: In this study assessing the LLM ChatGPT-4, we define terms used in prompting procedures including “input prompt,” “variable,” “demographic variable and clause,” “independent variable and clause,” “dependent variable and clause,” “generative clause,” and “output.” This methodology was implemented with three sample patient cases from both a patient and physician perspective.

Results: As demonstrated in our three cases, precise combinations of variables and clauses that consider the patient’s age, gender, weight, height, and education level can yield unique outputs. The software can do so quickly and in a personalized, patient-specific manner. Our findings demonstrate that LLMs can be used to generate comprehensive sets of educational material to augment current limitations, with the potential of improving healthcare outcomes as the use of LLM is further explored.

Conclusion: The framework we describe represents a unique attempt to standardize a methodology for medical inputs into a large language model. Doing so expands the potential for outlining patient-specific information that can be implemented in a query by either a patient or a physician. Most notably, future projects should consider the specialty- and presentation-specific input changes that may yield the best outputs for the desired goals.

Introduction: In this study we sought to to assess the extent to which emergency physicians adhered to an institutional protocol for rapid chest pain assessment that incorporates a high sensitivity troponin I (hs-TnI) assay. We also sought to characterize clinical outcomes stratified by protocol adherence.

Methods: We conducted a retrospective cohort study that included all adult patients presenting to five major metropolitan hospital emergency departments (ED) with suspected cardiac chest pain who had at least one troponin measured. The study period was November 9, 2020–June 20, 2022. The primary outcome was protocol adherence for indeterminate-risk and high-risk patients, as defined by the protocol in use at the time of each patient’s presentation to hospital. Adjusted odds ratios (aOR) are reported with associated 95% confidence intervals.

Results: A total of 14,027 patients were included in the study, among whom 8,962 (63.9%) were classified as low risk, 4,064 (29.0%) as indeterminate risk, and 1,001 (7.1%) who were in the high-risk/rule-in group. Overall, 35.9% of patients had care that adhered to the chest pain pathway protocol—22.1% of indeterminate-risk patients and 91.6% of high-risk/rule-in patients. Protocol adherence among indeterminate-risk patients was 6.6% when the initial troponin was in the range of 4-19 nanograms per liter (ng/L) and 75.4% for initial troponin levels 20-99 ng/L. Male sex was most strongly associated with protocol adherence; among those receiving adherent care, 65.8% were male compared to 34.2% female (aOR 1.67; 95% CI, 1.46-1.91). Patients in the non-adherent group with an initial troponin 4-19 ng/L experienced a significantly higher incidence of major adverse cardiac events (4.5% vs 1.7%, P < .001), compared to those in the low-risk group.

Conclusion: Adherence to proposed assessment protocols for patients presenting to the ED with chest pain was low. This lack of adherence appears to disproportionally affect females and is associated with poor outcomes. Improving adherence to evidence-based guidelines in this setting is urgently needed.

Introduction: Maricopa County, Arizona, experienced its largest West Nile virus outbreak in 2021, with 1,487 cases and 101 deaths, in the midst of the COVID-19 pandemic. We sought to describe initial presentations of emergency department (ED) patients ultimately diagnosed with West Nile virus and determine how often patients presented to the ED before their diagnosis. To assist with disease recognition during future outbreaks, we examined in detail cases where emergency physicians initially did not suspect West Nile virus.

Methods: We reviewed records from May–December 2021 for patients with a positive West Nile virus result and at least one ED visit within 15 days. Data included age, sex, race, Emergency Severity Index (ESI) score, number of ED visits, chief complaint, vital signs, blood or cerebrospinal fluid (CSF) testing, diagnosis, and disposition. We excluded cases with only immoglobulin G-positive results or outpatient tests, leaving 147 cases.

Results: Among 147 ED West Nile virus cases, the median patient age was 67 years, with patients being predominantly male (66.7%) and White (97.3%). The most common presenting chief complaints included fever (23.8%), headache (17.7%), and generalized weakness (11.6%). Emergency physicians initiated testing for the virus in 63 cases (42.9%). Patients dispositioned (n = 84, either discharged or admitted) from the ED without initiation of testing tended to be older (median 73 vs 62 years, P < .001), with higher triage respiratory rate (mean 19.4 vs 18.3 breaths per minute, P = .05) and lower triage oxygen saturation (median 96% vs 97%; P =.02). Emergency physicians predominantly performed CSF testing (n = 42 patients) over serum testing (n = 21 patients). Patients tested via CSF had lower ESI scores than those tested via serum (ESI score of 1-2 45.3% vs 14.3%, P = .03). 

Conclusion: Emergency physicians did not initiate testing in 57.1% of initial ED encounters of patients ultimately found to have West Nile virus. During West Nile virus outbreaks, emergency physicians should stay vigilant for less acute presentations, such as generalized weakness in elderly patients, along with typical presentations including fever and headache, to avoid delayed diagnosis.

Introduction: First-generation antihistamines are frequently used in the emergency department (ED) but are discouraged in older adults due to increased adverse drug effects. Whether concerns about adverse drug effects apply to the ED is uncertain, as ED-specific data are limited, and risks with single-dose administration may differ from risks with chronic use. In this study we assessed frequency of use, adverse drug effects, and indications of first-generation antihistamines administered to older adults during ED visits.

Methods: This retrospective cohort study identified adults ≥ 65 years of age who received first?generation antihistamines from January 1–December 31, 2022 in the ED at a single, urban, academic medical center. Abstractors blinded to study hypotheses identified indications for use and adverse effects through chart review. Indications other than severe allergic reactions and continuation of home use were classified as potentially inappropriate. We evaluated sex, age ≥ 85, history of cognitive impairment, drug received, and number of doses for association with adverse drug effects by regression analysis.

Results: First-generation antihistamines were administered in 261 encounters (3% of geriatric ED encounters). Median patient age was 71 (range 65-107, interquartile range [IQR] 67-77) and 60.5% were female. Adverse drug effects occurred in 15% of encounters, with delirium (n = 20, 7.7%) and urinary retention (n = 11, 4.2%) being the most common. On multivariate analysis, patient age ≥ 85, history of cognitive impairment, and receipt of multiple doses were associated with elevated risk of adverse drug effects, with risk ratios of 5.5 (95% CI, 2.7-11.4), 3.1 (95% CI, 1.8-5.4), and 1.9 (95% CI, 1.1-3.6), respectively. Indications were classified as potentially inappropriate in 92% of encounters. Diphenhydramine was most used in patients with headache (n = 53, 30.1% of doses) and history of iodinated contrast media reaction (n = 46, 26.1% of doses), while hydroxyzine was most used for anxiety (n = 51, 60% of doses). The kappa value between abstractors was 0.84, indicating excellent agreement. 

Conclusion: Emergency department use of first-generation antihistamines in older adults, especially those ≥ 85 years of age and with prior cognitive impairment, was associated with infrequent but clinically significant harm. Most use was potentially inappropriate. Prophylactic use of diphenhydramine for patients with a prior reaction to iodinated contrast media emerged as a common indication.