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

Introduction: Suicide is a growing public health issue in the United States. Healthcare visits in the year prior to suicide death, including those to emergency departments (ED) and inpatient settings, may be missed opportunities for risk-screening and intervention delivery. Our objective in this study was to evaluate the distribution of hospital visits of suicide decedents in the year prior to death by setting (ED and inpatient), last visit proximity to death, and presence of suicide risk factors, and to consider each setting’s potential for reaching those at risk of suicide.

Methods: Using linked data from the Illinois Hospital Discharge Data Set and the Illinois Violent Death Reporting System, we examined suicide decedent hospital visits 365 days prior to suicide death. We described the distribution of visits by setting (ED vs inpatient), timing of the last visit prior to death, and groupings of visit primary diagnosis codes, as per the International Classification of Diseases, 10th Revision, reflecting suicide risk (deliberate self-harm, suicidal ideation, mental health disorders, and substance use disorder). The study was conducted between 2022–2025.

Results: Of the 2,562 suicide decedents, 960 (37.4%) had a visit in the year preceding their death. The 960 decedents had a total of 3,131 visits, an average of 3.3. per person. Of those visits, 2,002 (63.9%) were to the ED. However, there was a greater proportion of last visits to an inpatient unit (687, 60.9%) that occurred under 180 days of death compared to last ED visits (1,060, 52.1%), P < .05). Inpatient visits also had higher percentages of visits for each of the suicide risk-diagnosis code groups compared to ED visits; deliberate self-harm, 22.2% (n = 251) vs 6.8% (n = 136); suicidal ideation 29% (n = 327) vs 8.6% (n = 173); mental health disorders, 5.7% (n = 64) vs 3.1% (n = 62); and substance use disorder, 75.1% (n = 848) vs 35.3% (n = 706), P < .05. Among both inpatient and ED visits, substance use was the most prevalent of the primary diagnosis suicide risk-factor groups endorsed, although inpatient visits had a statistically significant higher proportion of primary diagnosis codes for substance use than ED visits, 75.1% (n = 848) and 35.3% (n = 706), respectively, all P < .05.

Conclusion: We found the proportion of suicide decedents with a hospital visit in the year prior to death was lower than other studies found for primary care settings. However, this does not mean that broad-based suicide screening and interventions would not be of value in hospital settings.7,14 Inpatient visits were fewer in number but a greater proportion of visits in closer proximity to suicide death and with suicide risk factors. This suggests that EDs may be better suited to broad-based screening and inpatient settings to targeted intervention efforts. Inpatient visits involving primary diagnosis suicide-risk factors may offer more easily identifiable opportunities for suicide prevention compared to those in ED settings, based on prevalence and temporal and logistical factors. Future interventions could consider how to systemically integrate risk screenings in both settings, particularly for patients with a diagnosis of substance use disorder.

Introduction: Best practice recommendations and guidelines for the assessment and management of suicidality within the emergency department (ED) have recently been updated. Despite national efforts to improve the management of suicidality in the ED, evidence-based practices remain underused with varied uptake among EDs and clinical team members. Given that the ED is a common point of entry for many people with suicidality, implementation of evidence-based strategies are needed to increase access to these strategies and improve patient outcomes.

Methods: To generate insights about the feasibility of implementing evidence-based practices for suicidality management, we developed a semi-structured interview guide focused on factors expected to influence the implementation process using a novel application of the Organizational Readiness for Innovation Implementation Framework. Working from a list or 80 EDs in the state of Indiana, we recruited emergency physicians, nurses, physician assistants, and social workers to participate in interviews. Interviews lasted approximately 45-60 minutes and were recorded, transcribed, and qualitatively analyzed using a multistage thematic analysis process.

Results: We conducted 11 interviews with ED clinical team members from eight EDs in Indiana, representing 10% of the 80 EDs invited to participate in our study. Identified barriers to effective implementation included a general lack of resources, resistance to change among clinical team members, and competing demands in the ED setting. Facilitators included openness to attending training, openness to implementing change in the ED, and leadership support. Openness to change and commitment to change appeared to be driven by discontent with current processes and a desire to improve patient experiences.

Conclusion: Considering mixed attitudes toward suicidality management and questions about whether these services are within the scope of clinicians who work in the ED, efforts to increase uptake of evidence-based practices may involve a multifaceted approach that involves identifying and training team members who are open and ready for change, while simultaneously establishing stronger relationships between ED clinical team members and behavioral health clinicians with specialized training who can provide consultative services in the ED.

Introduction: A core principle of emergency care is the rapid transport of severely injured patients to hospitals capable of providing definitive care. Although the social, financial, and emotional factors associated with transfers, and their impact on hospital crowding, may necessitate a more nuanced approach, little has been published on how physicians actually make the decision to transfer a potentially moribund patient. We, therefore, sought to better understand these factors as the next step toward optimizing transfer flow and patient care.

Methods: We conducted one-hour, semi-structured interviews with 16 emergency physicians at referring and referral centers, including eight accepting physicians at a quaternary-care center and eight transferring physicians at community hospitals. Interviews focused on decision-making regarding interhospital transfers for moribund patients, defined as those with injuries or disease processes judged likely to be non-survivable. Interviews were transcribed and analyzed using reflexive thematic analysis to identify common themes and decision-making factors.

Results: We identified four emerging themes that underpinned a decision to transfer or accept a potentially moribund trauma patient: 1) the accepting physician’s perceived obligation to hospitals with fewer resources; 2) the difficulty of prognostication; 3) the imperfection and limitations of current advanced care planning documents; and 4) the impact of family and patient preferences.

Conclusion: The rationale behind initiating and accepting transfers of moribund trauma patients is multifaceted. This study is the first to our knowledge that explores physician decision-making in this domain. Physicians feel an obligation to patients, families, and other hospitals, which leads to almost universally initiating or accepting transfers even in cases with limited hope of survival. These interviews offer insight into opportunities to improve statewide trauma operations and highlight avenues for promoting transfer-decision heuristics and pre-transfer goals-of-care conversations without compromising patient care.

Introduction: Patient experience has important implications for hospitals and patient care including its ties to reputation, reimbursement, and clinical outcomes. Despite its importance, little is known about how operational factors in the emergency department (ED) impact formal complaints. In this study we aimed to identify encounter-level operational characteristics associated with the risk of formal patient complaints.  

Methods: We conducted a retrospective matched-cohort study of ED encounters between October 2023–December 2024 at three EDs affiliated with a large academic health system. Each complaint case was matched to three non-complaint cases (3:1 matching) based on age, sex, race/ethnicity, acuity score, and chief complaint. We used logistic regression to assess the associations between operational factors and the likelihood of submitting a formal complaint. A Bonferroni correction was applied for multiple comparisons with statistical significance set at P < .005. 

Results: Of 246,983 ED visits, 476 (0.19%) formal complaints were submitted. These were matched with 1,428 non-complaint cases. Baseline characteristics, which included age, sex, race/ethnicity, primary insurance, and chief complaint, did not differ, by design, between groups. Analysis revealed that ED length of stay ≥ 12 hours (odds ratio OR 3.12; 95% CI, 2.34-4.18) and an average of more than one ED visit per month (2.00; 1.45-2.73) were significantly associated with increased odds of filing a complaint. In contrast, any imaging performed during the visit (0.43; 0.35-0.54), hospital admission (0.72; 0.57-0.90), and presenting to the ED during a high-volume time (0.47; 0.33-0.67) were significantly associated with decreased odds of filing a complaint. 

Conclusion: Length of stay > 12 hours and frequent ED visits were associated with a significantly increased complaint risk. Any form of diagnostic imaging, admission to the hospital, and presenting to the ED during a high-volume period were associated with fewer complaints. These findings offer ED and hospital leadership insights on the patient experience and highlight that improving capacity constraints for all patients can have downstream benefits for those who submit formal complaints.

Introduction: Effective disaster response in healthcare depends on coordinated strategies that maintain access to critical supplies across institutions. During Hurricane Helene in September 2024, a major intravenous (IV) fluid shortage caused by the destruction of a manufacturing plant exposed the vulnerability of centralized supply chains. Our objective in this study was to evaluate the impact of a multisite IV fluid conservation initiative on ordering patterns, cost, and environmental outcomes across three emergency departments (ED).

Methods: We conducted a retrospective study evaluating large-volume, IV fluid-bolus orders placed before, during, and after the critical shortage. Interventions included an interruptive alert in the electronic health record, clinician education, and workflow adjustments. Our primary outcome measure was the number of IV fluid-bolus orders placed during each period. Secondary outcomes included total fluid volume administered, total cost of fluids, estimated carbon dioxide emissions, and the proportion of ED encounters involving fluid administration.

Results: During the pre-shortage period, 24,251 IV fluid-bolus orders were placed across 41,752 ED encounters (41.8%). Orders dropped to 18,692 during the critical shortage across 39,840 encounters (30.8%), reflecting a 22.9% relative reduction. In the post-shortage period, 23,911 orders were placed across 40,967 encounters (39.6%), remaining slightly below baseline. Estimated cost savings during the shortage period totaled $27,202, with a projected annual savings of $108,808. Carbon dioxide emissions dropped by 3.1 metric tons—the equivalent of avoiding the use of over 349 gallons of gasoline.

Conclusion: Emergency department-based conservation strategies were associated with measurable reductions in IV fluid use, cost, and environmental impact. Further validation is needed to understand their impact on clinical outcomes and healthcare system resilience.

Objective: The surge in the number of emergency department (ED) visits due to a growing population, aging society, and easier access to healthcare highlights the need for an effective triage process. Our goal in this study was to compare the clinical and operational performance of a triage system supported by artificial intelligence (AI) with two traditional methods—the Emergency Severity Index and the Manchester Triage System—in a high-volume ED.

Methods: In this prospective study, 18,000 adult patients were randomized equally to one of the three triage systems. Primary and secondary outcomes included patient wait time, complication and mortality rates, resource utilization, medical errors, legal issues, and patient satisfaction.

Results: Compared with the Manchester Triage System, the AI-supported system was associated with significantly lower in-ED mortality (OR 0.39, 95% CI, 0.32–0.47; P < .001) and lower complication rates (4.42% vs 10.25%), as well as higher patient satisfaction scores (9.0 vs 7.0; P < .001). Resource utilization was also more balanced in the AI-supported triage cohort.

Conclusion: The AI-assisted triage system showed favorable clinical and operational patterns relative to traditional methods. However, the single-center design and short observation period limit generalizability, and causal inferences could not be firmly established.

Introduction: Approximately 12% of patients with cancer annually visit the emergency department (ED) for disease- or treatment-related issues. These patients often face delays in care, including prolonged wait times and extended length of stay (LOS), contributing to ED crowding, delayed treatment, and increased mortality. Numerous studies have investigated interventions to reduce LOS and prevent ED visits for patients with cancer. However, a systematic overview of these interventions is currently lacking. In this review we aimed to present interventions that optimize input, throughput and output in ED care by reducing ED LOS or ED visits for patients with cancer.

Methods: We searched five electronic library databases: Medline ALL via Ovid; Embase.com; Web of Science Core Collection; the Cochrane Central Register of Controlled Trials via Wiley; and Google Scholar. Inclusion criteria for this review were as follows: 1) research on (a subset of) patients with cancer; 2) conducted in or in collaboration with the ED; 3) the introduction of an intervention aimed at optimizing ED input, throughput, and output; and 4) performance of the intervention was measured using outcomes, such as ED LOS, number of ED visits or hospitalizations, use of acute-care services, or time to antibiotics.

Results: The literature search yielded 11,357 articles. After removing duplicates, 7,315 unique articles remained for screening. Of these, 109 were selected for detailed abstract review. Following this second screening, 35 articles underwent full-text analysis, and 16 articles met all inclusion criteria. These studies identified four categories of interventions: scoring systems (n=5); dedicated cancer urgent care facilities (n=5); protocolized care (n=3); and staffing optimization (n=3). Among scoring systems, use of the Edmonton Symptom Assessment Scale reduced ED visits (relative rate (RR) = 0.92) and hospitalizations (RR = 0.86), while the Clinical Index of Stable Febrile Neutropenia score showed higher specificity (98.3%) than the Multinational Association for Supportive Care in Cancer score (54.2%) for identifying low-risk febrile neutropenia.

Conclusion: We identified four categories of intervention that could potentially reduce ED visits and ED LOS, of which scoring systems showed the most potential. Rather than developing new tools, future efforts should prioritize the implementation, validation, and refinement of these existing strategies to optimize treatment of cancer patients in the emergency department.

Objectives: Climate change has led to more frequent and intense heat events with dramatic increases in heat illness and heat-related deaths. We compared demographic characteristics such as age, sheltering status, and underlying health conditions that contribute to susceptibility to extreme heat. We described the clinical course of these patients, presenting over a 12-year span, who were diagnosed with heat-related illness, to inform local risk stratification. 

Methods: We conducted retrospective chart abstraction of encounters between January 1, 2012–December 31, 2023, which included adults 18-89 years of age, presenting to a single hospital system’s emergency department (ED), with an International Classification of Diseases, 10th Revision, discharge diagnosis within the T67 heat-related diagnosis code family. We compared demographic characteristics to baseline ED presentations and summarized clinical characteristics in frequencies. Trends were described over time juxtaposed with temperature data. 

Results: The 141 patients with a heat illness diagnosis were older, with a mean age of 53, and were more likely to be male (81.6%), White (51.8%), or Native American (7.8%) as compared to adult (18-89 years of age) all-comer ED presentations. Patients with a heat illness often carried co-occurring diagnoses of contact burns (38.3%) or rhabdomyolysis (25.5%). Common chronic comorbid conditions included cardiovascular disease (33.3%) and substance use disorder (22.0%). Antipsychotics (22.0%), laxatives (24.1%), and beta blockers (15.6%) were frequent home medications among heat-affected patients. Of the patients who were the most critically ill from heat illness, 35.5% required ED intubation and 95.7% were admitted, with 45.9% of those requiring intensive care. While most were discharged to self-care (59.3%), 26.7% required skilled nursing care at discharge. 

Conclusion: This review describes the characteristics and clinical course of patients diagnosed with heat illness over more than a decade of increasingly frequent and extreme heat in Phoenix, AZ. It provides a unique and sizeable cohort that can guide the surveillance and treatment of heat illness. We highlight clinical trends and gaps in clinical heat illness data to identify vulnerabilities and protective factors among our patients.

Emergency physicians are on the front lines of climate-driven illness and disaster. Reducing healthcare’s carbon footprint and increasing sustainability can improve planetary and patient health, lower healthcare costs, and boost healthcare job satisfaction. Over the last decade, the American College of Emergency Physicians (ACEP) progressed from early recognition of climate impacts on health to actionable sustainability advocacy. Council resolutions—ACEP’s formal mechanism for policy development—reflects this trajectory, beginning with requests to study climate effects, advancing to coalition engagement, and culminating in operational guidance for reducing emergency department waste and carbon emissions. This paper summarizes the climate and sustainability resolutions presented to the ACEP Council, including brief descriptions and their outcomes. It provides emergency physicians and health system leaders a framework to track and implement ACEP’s sustainability advocacy, with the goal of reducing healthcare’s carbon footprint and improving both planetary and patient health.

Introduction: Heat stroke can rapidly progress to end organ damage and death if not promptly treated. The diagnosis is characterized by core body temperature > 40.5 °C. In this study we evaluate how the form of ice (crushed vs cubed), the addition of sodium chloride, and the initial temperature of water together affect the rate of cooling for standardized cooling bath mixtures used to treat patients experiencing heat stroke.

Methods: We prepared four cold water immersion mixtures using 12 quarts of ice and 12 quarts of water (11.36 liters) under different conditions:
Test Case 1: Cubed ice with trauma bay tap water (~35 °C);
Test Case 2: Crushed ice with cold tap water (~24 °C);
Test Case 3: Crushed ice with cold tap water plus four pounds of rock salt; 
Test Case 4: Cubed ice with cold tap water,
After each mixture was poured into a 40-quart bucket and mixed thoroughly, we recorded the temperature at 20-second intervals over a total duration of 300 seconds using a food-grade thermometer. Room temperature during the experiment was 25.0 °C. 

Results: After 100 seconds, water from the trauma bay with cubed ice reached 6.2 °C, while cold tap water with cubed ice cooled to a slightly lower temperature of 5.5 °C. Crushed ice in cold tap water reached an even lower temperature of 3.6 °C. The coldest mixture was made with crushed ice with salt, which rapidly reduced the water temperature to 2.2 °C. It took approximately 300 seconds for all test groups to approach equilibrium, with final temperatures of 2.4. °C for cubed ice in trauma bay water, 1.4 °C for cubed ice in cold tap water, 1.2 °C for crushed ice in cold tap water, and 0.2 °C for crushed ice with salt in cold tap water.

Conclusion: A mixture of cold tap water, crushed ice, and sodium chloride achieved a lower equilibrium temperature and cooled more rapidly than mixtures lacking salt, using cubed ice, or prepared with warmer initial water temperature. These findings suggest that optimizing cold water immersion protocols with crushed ice, added salt, and the coolest available tap water may enhance cooling speed in simulated mixtures. Whether these differences translate into improved patient outcomes remains to be determined.

Introduction: Our goal in this study was to evaluate the diagnostic utility of bedside D-dimer testing for identifying secondary headache due to intracranial pathology among patients presenting to the emergency department (ED) with non-traumatic headache and no neurological deficits.

Methods: We conducted this prospective, multicenter, cross-sectional study across six tertiary care EDs in Türkiye. Adult patients presenting with non-traumatic headache and no neurological deficits who underwent cranial computed tomography (CT) based on clinical suspicion for intracranial pathology were enrolled. Exclusion criteria were recent trauma, pregnancy, fever, hematologic conditions, and known intracranial pathology. We measured bedside D-dimer using a D-dimer assay with a predefined threshold of 500 nanograms per milliliter. The primary outcome was secondary headache related to intracranial pathologies as determined on the index CT and additional tests as needed or during one-month follow-up. 

Results: Of the 3,279 patients screened, 1,522 were included in the final analysis. Secondary headache due to intracranial pathology was identified in 57 patients (3.7%). The most common etiologies were subarachnoid hemorrhage (n = 20, 35.1%), ischemic stroke (n = 16, 28.1%), cerebral vein thrombosis (n = 6, 10.5%), and subdural hemorrhage (n=6, 10.5%). Bedside D-dimer demonstrated a sensitivity of 82.5% (95% CI, 70-91%) and specificity of 89.2% (95% CI, 87-91%) for identifying intracranial pathology, with a positive likelihood ratio of 7.6 (95% CI, 6.3-9.2) and negative likelihood ratio of 0.2 (95% CI, 0.1-0.35). Diagnostic accuracy was highest for cerebral venous thrombosis: sensitivity was 100% with a wide CI (95% CI, 54-100%), specificity was 86.8% (95% CI, 85-88%), and positive likelihood ratio was 7.6 (95% CI, 6.7-8.6). For subarachnoid hemorrhage, where sensitivity reached 90% (95% CI, 68-99%), specificity was 87.5% (95% CI, 86-89%), the positive likelihood ratio was 7.2 (95% CI: 5.9–8.8), and the negative likelihood ratio was 0.1 (95% CI: 0.03-0.4).

Conclusion: Bedside D-dimer testing showed moderate performance as a screening adjunct in ruling out secondary headache due to intracranial causes in ED patients with non-traumatic headache and no neurological findings.

Introduction: Non-traumatic headache is a common emergency department (ED) presentation, yet identifying intracranial causes remains challenging in the absence of neurological deficits. In this study we aimed to evaluate the incidence and predictive ability of clinical red flag signs and symptoms for intracranial pathology.

Methods: We conducted a prospective, multicenter, cross-sectional study across six academic EDs with residency programs in Türkiye. We enrolled consecutive adult patients with non-traumatic headache and no neurological deficits who had cranial computed tomography (CT) at the discretion of the treating attending physician. Exclusion criteria were recent trauma, pregnancy, fever, hematologic conditions, and known intracranial pathology. We recorded clinical features using standardized forms. The primary outcome was the presence of intracranial pathology confirmed by CT or subsequent diagnosis within a one-month follow-up. 

Results: Of 1,522 patients, 57 (3.7%, 95% CI, 2.8-4.8) had intracranial pathology; 104 (6.8%) patients could not be reached during the one-month follow-up. The most common diagnoses were subarachnoid hemorrhage (SAH) (n = 20, 35.1%); ischemic stroke (n = 16, 28.1%); subdural hemorrhage (n = 6, 10.5%); and sinus vein thrombosis (n = 6, 10.5%). Both univariate and multivariate analyses identified that headache aggravated by physical activity (OR 5.98; 95% CI, 2.3-15.2) and age > 50 years (OR 3; 95% CI, 1.65-5.5) independently predicted the cause of the headache. For SAH, headache exacerbated by physical activity (OR 18.6; 95% CI, 5.6-62.3), and syncope (OR 5.7; 95% CI, 1.4-24.3) were independent risk factors. Notably, “sudden onset” and “worst headache ever” were not significant predictors of intracranial pathology in this cohort. The prevalence of sudden-onset headache (45%, n = 9, vs 50.3%, n = 753; P = .64) and “worst headache ever” (55%, n = 11, vs 59.4%, n = 890; P = .69) did not differ significantly between patients with and those without SAH. The odds ratios from the multivariable analyses for sudden onset (OR 1.13, 95% CI, 0.4-3.0) and “worst headache ever” (OR 1.38, 95% CI, 0.47-4.0) were not statistically significant for SAH.

Conclusion: In ED patients presenting with non-traumatic headache and no focal neurological deficits, headache aggravated by physical activity is a significant indicator for any intracranial pathology causing headache and, specifically, for subarachnoid hemorrhage. While age > 50 years was associated with intracranial pathology causing headache, syncope was specifically linked to subarachnoid hemorrhage. These findings may help refine clinical decision-making for neuroimaging in this patient population.

Introduction: There are significant gaps in knowledge regarding the epidemiology, management, and outcomes of patients presenting to the emergency department (ED) with vaginal bleeding.

Methods: This was a retrospective, successional cross-sectional study using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) examining all adult patients presenting to EDs with vaginal bleeding from 2011–2019. Patients were stratified by age, race/ethnicity, and pregnancy status. Main outcomes were ultimate outcome severity, presenting vital signs, and diagnostic tests performed. We defined high-severity outcome as any patient who was dead on arrival, died in the ED, or during that hospitalization; any patient admitted to the intensive care or stepdown units or to the cardiac catheterization lab or the operating room; or patients transferred to a non-psychiatric hospital. Moderate severity was defined as any patient admitted to floor-level care, held in observation, or transferred to a psychiatric hospital. We defined low-severity outcome as any patient discharged home.

Results: Patients presenting with a chief complaint of vaginal bleeding comprised 1.3% (95% CI, 1.2-1.4%,) of all ED visits, representing 14,620,933 total encounters. Of these patients, 53.0% (95% CI, 49.4-56.7%) were identified as pregnant. There was a lower prevalence of White patients presenting with this complaint compared to White patients presenting with any chief complaint (45.6% [95% CI, 41.9-49.4] vs 60.3% [95% CI, 57.7-62.8%]), with a reciprocal higher prevalence of Hispanic patients (21.1% [95% CI,17.7-24.5%] vs 13.2% [95% CI, 11.7-14.8%]). The majority of patients (88.1%, 95% CI, 86.1-90%) were classified as having a low-severity outcome, 10.3% (95% CI, 8.5-12.1%) were classified as moderate-severity, and 1.6% (95% CI,1.0-2.2%) as high-severity. Patients who were ultimately classified with high-severity outcomes had significantly higher shock indices at presentation and shorter wait times than patients with low-severity outcomes (0.75 [95% CI, 0.72-0.78] vs 0.68 [95% CI, 0.67-0.69], and 23.4 minutes [95% CI, 17.1-29.8] vs 41.7 minutes [95% CI, 37.1-46.4], respectively), despite no difference in median Emergency Severity Index triage score (2.5 [IQR 2.1-2.8] v 2.6 [IQR 2.2-2.9]). A quarter of patients (24.3% [95% CI, 20.8-27.7%]) received a pelvic exam: there were no significant differences in pelvic exam rate by age, pregnancy status, race/ethnicity, or ultimate outcome severity.

Conclusion: Although most patients presenting to EDs with vaginal bleeding are discharged home, current triage models do not appear to appropriately risk-stratify higher risk patients. Disparities in presentation exist.

Introduction: Social determinants of health (SDoH) have emerged as a critical focus of research due to their significant impact on clinical outcomes; however, there is a gap in research specific to women’s health. Understanding the factors underlying trends in gynecologic emergency diagnoses requires a more comprehensive examination of SDoH. In this study we characterize the demographic and clinical profile of patients with documented SDoH International Classification of Diseases, 10th revision (ICD-10), Z codes (Z55-Z65) who presented to the emergency department (ED) with salpingitis and oophoritis, and explore patterns of healthcare utilization and management.

Methods: In this retrospective cohort study we used TriNetX Research Network data to compare adult females (18-49 years of age) presenting to the ED with diagnosed salpingitis and oophoritis between January 1, 2000–January 1, 2024, by presence or absence of SDoH Z codes. Propensity score matching balanced baseline demographics and comorbidities. The outcomes assessed one year from ED presentation included surgical intervention, hospital admission, ED revisits, utilization of critical care service, analgesic use, and new mental health diagnoses such as anxiety, post-traumatic stress disorder, and depression. Risk analyses compared outcome proportions between cohorts, reported as risk ratios (RR) with 95% confidence intervals.

Results: Before propensity score matching, the proportion of the initial cohort that had at least one SDoH Z code was 11.9%. Following propensity score matching, we analyzed 5,570 patients, 50% of whom had documented SDoH Z codes. We found that 10.2% of patients with documented SDoH Z codes received surgery compared to 15.0% of patients without (RR, 0.679; 95% CI, 0.577-0.799, P < .001). On the contrary, 45.7% of patients with Z codes were hospitalized compared to 34.3% without (RR, 1.333; 95% CI, 1.248-1.423, P < .001). Of patients with SDoH Z codes, 58.1% revisited the ED compared to 45.2% without (RR, 1.287; 95% CI, 1.222-1.355, P < .001). 4.4% of patients with Z codes required critical care services compared to 2.5% without (RR, 1.757; 95% CI, 1.317-2.345, P < .001). Lastly, patients with SDoH Z codes experienced new mental health diagnoses. This included 8.4% with Z codes diagnosed with depression (RR, 1.890; 95% CI, 1.432-2.495, P < .001) compared to 4.6% without, 11.1% with Z codes diagnosed with anxiety (RR, 1.565; 95% CI, 1.241-1.973, P < .001) compared to 7.1% without, and 2.7% with Z codes diagnosed with post-traumatic stress disorder (RR, 3.026; 95% CI, 1.897-4.826, P < .001) compared to 0.9% in patients without documented Z codes.

Conclusion: Patients with documented ICD-10 Z codes for social determinants of health were less likely to receive surgery but were associated with increased ED repeat visits, hospitalization, need for critical care, and mental health conditions. These findings highlight the clinical relevance of SDoH in acute care utilization and patient outcomes, underscoring the importance of routine screening and documentation of SDoH in electronic health records. Addressing underlying social needs may be a key strategy in reducing healthcare burden and improving long-term outcomes for vulnerable populations. 

Introduction: Distal radius fractures account for up to 18% of fractures in older adults and up to 20% of all fractures treated in the emergency department (ED). These fractures often require reduction and immobilization, with different modalities to provide analgesia. Our objective in this study was to summarize the management for distal radius fracture reductions in the real world of community and academic EDs.

Methods: Following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) and retrospective chart review guidelines for cohort studies, we identified adult visits for isolated distal radius fractures over a four-year period across three academic and 18 community hospital EDs from more than 490,000 per annum total visits. Visits were grouped by whether they were reduced in the ED. Reductions were further categorized by use of ultrasound-guided nerve block (UGNB), procedural sedation, or hematoma block. We recorded patient demographics, including age, sex, race and ethnicity, and Emergency Severity Index scores. Our primary outcome was patient-reported pain scores (0-10 scale) at presentation and prior to disposition. Secondary outcomes were total milligrams of morphine equivalents administered, ED length of stay and 30-day ED return rates. We used Kruskal-Wallis (numeric) and chi-squared or Fisher exact (categorical) tests to compare characteristics.

Results: There were 3,642 total patients with distal radius fractures, and 2,608 (71.6%) met inclusion criteria. Of the patients included, 695 (26.6%) received fracture reduction. Of the reductions performed, 522 (75.1%) received hematoma blocks, 151 (21.7%) received procedural sedation, and 22 (3.2%) received UGNB. The majority of UGNB (72.7%, n = 16), procedural sedation (64.2%, n = 97), and hematoma block reductions (51.3%, n = 268) were performed in community hospital EDs. Patient age was greatest for the hematoma block (median 67 [57, 76]), followed by no ED reduction (65 [51, 77]), UGNB (65 [51, 68]), and procedural sedation (62 [43, 72]) (P < .01 for the four-group comparison). The majority of patients (93.7%) were White and not Hispanic or Latino (94.5%). There was no difference in treatment type by race or ethnicity. Pain score reduction between arrival and the last score reported in the ED was statistically greatest for the procedural sedation group (8 to 4, difference of -4 [-6, -2]), followed by UGNB (8 to 5, difference of -3 [-5, 0]), hematoma block (8 to 5, difference of -3 [-5, 0]) and no reduction (7 to 5, difference of -2 [-4, 0]), (P < .001 for the four-group comparison). Median total milligrams of morphine equivalents was higher for UGNB (7.5 [6.8, 13.9]) and procedural sedation (7.5 [2.0, 14.0]), as compared to hematoma block (6.7 [0, 13.0]) and no ED reduction (4.0 [0.0, 7.5]) (P < .001 for the four-group comparison). Length of stay in the ED was longest for the UGNB group (314 minutes [226, 432]) when compared to hematoma block (275 minutes [204, 370]), procedural sedation (258 minutes [192, 350]) (P = .08), and no reduction (190 [127, 290]) (P < .001 for the four-group comparison). Thirty-day return rates were 16.6% for procedural sedation, 15.1% for hematoma block, 12.3% for no reduction, and 9.1% for UGNB (P = .18).

Conclusion: Most distal radius fracture reductions were performed with a hematoma block. Ultrasound-guided nerve block was a less commonly used alternative to procedural sedation and was performed predominantly in the community hospital ED setting. Procedural sedation and UGNB were most effective at reducing pain. Triage severity scores, milligrams of morphine equivalents administered, and length of stay were similar between UGNB and procedural sedation. 

Introduction: Anemia is common in the emergency department (ED). Physicians often rely on inspecting conjunctival pallor or other body parts for gestalt estimates. We aimed to evaluate the validity and reliability of physician gestalt for anemia detection and examine the impact of clinical experience and incorporating images of multiple body parts on physician gestalt-based anemia detection.

Methods: Prospective observational study in the ED at an academic medical center between January–November 2023. Using convenience sampling, we included patients ≥ 18 years with recent laboratory hemoglobin (Hgb) measurements. We used a smartphone to capture the images of the patient’s conjunctiva, palm, and fingernails. Five board-certified attending emergency physicians (two junior, two mid-level, and one senior) reviewed the patient images and provided gestalt predictions of Hgb levels and anemia likelihood on a 1-10 scale. Two pairs of physicians evaluated the same set of patient images to assess reliability. Anemia was defined as Hgb < 13.1 grams per deciliter (g/dL) for men and < 11.0 g/dL for women, according to our laboratory standard.

Results: We enrolled a total of 100 patients (mean age 67 years; 45% male). Of these, 59 (59%) had anemia and 41 (41%) did not. The correlation coefficients between physicians’ predicted Hgb levels and actual Hgb levels were only moderate (0.31, 0.41, and 0.40 for junior, mid-level, and senior physicians, respectively; P < .05 for all). Although not statistically significant, the mid-level physicians’ gestalt had the highest area under the receiver operating characteristic curve (0.78), followed by senior- (0.74) and junior physicians (0.72). The impact of incrementally adding images of other body parts to conjunctiva was small (mean changes in anemia likelihood <1 on a 1-10 scale). The agreement on predicted Hgb levels between the paired physicians was high (0.71 for junior physicians, 0.67 for mid-level physicians, P < .001 for both).

Conclusion: Physician gestalt demonstrated moderate validity and moderate-to-high reliability for anemia detection. Adding images other than conjunctiva did not improve the performance of physician gestalt. However, the clinical experience did matter slightly in detecting anemia.

Introduction: Sepsis is a life-threatening condition caused by an exaggerated immune response to infection, causing damage to the body’s own tissues and organ dysfunction. The elderly are at higher risk for mortality from sepsis compared to younger adults. Our objective in this study was to evaluate the use of a modified systemic inflammatory response syndrome (SIRS) criteria for patients ≥ 65 years of age including new criteria of reduced heart rate (> 75 rather than 90 beats per minute [bpm]) for patients taking atrioventricular nodal blocking drugs and altered mental status.

Methods: This was a retrospective observational study sampling patients ≥ 65 years of age diagnosed with sepsis. We compared our proposed modified SIRS criteria to the original criteria (heart rate, white blood cell count, respiratory rate, and temperature). Our primary outcome measure was comparing sensitivity and specificity of each model. We performed a regression analysis to evaluate the relationship of each individual criterion and its association with sepsis. Approximately half (47.1%) of the sampled population were taking an atrioventricular nodal blocking drug.

Results: Based on a 1:1 case-matched dataset, the modified SIRS criteria yielded a higher sensitivity (98.9%; 95% CI, 98.4-99.2%) compared to the original criteria (97.7%; 97.0-98.2%) in diagnosing sepsis and a lower specificity (14.1%, 12.8-15.5%) compared to the original criteria (20.5%; 18.9-22.1%). The modified model demonstrated an area under the curve (AUC) of 0.797 (95% CI, 0.785-0.809; P < .001), outperforming the original model (AUC 0.764; 0.751-0.778; P < .001). Altered mental status had the second highest individual specificity for sepsis (88.4%; 87.1- 89.6%), and third was the reduced heart rate > 75 bpm for patients using atrioventricular nodal blockers criterion (53.9%; 51.9-55.8%). Among 1,164 sepsis patients receiving atrioventricular nodal blockers, 83 additional cases (7.1%; 5.8-8.8%) were identified solely by the modified heart rate ≥ 75 bpm criterion.

Conclusion: The modified SIRS criteria is associated with minimally higher but statistically significant rates of identifying sepsis at the cost of reduced specificity. These new criteria identify an additional 1.21% of septic patients in the vulnerable elderly population with a 6.4% reduction in specificity. Overall, sensitivity increased marginally at the expense of specificity with the modified criteria. However, the new criteria of altered mental status and 75bpm for patients taking atrioventricular nodal blocking medications had the second and third highest individual specificity for sepsis, respectively. 

Introduction: Emergency department (ED) use declined drastically in the early stages of the COVID-19 pandemic. While the immediate effects of the pandemic are well-characterized, the longer term recovery patterns in ED use and regional differences in these patterns remain poorly understood. In Canada, provincial differences in public health policy responses may have influenced ED utilization during the pandemic, where Ontario implemented more restrictive and prolonged public health measures compared to Alberta, making Canada an ideal place to examine how regional variation in policy impacted ED use. Our objective in this study was to evaluate the impact of the pandemic on patterns of ED use in Ontario and Alberta and explore the potential differences in these patterns.

Methods: Our primary outcome measure was the monthly count of all-cause ED visits in Ontario and Alberta. We obtained 146 entries of monthly counts of all-cause ED visits from April 2011–May 2023 (73,690,650 ED visits in Ontario and 27,132,554 in Alberta) from 206 EDs in Ontario and 113 EDs in Alberta and conducted a retrospective, interrupted time series analysis. Negative binomial regression models were used to estimate trends before and after the pandemic onset in March 2020 in each province and to test cross-provincial differences.

Results: Ontario and Alberta experienced immediate and statistically significant reductions in monthly ED visits following the pandemic onset by 26.9% and 27.7%, respectively. Pandemic trend showed gradual recovery in both provinces. However, by May 2023 ED volumes in Ontario remained 5.5% below the expected volume, while Alberta’s exceeded it by 2.5%. Relative risk (RR) estimates confirmed significant declines in ED volumes during the pandemic in Ontario (RR = 0.64) and in Alberta (0.72). No statistically significant cross-provincial differences were observed in the immediate reduction and the speed of recovery of the ED utilization during the pandemic.

Conclusion: Ontario experienced a decline in ED visits followed by a steady recovery that did not reach pre-pandemic projections, raising concern for missed care. Alberta also experienced an immediate decline but demonstrated a slightly faster recovery, eventually surpassing pre-pandemic projections. Model parameters characterizing the ED use patterns in each province were not significantly different, despite differences in provincial public health policies introduced in the pandemic’s early phases. Thus, broader national or individual level factors may have contributed more substantially to healthcare utilization than provincial policies during the COVID-19 pandemic. 

Introduction: Diastolic dysfunction occurs when the ventricular walls of the heart stiffen and fail to relax appropriately. Early recognition in the emergency department (ED) enables identification of heart failure with preserved ejection fraction, guides antihypertensive and diuretic therapy, and facilitates timely cardiology referral to reduce morbidity and readmissions. Prior studies show emergency physicians (EP) can diagnose diastolic dysfunction with point-of-care ultrasound using mitral valve inflow velocities and tissue Doppler indices, although quantitative measurements are time-consuming. This study evaluates whether EPs can accurately diagnose and grade diastolic dysfunction based solely on visualization of mitral valve inflow velocities and tissue Doppler wave forms.

Methods: After a focused training session, EPs (postgraduate year 1-3 residents, ultrasound fellows, and attendings) were randomized to review archived echocardiograms obtained by certified technicians. The EPs visually assessed echocardiograms for diastolic dysfunction (grades I-III) and whether they were considered “severe” (grade III). Their interpretations were then compared with a cardiologist’s gold-standard readings.

Results: Twenty-three EPs interpreted 100 echocardiograms containing 25 of each grade. Overall accuracy for exact grading was 54.8%. Ultrasound attendings scored highest (70.0%), followed by non-ultrasound fellows (55.0%), attendings (54.0%), and residents (52.9%). For identification of any diastolic dysfunction, the EPs had a sensitivity of 84.6% (95% CI, 78.5-89.5%), specificity of 44.8% (95% CI, 31.7-58.5%), positive likelihood ratio (+LR) 1.53 (95% CI, 1.21-1.95), and negative likelihood ratio (-LR) 0.34 (95% CI, 0.22-0.54). For identification of severe diastolic dysfunction, the EPs’ intrepretations had a sensitivity of 59.4% (95% CI, 46.4-71.5%), specificity of 90.3% (95% CI, 85.0-94.3%), +LR 6.15 (95% CI 3.75-10.09), and -LR 0.45 (95% CI, 0.33-0.61).

Conclusion: Emergency physicians can visually estimate diastolic function using mitral valve inflow velocities and tissue Doppler morphology with good sensitivity for detecting dysfunction and high specificity for identifying severe cases. 

Introduction: Sepsis, a critical condition caused by dysregulated host responses to infection, frequently involves cardiac complications. Electrocardiogram (ECG) provides valuable insights into the cardiovascular status of sepsis patients and may guide early interventions. However, comprehensive data on ECG patterns in sepsis patients within the emergency department (ED) is limited. In this study we aimed to identify common ECG rhythms and patterns in sepsis patients presenting to the ED and analyze their association with poor clinical outcomes, including intensive care unit (ICU) admission, prolonged hospital stay (> 14 days), and in-hospital mortality.

Methods: We conducted a retrospective observational study using data from 3,598 adult sepsis patients presenting to the ED of Srinagarind Hospital, Khon Kaen, Thailand, between January–December 2023. ECG abnormalities were extracted from the automated ECG interpretation system. Cardiologists reviewed only ECGs flagged as potential acute infarction or ST elevation to confirm acute coronary syndrome patterns. We analyzed associations between ECG abnormalities and clinical outcomes using univariate logistic regression models.

Results: Common ECG rhythms in sepsis patients included sinus rhythm (41.7%), sinus tachycardia (39.0%), and atrial fibrillation/flutter (8.8%). The automated algorithm identified prolonged QT intervals (54.4%) and ST elevation in 10.4% of patients; however, only 1.7% met cardiologist-confirmed criteria for acute coronary syndrome. Compared with patients with better outcomes, those with poor outcomes more frequently had atrial fibrillation/flutter (14.9 vs. 7.5%), new-onset atrial fibrillation/flutter (6.0 vs. 2.8%), QT prolongation (61.6 vs. 52.9%), and abnormal T waves (10.9 vs. 8.4%), corresponding to odds ratios of 2.19 (95% CI, 1.77-2.69), 2.24 (1.50-3.28), 1.43 (1.20-1.70), and 1.34 (1.01-1.76), respectively.

Conclusion: Certain ECG abnormalities in sepsis patients are associated with adverse clinical outcomes. Incorporating ECG assessments into sepsis protocols may enhance the early identification of high-risk patients and improve management strategies in the ED.

Introduction: The Standardized Letter of Evaluation (SLOE) is a core component of emergency medicine (EM) residency applications, designed to assess clinical performance, professionalism, and leadership potential. While its utility in selecting residency candidates is well established, its association with future leadership roles, such as chief resident, remains unclear. Identifying early indicators of leadership potential could inform both recruitment and resident development efforts. In this study we aimed to evaluate whether medical students’ SLOEs are associated with subsequent selection as chief residents, offering insight into the SLOE’s potential to forecast future leadership within EM.

Methods: We conducted a retrospective review of 243 de-identified SLOEs from 101 residents at a single urban, academic EM residency program between 2015–2021; 21 residents (20.8%) went on to hold chief resident roles between 2018–2024. The SLOEs were numerically scored across 10 groups. We excluded SLOEs lacking quantitative ratings or written for non-core EM rotations.

Results: Chief residents scored significantly higher than non-chief residents in three of 10 evaluated domains following Bonferroni correction for multiple comparisons: teamwork (P = .002), overall comparison to EM applicants from prior years (P = .003), and anticipated rank-list placement (P = .004). No significant differences were found in domains such as clinical reasoning, communication skills, or commitment to EM. Sex distribution among chief residents was approximately equal, minimizing concerns for confounding.

Conclusion: The Standardized Letter of Evaluation may offer limited but meaningful insight into future leadership potential in EM. Traits such as teamwork, self-directed learning, and perceived autonomy may distinguish future chief residents even prior to matriculation. However, traditional academic indicators alone may not identify those who ultimately assume leadership roles. These findings underscore the need for structured leadership development opportunities for all residents, regardless of early SLOE evaluations. Future research should explore whether intentional cultivation of leadership competencies throughout training can better support residents in achieving roles such as chief resident and beyond.

Objectives: Effective resuscitation leadership is essential for emergency physicians, yet formal training in this domain remains limited within emergency medicine (EM) residency programs. Generic healthcare teamwork frameworks do not fully address the unique demands of EM resuscitations, including diagnostic uncertainty, time pressure, and frequent interruptions. Without consensus on the key competencies or instructional strategies needed to teach these EM-specific resuscitation leadership skills, residency programs lack clear curricular guidance. We aimed to achieve expert consensus on the learning objectives and educational strategies for a longitudinal model resuscitation leadership curriculum for EM residents using a modified Delphi approach.

Methods: We conducted a three-round modified Delphi study from September 2024–March 2025. Panelists were selected based on expertise in resuscitation leadership education and scholarship. We conducted a PubMed literature review that identified 19 references encompassing 244 skills and synthesized them into 31 initial learning objectives. By consensus, 12 educational strategies were identified. Panelists rated the importance of proposed learning objectives and educational strategies derived from a review of the literature and existing assessments. Additional items were added and refined across rounds based on panelist feedback. Consensus thresholds were predefined as > 75% agreement for inclusion (rated as important/very important or agree/strongly agree).

Results: Twelve experts participated in the study, representing diverse institutions and training backgrounds. By Round 3, consensus was achieved for 28 learning objectives and 13 educational strategies. Items were thematically categorized, and supplemental resources were developed to guide curricular implementation. The final curriculum integrates cognitive, procedural, and non-technical competencies contextualized within resuscitation environments and sequenced to support longitudinal skill development.

Conclusion: This study presents the first expert consensus-derived resuscitation leadership curriculum for EM residents. The resulting framework provides EM residency programs with adaptable, evidence-informed guidance to support structured, longitudinal resuscitation leadership training and improved resuscitation team performance.

Introduction: Over 335,000 adults are hospitalized annually for proximal hip fractures, with the incidence of these injuries increasing as the population ages. Our objective in this study was to compare pain scores of patients with proximal hip fracture 30 minutes after undergoing a combined fascia iliaca plus femoral nerve block vs standard fascia iliaca block.

Methods: We performed a retrospective cohort study including all isolated proximal hip fracture patients > 18 years of age who underwent regional anesthesia by ultrasound fellowship-trained emergency physicians in a community hospital emergency department between January 1, 2022– September 26, 2024. We excluded patients with distal femur fractures, those who had received additional pain medications within 30 minutes of the block, or those who could not reliably relay a pain score. The primary outcome was subjective pain scores (scale 1-10) after undergoing regional anesthesia.

Results: Of 89 patients who underwent regional anesthesia for proximal hip fracture, 20 were excluded. A total of 31 fascia iliaca blocks and 38 combined blocks were performed. Patient age, weight, and pre-procedure pain scores were similar between the groups. Females were more predominant in the fascia iliaca block group (67.7% vs 42.1%; P = .03). On average, patients who received the combined block rated their post-procedure pain score 1.4 points lower than those who received a fascia block (3.8 vs 5.2/10, P = .01). This finding was consistent when controlling for sex and pre-procedure pain scores (β: 1.5; 95% CI, 0.6-2.4).

Conclusion: Undergoing combined fascia iliaca plus femoral nerve block was associated with lower pain scores after 30 minutes compared to isolated fascia iliaca block in patients with proximal hip fractures. These patients may benefit from using this single-injection procedure for improved pain control.

In the United States from 2014-2024, an average of 18.2 national disasters per year caused over a billion dollars in inflation-adjusted damage, compared with 3.3 national disasters per year during the 1980s. The increased frequency and intensity of severe weather phenomena—attributed by climate science experts to climate change—have raised concerns about national emergency preparedness. One aspect of emergency preparedness is the functioning of emergency departments (ED). In this narrative review, we examine patterns of ED use and operations amid natural disasters in the US, with a special focus on vulnerable populations. The review highlights studies comparing ED use patterns between periods of disaster and non-disaster for specific disaster types, including hurricanes, wildfires, floods, winter storms, and earthquakes, as well as studies that identify disaster-mediated changes in ED visits among specific populations, including the elderly, individuals experiencing homelessness, children and youth with special health care needs, and individuals with chronic medical and psychiatric conditions. Finally, we highlight the challenges posed to EDs by these disasters, including crowding, resource scarcity, and operational strain, and proposed steps to strengthen ED preparedness for climate-related disasters.

Introduction: Vital sign monitoring is essential to the management of critically ill and injured patients. Recent advances in patient monitoring systems have the potential to improve outcomes by providing real-time data and predictive insights, which are particularly valuable in prehospital and resource-limited settings. We conducted a systematic review of the literature to assess the capabilities, performance, and clinical impact of patient monitoring technologies designed for these environments.

Methods: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review using PubMed and Scopus search engines on studies published between 2018-2022 that proposed or tested novel patient monitorint systems with utility in prehospital or resource-limited settings. Two reviewers independently screened studies, and discrepancies were resolved by a senior author. Of 217 studies identified in the search, 40 met the proposed inclusion criteria.

Results: Compared to standard platforms, wearable and contactless systems for patient monitoring demonstrated high accuracy but with delayed responsiveness and less reliable temperature measurements. Artificial intelligence (AI)-based platforms consistently outperformed well-accepted scoring systems in predicting outcomes such as mortality, intensive care unit (ICU) admission, and clinical decompensation. In this review we summarize proposals for prototypes of integrated patient monitoring systems that combine biosensors, AI algorithms, global positioning system, and wireless communication designed to facilitate triage in prehospital settings, and we then compare their components. Various platforms were piloted and demonstrated minimal disruption to workflow and positive user feedback, although most lacked comprehensive cost analyses. 

Conclusions: Emerging patient monitoring system technologies may enhance remote triage and care delivery, particularly in resource-limited settings. However, significant barriers remain, including cost, limited testing in real-world environments, and the lack of higher tiers of evidence. Future efforts should prioritize field-based testing, usability in low-resource settings, and cost-effectiveness analyses to guide clinical adoption.

Objectives: Mobile integrated health programs have emerged as a means to reduce avoidable emergency department (ED) visits and optimize healthcare resource utilization. Such models are estimated to cost less than ED encounters but may be more costly than traditional ambulatory services. However, mobile integrated health is not reimbursed by most payors, and its operational costs are poorly understood. Our objective if this study was to estimate the costs of delivering acute care services through a mobile integrated health program.

Methods: This study was performed at an urban academic tertiary care center with a hospital-affiliated emergency medical services agency in which a mobile integrated health program is embedded. Home visits are conducted by paramedics who collaborate with a remotely located, actively engaged physician to evaluate and treat patients. We compiled cost data derived from real-world mobile integrated health patient encounters to account for all the resources needed to perform acute care visits. Mobile integrated health visits were categorized as basic, involving lower complexity evaluations with limited diagnostics, or advanced, which include higher acuity care with intravenous medications and multiple diagnostic studies. We used Monte Carlo simulations to provide probabilistic estimates of the cost per visit of mobile integrated health-facilitated care. 

Results: Using a Monte Carlo simulation with 1,000 iterations, we established cost estimates for basic and advanced service categories of mobile integrated health services.  The median cost of a basic call is $550 (90% CI [$512–$676]), and $1400.00 for an advanced call (90% CI [$810–$1,813]).  

Conclusion: This project, which generated real-world cost estimates for mobile integrated health programs delivering acute care services, offers essential context for policymakers and payors evaluating sustainable reimbursement models. We estimate that mobile integrated health services cost more than the mean cost of most outpatient clinic visits ($160) but remain substantially less expensive than emergency department visits ($2,715) or inpatient admissions ($24,680). These findings should be interpreted with caution, given the limitations of simulation-based estimates in a single system. They highlight the ongoing need to prospectively and rigorously assess the cost-effectiveness of mobile integrated health models.

Introduction: The concept of commensality, the act of eating together, is as old as humanity and has been extensively explored in the social sciences and humanities. We sought to assess whether an interdepartmental commensality program would improve cross-departmental familiarity, willingness to engage in scholarly discussions, and enhance collaborative efforts.

Methods: A program was established to arrange dinners for emergency department (ED) faculty with six other departments, after which participants were surveyed about their thoughts on the dinner’s impact. Our primary outcome measure was change in perceived familiarity with interdepartmental colleagues. Secondary outcomes included willingness to engage in academic discussion and perceived likelihood of future collaboration. A program was established to arrange dinners between the ED and six other departments (obstetrics and gynecology, neurology, psychiatry, internal medicine, otolaryngology, and ophthalmology), followed by a post-event survey.

Results: A total of 55 of 81 participants responded to the survey (response rate 67.9%). We found significant increases in familiarity with colleagues (2 pre- to 4/5 post-intervention, P < .001), willingness to discuss academic issues (4 to 5/5, P < .001), and anticipated collaborations (2 to 5/5, P < .001).

Conclusion: An interdepartmental commensality program initiated by an institution’s department of emergency medicine can potentially improve interdepartmental collaboration, familiarity, and discussions.

Introduction: Diagnostic uncertainty significantly impacts patient safety in emergency medicine, leading to missed diagnoses and severe harm. Current predictive models primarily emphasize diagnostic likelihood without explicitly addressing potential clinical harm from errors. We propose Triage and Risk Assessment via Cost Estimation (TRACE), a machine-learning framework that incorporates expected-value calculations, defined as the probability-weighted estimate of clinical harm, and patient similarity metrics to address both diagnostic accuracy and risk assessment.

Methods: Using the Medical Information Mart for Intensive Care IV - Emergency Department dataset, we developed TRACE, comprising two modules: the expected value-powered triage index (TRACE-T), which calculates expected patient acuity from vital signs and chief complaints, and the patient similarity diagnosis engine (TRACE-Dx), which predicts diagnoses by identifying historically similar patients and weighing their outcomes by clinical harm. We assessed TRACE-T’s predictive performance, our primary outcome, using decision trees, random forests, and Lasso (least absolute shrinkage and selection operator) regression. The TRACE-Dx predictions, our secondary outcome, were evaluated through string matching (comparing diagnostic text) and sentence embedding similarity (comparing diagnostic phrases).

Results: Our final analysis included a total of 2,501 patients from the dataset, due to requirements for diagnosis-string cleaning and computational demands of similarity calculations. Within this subset, TRACE-T significantly improved triage prediction accuracy, with the random forest classifier’s accuracy increasing from 0.605 to 0.705 (P = .04) and demonstrating a notable reduction in root mean square error from 0.635 to 0.541 (P < .001). The decision tree model improved from 0.467 to 0.593 (P = .78) but did not reach statistical significance. The TRACE-Dx generated five expected value-ranked predicted diagnoses per encounter (12,505 predictions across 2,501 patients) and achieved average sentence embedding and string match similarities of 93.3% (95% CI, 92.7-94.0%) and 92.5% (95% CI, 90.7-94.3%), respectively, indicating strong alignment with actual outcomes.

Conclusion: Expected value-based clinical harm modeling with patient similarity scoring enhances triage accuracy and diagnostic prediction in emergency care. Triage and Risk Assessment via Cost Estimation provides interpretable, actionable insights that could be incorporated into real-time clinical workflows as decision-support tools to reduce diagnostic uncertainty and improve patient outcomes.

Introduction: Gender and sex equity-promoting (GSEP) clinical research is essential to improving diversity and inclusivity in medicine. In this study we aimed to compare journal impact metrics in emergency medicine (EM) between journals that integrated gender- and sex-based considerations and those that did not.

Methods: We searched the 2023 Journal Citations Report (Clarivate Analytics) for EM journals. Submission guidelines of each EM journal were examined according to the SAGER (Sex and Gender Equity in Research) guidelines and stratified as conforming or non-conforming depending on whether at least one SAGER criterion was met. Our primary outcome measure was the journal impact factor. Secondary outcome measures included other citation and influence metrics: total citations; 5-year journal impact factor; journal citation indicator; article influence score, normalized Eigenfactor score; citable items; total articles; and immediacy index.

Results: Based on our classification system informed by the SAGER criteria, most journals (66%, 31/47) were classified as non-compliant. The EM journals that conformed to the sex and gender equity guidelines were rated higher than non-conforming journals across all studied journal metrics. We found that conforming journals had a significantly higher median difference (MD) than non-conforming EM journals in total citations (MD 1,586; GSEP: 3,599 vs non-GSEP: 901); 2023 2-year journal impact factor (MD 0.8; 2.3 vs 1.4); 5-year journal impact factor (MD 0.7; 2.5 vs 1.9); article influence score (MD 0.26; 0.76 vs 0.47); normalized Eigenfactor score (MD 0.79; 1.06 vs 0.26); citable items (MD 37; 103 vs 56), and total articles (MD 41; 87 vs 42). All differences were statistically significant (P < 0.05). 

Conclusion: Using criteria informed by the Sex and Gender Equity in Research guidelines, most EM journals (66%) were classified as non-conforming to these guidelines. This indicates a significant gap in the integration of gender- and sex-based considerations in EM research publication practices.

Introduction: Among ED visits, presentation for a non-traumatic dental condition represents one of the most preventable, as 79% of these visits are considered avoidable. Our goal was to investigate the association between individual-level socioeconomic status (SES) and emergency department (ED) use for non-traumatic dental conditions.

Methods: In this retrospective, pooled cross-sectional analysis we used data from a database of administrative health claims for members of large commercial and Medicare Advantage health plans. The sample included adults (≥ 18) who presented to the ED between 2017-2021 and had complete data on SES indicators (ie, income, education level, net worth, homeownership, and low-income subsidy status). The primary outcome was ED use for non-traumatic dental conditions, identified via International Classification of Diseases diagnosis codes. We used multivariate logistic regression models with marginal effects to examine the relationship between SES and ED visits, adjusted for demographics, geographic region, and disease burden.

Results: Among 3,894,785 individuals, 74,685 (1.9%) had an ED visit related to non-traumatic dental conditions. Lower SES was significantly associated with increased ED visits for these conditions, with income exhibiting the strongest effect. Compared to individuals earning > $100,000 annually, those earning < $40,000 were 0.7 percentage points (1.5% vs 2.2%) more likely to visit the ED for non-traumatic dental conditions (P < .001). A dose-dependent effect was observed for the composite SES score, with individuals in the lowest SES quartile 1.3 percentage points (1.3% vs 2.6%) more likely to visit the ED compared to the highest quartile (P < .001).

Conclusion: Lower socioeconomic status is associated with higher ED use for non-traumatic dental conditions, underscoring disparities in oral healthcare access. Targeted policy interventions and better integration of oral and medical healthcare systems are needed to reduce preventable ED visits.

Introduction: Emergency physicians pursuing critical care training must enter fellowships designed for internal medicine, anesthesiology, or surgery trainees. In this study we aimed to assess how emergency medicine (EM)-trained fellows are perceived by critical care fellowship leadership compared to their peers and to identify specialty-specific strengths and gaps that may inform targeted educational approaches.

Methods: We conducted a national, cross-sectional survey of program directors and associate/assistant directors of Accreditation Council of Graduate Medical Education-accredited critical care fellowships. Respondents rated the baseline competence of incoming fellows across 11 core critical care domains using a 5-point Likert scale. We compared competency ratings across residency training backgrounds using linear mixed models, accounting for clustering and adjusting for rater specialty where appropriate.

Results: Of 429 distributed surveys, 118 (27.5%) were completed. Our respondents represented internal medicine-based fellowships (63, 53%), surgical fellowships (32, 27%), and anesthesia fellowships (23, 20%). On a 5-point Likert scale ranging from 1 = “Not competent” to 5 = “Very competent,” EM-trained fellows were rated significantly higher than their internal medicine-trained peers in intubation (3.93 vs 1.86, P < .01); vascular access (3.72 vs 2.52, P < .01); point-of-care ultrasound (3.80 vs 2.52, P < .01 ); surgical critical care (2.39 vs 1.99, P < .01); and neurologic emergencies (2.59 vs 2.10, P < .01). Fellows trained in internal medicine were rated higher in ventilator management (2.54 vs 2.06, P < .01); palliation (3.05 vs 2.08, P < .01); and renal physiology/acid-base disturbances (3.18 vs 2.40, P < .01). Slightly different patterns emerged when comparing EM to surgery and anesthesiology trainees, where EM-trained fellows were rated similarly or lower in procedural domains but demonstrated more robust competence in organ-specific physiology and ultrasonography. These patterns remained largely consistent in sensitivity analyses adjusting for rater specialty.

Conclusion: Critical care fellows who trained in EM bring distinct strengths in diagnostics and resuscitation to critical care training, but their educational needs may differ from those of peers within specialty-specific fellowships. Tailoring curricula to address these differences can help ensure all trainees achieve proficiency across core domains.