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

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Introduction: Emergency medicine (EM) residency programs are required to teach quality improvement (QI), yet few adopt a sustainability lens to QI despite broad recognition of the importance of climate sustainability in healthcare. To address this gap, some programs have piloted innovative approaches such as sustainability QI electives or projects, although evidence of their effectiveness remains limited.

Methods: We designed and implemented a sustainability QI initiative to recycle used instruments from three bedside procedure kits (laceration repair, incision and drainage, chest tube placement) commonly used in the emergency department to reduce waste. Our goal was to describe the effectiveness of a financial intervention on instrument recycling by comparing the differences in recycling rates between the baseline and incentive periods using a quasi-Poisson regression analysis.

Results: At the end of the first year of instrument recycling, the recycling rate was 9%. Providing a financial incentive to residents over a two-year period significantly increased the recycling rate to a mean of 24% (standard deviation 13), with a rate ratio of 3.03 (95% CI 1.57–5.85), P < .001. While the residents did not meet their recycling target of 50% to receive the incentive payment, their overall recycling rate increased.

Conclusion: Providing a financial incentive to residents for recycling efforts was modestly successful in encouraging residents to participate in an instrument recycling initiative. Motivating busy clinicians to engage in sustainable practice is challenging; projects that prioritize systems-level changes may be more effective than those that require changes in individual clinical practices.

Introduction: Excessive environmental heat exposure is clearly associated with an increased likelihood that individual patients will suffer adverse health outcomes. Such heat exposure also strains healthcare systems via increased utilization, a burden which can challenge systems’ capacities. Health impacts vary geographically with urban heat islands potentially contributing to higher temperatures and greater health risks. However, those most vulnerable to this exposure are not well identified. Our objective in this novel study was to compare and quantify differences in emergency medical services (EMS) use by selected patients during hot days in Rhode Island. Patients were recruited from low socioeconomic residential locations, stratified by whether they accessed EMS from within one of the state’s “urban heat islands,” or from other locations without “heat island” effects. We also compared selected patient demographic characteristics, and other EMS run data, between events associated with EMS access from these two types of areas.

Methods: This retrospective, cross-sectional cohort study evaluated how the probability of an EMS encounter varied in response to daily mean temperature and the urban heat island status of the encounter location. We aggregated EMS dispatch data, daily mean temperature, urban heat island classification and the Area Deprivation Index of the encounter location. A quasi-Poisson regression model assessed the relationship between EMS encounter frequency and potential risk factors including daily temperature, urban heat island status, year, day of the week, sex, age, and relevant interaction terms. The model was restricted to low socioeconomic, residential encounter locations to reduce confounding (noted elsewhere by year) and focus on the target population. The primary outcome was the rate ratio (RR) of EMS encounters for urban heat island locations vs locations without an urban heat island effect, in response to summer temperatures. Secondary outcomes included RRs of EMS encounters stratified by age, sex, weekday vs weekend, and year.

Results: Higher temperatures were associated with increased EMS call rates across all demographic subgroups. A 5 °F (2.8 °C) increase in mean daily temperature was associated with an increase in an overall EMS encounter rate of 1.5% (RR, 1.015; 95% CI, 1.005-1.031, P = .004). On a weekday in 2021, at 75 °F degrees, 68 EMS encounters would be predicted for the residential, low socioeconomic status locations in the state while at 95 °F, 73 EMS encounters would be expected. The EMS rates were consistently higher in urban heat islands across all study years, after accounting for daily temperature, year, day of the week, demographic characteristics, population size and interactions between age, sex, urban heat island and weekday vs weekend. The largest relative increase in EMS encounters was observed in 2019, with rates 34% higher in urban heat islands compared to locations without an urban heat island effect (RR, 1.34; 95% CI, 1.27-1.42). The smallest increase occurred in 2020 (RR, 1.12; 95% CI, 1.06-1.18).

Conclusion: In residential and low socioeconomic locations, living in an urban heat island increased the probability of an EMS encounter, highlighting potential compounding effects of social and environmental vulnerability. As climate change intensifies extreme heat events, locationally targeted interventions may be critical in reducing heat-related health impacts.

As climate-related health impacts intensify, emergency physicians (EP) increasingly encounter patients whose conditions are influenced by environmental change. To provide care for climate- vulnerable patients in the emergency department (ED), EPs should be educated on the impacts of climate change. The goal of our intervention was to provide a structured climate health educational curriculum to attending physicians, residents, and medical students and assess the perceived effectiveness of the curriculum. A longitudinal climate health curriculum was delivered in a four-part lecture series over the course of three months to medical students, postgraduate year 1-3 emergency medicine residents, and academic emergency attending physicians. We measured learners’ perceived knowledge pre- and post-curriculum with surveys assessing four core areas: 1) climate change topics; 2) climate impacts on human health; 3) confidence in treating medical conditions exacerbated by climate change; and 4) climate change solutions. At the completion of the three-month curriculum, the learners reported a statistically significant improvement in perceived level of knowledge in overall climate health topics in 87.5% (28/32 concepts with P < .05) of concepts assessed during the climate health education curriculum. Specifically, learners reported a perceived knowledge improvement in concepts of general climate change (6/6 topics, P < .05), impacts on human health (7/8 topics, P < .05), confidence in treating medical conditions exacerbated by climate change (8/9 topics, P < .05), and knowledge of climate solutions (7/9 topics, P < .05). Overall, learners reported a higher median likelihood of implementing individual climate solutions after the conclusion of the climate health education curriculum, although this was not statistically significant (5.0 vs 7.0, P = .073). Our model introduces the concept of a longitudinal, lecture-based climate change curriculum to assist in educating resident learners in evidence-based climate health knowledge, assist in preparing EPs to better treat climate-vulnerable patient populations, and share climate solutions. 

Introduction: Climate change represents one of the most significant global health threats, with emergency departments (ED) serving as frontline responders to climate-related health emergencies. While EDs are major contributors to healthcare’s environmental footprint and critical responders for climate disasters, no comprehensive review has examined sustainability and climate-resilience initiatives specifically implemented in ED settings.

Methods: We conducted a scoping review examining literature on sustainable and climate-resilient measures in EDs. Comprehensive searches of PubMed, Scopus, and Embase were performed from inception through November 2024, using terms related to EDs combined with sustainability and climate-resilience concepts. Two reviewers independently screened papers, with inclusion criteria requiring ED-specific focus and concrete sustainability or resilience interventions.

Results: Seven studies met inclusion criteria, representing diverse geographic contexts. Three addressed sustainability interventions including waste reduction, sustainable procurement, device reprocessing, and renewable energy adoption. Case examples demonstrated co-benefits, such as 31% reduction in ambulance carbon dioxide emissions and $3 million savings from device reprocessing programs. All studies described resilience interventions encompassing disaster preparedness, surge capacity, infrastructure continuity, and clinical protocols. However, significant gaps were identified: Only 13-20% of hospitals in surveyed countries had disaster plans, and no studies documented fully operational climate-smart EDs. Global frameworks were referenced but not operationalized in ED settings.

Conclusion: There is a limited body of peer-reviewed studies that describe measures to close the implementation gap between current climate science and operational practices in EDs. Despite extensive policy recommendations and demonstrated benefits, no studies have described any existing programs. Emergency medicine requires translation of conceptual frameworks into measurable interventions, standardized outcome measures, and systematic implementation of climate-smart healthcare practices.

Introduction: Climate change is reshaping emergency medicine (EM) practice through rising temperatures, extreme weather events, and deteriorating air quality. Emergency medicine serves as a critical frontline indicator for climate-sensitive health conditions, yet evidence describing climate impacts across EM subspecialties remains fragmented. This scoping review synthesizes existing literature at the intersection of climate change and EM to identify key findings, knowledge gaps, and priorities for building climate-resilient emergency care systems.

Methods: We conducted a scoping review with reporting aligned to the PRISMA Extension for Scoping Reviews. We searched PubMed, Scopus, and Embase through March 2025, combining climate-related terms with EM terms. Two independent reviewers screened 794 articles, with 35 studies meeting inclusion criteria. We extracted data on study characteristics, climate exposures, EM outcomes, vulnerable populations, and system-level impacts across five EM subspecialties: emergency medical services; trauma; disaster medicine; toxicology; and mental health.

Results: Across 35 studies spanning five EM subspecialties, most examined temperature-related exposures, with additional focus on extreme weather events and air quality. In emergency medical services, heatwaves and compound climate events were associated with increased call volume and operational strain, with vulnerabilities identified among older adults, working-age males, and populations in resource-limited settings. Trauma studies demonstrated consistent associations between ambient temperature and injury patterns, including traffic injuries, falls, and assaults with reproducible lag effects of 1-6 days. Disaster medicine studies highlighted critical preparedness and infrastructure gaps, including limited emergency management capacity, and predictable post-event surges in emergency department (ED) utilization. Toxicology studies linked higher temperatures and air quality changes to increased emergency visits for substance-related overdoses and respiratory conditions, while mental health studies consistently reported increased ED use and hospitalizations for psychiatric and substance use disorders during periods of extreme heat. Across subspecialties, socially marginalized populations, including individuals experiencing homelessness, those of lower socioeconomic status, older adults, and people with mental health or substance use disorders were disproportionately affected.

Conclusion: Climate change is placing increasing strain on emergency care systems while amplifying existing health inequities. Current evidence is limited by geographic concentration in high-income settings, a predominant focus on temperature-related hazards, a lack of evaluated interventions, and insufficient integration of climate projections into health system planning. Addressing these gaps will be essential for developing climate-informed emergency medicine strategies capable of protecting vulnerable populations as climate-related health risks intensify.

Introduction: Heatstroke is a life-threatening condition defined by a core body temperature exceeding 40° C and central nervous system dysfunction. Its onset is potentiated by high heat and humidity, especially if superimposed upon high thermal loads due to exertion or to impaired ability to sweat as associated with the use of certain medications. The condition can trigger systemic inflammation and potentially fatal multi-organ failure. The heart is a primary organ affected; heatstroke-associated myocardial dysfunction may present as tachycardia, arrhythmias, heart failure, or ischemic injury.

Methods: This narrative review was informed by a structured search of PubMed and Embase. The search focused on literature from the past 10 years, supplemented by earlier seminal studies where necessary. Key search terms included heatstroke, myocardial injury, dysfunction, biomarkers, cooling strategies, monitoring, and circulatory support. We prioritized human clinical studies, reviews, and consensus statements on acute management, along with preclinical studies.

Results: Heatstroke-associated myocardial dysfunction has a multifactorial pathophysiology involving direct thermal cytotoxicity, systemic inflammation, endothelial injury, coagulopathy, mitochondrial dysfunction, and dysregulated cell death. Cardiac manifestations include myocardial injury, arrhythmia, and ventricular dysfunction. Early diagnosis requires an electrocardiogram, cardiac biomarkers, and echocardiography. Management is centered on rapid cooling, hemodynamic support, and close monitoring. Refractory cases may require invasive temperature control or mechanical circulatory support.

Conclusion: Heatstroke-associated myocardial dysfunction is a clinically important and potentially reversible complication. Timely cooling, vigilant cardiovascular assessment, and supportive management remain central to care, while targeted therapies and refined risk-stratification strategies require further clinical investigation.

Introduction: Evidence-based medicine (EBM) skills are fundamental to lifelong learning. These can be tracked the same way that procedural skills are tracked—via residency program logs. Review of the logs can inform faculty on the EBM activity of their trainees. An understanding of the topics residents query while on shift can provide insight into where they need further knowledge to provide optimal patient care. Our objective in this project was to categorize the relationship of the clinical questions posed by emergency medicine (EM) residents while working in the emergency department to the American Board of Emergency Medicine (ABEM) Model of Clinical Practice. 

Methods: We conducted this institutional review board-approved study (deemed exempt research) in a postgraduate year (PGY) 1-4 EM residency. A toxicology rotation and fellowship were established during the study period. Residents were required to submit three to five descriptions of EBM activity per 28-day EM rotation block into the program’s management software. We analyzed each complete log submitted from June 2013–May 2020 using the 2019 ABEM Model of Clinical Practice. The clinical questions posed were mapped to the ABEM Model for content, including sub-categories and acuity level. Demographic information in the logs allowed for analysis for ABEM’s pediatric and geriatric modifiers. The primary outcome measure was the number of clinical questions mapped to each section of the Model.

Results: From June 2013–May 2020, 10,444 discrete completed logs were completed by 137 residents. “Procedures and Skills” (n = 1,110, 10.63%) and “Cardiovascular Disorders” (n = 991, 9.49%) were the most prevalent ABEM content areas. “Trauma” (n = 812, 7.77%) and “Drugs and Chemical Classes” (n = 749, 7.17%) were the most prevalent ABEM sub-categories. “Emergent” (n = 7,770, 74.3%) was the most commonly searched ABEM acuity, followed by “lower acuity” (n = 5,341, 51.1%) and “critical” (n = 5,192, 49.7%). Of note, not all conditions have ABEM acuity codes, and some have multiple. Clinical questions addressed issues regarding pediatric patients in 10.16% (n = 1,061) and geriatric patients in 8.05% (n = 841) of logs.

Conclusion: In this single-site cohort, “Procedures and Skills” was the most common source of on-shift questions for EM residents, perhaps representing just-in-time training. “Trauma” was the most common sub-category, potentially the result of a large footprint in the ABEM Model of Clinical Practice. The residency program’s toxicology rotation and fellowship may have influenced the types of conditions treated by residents and the subsequent content of their logs. Furthermore, completing logs on shift may have impacted the mapping to ABEM acuity levels. Programmatic understanding of residents’ on-shift, evidence-based medicine questions could serve to identify educational gaps and opportunities.

Introduction: Telehealth continues to reshape healthcare delivery in the United States. Recognizing its growing importance and the need for advances in education, the Association of American Medical Colleges released telehealth competencies in 2021, and the Accreditation Council of Graduate Medical Education (ACGME) recently proposed a structured telemedicine experience as part of all emergency medicine (EM) residencies. Despite these efforts, it is unclear whether EM residencies have adopted these new educational mandates. Our primary objective in this study was to understand whether (and how) U.S. EM residencies have implemented telehealth education.

Methods: We developed a cross-sectional, national survey to describe existing telehealth curricula among ACGME-accredited EM residencies. Program directors were surveyed via email. Our primary outcome measure was the percentage of residencies with existing telehealth curricula. Secondary outcomes assessed telehealth curricula emphases, implementation barriers, and telehealth’s perceived importance to EM training.

Results: Of 282 U.S.-based EM residencies, 67 programs responded (24% response rate). Of these, only five (7.5%) reported having a formal telehealth curriculum. Programs with curricula were likely to teach real-time telehealth skills (80%) and focus on data collection (80%), patient safety (80%), and communication (60%). Programs without curricula identified prioritization of other curricula (76%), insufficient faculty expertise (65%), and limited infrastructure (50%) as barriers. We also found that 61% of programs viewed telehealth education as of limited importance to EM training. At the same time, program directors expressed interest in the development of asynchronous telehealth content from trusted national EM organizations (60%). 

Conclusion: Formal telehealth curricula remain the exception rather than the rule among U.S. EM residencies. Despite accreditation bodies urging its adoption, telehealth education faces multiple barriers, including limited faculty expertise, lack of telehealth infrastructure, and low perceived education importance. Our research suggests that national organizations may play a key role in providing early telehealth education while programs adapt to these new educational requirements

Background: Emergency medicine (EM) clerkship directors view end-of-rotation exam scores as one of the most important components in the assessment of medical student performance. Understanding factors that may impact end-of-rotation exam scores is important because strong performance during fourth-year EM clerkships is crucial for matching in EM residency. One factor that may affect exam scores is increased experience through clinical encounters. Our objective in this study was to assess the relationship between the number of clinical encounters and end-of- rotation exam scores. 

Methods: This was a single-site, retrospective study involving fourth-year medical students who completed a four-week EM elective between 2021–2024. We obtained exam scores and student home/away rotation status from clerkship evaluation records. The number of clinical encounters was extracted from electronic health records (EHR) via two exposure measurement methods: 1) signed notes only; and (2) signed notes or assignment to the care team on electronic EHR. We used a multivariable linear regression model to assess the impact of clinical encounters and home/away rotation status.

Results: We included 108 students in this analysis. The linear regression coefficient for each clinical encounter was 0.134 (P = .02) and 0.089 (P = .09) for the two exposure measurements, respectively. Away rotation status, when controlled for the number of patients seen, demonstrated a coefficient of 2.627 (P = .06) and 2.464 (P = .08).
Conclusion: The number of clinical encounters and home/away status had minimal to no impact on end-of-rotation exam scores.

This scholarly perspective explores the integration of competency-based medical education (CBME) within graduate medical education assessment systems, specifically the clinical competency committee (CCC). We discuss the role of the CCC in operationalizing the core components of CBME, providing guidance on best practices-related meeting structure, assessment data, and learner outcomes. By analyzing the evolving responsibilities of faculty assessors and the impact on learner progression toward unsupervised practice, this perspective highlights challenges and strategies for successful implementation of CBME principles in medical education, including an outline to use when discussing each trainee in CCC meetings.

Introduction: Emergency physicians commonly receive feedback in the form of performance metrics such as patients seen per hour. Reviewing metrics has been associated with increased stress and burnout. Although effects on efficiency have been examined, studies have not yet investigated the potential psychological and motivational impacts of providing performance metrics to residents during training. In this study we explore residents’ interest in receiving performance metrics during training and how receiving performance metrics might affect their 1) perceived pressure and motivation to change performance, 2) perspectives on the importance and actionability of metrics, 3) perceived readiness to receive metrics after graduation, and 4) possible effects on their postgraduate career plans. 

Methods: Senior emergency medicine residents at a single, quaternary-care training center completed an anonymous pre-metric survey using a 5-point Likert scale of agreement (1 = strongly agree, 5 = strongly disagree) on the psychological and motivational impacts of receiving performance metrics. All senior residents, regardless of survey completions, were then given the option to view their personal performance metrics in comparison to deidentified metrics for the senior classes. Residents who viewed their metrics were offered the opportunity to complete the post-metric survey, which was identical to the pre-metric survey. Resident interest in viewing their metrics was recorded, and we compared survey responses using unpaired t-tests. 

Results: All 26 residents (100%) chose to view their metrics, 25 (96%) completed the pre-metrics survey and 17 (73%) completed the post-metrics survey. After receiving performance metrics, residents reported feeling less pressure to change their performance (pre-metrics mean 2.32 [standard deviation 0.80]), post-metrics mean 3.05 [0.71], P < .01), and they reported feeling more prepared to receive metrics after graduation (pre-metrics mean 2.32 [0.95], post-metrics mean 1.68 [0.58], P = .01]. There was no significant change in residents’ responses to questions about metrics perceptions, motivation, or interest in administrative leadership after graduation. 

Conclusion: This single-site, academic study indicated that senior residents are interested in seeing their personalized and deidentified group performance metrics and that viewing these metrics increases their sense of preparedness for graduation without necessarily affecting the pressure or motivation they felt during training.

Introduction: As electronic cigarette (e-cigarette) use becomes more prevalent, understanding how populations perceive the harms associated with use is vital for tailoring public health interventions. Our aims in this study were to explore the perceptions of health risk associated with e-cigarettes among young patients in the emergency department (ED) who consume e-cigarettes as well as similarly aged medical students regardless of e-cigarette use and to determine medical students’ perception of their curriculum to prepare them for future counseling of patients on e-cigarette use.

Methods: A cross-sectional survey was completed by 276 participants: 90 ED patients 18-35 years of age who had ever used e-cigarettes (4.2% response rate) and 187 medical students from a U.S. allopathic medical school (17.7% response rate). Our primary outcomes were perceptions of health risks associated with e-cigarette use and medical student perceptions of the medical school curriculum. The secondary outcome was perceptions of e-cigarettes compared to tobacco cigarettes and perceptions of medical students’ readiness to counsel patients on e-cigarette use. Bivariate analyses using chi-square tests assessed differences between groups.

Results: We received 90 completed surveys from ED patients, and 187 from medical students. The majority of ED patients reported believing that e-cigarette use can lead to lung injury (77.8%), heart disease (30%), and cancer (82.2%). Medical students were more likely than ED patients to associate e-cigarette use with harm (lung injury, 94.7% vs 77.8%, P < .001; heart disease, 84.0% vs 70.0%, P = .007; and cancer 90.9% vs 82.2%, P = .037). A modest proportion of ED respondents stated that e-cigarette use did not carry risk of lung injury (22.2%), heart disease (30%), and cancer (17.2%). Most medical students (61.0%) believed that their medical school curriculum did not prepare them for future conversations with patients about e-cigarettes, and over half of the students (54.0%) expressed low confidence in counseling patients.

Conclusion: In our population, a significant proportion (20-30%) of ED patients did not perceive risk with e-cigarette use, suggesting room for education and intervention in this population. Medical education is likely associated with increased awareness of risk of e-cigarette use. Medical students generally did not feel prepared for the growing need to counsel patients on e-cigarette use, suggesting medical curricula could be adapted to meet this need.

Introduction: Older adults are increasingly presenting to emergency departments (ED) with psychiatric emergencies amid limited inpatient psychiatric capacity, resulting in prolonged ED boarding. Our primary objective was to quantify ED boarding duration for older adults awaiting psychiatric hospitalization in community EDs. We examined whether longer boarding was associated with functional decline and physical restraint.

Methods: We conducted a retrospective cohort study of ED encounters among adults ≥ 65 years of age who received a behavioral health evaluation by emergency services program (ESP) clinicians (non-prescriptive behavioral health professionals) who determined psychiatric level of care in two community EDs. The study period was from January 2023–June 2024. The primary outcome was boarding duration. We measured boarding duration from initiation of a psychiatric bed search to ED departure or psychiatric clearance. Secondary outcomes were functional decline (new loss of physical function that impaired activities of daily living, identified from serial nursing documentation during the ED stay) and physical restraint episodes. 

Results: Of 334 behavioral health encounters (mean age 76 years ± 7.4 years), 180/334 (53.9%) boarded ≥ 24 hours. The median boarding duration for psychiatric hospitalization was 44 hours (interquartile range 24-70). Functional decline occurred in 42/334 (12.6%) and restraint episodes in 27/334 (8.1%), with both events occurring only among encounters boarding ≥ 24 hours. Patients with neurocognitive disorders (157/334, 47.0%) had higher rates of functional decline (difference 17.1%, 95% CI, 7.3-26.4; P < .001) and restraint episodes (difference 11.2%, 3.0-19.1; P < .001) compared to patients without neurocognitive disorders.

Conclusion: In this community ED cohort, older adults awaiting psychiatric hospitalization frequently experienced prolonged boarding, associated with higher rates of functional decline and physical restraint. Limitations include the retrospective design and reliance on nursing documentation to identify functional decline, with wide confidence intervals due to small event counts, limiting causal inference.

Introduction: Emergency department (ED) patients exhibit higher rates of depression than those in primary care and the general population, but it is unclear whether these symptoms reflect chronic conditions or transient responses to acute stress. Our objective in this study was to evaluate the longitudinal trajectory of depression and anxiety identified in the ED to inform evidence-based screening and intervention strategies.

Methods: Adult, English-speaking ED patients with adequate literacy who presented to two urban academic EDs with somatic (non-psychiatric) chief complaints completed six mental health screening assessments at enrollment. Of 262 approached patients, 188 were enrolled, representing approximately 0.5% of all adult ED visits (188/37,898) during the study period. Follow-up assessments were completed through a secure phone app at one, two, and four weeks after ED discharge. The primary outcome was the longitudinal stability of depression and anxiety symptoms. The secondary outcome was differences in follow-up completion rates by baseline mental health status.

Results: Among 188 patients with baseline assessments, 44 (23%) screened positive for major depressive disorder, 17 (9%) for moderate/severe depression, and 34 (18%) for moderate/severe anxiety at baseline. Overall, 50 patients (27%) screened positive for at least one of these conditions. Follow-up responses at weeks 1 (n = 42, 22%), 2 (n = 41, 22%), and 4 (n = 27, 14%) showed no significant changes in levels of depression as measured by the Computerized Adaptive Test-Depression Inventory or severity of anxiety as per the Computerized Adaptive Test for Anxiety severity. High intraclass correlation coefficients (0.76-0.84) for all measures indicated inter-individual differences accounted for most variance. Stability of the Computerized Adaptive Diagnostic Test for Major Depressive Disorder ranged from moderate to substantial (Cohen kappa: 0.74 at week 1 to 0.46 at week 4). Patients who were positive for major depressive disorder had significantly higher follow-up completion rates at weeks 2 and 4 (P = .04).

Conclusion: High baseline rates of depression and anxiety highlight the substantial mental health burden in ED patients. Among those who completed follow-up assessments, severity scores remained stable, suggesting these symptoms reflect ongoing conditions rather than transient stress. Future work should improve follow-up responses and assess whether ED-based identification and treatment improve outcomes.

Introduction: The opioid epidemic remains a public health crisis in the United States. Naloxone is a cornerstone of overdose reversal, and its increasing availability to bystanders has improved immediate survival. However, little is known about how bystander naloxone administration influences use of emergency medical services (EMS), particularly patient refusal of transport. Understanding these dynamics is critical for development of EMS protocol and harm reduction strategies. 

Methods: We performed a retrospective cohort study of suspected opioid overdoses reported to the Connecticut Statewide Opioid Reporting Directive (SWORD) between November 1, 2019–June 30, 2024. The primary outcome was EMS transport refusal, defined as non-transport after naloxone administration. The primary exposure was initial naloxone administrator (bystander vs first responder). Secondary variables included naloxone dose frequency, patient demographics, and time. Bivariate tests compared group differences. We used multivariable logistic regression to assess the association between bystander naloxone and refusal, adjusting for covariates. To evaluate temporal trends, we performed separate logistic regression models with calendar quarter (Q) modeled as a continuous variable (Q1 2020–Q2 2024). 

Results: Among 15,025 nonfatal suspected overdoses involving naloxone in Connecticut, bystanders were initial administrators in 18%. Transport refusal occurred more often after bystander administration compared to first responder administration (16.1% vs 6.2%). In adjusted analyses, bystander administration was associated with nearly threefold higher odds of refusal (adjusted odds ratio [aOR] 2.90; 95% CI, 2.53-3.31). Multiple-dose incidents were associated with decreased refusal (aOR 0.83; 0.72-0.93). During the study period, bystander administration increased from 15% in Q4 2019 to 24% in Q2 2024, corresponding to a 3.8% increase in odds per quarter (OR 1.04; 95% CI 1.03-1.05, P < .001). Refusal more than doubled from 4% to 12%, with odds increasing 4.5% per quarter (OR 1.05; 1.04-1.06, P < .001). 

Conclusion: Bystander-administered naloxone is increasingly common and strongly associated with higher odds of EMS transport refusal. While refusal does not always equate to unsafe outcomes, it represents missed opportunities for initiation of medications for opioid use disorder, harm reduction counseling, and linkage to care. Emergency medical services agencies should consider strategies such as leave-behind naloxone, peer recovery coach deployment, and EMS-initiated buprenorphine to capitalize on these encounters.

Background: Artificial intelligence (AI) tools are increasingly being explored for medical applications; however, their effectiveness in emergency electrocardiogram (ECG) interpretation is under-investigated. In this pilot study we aimed to evaluate the diagnostic performance of AI interpretation of ECGs by comparing its results to those of an experienced emergency physician.

Methods: We sourced 20 ECG cases representing common critical conditions from publicly available academic repositories—ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, atrial fibrillation, supraventricular tachycardia, ventricular tachycardia, third-degree atrioventricular block, left and right bundle branch block, hyperkalemia, Brugada syndrome, Wellens syndrome, fusion beats, and torsades de pointes.The AI tool ChatGPT-4 and an experienced emergency physician, who served as the reference (gold standard) interpreter, independently analyzed each case across five key parameters: rhythm and heart rate; cardiac axis; ST/T segment changes; preliminary diagnosis; and emergency management recommendation. Full concordance was defined as complete agreement across all five parameters.

Results: Agreement between AI and the emergency physician was observed in 18 of 20 cases (90%). The Cohen kappa was 0.80, indicating substantial chance-corrected agreement. Concordance by diagnostic category was as follows: myocardial infarction (6/6, 100%); arrhythmias including atrial fibrillation, supraventricular tachycardia, and ventricular tachycardia (6/6, 100%); conduction disorders (3/3, 100%); and hyperkalemia (1/1, 100%). Among the atypical or complex ECGs, concordance was 1/1 (100%) for Brugada syndrome, 1/1 (100%) for Wellens syndrome, 0/1 (0%) for fusion beats, and 0/1 (0%) for torsades de pointes. In the torsades case, ChatGPT did not recommend intravenous magnesium sulfate—the standard first-line treatment—despite recognizing the condition.

Conclusion: An AI tool demonstrated moderate diagnostic concordance with one experienced emergency physician in interpreting some common ECG findings in the emergency setting. However, discrepancies, particularly in complex cases and critical management recommendations, highlight the need for larger scale investigations. Our findings from this pilot study do not support the independent use of AI for definitive ECG interpretation or emergency management decisions; it should serve as an adjunct tool that enhances rather than supplants human clinical judgment.

Introduction: Acute chest pain, commonly caused by coronary artery disease, is a frequent reason for emergency department (ED) visits. While sex disparities in the evaluation and treatment of chest pain are well known, there is limited research on sex differences in the use of opioid analgesics for this condition in the ED. In this study we aimed to evaluate sex differences in the administration of opioid analgesics (morphine and fentanyl) and to compare the time to medication administration in patients presenting with acute cardiac chest pain.

Methods: This retrospective observational study included adult patients (≥ 18 years of age) presenting with acute cardiac chest pain and confirmed elevated troponin between 2019–2024. The primary outcome was receipt of intravenous (IV) morphine and/or IV fentanyl. The secondary outcome was time from medication order to administration. For male vs female comparisons, we used t-tests or Mann-Whitney U tests for continuous variables, and chi-square tests for categorical variables. Logistic and linear regression analyses were performed to assess sex differences in opioid administration and time to medication, adjusting for potential confounders.

Results: A total of 2,168 patients were included in the study, with 924 females (42.6%). Among morphine recipients, the median initial IV morphine dose was 5 mg (interquartile range [IQR] 4-5 mg; range 2-6 mg). Males had higher adjusted odds of receiving morphine compared to females (adjusted odds ratio [OR] 1.28, 95% CI, 1.04–1.57, P = .02). Females had a longer unadjusted time from order to morphine administration (median 11 minutes [IQR 6-20] vs 9 minutes [IQR 4-17]; P = .003). Time to fentanyl administration did not differ by sex. In adjusted analyses, there were no significant sex differences in time to morphine or fentanyl administration. 

Conclusion: This study identifies significant sex disparities in the administration of morphine to patients with acute chest pain. After adjusting for other factors, male patients had higher odds of receiving IV morphine compared to females. These findings highlight the need for further research to understand the underlying causes of these disparities and to develop strategies to ensure equitable chest pain management in the ED.

Introduction: Hypertension is a recognized risk factor for acute coronary syndrome and major adverse cardiovascular events, yet its influence on high sensitivity cardiac troponin (hscTn) concentrations and on the prognostic value of intermediate hscTnI results remains uncertain. We assessed whether blood pressure category confounds the relationship between intermediate hscTnI values (4-18 nanograms per liter [ng/L]) and 30-day major adverse cardiovascular events.

Methods: We performed a secondary analysis of the Rapid Acute Coronary Syndrome Evaluation-Implementation Trial (steppedwedge randomized trial across nine Michigan emergency departments [ED] (July 2020–April 2021). From 32,609 patients in the primary trial, we analyzed only those with available hs-cTnI values reported to be in the intermediate range (4-18 ng/L). The first recorded ED blood pressure-determined category: normotensive (< 140/< 90 millimeters of mercury [mm Hg] moderate [140-179/90-109 mm Hg]; or severe [≥ 180/≥ 110 mm Hg]. Generalized linear models and penalized logistic regression examined associations with hscTnI and 30-day major adverse cardiovascular events (allcause death, myocardial infarction, or urgent revascularization), respectively, adjusting for confounders.

Results: Analysis included 23,803 patients. Mean age was 57.5 ± 17.9 years; 57.5% were women and 32.7% Black. Blood pressure categories were normotensive 40.9%, moderate 46.5%, and severe 12.6%. After adjustment, severe blood pressure was associated with a 16% higher mean hscTnI (calculated as %change= 10β – 1; β = 0.064, 95%, CI 0.047-0.082). Major adverse cardiovascular events at 30-days occurred in 148 patients (0.6%), 47 of them normotensive (0.5%), 77 with moderate hypertension (0.7%), and 24 with severe hypertension (0.8%). Compared with normotension, moderate blood pressure independently increased 30-day major adverse cardiovascular events risk (adjusted odds ratio [AOR] 1.47, 95% CI, 1.02-2.13; absolute risk difference +0.25%, 95% CI, 0.01-0.49), whereas severe blood pressure showed no clear association (AOR 1.32, 95% CI, 0.80-2.18; absolute risk difference +0.17%, 95 % CI, −0.09 to 0.43). Estimates were similar in sensitivity analyses limited to patients without coronary artery disease.

Conclusion: Among ED patients with intermediate hscTnI, blood pressure ≥ 140/90 mm Hg confers modestly higher short term risk of major adverse cardiovascular events, but incremental severity beyond this threshold does not add prognostic value. Elevated hscTnI in the context of severely elevated blood pressure likely reflects myocardial stress rather than additional ischemic risk. Clinicians should interpret intermediate troponin results in hypertensive patients cautiously, integrating clinical presentation and established risk factors.

Introduction: Adolescent substance use and substance use disorders are significant public health issues. Our goal was to evaluate the association between adolescent substance use, detected via blood alcohol levels and urine drug screens, and trauma-related outcomes at a Level I pediatric trauma center. Most of the literature is focused on adult trauma patients with limited data in the pediatrics.

Methods: In this retrospective cohort study, we analyzed data from adolescent trauma patients 13-17 years of age presenting to a Level I pediatric trauma emergency department (ED). Demographic data,  Injury Severity Score (ISS), intensive care unit (ICU) admission, hospital length of stay (LOS), and ED disposition were extracted from the Pennsylvania Trauma Systems Foundation Database Collection  System, which includes comprehensive information on demographics, clinical characteristics, and outcomes of trauma patients. These data were compared between patients whose alcohol levels and urine drug screening were positive and negative. Our primary outcome measures were ISS and LOS in the hospital and ICU. Our secondary outcome measures were need for surgery, mortality, and disposition from the ED. Specific substances, including tetrahydrocannabinol (THC), benzodiazepines, and opioids, were further analyzed as drugs associated with these outcomes. We performed multivariate regression models to identify independent associations of blood alcohol levels or urine drug screen positivity with trauma severity and ICU admissions. 

Results: Among 405 adolescents who had toxicology testing done, 11/286 (3.8%) tested positive for alcohol, while 95/377 (25.2%) had positive urine drug screens predominantly for THC (19.9% of the 95 who had a positive screen). Blood alcohol level-positive patients demonstrated significantly lower ISS (P < .001), shorter ICU stays (P. < .01), and shorter overall hospital stays (P< .01) compared to blood alcohol level-negative patients. Conversely, benzodiazepine positivity was strongly associated with higher ISS, increased ICU admissions, and prolonged hospitalization stays. Multivariate analysis showed that older age was associated with increased ISS (β = 0.30 per year, P < .06) and ICU admission (OR 1.16, 95% CI, 1.04-1.28, P < .01). Blood alcohol level and most urine drug screen results were not independently associated with primary outcomes of ISS and LOS in the hospital and ICU, although benzodiazepine positivity was strongly associated with increased ISS (P < .001) and ICU admission (OR ≈ 30, P < .001). 

Conclusion: Adolescent trauma patients who were positive for benzodiazepines were associated with significantly worse outcomes, emphasizing the need for targeted screening and intervention strategies. Alcohol positivity was paradoxically associated with less severe trauma presentations. These findings highlight the complexity of substance use  on adolescent trauma and underscore the importance of nuanced clinical assessments and targeted interventions addressing both substance use and underlying sociodemographic vulnerabilities.

Introduction: The extended focused assessment with sonography in trauma (eFAST) is a point-of-care ultrasound protocol that identifies life-threatening thoracoabdominal trauma. Clinical documentation of the eFAST is essential to convey medical decisions, but the extent of documentation in clinical practice is unknown. This study describes the proportion of eFAST exams that are documented in the medical record, the type of documentation (free text vs procedure note), and clinical factors associated with documentation.

Methods: This prospective, single-center study evaluated the documentation of consecutive eFAST exams performed at a single Level I trauma center between November 2021–November 2022. Research coordinators observed all trauma activations and noted whether any portion of an eFAST was performed. Our primary outcome was the presence of any documentation in the chart. We analyzed secondary outcomes using a multivariable logistic regression model and included the type of documentation (any documentation vs billable procedure note) as well as patient- (body mass index, age, sex, shock index > 1, and presence of pathology on reference test) and operator-level (involvement of ultrasound faculty) factors associated with each type of documentation.

Results: A total of 335 patients had a witnessed eFAST performed during the study period. No documentation was observed in 114/335 (34%) patients compared to any documentation in 221/335 (66%). Most documentation was free text only in 134/335 (40%) patients, with only 87/335 (25.9%) of patients with billable documentation. Regression analysis found that shock index > 1 (adjusted odds ratio [aOR] 7.37; 95% CI, 2.55-31.29), presence of pathology on eFAST (aOR 2.07; 95% CI, 1.24-3.51), and involvement of ultrasound section faculty (aOR 1.93; 95% CI, 1.05-3.66) were significantly associated with an increase in any documentation.

Conclusion: Approximately one-third of performed trauma eFAST exams are undocumented, and only one-quarter of exams have structured documentation that enables billing. Further work is needed to understand factors that can lead to improved documentation quality to communicate results, justify medical decision-making, and augment reimbursement.

Introduction: Traumatic injuries are the leading cause of death in the U.S. of persons < 45 years of age, with 5-10% of all traumas caused by penetrating neck injuries (PNI). The neck contains several large blood vessels that supply the brain; thus, exsanguination is the leading cause of fatality in PNI. Vascular neck trauma is common in assaults, motor vehicle accidents, battlefields, and sporting events, particularly in ice hockey. There is a general lack of guidance on prehospital management of these injuries, and educating first responders, medics, and sports trainers on how to manage these complex injuries is challenging due to high costs, limited availability, and ethical considerations regarding use of cadavers or live animals. Here, we describe the development of a prehospital PNI-hemorrhage curriculum paired with a novel hands-on simulator and its pilot implementation with a group of professional hockey athletic trainers.

Methods: We conducted a literature review to understand previously proposed algorithms for PNI, traumatic life support, combat trauma, and massive hemorrhage. Concepts from each of these algorithms were considered when determining the key steps of managing a PNI and how these should differ from previously proposed algorithms. We developed a synthetic medical simulator and training curriculum in conjunction with the National Hockey League (NHL) to create a training program for athletic trainers and team physicians to improve rapid response. The simulator was designed using computed tomography of a human neck and was fabricated to mimic the material properties of human tissue. 

Results: The algorithm for prehospital management of PNI was developed in three fundamental steps: 1) identify venous vs arterial bleeding patterns; 2) control the hemorrhage; and 3) transfer the patient to a trauma center. The synthetic medical simulator allowed for the simulation of arterial and venous bleeding and was used to train 180 NHL athletic trainers and physicians at their annual meeting in 2024. Voluntary quantitative and qualitative post-training feedback obtained from 46% of trainers who participated was very positive (overall rating 4.7/5).

Conclusion: Penetrating neck injuries are high-risk events that first responders are generally undertrained to manage due to their rarity. Simulation is effective to potentially improve the outcomes of these scenarios, and the use of synthetic medical simulators is cost effective. We developed a novel algorithm, medical simulator, and training curriculum for the management of PNI in conjunction with the NHL for training athletic trainers and physicians.

Introduction: In-situ simulation offers a realistic training environment with a higher level of fidelity compared to other simulation models. It is associated with enhanced knowledge retention and a higher level of composure during real clinical encounters. One common barrier to undertaking in-situ simulation is the concern that it contributes to a delay in providing patient care. In this study we gave patients in the waiting room seven hypothetical emergency medical scenarios, two of which were training simulation scenarios, and we asked them how long they would be willing to delay their care if the different scenarios were actually occurring in the emergency department (ED). Our objective was to investigate whether patients in the ED waiting room would be willing to delay their care if they knew that there were simulation training scenarios occurring.  

Methods: This was a prospective convenience sample of participants conducted at a Level 1 trauma centre. Participants completed a survey that presented seven hypothetical scenarios, including two in-situ simulation scenarios. They were then asked to indicate the amount of additional wait time they would deem acceptable for each scenario.

Results: Responses to the two in-situ simulation scenarios indicated that 342 (40%) and 335 (40.5%) of the 827 study participants, respectively, were willing to wait > 40 minutes for these to occur. In contrast, and after controlling for age, sex, waiting time, and time of recruitment, subjects reported they would tolerate shorter wait times for simulation scenarios than for real patient-care scenarios. [Willingness to wait > 40 minutes for the five real scenarios ranged from 70.5–79.9%, P < .05). 

Conclusion: While patients demonstrated lower tolerance for simulation-related delays than for routine clinical care, our results showed that most were still willing to wait up to an additional hour to allow in-situ simulation to proceed. These findings indicate that in-situ simulation is broadly acceptable to patients and supports its continued use in clinical settings. 

Introduction: Emergency departments (ED) in the United States serve as a safety net for millions, including those with limited English proficiency (LEP). Eight percent of individuals living in the United States have LEP, placing them at risk for language barriers that can adversely affect the quality and safety of their care. Many hospitals lack language-concordant care, especially at the time of discharge. Miscommunication at discharge can lead to adverse health outcomes, including medication errors, poor compliance, and unnecessary return visits to the ED. Our objectives in this study were to evaluate the quality and safety of artificial intelligence (AI)-generated translations of physician-written, patient-specific ED discharge instructions and to assess performance across varying levels of instruction complexity. 

Methods: Emergency physicians wrote free-form discharge instructions, representing patient-specific guidance, which are typically provided at the time of ED discharge. Four topics were selected: abdominal pain; chest pain; wrist fracture; and vaginal bleeding in pregnancy. These instructions were intentionally developed to vary in linguistic complexity and were assessed using the Flesch Reading Ease and Flesch-Kincaid Grade Level scales. Instructions were translated into Albanian, Brazilian Portuguese, and Vietnamese using the AI-based translation tools ChatGPT-4, Microsoft Copilot, and Google Translate. Translations were evaluated for semantic and syntactic accuracy. Criteria included adequacy, fluency, meaning, and severity on a 5-point scale (1 = lowest accuracy, 5 = highest accuracy). Preference and formality were rated on a 3-point scale (1 = lowest, 3 = highest). The primary outcome was the quality and safety of AI-generated translations of patient-specific discharge instructions. Secondary outcomes included the ability to handle varying instruction complexity. Professional medical translators primarily responsible for the written translation of medical text evaluated and scored the translations for accuracy and quality metrics.

Results: Overall adequacy, fluency, meaning, and severity scores were similar across models. ChatGPT-4 (3.79), Microsoft Copilot (3.60), and Google Translate (3.50), showed no statistically significant differences. Albanian translation was an exception, with ChatGPT-4 scoring significantly higher (3.75) than Google Translate (3.19) (P < .001). There were no other significant differences observed for Brazilian Portuguese or Vietnamese. ChatGPT-4 was also found to be the highest rated for Albanian and Brazilian Portuguese. Both Microsoft Copilot and Google Translate produced a total of five potentially harmful translation errors, whereas none were identified for ChatGPT-4. 

Conclusion: Miscommunication during discharge can lead to negative patient outcomes. This study evaluated ChatGPT-4, Microsoft Copilot, and Google Translate in translating ED instructions into Albanian, Brazilian Portuguese, and Vietnamese. ChatGPT-4 performed best overall and produced no harmful translations, and significantly outperformed Google Translate in Albanian. While AI-based translation tools show promise, human oversight remains necessary to mitigate risks from translation inaccuracies. 

Objectives: In light of the ongoing opioid epidemic, emergency clinicians have faced the difficult challenge of managing acute pain while reducing opioid prescriptions. Improved use of non-opioid analgesics could decrease the need for opioid medications in the management of acute pain. Limited work has been done to systematically produce a comprehensive list of non-opioid pharmaceuticals targeted to specific pain-associated conditions.  

Methods: We conducted a scoping review of recent literature for non-opioid pharmaceuticals that could help manage five painful conditions commonly treated in our institution’s ED: abdominal pain; back pain; chest pain; fracture pain; and headache. In November 2023, we identified reviews published from November 2018–2023 in PubMed to curate a list of alternatives to opioids to effectively manage acute pain.

Results: We screened 246 studies that reviewed management approaches for the five chosen conditions that commonly present with pain in the ED and included 23 studies. Acetaminophen and nonsteroidal anti-inflammatory drugs were recommended for all five painful conditions. Ketamine was suggested for abdominal pain, chest pain, and headaches. For back pain, anti-depressants and muscle relaxants were advised. Benzodiazepines and anti-psychotics were indicated for abdominal pain. Triptans, anti-psychotics, and anti-emetics were suggested for headaches. 
 
Conclusion: This review highlights several non-opioid medications for treating acute pain in the ED. The targeted, comprehensive list generated in this study can serve as a practical resource to support alternative-to-opioid programs in EDs by guiding the creation of pharmaceutical order sets tailored to common ED presentations. Ultimately, this tool may help reduce unnecessary opioid exposure and improve patient outcomes in emergency care settings.

Introduction: Intravenous (IV) fluids are routinely administered empirically in the emergency department (ED) for patients presenting with stimulant intoxication (eg, cocaine, methamphetamine, synthetic marijuana), although the literature is sparse regarding the benefits and risks of this practice. Our primary objective in this study was to assess whether empiric administration of IV fluids in the ED is associated with increased discharge length of stay (LOS) among ED patients presenting for stimulant intoxication who were subsequently discharged. 

Methods: This single-center, retrospective cohort study included 100 patients 18-69 years of age who were discharged from the ED with a non-incidental diagnosis related to stimulant intoxication between May 29, 2020–December 31, 2023, based on International Classification of Diseases code and chart review, in addition to a triage heart rate ≥ 90 beats per minute. We excluded patients if the medical decision-making reflected a clear indication for IV fluids or the presence of pre-defined confounding diagnoses or an uncontrolled factor that would have inherently impacted discharge LOS. Our primary outcome measure was discharge LOS. A multiple linear regression model controlled for the potentially confounding secondary outcome measures of age, sex, alcohol involvement, advanced imaging, sedation, and discharge escort. 

Results: A total of 100 patients were included, including 50 (50%) patients who did not receive IV fluids and 50 (50%) patients who did. Median patient age was 35 (interquartile range [IQR] 29-41) and 73% of patients were male. Patients who received IV fluids had a median LOS of 345 minutes (IQR 260-470) vs 305 minutes (IQR 205-413), with multivariable linear regression showing no statistically significant difference (β = 40.3, 95% CI, –13.6 to 94.2, R2 = 0.162). 

Conclusion: This study suggests that empiric IV fluid administration in stimulant-intoxicated ED patients was not significantly associated with discharge length of stay. Although the observed difference and confidence interval suggest the possibility of a clinically meaningful increase in discharge LOS with empiric IV fluid, these findings should be interpreted cautiously. Time is an important resource in high-volume ED settings, and this study suggest the need for judicious use of IV fluids in the absence of a clear indication.

Introduction: Urinary tract infections (UTI) are among the most common bacterial infections diagnosed in the emergency department (ED), yet the urinalysis results can be neither sensitive nor specific for UTI. Our objective was to quantify inter-rater variability of three emergency attending physicians for the clinical diagnosis of UTI, and secondarily to compare the diagnosis made at bedside by the treating clinician with the evaluations of three emergency physician-chart reviewers after the fact.

Methods: Chart reviewers read 18 articles on the diagnosis of UTI before retrospectively evaluating a convenience sample of 473 ED encounters where patients received both a urinalysis and urine culture as part of their ED evaluation. The chart reviewers were blinded to the urine culture results, medications administered and prescribed, and to the treating clinician’s diagnoses. Reviewers were asked to rate the likelihood of UTI based on a 0-4 ordinal scale. A “true positive” UTI occurred when the treating clinician diagnosed the patient with a UTI and the urine culture had ≥10,000 colony-forming units (CFU)/mL of bacteria. We considered a “false positive” to be when the treating clinician diagnosed the patient with a UTI, but the urine culture was < 10,000 CFU/mL of bacteria. A “true negative” occurred when the treating clinician did not diagnose the patient with a UTI, and the urine culture was < 10,000 CFU/mL of bacteria.

Results: Median patient age was 63 years, 355 (75%) were female sex, 409 (86.5%) were White race, and 207 were admitted to the hospital. The inter-rater agreement among the three independent reviewers was high (κ 0.82-0.85) with intraclass coefficient (2,1) = 0.83. However, the reviewers-to-treating clinician agreement was only moderate in the true positives (treating clinician diagnosed patient with a UTI and the patient had a positive urine culture) and lowest in the false positives (treating clinician diagnosed the patient with a UTI, but the urine culture was < 10,000 CFU/mL with κ values of 0.44 and 0.21, respectively). The variables associated with consensus among reviewers were nitrites, leukocyte esterase, and higher urine white blood cells.

Conclusion: There was high consensus among reviewers about the likelihood of a urinary tract infection, but lower consensus when comparing reviewers’ impressions with those of the treating clinician. At bedside emergency clinicians were more likely to diagnose a UTI with a resultant negative urine culture. Further research is needed to improve the diagnostic accuracy of UTI in the emergency department.

Introduction: In 2024 the United States experienced a rare co-emergence of two periodical cicada broods (XIII and XIX), along with annual cicadas. Although not inherently dangerous, cicadas have been linked to allergic reactions and unintentional injuries. The public health impact of this extraordinary event is poorly understood. In this study we aimed to characterize emergency department (ED) and urgent care (UC) visits associated with the 2024 cicada emergence. 

Methods: We conducted a retrospective chart review across ED and UC sites in a large healthcare system in the Midwest and Southeast that coincides with the ranges of the periodical cicada broods, from April 1–July 31, 2024. Electronic health records were searched for “cicada” and common variants. Two emergency physicians in each region reviewed identified records. Data extracted included demographics, diagnoses, visit characteristics, diagnostics, treatments, and outcomes.    

Results: Of 1,304,743 total visits, 68 mentioned “cicada” or a variant; 42 were confirmed as cicada related. Patient ages ranged from 7 weeks to 87 years of age (median 38 years). Trauma was the most common cicada-related presentation (33), followed by falls (21), blunt trauma (6), vehicular/bicycle accidents (3), and other mechanisms. Additional cases involved allergic reactions (3), environmental exposure (2), and neurologic symptoms (2). Imaging was common: 57% had radiographs and 43% computed tomography. Seven patients sustained fractures; one required laceration repair, and six were admitted. 

Conclusion: While the overall health system impact was limited, cicada-related visits revealed important patterns of injury. Findings support the need for public education and preparedness during future mass insect events.

Introduction: Excessive use of force by law enforcement officers is a critical public health issue linked to serious health consequences such as hypertension, post-traumatic stress disorder (PTSD), and depression. While emergency physicians (EP) are often the first to treat patients with excessive use of force-related injuries, the work-life and psychological toll of witnessing these incidents remains underexplored. In this study, we examine how awareness of and exposure to excessive use of force affects the psychological well-being and professional environment of EPs.

Methods: An observational cross-sectional survey was developed by EPs and psychiatrists to assess work-life and psychological impacts of awareness of excessive use of force on EPs. The survey included multiple-choice and Likert-scale questions and used the Impact of Event Scale–Revised (IES-R). It was distributed anonymously to EPs at three Texas academic institutions. We used the Fisher exact test and the Wilcoxon rank-sum test to compare groups. Our primary outcome measure was psychological distress, assessed with the IES-R. Secondary outcome measures included self-reported effects of awareness of excessive use of force on subjects’ work environments, patient care, and interactions with law enforcement.

Results: Of 282 surveys sent to EPs, 43 responded (15%). Eighteen of 40 (45%) reported experiencing work-life impacts and 15 of 40 (37.5%) experienced psychological distress; three did not comment. Abnormal IES-R scores were found in seven (19.6%) of 35 participants; eight did not respond. Participants who noted work-life effects of excessive use of force were more likely than those whose work-life was not affected to report modified patient care approaches (61% vs 0%, P < .001), altered interactions with law enforcement (83% vs 0%, P < .001), and altered interactions with patients (50% vs 0%, P < .001). Psychological distress was more prevalent among participants with personal exposure to excessive use of force compared to those without personal exposure (47% vs 12%, P = .02), and among those with second-hand exposure compared to those without second-hand exposure to excessive use of force (80% vs 56%, P = .04).

Conclusion: This pilot study demonstrates that exposure to excessive use of force is associated with psychological distress and professional impact among emergency physicians, influencing interactions with patients and law enforcement. These findings underscore the need for further characterization of the effects of awareness of and exposure to excessive use of force on EPs. This, in turn, may inform institutional interventions and national protocols aimed at mitigating psychological burden, supporting physician resilience, and promoting high-quality, equitable patient care.

Introduction: Program diversity impacts rank-list creation for emergency medicine (EM)-bound applicants, but how lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and other sexual and gender minorities (LGBTQIA+) identities influence residency selection is unknown. This study investigates general patterns in EM applicant LGBTQIA+ identities, disclosure of those identities, and how LGBTQIA+ factors impact residency selection. Additionally, we present data exploring the relationship between medical school location and the location of top-ranked programs for LGBTQIA+ and non-LGBTQIA+ identifying applicants. 

Methods: We surveyed 2,287 EM-bound United States MD/DO applicants who applied to one of five author EM programs and programs affiliated with the Emergency Medicine Education Research Alliance from May 16–June 30, 2024. The survey included multiple-choice, free-text, and Likert scale questions. Data were explored with descriptive statistics, and we used chi-square and Fisher exact tests to compare differences in proportions. We also analyzed applicants’ medical school state and a graphical representation of the top three positions on their residency rank lists, using inverse-proportional weighting.

Results: Of 445 respondents (19.4%), 59 (13.3%) identified as LGBTQIA+. Gender identities included 173 cisgender men (38.9%), 254 cisgender women (57.1%), one transgender man (0.2%), one transgender woman (0.2%), four non-binary (0.9%), one genderqueer (0.2%), and seven “preferred not to answer” (1.6%). Among LGBTQIA+ respondents, seven (11.9%) disclosed their status within the application, nine (15.3%) during the interview, 18 (30.5%) in both, and 25 (42.4%) did not disclose. Among 56 respondents, 36 (64.3%) supported adding LGBTQIA+ status to the residency application; 20 (35.7%) did not. Of the program factors considered, program diversity (91.1%) and commitment to underserved communities (96.4%) were significantly more important for LGBTQIA+ respondents (P < .01), while proximity to partner(s) (64.3%; P < .01) and program length (66.1%; P = .02) were significantly less important compared with non-LGBTQIA+ respondents. Additional factors that influenced LGBTQIA+ applicants’ rank list included political environment, friendliness of the learning environment, and presence/absence of anti-LGBTQIA+ laws. 

Conclusion: Many LGBTQIA+ applicants do not disclose their identities when applying for residency. LGBTQIA+ respondents value program diversity and commitment to underserved communities, and they consider LGBTQIA+-specific factors such as the presence of anti-LGBTQIA+ legislation. These insights can inform residency programs and recruitment practices.

Introduction: Foreign body removal for airway obstruction is an infrequent skill performed by paramedics, and Magill forceps for removal of a foreign body from the airway is reserved for patients with persistent obstruction. Traditional paramedic instruction uses direct laryngoscopy to visualize foreign body removal. Our objective in this study was to evaluate time to removal of an obstruction comparing hand position and hyperangulated video laryngoscopy vs direct laryngoscopy with Magill forceps.

Methods: A foreign body airway obstruction station was included in paramedics’ annual competency assessment over a two-year period as a quality improvement project. Paramedics were randomized to remove the foreign body with either direct laryngoscopy or hyperangulated video laryngoscopy with a handheld video laryngoscope. Our primary outcome measure was time from blade insertion to foreign body removal. The paramedics had further training regarding hand position prior to the second year’s annual competency assessment. After fitting a mixed-effects statistical model to the data, we included fixed effects of competency assessment year, device used, hand position, and random effect of paramedic. We evaluated the significance of these predictors on the dependent variable of time for removal.

Results: We observed 245 foreign body airway obstruction removals, 77 in year 1 and 168 in year 2. The direct laryngoscopy (n = 123) and hyperangulated video laryngoscopy (n = 122) groups were nearly equal. During year 1, hand position was noted to be an important factor for removal time, as paramedics were seen to use different hand positions. Recording of hand position began during year 1, which excluded 95 earlier observations from year 1. Competency training year was not a significant factor for time to removal. However, direct laryngoscopy was faster at 14.9 seconds [sec], (95% CI 12.9-17.1) than hyperangulated video laryngoscopy at 19.2 sec [16.9-22]; P < .001. Of the four possible hand positions, forceps grasped by the right thumb and either middle or fourth finger, with the hand in a handshake position, and with the forceps superior to the hand was associated with the shortest time to foreign body removal. This optimal hand position was significantly better than the other grasping methods, with a mean of 11.2 sec (95% CI, 10.2-12.4) vs underhand method, 17.5 sec (14.7-21); overhand method, 15.1 sec (10.7-21.2); and multiple positions (27.5 sec, 22-34.5); P < .001).

Conclusion: We found that hand positioning for Magill forceps significantly affected time to foreign body removal. In addition, direct laryngoscopy outperformed hyperangulated video laryngoscopy. Given these findings, training on removal of foreign body airway obstruction with Magill forceps should emphasize optimal hand positioning. Paramedics may also consider the use of direct laryngoscopy over hyperangulated video laryngoscopy in removal of these obstructions. Further research is required to validate these findings.

Introduction: Efficient allocation of physician-staffed emergency medical services (EMS) is crucial for optimal resource use in urban prehospital systems. The rendezvous model differs fundamentally from the traditional ambulance model: It deploys a lighter, nontransport-capable, passenger vehicle that may offer operational advantages, although comparative evidence with regard to traditional models remains limited. In this study we aimed to evaluate the impact of a physician-staffed rendezvous model on response times and physician-staffed crew availability within the EMS system in Košice, Slovak Republic.

Methods: We conducted a retrospective, cross-sectional study, analyzing all primary responses by physician-staffed EMS units in the Košice region from January 2023–March 2025. In August 2024, one of three traditional, physician-staffed transport units was replaced by a physician-staffed rendezvous unit, yielding a post-intervention system with two transport units and one rendezvouz unit, a faster, physician-staffed non-transport vehicle that provides specialized medical care on scene. We extracted time intervals in minutes—response time, time on scene, time to transport initiation, and total time until crew availability—from the national EMS database and compared them to the pre- and post-introduction of the rendezvous model. We analyzed data using non-parametric statistical tests (Mann-Whitney U test, Kruskal-Wallis test), and we conducted a multivariable ordinary least squares regression to adjust for potential confounders.

Results: Of 11,347 eligible cases, 11,094 met the inclusion criteria (8,389 patients treated during the pre-intervention period and 2,705 during the post-intervention period). Of these, 488 patients (4.4% of the overall cohort and 18.0% of the post-intervention cases) were managed by the rendezvous unit. Following rendezvous unit implementation, the mean response time was reduced compared to that of the standard physician-staffed transport units (–0.77 minutes per response; P < .001). The rendezvous unit demonstrated reductions in time to crew availability across districts, with absolute decreases ranging from 11.12 to 18.01 minutes; these differences were statistically significant in all districts except the undefined/border region (P < .001 for each comparison). The time spent on scene was slightly longer for the rendezvous unit in most districts, although these differences did not reach statistical significance. The time to transport initiation showed mixed trends. Ordinary least squares regression confirmed the independent association between rendezvous unit implementation and shorter response times.

Conclusion: Replacing a standard physician-staffed ambulance with a lighter, faster, non-transport rendezvous vehicle improved operational efficiency by reducing response times and expediting physician-staffed crew availability. These findings suggest that the rendezvous model can enhance system-level performance in urban EMS settings by supporting more flexible physician deployment and informing decisions on resource allocation within tiered prehospital systems.

Introduction: The United States faces a high rate of unwanted pregnancies. Despite this, many people continue to face barriers to accessing contraception. The emergency department (ED) can help bridge these gaps, but emergency clinicians must first feel comfortable offering contraceptive services. In this study, we sought to determine emergency clinician comfort in prescribing contraceptives and educating patients on their use. We also gauged clinician interest in receiving education specifically geared toward contraceptive care.

Methods: We conducted an online survey of ED residents, attendings, and advanced practice clinicians at Thomas Jefferson Univerity Hospital and affiliates in both the urban and suburban setting. Questions focused on current practices and interest in an educational session on contraceptive care in the ED.

Results: We received 106 responses representing clinicians from 12 hospitals (estimated response rate 20%). While 61% of respondents reported that they offered contraceptive services less than once a month, 64% reported they were comfortable educating patients on the topic and 51% were comfortable providing prescriptions. Of those comfortable prescribing, 84% stated they would be more comfortable after an educational session, while 58% of those currently not comfortable prescribing believed that education would help (P < .01). Perceived benefit of education was also dependent on age, with clinicians < 35 years of age more likely to perceive a benefit (P < .01), and job title, with residents more likely to perceive a benefit (P = .04).

Conclusion: Our data suggest that many emergency clinicians are open to offering contraceptive services, but lack of education may serve as a barrier. Although limited by self-selection bias, this study demonstrates a robust interest in overcoming this barrier within our sample group. Future work will aim to implement clinician education and assess for translation to clinical practice with the goal of increasing access to contraceptive services.

Introduction: Emergency physicians must consider ovarian torsion in all biologically female patients who present to the emergency department (ED) with abdominal pain. A misdiagnosis can result in detrimental outcomes, such as loss of an ovary. Female patients who present to the ED for evaluation of their abdominal pain may have a computed tomography (CT) or pelvic ultrasound performed to further evaluate for concerning pathology. Our objective in this study was to describe the occurrence of critical or emergent findings on pelvic ultrasound not identified on a concurrent or previously performed CT of the abdomen and pelvis.

Methods: We conducted a retrospective chart review of ED visits from January 1–December 31, 2021 at a large, suburban, academic medical center. Eligible patients were adult females (≥ 21 years of age) who had a CT of the abdomen and pelvis and pelvic ultrasound, with the CT ordered either before or simultaneously with the pelvic ultrasound. We excluded from the study CTs with abdominal or pelvic pathology. The primary outcome measure was to determine the occurrence of pelvic ultrasounds without acute pathology with a negative CT. The secondary outcome measure was to identify non-emergent findings on pelvic ultrasound with a negative CT.

Results: Of 281 eligible ED visits, 172 patients (61.2%) had gynecologic pathology on CT and 60 patients (21.4%) had other pathology on CT. The mean age was 43.3 years (SD 16.4). Forty-nine patients (17.4%) had unremarkable CT results. Of those, 39 patients (79.6%; 95% CI, 65.7-89.8%) had a normal ultrasound; three patients (6.1%; 95% CI,1.3-16.9%) had an ovarian cyst; six patients (12.2%; 95% CI, 4.6-24.8%) had other non-emergent results; and one patient (2.0%; 95% CI, 0.05-10.9%) had a 10- by 11-mm ovarian mass on ultrasound. In patients with unremarkable CTs, 48 (98.0%; 95% CI, 89.1-99.9%) also had normal or not clinically significant ultrasound results. No definite ovarian torsions were diagnosed on ultrasound after a negative CT. 

Conclusion: Obtaining a pelvic ultrasound following an unremarkable CT of the abdomen and pelvis may not produce additional clinically relevant results in an emergency setting.

Introduction: Ultrasound-compatible procedural phantoms are critical for vascular access training, but commercial models are expensive, degrade with use, and provide limited simulation of key procedural steps. Existing low-cost alternatives often lack durability and fidelity.

Methods: We synthesized a novel, self-healing, ultrasound-compatible hydrogel (SonoGuar) using guar gum, borax, glycerol, oil, and water. We constructed vascular-access task trainers and evaluated SonoGuar across three domains: 1) rheological analysis of viscoelastic recovery after injury; 2) a blinded ultrasound image comparison study comparing SonoGuar against a commercial model; and 3) a prospective, randomized, single-blind crossover simulation study comparing SonoGuar to a commercial model with 41 participants (medical students, residents, and attendings). 

Results: At grocery store material prices, one kilogram of SonoGuar took 10 minutes of active time and about $3 to fabricate, including vessel-mimic balloons. The commercial comparison model was quoted at $350 for a single replacement insert. SonoGuar recovered its viscoelastic profile within 30 minutes of injury and demonstrated visible healing of needle tracts by five hours.  In the image comparison, SonoGuar was 1.8 times more likely than the commercial model to be selected as resembling human tissue in a head-to-head comparison (64.5% SonoGuar vs 35.5% commercial model, P < .001). In simulation, 41 -residents and attendings rated SonoGuar higher than the commercial phantom across all model aspects, including anatomy identification, appearance, tactile feedback, and needle visualization (average of 4.47 vs 3.77 on a 5-point Likert scale, P < .01). After cost was disclosed, all preferred SonoGuar. Medical students rated both models similarly across all model aspects and demonstrated increased levels of confidence after training with SonoGuar or commercial phantom (pre-simulation average confidence on a 5-point Likert scale of 1.46 and post-simulation average of 3.54 and 3.37, respectively, both comparisons P < .05).

Conclusion: A do-it-yourself, high-fidelity hydrogel with self-healing properties, SonoGuar can be rapidly fabricated and is suitable for realistic, durable, and scalable ultrasound-guided procedure training. The low-cost hydrogel outperformed a leading commercial model in imaging realism, user confidence, and overall preference among experienced clinicians.

Introduction: Awake fiberoptic intubation is a critical skill of emergency physicians in scenarios where rapid sequence intubation may be impossible or catastrophic. While the equipment to perform awake fiberoptic intubation has become more readily available to emergency physicians, inadequate training and lack of confidence are often cited as barriers to performing the procedure. To address this, we created and studied a simulation-based awake fiberoptic intubation curriculum with the goal of improving physicians’ performance of this skill. 

Methods: A procedural checklist was developed and iteratively refined among EM, anesthesiology, and critical care physicians. An instructional video was created based on this checklist. Participants viewed the instructional video and underwent supervised deliberate practice on a manikin and bronchoscopy simulator using a rapid-cycle deliberate practice paradigm with 1:1 supervision from an instructor. Comparisons were made between a pre-test and a three-month post-test. We evaluated participants using calculated simulator metrics, the Objective Structured Assessment of Technical Skill global rating scale (GRS), a checklist, and pre- and post-intervention self-assessment. 

Results: We collected data from 46 participants. Observed performance using the GRS improved from 22.5 (standard deviation 4.5) to 28.8 (6.3) (P < .001). Time from scope insertion to verbalized passage of the endotracheal tube on the simulator decreased from a mean of 147.0 (148.3) seconds to 84.6 (39.1) seconds (P = .01). Participants reported improved self-assessed performance compared with others at their stage of training, 3.7 (1.5) to 5.0 (1.2), P < .001, and their reported confidence performing the procedure increased from 3.0 (1.5) to 5.1 (1.2), P < .001. No significant difference was seen among checklist scores. 

Conclusion: In this novel simulation-based awake fiberoptic intubation curriculum, subjective and objective performance improvements were observed at three months. Learners who participated in the course reported feeling more confident and capable of performing awake fiberoptic intubation and being satisfied with the curriculum.

Background:  Musculoskeletal back pain is a common presenting complaint to emergency departments (ED) worldwide. In this study we aimed to evaluate the effectiveness of transcutaneous electrical nerve stimulation (TENS) as an adjunct to standard care in reducing pain for patients presenting with acute low back pain.

Methods: This study has a dual-center, open-label, cluster-randomized controlled trial design. Participants were recruited from two tertiary-care EDs in Canada. We included patients with acute or acute-on-chronic back pain of < 3 weeks duration. Participants were randomized to receive either TENS for 30 minutes plus standard care, or standard care alone. We measured pain scores using the Visual Analogue Scale (VAS) at baseline, 30 minutes, and 60 minutes after initiation of the intervention. The primary outcome was the difference in mean VAS pain scores at 60 minutes between the two groups.

Results: Of 94 patients considered, we enrolled 25 participants (15 control and 10 intervention). The group receiving TENS plus standard care showed a statistically significant reduction in pain scores compared to the standard care alone group at both the 30-minute (relative mean difference: 22.6%; absolute difference: 1.7 points on 10-point VAS (95% CI, -31.9%, -13.4%, P < .001) and 60-minute timepoints (relative mean difference 18.2%, absolute difference 1.4 points (-32.7%, -3.8%, P = .04). There were two return visits in the intervention group within two weeks from the index visit, and two patients reported slight discomfort with using TENS, although they kept the device on for the duration of the trial period. 

Conclusion: The addition of transcutaneous electrical nerve stimulation to standard care resulted in a modest but statistically significant reduction in pain scores for patients with acute back pain in the ED setting, although it did not meet our predefined threshold of clinical significance. Further research with larger sample sizes is required to clarify the effect size and role of TENS for acute back pain in the ED waiting room.

Introduction: Urinary tract infections are common in the emergency department (ED) but are frequently misdiagnosed and mismanaged. We sought to determine whether eXtreme Gradient Boosting (XGBoost), an open-source machine-learning library, could predict the organisms growing in urine cultures ordered from the ED.

Methods: We developed XGBoost algorithms to retrospectively examine 62,963 Mayo Clinic ED encounters between January 1, 2017–December 31, 2021, during which a urinalysis and urine culture were performed. The model used 1,303 patient variables. All patient ages were included. Data were from the electronic health record and available to the clinician during the patient encounter.

Results: For the most common bacteria growing in urine culture, XGBoost was able to predict the presence of a member of the Enterobacteriaceae family with an area under the receiver operating curve (AUC) of 0.90 and an accuracy of 0.79. The model predicted the presence of 10 different bacterial genera with an AUC of 0.70-0.88 and an accuracy of 0.87-0.99. Furthermore, XGBoost was able to predict whether the urine culture would report Gram-positive or Gram-negative bacteria with an AUC of 0.81 and 0.90, respectively, and an accuracy of 0.85 and 0.86, respectively. The model predicted whether yeast would be reported with an AUC of 0.84 and an accuracy of 1.00.

Discussion: XGBoost can predict the bacterial genus and Gram-staining results of the bacteria growing in urine cultures

Introduction: Succinylcholine and rocuronium are neuromuscular blocking agents commonly used as paralytics in the emergency department (ED) during rapid sequence intubation. Prior studies have shown mixed results regarding the preferred agent aside from settings where there are contraindications. This study compares outcomes of death, myocardial infarction, and post-traumatic stress disorder for succinylcholine vs rocuronium when used in rapid sequence intubation using data from a large, multicenter database.

Methods: In this retrospective study, we extracted 105 million patient records from 61 healthcare organizations in the United States from the TriNetX database between 2004–2023. Adults ≥ 18 years of age who underwent intubation on the same day as an ED visit and received succinylcholine or rocuronium with the hypnotic anesthetic etomidate were included. The outcomes evaluated were mortality and myocardial infarction within 60 days after intubation. We excluded patients with prior history of myocardial infarction. We performed propensity matching for demographics and nine pre-existing conditions associated with mortality. 

Results: There were 15,514 patients in the succinylcholine group and 14,675 patients in the rocuronium group for a total of 30,189 adults prior to propensity matching. The final cohort included 26,884 patients evenly divided between groups after propensity matching. Patients given succinylcholine were associated with a significantly lower risk of mortality (30.1% vs 33.4%, risk ratio [RR] 0.901, 95% CI, 0.869-0.933, P < .001, absolute risk reduction of 3.3%) and myocardial infarction (10.5% vs 11.9%, RR 0.888, 95% CI, 0.828-0.953, P = .001, absolute risk reduction of 1.4%) within 60 days after rapid sequence intubation. Trends were similar before propensity matching.  

Conclusion: Succinylcholine administration was associated with reduced mortality compared to rocuronium. These findings suggest succinylcholine may be a safer paralytic agent for rapid  sequence intubation when no contraindications are identified.

Introduction: Sexually transmitted infections (STIs), including HIV and syphilis, are increasing. In 2023, there were over 2.4 million reported cases of chlamydia, gonorrhea, and syphilis in the United States, a 32.5% increase from 2014. Emergency departments (EDs) are vital touchpoints for STI testing, yet HIV and syphilis testing among patients undergoing Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) testing is suboptimal. We aimed to determine testing frequency and to identify factors associated with HIV and syphilis co-testing among ED patients undergoing NG/CT testing.
 
Methods: We conducted a retrospective observational study of all patients tested for NG/CT from 2021–2024 at two Los Angeles EDs. Covariates including sociodemographic and behavioral data were extracted from the medical record. The primary outcome was complete STI testing, defined as  both HIV and syphilis testing during or up to six months prior to an ED encounter with NG/CT testing. Multivariable logistic regression was used to evaluate factors associated with complete STI testing. 

Results: Of 3,940 patients, 459 (11.7%) received complete STI testing. Among patients receiving complete STI testing, 176 (38.3%) were female, 282 (61.4%) were male, 96 (20.9%) were Hispanic, 98 (21.4%) were non-Hispanic Black, 195 (42.5%) were non-Hispanic White, 220 (47.9%) had Medicare insurance, 132 (28.8%) had private insurance, 225 (49.0%) were experiencing homelessness, 14 (3.1%) identified as bisexual, and 90 (19.6%) identified as heterosexual. In multivariable analysis, patients who were bisexual (adjusted odds ratio [aOR] 2.51; 95% CI, 1.32-4.80; P = .005); had Medicare insurance (aOR 1.89; 1.20-2.98; P = .006); or were experiencing homelessness (aOR 5.21; 4.00-6.78; P < .001) had higher odds of complete STI testing. Patients who were Hispanic (aOR 0.69; 0.52-0.92; P = .01); non-Hispanic Black (aOR 0.75 ; 0.56-1.00, P = .05); or female (aOR 0.68; 0.54-0.85; P = .001) had lower odds. Of 261 patients with multiple ED encounters, 217 (83.1%) never received complete testing.
 
Conclusion: Complete HIV and syphilis testing among ED patients tested for N. gonorrhoeae and C. trachomatis was low, even among patients with multiple ED encounters. Lower testing among Hispanic and non-Hispanic Black patients may exacerbate existing disparities in STIs. Implementation research is needed to improve the integration of STI testing in EDs. 

Background: The success of clinical programs aimed at preventing suicide risk depends in part on whether they can be used to identify and act upon risk factors for suicide. Our aim in this study was to describe frequency of clinician documentation of firearm access and the delivery of safety interventions among patients who received a suicide risk evaluation in Veterans Health Administration (VHA) emergency departments (ED) or urgent care (UC) settings. 

Methods: We used electronic health record data of patients who received care in VHA ED/UC settings January 2021–October 2022 and underwent suicide risk evaluation by clinicians using the Veterans Affairs (VA) Comprehensive Suicide Risk Evaluation (CSRE) prior to discharging home. The proportion of patients with self-reported firearm access was identified from clinician-documented CSRE templates. Among those who reported firearm access, we identified the proportion who received any safety intervention (delivery of lethal means safety counseling and/or distribution of firearm cable locks per CSRE documentation, or update/creation/review of a VA Safety Plan) within 24 hours of the ED/UC encounter. We compared differences using chi-square or Fisher exact tests for categorical outcomes and analysis of variance or independent sample t-tests for continuous outcomes. 

Results: Of 17,194 patients who were discharged home, 15.2% were documented as having firearm access (8.5% access to “other” lethal means, 68.8% no lethal means access, 7.4% unknown access). Of 2,624 patients with documented firearm access, 80.6% were documented as having received a safety intervention. Of those, 56.8% received lethal means safety counseling, 13.2% received a firearm cable lock, and 88.6% reviewed or completed a new or updated VA Safety Plan.

Conclusion: Among patients who underwent suicide risk evaluation prior to discharging home from a Veterans Health Administration ED/UC setting, a low percentage were documented as having firearm access. Of those with firearm access, a large majority received at least one safety intervention. System-wide strategies to encourage delivery of safety interventions can reach a large proportion of at-risk patients. Additional efforts are needed to increase reporting and documentation of firearm access.

Introduction: Increased pediatric readiness has been shown to decrease pediatric mortality, although disparities in access to pediatric-ready emergency departments (ED) have not been studied. The Child Opportunity Index (COI) is a comprehensive measure of the quality of neighborhood resources impacting child health and development. Our objective was to determine whether low-resourced areas with low COI levels are associated with farther travel distances to the nearest pediatric-ready ED.

Methods: In this retrospective, cross-sectional study we evaluated the 2021 National Pediatric Readiness Project (NPRP) assessments of 91 EDs throughout the state of Missouri in relationship to COI 3.0 U.S. census tract data. The EDs were classified into quartiles based on weighted pediatric readiness scores (wPRS). Our primary outcome measure was travel distances to the nearest ED, which were obtained by measuring the shortest distance from the geographic center of each U.S. census tract to the closest ED. We used the Kruskal-Wallis H test to assess distances from the geographic center of each census tract to the nearest EDs. P values were adjusted for multiple comparisons using Dunn-Bonferroni post hoc tests. 

Results: Of the 113 EDs in Missouri that were invited to take the 2021 NPRP assessment, 91 (81%) participated and 22 (19%) were nonrespondent. Child Opportunity Index data were available for all 1,393 Missouri U.S. census tracts. When compared to low-resourced, low COI census tracts, well- resourced, very high COI census tracts were found to have significantly shorter travel distances to the nearest ED (6 vs 2.9 miles, [95% CI, 3.03-3.6; P < .001]). Families living in low COI census tracts travel 4.6 times farther (18 additional miles) to reach an ED in the highest wPRS quartile compared to families living in very high COI census tracts (23.3 vs 5.1 miles, [95% CI, 5.6-6.5; P < .001]). Families living in low COI census tracts travel 4.4 times farther (48 additional miles) to reach the nearest of the top three most pediatric-ready EDs [62.6 vs 14.4 miles, [95% CI, 14.6-19.1; P < .001].

Conclusion: Families from resource-limited communities with low Child Opportunity Index levels must travel significantly farther to access pediatric-ready EDs compared to families from well-resourced communities. Dissemination of pediatric-readiness improvement efforts, especially to under-resourced areas, may help address disparities in healthcare access and promote health equity.

Introduction: Early recognition and referral are critical to minimizing morbidity and mortality in acute stroke, but evaluation and referral processes differ worldwide. In this systematic review we examined the accuracy of recognition tools, referral patterns, outcomes, and factors affecting efficiency in primary and emergency care settings.

Methods: Following PRISMA 2020 guidelines, we searched PubMed, Scopus, Web of Science, and Cochrane Library for studies published January 2003–December 2025. Eligible studies included randomized controlled trials, cohort, case-control, cross-sectional, and large case series (> 30 patients) involving adults with acute ischemic or hemorrhagic stroke. Risk of bias was assessed using Cochrane Risk-of-Bias 2 (RoB) and RoB in non-standardized studies-I. We extracted data on diagnostic accuracy, referral pathways, outcomes, and systemic factors.

Results: We identified 206 papers, of which 33 studies met our inclusion criteria. Recognition tools such as Face, Arms, Speech, Time (FAST); Recognition of Stroke in the Emergency Room, the Cincinnati Prehospital Stroke Scale, and National Institutes of Health Stroke Scale showed good pooled sensitivity (79-95%) but variable specificity (52-84%). Newer technologies, including the  PreHospital Ambulance Stroke Test, FAST-ED, and artificial intelligence (AI)-based models, showed promise but need validation. Referral strategies such as emergency medical services prenotification, dispatcher triage, and mobile stroke units reduced prehospital delays. Seven studies reported onset-to-door times 12-22 minutes faster and 7-12% increase in reperfusion eligibility. Increased referral efficiency was associated with a reduction in mortality of approximately 8-12% and improvements in functional independence of 10-15%, with persistent disparities reported in resource-limited settings. 

Conclusion: Early recognition and referral improve outcomes in patients with acute stroke. Structured tools and system-level interventions reduce mortality, while AI and mobile stroke units show promise. Strengthening referral systems and adopting cost-effective triage strategies may support equitable implementation, particularly in low-resource settings, as addressing systemic and geographic barriers is critical for equitable stroke care.

Introduction: Organophosphate (OP) poisoning is a significant global health issue, particularly in tropical regions. Despite established treatments such as atropine and oximes, the effectiveness of other interventions remains uncertain. This umbrella review is a critical synthesis of evidence from systematic reviews and meta-analyses on OP self-poisoning.  

Methods: Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, we conducted a review of systematic reviews and meta-analyses published up to January 2025. Databases searched included PubMed, Epistemonikos, and the Cochrane Library. We performed quality assessment using A Measurement Tool to Assess Systematic Reviews, version 2 (AMSTAR-2), and applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate evidence certainty. 

Results: Of 416 potential papers identified we assessed 27 for eligibility, of which 19 were included in the review. The papers evaluated 11 different interventions as an adjuvant to atropine. Oximes, although commonly used, showed neither benefit nor harm. The systematic reviews and meta-analyses on gastric lavage, plasma exchange with hemoperfusion, lipid emulsions, magnesium sulfate, penehyclidine, rhubarb, and xuebijing have reported significant reductions in mortality, but the evidence comes from very low-quality studies. Alkalinization was not found to be effective for OP poisoning. Evidence was limited by small sample size, inconsistent protocols, and geographical bias, with many studies originating from China. 

Conclusion: After careful scrutiny of evidence pooled by various systematic reviews and meta-analyses, we found that atropine remains the mainstay of treatment for OP self-poisoning. It may be supplemented with oximes, as recommended by the World Health Organization. Gastric lavage has doubtful efficacy and may even be harmful. Additionally, we recommend against the routine use of penehyclidine, rhubarb, xuebijing, hemofiltration, plasma exchange with hemoperfusion, lipid emulsions, magnesium sulfate, and alkalinization in the management of OP self-poisoning.

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