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Introduction: Overdose deaths from high-potency synthetic opioids, including fentanyl and its analogs, continue to rise along with emergency department (ED) visits for complications of opioid use disorder (OUD). Fentanyl accumulates in adipose tissue; although rare, this increases the risk of precipitated withdrawal in patients upon buprenorphine initiation. Many EDs have implemented medication for opioid use disorder (MOUD) programs using buprenorphine. However, few offer methadone, a proven therapy without the risk of precipitated withdrawal associated with buprenorphine initiation. We describe the addition of an ED-initiated methadone treatment pathway and compared its 72-hour follow-up outpatient treatment engagement rates to our existing ED-initiated buprenorphine MOUD program.Methods: We expanded our ED MOUD program with a methadone treatment pathway. From February 20–September 19, 2023, we screened 20,504 ED arrivals; 5.1% had signs of OUD. We enrolled 61 patients: 28 in the methadone; and 33 in the buprenorphine pathways. For patients who screened positive for opioid use, shared decision-making was employed to determine whether buprenorphine or methadone therapy was more appropriate. Patients in the methadone pathway received their first dose of up to 30 milligrams (mg) of methadone in the ED. Two additional methadone doses of up to 40 mg were dispensed at the time of the ED visit and held in the department, allowing patients to return each day for observed dosing until intake at an opioid treatment program (OTP). We compared 72-hour rates of outpatient follow-up treatment engagement at the OTP (for those on methadone) or at the addiction treatment center (ATC) (for those on buprenorphine) for the two treatment pathways.Results: Of the 28 patients enrolled in the methadone pathway, 12 (43%) successfully engaged in follow-up treatment at the OTP. Of the 33 patients enrolled in the buprenorphine pathway, 15 (45%) successfully engaged in follow-up treatment at the ATC (relative risk 1.06; 95% confidence interval 0.60–1.87).Conclusion: Methadone initiation in the ED to treat patients with OUD resulted in similar 72-hour follow-up outpatient treatment engagement rates compared to ED-buprenorphine initiation, providing another viable option for MOUD.

Introduction: Isolated oculomotor nerve palsy after mild traumatic brain injury is unusual and prognostically significant due to unclear mechanisms and recovery challenges. We present a case of isolated oculomotor nerve palsy following minor head trauma, shedding light on this unusual occurrence.Case Report: A 24-year-old male experienced severe vision loss and right-sided oculomotor nerve palsy after a motor vehicle collision. Initial imaging showed a hemorrhagic focus in the left posterior fossa and a contusion in the corpus callosum, yet no direct cause for the nerve palsy was found. Partial recovery was observed after 12 months.Conclusion: This case underscores the importance of maintaining a heightened suspicion for occult intracranial findings, especially when the initial non-contrast computed tomography was inconclusive. Timely clinical assessment and appropriate radiological investigations by emergency physicians are crucial for improving the prognosis.

Purpose: During the third-year emergency medicine (EM) clerkship, medical students are immersed in traumatic incidents with their patients and clinical teams. Trauma-informed medical education (TIME) applies trauma-informed care (TIC) principles to help students manage trauma. We aimed to qualitatively describe the extent to which students perceived the six TIME domains as they navigated critical incidents during their EM clerkship.Methods: We employed a constructivist, modified grounded theory approach to explore medical students’ experiences. We used the critical incident technique to elicit narratives to better understand the six TIME domains as they naturally appear in the clerkship. Participants were asked to describe a traumatic incident they experienced during the clerkship, followed by the clerkship’s role in helping them manage the incident. Using the framework method, transcripts were analyzed 1) deductively by matching transcript excerpts to relevant TIME domains and 2) inductively by generating de novo themes to capture factors that affected students’ handling of trauma during critical incidents.Results: Twelve participants were enrolled and interviewed in July 2022. “Safety” was the most frequently described TIME domain, whereas “Gender, Cultural, and Historical issues” and “Peer Support” were discussed least. Inductive analysis revealed themes that hindered or supported their ability to manage traumatic experiences, which were grouped into three categories: 1) student interactions with the learning environment: complex social determinants of health, inequalities in care, and overt discrimination; 2) student interactions with patients: ethically ambiguous care, witnessing acute patient presentations, and reactivation of past trauma; and 3) student interactions with supervisors: power dynamics, invalidation of contributions, role-modeling, and student empowerment.Conclusion: The six TIME domains are represented in students’ perceptions of immediate, stressful critical incidents during their EM clerkship, with “Safety” being the most commonly described; however, the degree to which these domains are supported in students’ experiences of the EM clerkship differ, and instances of inadequately experienced domains may contribute to student distress. Understanding the EM clerkship through the specific lens of students’ experiences of trauma may be an effective strategy to guide curricular changes that promote a supportive learning environment for students in the emergency department.

Introduction: Initiation of buprenorphine for opioid use disorder (OUD) in the emergency department (ED) is supported by the American College of Emergency Physicians and is shown to be beneficial. This practice, however, is largely underutilized.Methods: To assess emergency clinicians’ attitudes and readiness to initiate buprenorphine in the ED we conducted a cross-sectional, electronic survey of clinicians (attendings, residents, and non-physician clinicians) in a single, academic ED of a tertiary-care hospital, which serves a rural population. Our survey aimed to assess emergency clinicians’ attitudes toward and readiness to initiate buprenorphine in the ED and identify clinician-perceived facilitators and barriers. Our survey took place after the initiation of the IMPACT (Initiation of Medication, Peer Access, and Connection to Treatment) project.Results: Our results demonstrated the level of agreement that buprenorphine prescribing is within the emergency clinician’s scope of practice was inversely correlated to average years in practice (R2 = 0.93). X-waivered clinicians indicated feeling more prepared to administer buprenorphine in the ED R2 = 0.93. However, they were not more likely to report ordering buprenorphine or naloxone in the ED within the prior three months. Those who reported having a family member or close friend with substance use disorder (SUD) were not more likely to agree buprenorphine initiation is within the clinician’s scope of practice (P = 0.91), nor were they more likely to obtain an X-waiver (P = 0.58) or report ordering buprenorphine or naloxone for patients in the ED within the prior three months (P = 0.65, P = 0.77). Clinicians identified availability of pharmacists, inpatient/outpatient referral resources, and support staff (peer recovery support specialists and care managers) as primary facilitators to buprenorphine initiation. Inability to ensure follow-up, lack of knowledge of available resources, and insufficient education/preparedness were primary barriers to ED buprenorphine initiation. Eighty-three percent of clinicians indicated they would be interested in additional education regarding OUD treatment.Conclusion: Our data suggests that newer generations of emergency clinicians may have less hesitancy initiating buprenorphine in the ED. In time, this could mean increased access to treatment for patients with OUD. Understanding clinician-perceived facilitators and barriers to buprenorphine initiation allows for better resource allocation. Clinicians would likely further benefit from additional education regarding medications for opioid use disorder (MOUD), available resources, and follow-up statistics.

Introduction: Methadone is a medically necessary and lifesaving medication for many patients with opioid use disorder. To adequately address these patients’ needs, methadone should be offered in the hospital, but barriers exist that limit its continuation upon discharge. The code of federal regulations allows for methadone dosing as an inpatient as well as outpatient dispensing forup to three days to facilitate linkage to treatment. As a quality initiative, we created a new workflow for discharging patients on methadone to return to the emergency department (ED) for uninterrupted dosing.Methods: Our addiction medicine team changed hospital methadone policy to better allow hospitalization as a window of opportunity to start methadone. This necessitated the creation of a warm-handoff process to link patients to methadone clinics if that linkage could not happen immediately on discharge. Thus, our team created the “ED Bridge” process, which uses the “3-day rule” to dispense methadone from the ED post hospital discharge. We then followed every patient we directed through this workflow as an observational cohort for outcomes and trends.Results: Of the patients for whom ED bridge dosing was planned, 40.4% completed all bridge dosing and an additional 17.3% received at least one but not all bridge doses. Established methadone patients made up 38.1% of successful linkages, and 61.9% were patients who were newly started on methadone in the hospital.Conclusion: Improving methadone as a treatment option remains an ongoing issue for policymakers and advocates. Our ED bridge workflow allows us to expand access and continuation of methadone now using existing laws and regulations, and to better use hospitals as a point of entry into methadone treatment.

The aim of this project was to increase willingness to receive the influenza vaccine to the optimal rate of ≥ 70%. Low acuity adult patients who visited an Emergency Department (ED) were assessed regarding their willingness to receive the influenza vaccine before and after an educational intervention that included a provider recommendation and an educational handout. A total of seventy-six patients (n = 76) were assessed. Patients willingness to receive the influenza vaccine rose from 29% pre-intervention to 72% post-intervention without disrupting the clinical flow in a busy ED. Similar vaccine educational strategies can be applied to influenza and other vaccines in EDs  to increase vaccination willingness in patients, including those who use the ED as a primary point of contact for healthcare, decreasing the burden of influenza illness in the community.

In the pursuit of ending the HIV epidemic, U.S. emergency departments (EDs) have emerged as a valuable setting to increase HIV testing and linkage to care. There is limited data available, however, describing the incorporation of HIV prevention initiatives in U.S. EDs. Over the last decade, HIV pre-exposure prophylaxis (PrEP) has significantly changed the HIV prevention landscape globally and very little is known about the provision of PrEP in U.S. EDs. To address this gap in the literature, we conducted a systematic review of peer-reviewed quantitative studies and conference abstracts spanning July 2012 - October 2022. Of 433 citations, 11 articles and 13 abstracts meet our inclusion criteria, representing 18 unique studies addressing PrEP screening, prescribing, and/or linkage to PrEP care.Most studies describe screening processes to identify PrEP-eligible patients (n = 17); most studies leveraged a patients STI history as initial PrEP eligibility screening criteria. Fewer studies describe PrEP prescribing (n = 2) and/or linkage to PrEP care (n = 8).Findings from this systematic review highlight the potential for U.S. EDs to increase PrEP uptake among individuals at risk for HIV infection. Despite a growing number of studies exploring processes for incorporating PrEP into the ED setting, such studies are small-scale and time limited. Models providing prescribing PrEP in the ED show higher initiation rates than post-discharge engagement models. Electronic health record (EHR)-based HIV screening is valuable, but post-ED linkage rates are low. Our findings emphasize the need to establish best practices for initiating and supporting prevention effective PrEP use in the ED setting.

Introduction: Healthcare organizations are under increasing pressure from policymakers, payers, and advocates to screen for and address patients’ health-related social needs (HRSN). The emergency department (ED) presents several challenges to HRSN screening, and patients are frequently not screened for HRSNs. Predictive modeling using machine learning and artificial intelligence, approaches may address some pragmatic HRSN screening challenges in the ED. Because predictive modeling represents a substantial change from current approaches, in this study we explored the acceptability of HRSN predictive modeling in the ED.Methods: Emergency clinicians, ED staff, and patient perspectives on the acceptability and usage of predictive modeling for HRSNs in the ED were obtained through in-depth semi-structured interviews (eight per group, total 24). All participants practiced at or had received care from an urban, Midwest, safety-net hospital system. We analyzed interview transcripts using a modified thematic analysis approach with consensus coding.Results: Emergency clinicians, ED staff, and patients agreed that HRSN predictive modeling must lead to actionable responses and positive patient outcomes. Opinions about using predictive modeling results to initiate automatic referrals to HRSN services were mixed. Emergency clinicians and staff wanted transparency on data inputs and usage, demanded high performance, and expressed concern for unforeseen consequences. While accepting, patients were concerned that prediction models can miss individuals who required services and might perpetuate biases.Conclusion: Emergency clinicians, ED staff, and patients expressed mostly positive views about using predictive modeling for HRSNs. Yet, clinicians, staff, and patients listed several contingent factors impacting the acceptance and implementation of HRSN prediction models in the ED.

Introduction: To expand access to naloxone, the state of Illinois implemented a standing order allowing registered pharmacies to dispense the drug without an individual prescription. To participate under the standing order, pharmacies were required to opt in through a formal registration process. In our study we aimed to evaluate the availability and price of naloxone at registered pharmacies.Methods: This was a prospective, de-identified, cross-sectional telephone survey. Trained interviewers posed as potential customers and used a standardized script to determine the availability of naloxone between February–December, 2019. The primary outcome was defined as a pharmacy indicating it carried naloxone, currently had naloxone in stock, and was able to dispense it without anindividual prescription.Results: Of 948 registered pharmacies, 886 (93.5%) were successfully contacted. Of those, 792 (83.4%) carried naloxone, 659 (74.4%) had naloxone in stock, and 472 (53.3%) allowed purchase without a prescription. Naloxone nasal spray (86.4%) was the formulation most commonly stocked. Chain pharmacies were more likely to carry naloxone (adjusted odds ratio [aOR] 3.16, 95% confidence interval [CI] 1.97–5.01, P < 0.01) and have naloxone in stock (aOR 2.72, 95% CI 1.76–4.20, P < 0.01), but no more likely to dispense it without a prescription. Pharmacies in higher population areas (aOR 0.99, 95% CI 0.99–0.99, P < 0.05) and rural areas adjacent to metropolitan areas (aOR 0.5, 95% CI 025–0.98, P < 0.05) were less likely to have naloxone available without a prescription. Associations of naloxone availability based on other urbanicity designations, overdose count, and overdose rate were not significant.Conclusion: Among pharmacies in Illinois that formally registered to dispense naloxone without a prescription, the availability of naloxone remains limited. Additional interventions may be needed to maximize the potential impact of a statewide standing order.

Introduction: As opioid overdose deaths continue to rise, the emergency department (ED) remains an important point of contact for many at risk for overdose. In this study our purpose was to better understand the attitudes, beliefs, and knowledge of ED nurses in caring for patients with opioid use disorder (OUD). We hypothesized a difference in training received and attitudes toward caring for patients with OUD between nurses with

Introduction: Bacterial urinary tract infections (UTI) and some sexually transmitted infections (STI) can have overlapping signs and symptoms or nonspecific findings, such as pyuria on urinalysis. Furthermore, results from the urine culture and the nucleic acid amplification test for an STI may not be available during the clinical encounter. We sought to determine whether gonorrhea, chlamydia, and trichomoniasis are associated with bacteriuria, information that might aid in the differentiation of STIs and UTIs.Methods: We used multinomial logistic regression to analyze 9,650 encounters of female patients whowere aged ≥18 years and who underwent testing for STIs. The ED encounters took place from April 18, 2014–March 7, 2017. We used a multivariable regression analysis to account for patient demographics, urinalysis findings, vaginal wet-mount results, and positive or negative (or no) findings from the urine culture and testing for Neisseria gonorrhoeae, Chlamydia trachomatis, or Trichomonas vaginalis.Results: In multivariable analysis, infection with T vaginalis, N gonorrhoeae, or C trachomatis was not associated with having a urine culture yielding 10,000 or more colony-forming units per mililiter (CFU/mL) of bacteria compared with a urine culture yielding less than 10,000 CFU/mL or no urine culture obtained. The diagnosis of a UTI in the ED was not associated with having a urine culture yielding 10,000 or more CFU/mL compared with a urine culture yielding less than 10,000 CFU/mL.Conclusion: After adjusting for covariates, no association was observed between urine culture results and testing positive for trichomoniasis, gonorrhea, or chlamydia. Our results suggest that having a concurrent STI and bacterial UTI is unlikely.

Introduction: Blind and visually impaired individuals, an under-represented population of the emergency department (ED), possess comorbidities and have a higher chance of in-hospital sequelae, including falls. This potentially vulnerable population, if not treated mindfully, can be subject to decreased quality of care, recurrent and/or longer hospitalizations, persistence of health issues, increased incidence of falls, and higher healthcare costs. For these reasons, it is crucial to implement holistic practices and train clinicians to treat blind and visually impaired patients in the ED setting.Methods: We identified and used a comprehensive article describing best practices for the care of blind and visually impaired patients to establish the ED-specific recommendations presented in this paper. A scoping review of the literature was then performed using PubMed to identify additional articles to support each recommendation. To ensure that recommendations could be implemented in a representative, scalable, and sustainable manner, we consulted an advocate for the blind to help refine and provide additional suggestions.Results: We identified 14 recommendations that focus on communication strategies, ED resource access, and continuity of care. The main recommendation is for the clinician to support the unique healthcare needs of the visually impaired individual and maintain the patient’s autonomy. Another recommendation is the consistent use of assistive devices (eg, canes, guide dogs) to aid patients to safely ambulate in the ED. Also identified as best practices were discharge education with the use of a screen reader and timely follow-up with a primary care physician.Conclusion: While we summarize a variety of recommendations in this article, it is important to implement only the strategies that work best for the patients, personnel, and environment specific to your ED. After implementation, it is vital to refine (as frequently as needed) the interventions to optimize the strategies. This will enable the provision of exceptional and equal care to blind and visually impaired patients in the ED.

Introduction: Coronavirus 2019 (COVID-19) inequitably impacted minority populations and regions with limited access to healthcare resources. The Barnes-Jewish Emergency Department in St. Louis, MO, serves such a population. The COVID-19 vaccine is an available defense to help achieve community immunity. The emergency department (ED) is a potential societal resource to provide access to a vaccination intervention. Our objective in this study was to describe and evaluate a novel ED COVID-19 vaccine program, including its impact on the local surrounding underserved community.Methods: This was a retrospective, post-protocol implementation review of an ED COVID-19 vaccination program. Over the initial six-month period, we compiled data on all vaccinated patients out of the ED to evaluate demographic data and the impact on underserved regional areas.Results: We report a successful ED-based COVID-19 vaccine program (with over 1,000 vaccines administered). This program helped raise regional and state vaccination rates. Over 50% of the population that received the COVID-19 vaccine from the ED were from defined socially vulnerable patient populations. No adverse effects were documented.Conclusion: Operation CoVER (COVID-19 Vaccine in the Emergency Room) Saint Louis was able to successfully vaccinate a socially vulnerable patient population. This free, COVID-19 ED-based vaccine program with dedicated pharmacy support, was novel in emergency medicine practice. Similar ED-based vaccine programs could help with future vaccine distribution.

Introduction: The incidence of sexually transmitted infections (STI) increased in the United States between 2017–2021. There is limited data describing STI co-testing practices and the prevalence of STI co-infections in emergency departments (ED). In this study, we aimed to describe the prevalence of co-testing and co-infection of HIV, hepatitis C virus (HCV), syphilis, gonorrhea, and chlamydia, in a large, academic ED.Methods: This was a single-center, retrospective cross-sectional study of ED patients tested for HIV, HCV, syphilis, gonorrhea or chlamydia between November 27, 2018–May 26, 2019. In 2018, the study institution implemented an ED-based infectious diseases screening program in which any patient being tested for gonorrhea/chlamydia was eligible for opt-out syphilis screening, and any patient 18–64 years who was having blood drawn for any clinical purpose was eligible for opt-out HIV and HCV screening. Weanalyzed data from all ED patients ≥13 years who had undergone STI testing. The outcomes of interest included prevalence of STI testing/co-testing and the prevalence of STI infection/co-infection. We describe data with simple descriptive statistics.Results: During the study period there were 30,767 ED encounters for patients ≥13 years (mean age: 43 ± 14 years, 52% female), and 7,866 (26%) were tested for at least one of HIV, HCV, syphilis, gonorrhea, or chlamydia. We observed the following testing frequencies (and prevalence of infection): HCV, 7,539 (5.0%); HIV, 7,359 (0.9%); gonorrhea, 574 (6.1%); chlamydia, 574 (9.8%); and syphilis, 420 (10.5%). Infectious etiologies with universal testing protocols (HIV and HCV) made up the majority of STI testing. In patients with syphilis, co-infection with chlamydia (21%, 9/44) and HIV (9%, 4/44) was high. In patients with gonorrhea, co-infection with chlamydia (23%, 8/35) and syphilis (9%, 3/35) was high, and in patients with chlamydia, co-infection with syphilis (16%, 9/56) and gonorrhea (14%, 8/56) was high. Patients with HCV had low co-infection proportions (

BackgroundSex and racial disparities in the presentation and management of chest pain persist, however, the impact of coronavirus disease 2019 (COVID-19) on these disparities have not been studied. We sought to determine whether the COVID-19 pandemic contributed to pre-existing sex and racial disparities in the presentation, management, and outcomes of patients presenting to the emergency department (ED) with chest pain.MethodsWe conducted an observational cohort study with retrospective data collection of patients between January 1, 2016, and May 1, 2022. This was a single study conducted at a quaternary academic medical center of all patients who presented to the ED with a complaint of chest pain or chest pain equivalent symptoms. Patient were further segregated into different groups based on sex (male, female), race, ethnicity (Asian, Black, Hispanic, White, and other), and age (18 - 40, 41 - 65, > 65). We compared diagnostic evaluations, treatment decisions, and outcomes during prespecified time points before, during, and after the COVID-19 pandemic.ResultsThis study included 95,764 chest pain encounters. Total chest pain presentations to the ED fell about 38% during the early pandemic months. Females presented significantly less than males during initial COVID-19 (48% vs. 52%, P < 0.001) and Asian females were least likely to present. There was an increase in the total number of troponins and echocardiograms ordered during peak COVID-19 across both sexes, but females were still less likely to have these tests ordered across all timepoints. The number of coronary angiograms did not increase during peak COVID-19, and females were less likely to undergo coronary angiogram during all timepoints. Finally, females with chest pain were less likely to be diagnosed with acute myocardial infarction (AMI) during all timepoints, while in-hospital deaths were similar between males and females during all timepoints.ConclusionsDuring COVID-19, females, especially Asian females, were less likely to present to the ED for chest pain. Non-White patients were less likely to present to the ED compared to White patients prior to and during the pandemic. Disparities in management and outcomes of chest pain encounters remained similar to pre-COVID-19, with females receiving less cardiac workup and AMI diagnoses than males, but in-hospital mortality remaining similar between groups and timepoints.

Introduction: During the coronavirus 2019 pandemic, hospitals in the United States experienced a shortage of contrast agent, much of which is manufactured in China. As a result, there was a significantly decreased amount of intravenous (IV) contrast available. We sought to determine the effect of restricting the use of IV contrast on emergency department (ED) length of stay (LOS). Methods: We conducted a single-institution, retrospective cohort study on adult patients presenting with abdominal pain to the ED from March 7–July 5, 2022. Of 26,122 patient encounters reviewed, 3,028 (11.6%) included abdominopelvic CT with a complaint including “abdominal pain.” We excluded patients with outside imaging and non-ED scans. Routine IV contrast agent was administered to approximately 74.6% of patients between March 7–May 6, 2022, when we altered usage guidelines due to a nationwide shortage. Between May 6–July 5, 2022, 32.8% of patients received IV contrast after institutional recommendations were made to limit contrast use. We compared patient demographics and clinical characteristics between groups with chi-square test for frequency data. We analyzed ED LOS with nonparametric Wilcoxon rank-sum test for continuous measures with focus before and after new ED protocols. We also used statistical process control charts and plotted the 1, 2 and 3 sigma control limits to visualize the variation in ED LOS over time. The charts include the average (mean) of the data and upper and lower control limits, corresponding to the number of standard deviations away from the mean. Results: After use of routine IV contrast was discontinued, ED LOS (229.0 vs 212.5 minutes,P =

Introduction: Rectus abdominis muscle strains are common and can be debilitating in both professional and amateur athletes who engage in strenuous activity.Case Report: We report a rare case of rectus abdominis muscle tear in an amateur bodybuilder diagnosed by point-of-care ultrasound (POCUS) in the emergency department (ED). The patient had presented to the ED three separate times after strenuous exercise, received costly diagnostic workups, and ultimately was diagnosed on the third visit with grade 2 bilateral rectus abdominis tear. The patient was given appropriate education and sports medicine follow-up. He underwent rehabilitation focused on trunk and core stability. At eight-week follow-up, the patient had made a full recovery.Conclusion: To our knowledge, a case of bilateral rectus abdominis tear diagnosed by ultrasound in the emergency setting has not been previously published. Our case report highlights the utility of POCUS in diagnosing musculoskeletal pathology and preventing costly bounce-back visits.

Background: Despite the prevalence of sexual assault presentations to emergency departments (ED) in the United States, current access to sexual assault nurse examiners (SANE) and emergency contraception (EC) in EDs is unknown.Methods: In this study we employed a “secret shopper,” cross-sectional telephonic survey. A team attempted phone contact with a representative sample of EDs and asked respondents about the availability of SANEs and EC in their ED. Reported availability was correlated with variables including region, urban/rural status, hospital size, faith affiliation, academic affiliation, and existence of legislative requirements to offer EC.Results: Over a two-month period in 2019, 1,046 calls to hospitals were attempted and 960 were completed (91.7% response rate). Of the 4,360 eligible hospitals listed in a federal database, 960 (22.0%) were contacted. Access to SANEs and EC were reported to be available in 48.9% (95%confidence interval [CI] 45.5–52.0) and 42.5% (95% CI 39.4–45.7) of hospitals, respectively. Access to EC was positively correlated with SANE availability. The EDs reporting SANE and EC availability were more likely to be large, rural, and affiliated with an academic institution. Those reporting access to EC were more likely to be in the Northeast and in states with legislative requirements to offer EC.Conclusion: Our results suggest that perceived access to sexual assault services and emergency contraception in EDs in the United States remains poor with regional and legislative disparities. Results suggest disparities in perceived access to EC and SANE in the ED, which have implications for improving ED practices regarding care of sexual assault victims.

Introduction: Point-of-care ultrasound (POCUS) performed by emergency physicians (EP) has emerged as an effective alternative to radiology department ultrasounds for the diagnosis of lower extremity deep vein thrombosis (DVT). Systematic reviews suggested good sensitivity and specificity overall for EP-performed POCUS for DVT diagnosis, yet high levels of heterogeneity were reported.Methods: In this systematic review and meta-analysis, we aimed to provide the most up-to-date estimates of the accuracy of EP-performed POCUS for diagnosis of DVT and to explore potential correlations with test performance. We performed systematic searches in MEDLINE and Embase for original, primary data articles from January 2012–June 2021 comparing the efficacy of POCUS performed by EPs to the local standard. Quality Assessment of Diagnostic Accuracy Studies-2 for individual articles are reported. We obtained summary measures of sensitivity, specificity, and their corresponding 95% confidence intervals (CI) using bivariate mixed-effects regression models. We performed meta-regression, subgroup, and sensitivity analyses as planned in the protocol CRD42021268799 submitted to PROSPERO.Results: Fifteen publications fit the inclusion criteria, totaling 2,511 examinations. Pooled sensitivity and specificity were 90% (95% CI 82%–95%) and 95% (CI 91%–97%), respectively. Subgroup analyses by EP experience found significantly better accuracy for exams performed by EP specialists (93%, CI 88%–97%) vs trainees (77%, CI 60%–94%). Specificity for EP specialists (97%, CI 94%–99%) was higher than for trainees (87%, CI 76%–99%, P = 0.01). Three-point compression ultrasound (CUS) was more sensitive than two-point CUS but was only statistically significant when limited to EP specialists (92% vs 88%, P = 0.07, and 95% vs 88%, P = 0.02, respectively).Conclusion: Point-of-care ultrasound performed by emergency physicians is sensitive and specific for the diagnosis of suspected DVT when performed by trained attending EPs. Three-point compression ultrasound examination may be more sensitive than two-point CUS.

Introduction: A solution for emergency department (ED) congestion remains elusive. As reliance on imaging grows, computed tomography (CT) turnaround time has been identified as a major bottleneck. In this study we sought to identify factors associated with significantly delayed CT in the ED.Methods: We performed a retrospective analysis of all CT imaging completed at an urban, tertiary care ED from May 1–July 31, 2021. During that period, 5,685 CTs were performed on 4,344 patients, with a median time from CT order to completion of 108 minutes (Quartile 1 [Q1]: 57 minutes, Quartile 3 [Q3]: 182 minutes, interquartile range [IQR]: 125 minutes). Outliers were defined as studies that took longer than 369 minutes to complete (Q3 + 1.5 × IQR). We systematically reviewed outlier charts to determine factors associated with delay and identified five factors: behaviorally non-compliant or medically unstable patients; intravenous (IV) line issues; contrast allergies; glomerular filtration rate (GFR) concerns; and delays related to imaging protocol (eg, need for IV contrast, request for oral and/or rectal contrast). We calculated confidence intervals (CI) using the modified Wald method. Inter-rater reliability was assessed with a kappa analysis.Results: We identified a total of 182 outliers (4.2% of total patients). Fifteen (8.2%) cases were excluded for CT time-stamp inconsistencies. Of the 167 outliers analyzed, 38 delays (22.8%, 95% confidence interval [CI] 17.0–29.7) were due to behaviorally non-compliant or medically unstable patients; 30 (18.0%, 95% CI 12.8–24.5) were due to IV issues; 24 (14.4%, 95% CI 9.8–20.6) were due to contrast allergies; 21 (12.6%, 95% CI 8.3–18.5) were due to GFR concerns; and 20 (12.0%, 95% CI 7.8–17.9) were related to imaging study protocols. The cause of the delay was unknown in 55 cases (32.9%, 95%CI 26.3–40.4).Conclusion: Our review identified both modifiable and non-modifiable factors associated with significantly delayed CT in the ED. Patient factors such as behavior, allergies, and medical acuity cannot be controlled. However, institutional policies regarding difficult IV access, contrast administration in low GFR settings, and study protocols may be modified, capturing up to 42.6% of outliers.

Introduction: Hypertension is the leading risk factor for morbidity and mortality throughout the world and is pervasive in United States emergency departments (ED). This study documents the point prevalence of subclinical heart disease in emergency patients with asymptomatic hypertension.Method: This was a prospective observational study of ED patients with asymptomatic hypertension conducted at two urban academic EDs that belong to an eight-hospital healthcare organization in New York. Adult (≥18 years of age) English- or Spanish-speaking patients who had an initial blood pressure (BP) ≥160/100 millimeters of mercury (mmHg) and second BP ≥140/90 mm Hg, and pending discharge, were invited to participate in the study. We excluded patients with congestive heart failure, renal insufficiency, and atrial fibrillation, or who were pregnant, a prisoner, cognitively unable to provide informed consent, or experiencing symptoms of hypertension. We assessed echocardiographic evidence of subclinical heart disease (left ventricular hypertrophy, and diastolic and systolic dysfunction).Results: A total of 53 patients were included in the study; a majority were young (mean 49.5 years old,[SD 14–52]), self-identified as Black or Other (n = 39; 73.5%), and female (n = 30; 56.6%). Mean initial blood pressure was 172/100 mm Hg, and 24 patients (45.3%) self-reported a history of hypertension. Fifty patients completed an echocardiogram. All (100%) had evidence of subclinical heart disease, with 41 (77.4%) displaying left ventricular hypertrophy and 31 (58.5%) diastolic dysfunction. There was a significant relationship between diastolic dysfunction and female gender [x2 (1, n = 53) = 3.98; P = 0.046]; Black or other race [x2 (3, n = 53) = 9.138; P = 0.03] and Hispanic or other ethnicity [x2 (2, n = 53) = 8.03; P = 0.02]. Less than one third of patients demonstrated systolic dysfunction on echocardiogram, and this was more likely to occur in patients with diabetes mellitus [x2 (1, n = 51) = 4.84; P = 0.02].Conclusion: There is a high probability that Black, Hispanic, and female patients with asymptomatic hypertension are on the continuum for developing overt heart failure. Emergency clinicians should provide individualized care that considers their unique health needs, cultural backgrounds, and social determinants of health.

Introduction: Timely diagnosis of patients affected by an emerging infectious disease plays a crucial role in treating patients and avoiding disease spread. In prior research, we developed an approach by using machine learning (ML) algorithms to predict serious acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection based on clinical features of patients visiting an emergency department (ED) during the early coronavirus 2019 (COVID-19) pandemic. In this study, we aimed to externally validate this approach within a distinct ED population.Methods: To create our training/validation cohort (model development) we collected data retrospectively from suspected COVID-19 patients at a US ED from February 23–May 12, 2020. Another dataset was collected as an external validation (testing) cohort from an ED in another country from May 12–June 15, 2021. Clinical features including patient demographics and triage information were used to train and test the models. The primary outcome was the confirmed diagnosis of COVID-19, defined as a positive reverse transcription polymerase chain reaction test result for SARS-CoV-2. We employed three different ML algorithms, including gradient boosting, random forest, and extra trees classifiers, to construct the predictive model. The predictive performances were evaluated with the area under the receiver operating characteristic curve (AUC) in the testing cohort.Results: In total, 580 and 946 ED patients were included in the training and testing cohorts, respectively. Of them, 98 (16.9%) and 180 (19.0%) were diagnosed with COVID-19. All the constructed ML models showed acceptable discrimination, as indicated by the AUC. Among them, random forest (0.785, 95% confidence interval [CI] 0.747–0.822) performed better than gradient boosting (0.774, 95% CI 0.739–0.811) and extra trees classifier (0.72, 95% CI 0.677–0.762). There was no significant difference between the constructed models.Conclusion: Our study validates the use of ML for predicting COVID-19 in the ED and demonstrates its potential for predicting emerging infectious diseases based on models built by clinical features with temporal and spatial heterogeneity. This approach holds promise for scenarios where effective diagnostic tools for an emerging infectious disease may be lacking in the future.

Introduction: People without reliable access to healthcare are more likely to be diagnosed with late-stage cancer that could have been treated more effectively if diagnosed earlier. Emergency departments (ED) may be a novel place for cancer screening education for underserved patients. In this study we sought to determine patient characteristics and barriers to cancer screening for those patients who presented to a large, academic safety-net ED and were overdue for breast, cervical, and colorectal cancer screening since the coronavirus 2019 (COVID-19) pandemic.Methods: Adult ED patients eligible for at least one cancer screening based on US Preventive Serivces Task Force guidelines completed a web-based survey. We examined the association of demographic characteristics and having a personal physician with being overdue on screening using chi-square or the Fisher exact test for categorical variables and t-tests for continuous variables.Results: Of 221 participants, 144 were eligible for colorectal, 96 for cervical, and 55 for breast cancer screening. Of eligible patients, 46% (25/55) were overdue for breast cancer screening, 43% (62/144) for colorectal, and 40% (38/96) for cervical cancer screening. There were no significant characteristics associated with breast cancer screening. Being overdue for cervical cancer screening was significantly more likely for patients who were of Asian race (P = 0.02), had less than a high school diploma (P = 0.01), and were without a routine checkup within the prior five years (P = 0.01). Overdue for colorectal cancer screening was associated with patients not having insurance (P = 0.04), being in their 40s (P = 0.03), being Hispanic (P = 0.01), and not having a primary care physician (P = 0.01). Of 97 patients overdue for at least one screening, the most common barriers were cost (37%), lack of time (37%), and lack of knowledge of screening recommendations (34%). Only 8.3% reported that the COVID-19 pandemic delayed their screening.Conclusion: The ED may be a novel setting to target patients for cancer screening education. Future work that refers patients to free screening programs and primary care physicians mayhelp improve disparities in cancer screening and cancer mortality rates for underserved populations.

Introduction: We examined the impact of a geriatric consult program in the emergency department (ED) and an ED observation geriatric care unit (GCU) setting on hospital admission rates for older ED patients.Methods: We performed a retrospective case control study from June 1–August 31, 2019 (pre-program) to September 24, 2019–January 31, 2020 (post-program). Post-program geriatric consults were readily available in the ED and required in the GCU setting. Hospital admission rates (outcome) are reported for patients who received a geriatric consult evaluation (intervention). We analyzed probability of admission using a mixed-effects logistic regression model that included age, gender, recent ED visit, Charlson Comorbidity Index, referral to ED observation, and geriatric consult evaluation as predictor variables.Results: A total of 9,663 geriatric ED encounters occurred, 4,042 pre-program and 5,621 post-program. Overall, ED admission rates for geriatric patients were similar pre- and post-program (44.8% vs 43.9%, P = 0.39). Of 243 geriatric consults, 149 (61.3%) occurred in the GCU. Overall admission rates post-program for patients receiving geriatric intervention were significantly lower compared to pre-program (23.4% vs 44.9%, P < 0.001). Post-program GCU hospital admission rates were significantly lower than pre-program ED observation unit admission rates (14/149, 9.4%, vs 111/477, 23.3%, P < 0.001). In the logistic regression model, admissions post-program were lower when a geriatric consult evaluation occurred (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.41–0.83). Hospital admissions for older ED observation patients were also significantly decreased when a geriatric consult was obtained (GCU vs pre-program ED observation unit; OR 0.27, 95% CI 0.14–0.50).Conclusion: Geriatric consult evaluations were associated with significantly lower rates of hospital admission and persisted when controlled for age, gender, comorbidities, and ED observation unit placement. This model may allow healthcare systems to decrease potentially avoidable hospital admission rates in older ED patients.

Introduction: Big data and improved analytic techniques, such as triple exponential smoothing (TES), allow for prediction of emergency department (ED) volume. We sought to determine 1) which method of TES was most accurate in predicting pre-coronavirus 2019 (COVID-19), during COVID-19, and post-COVID-19 ED volume; 2) how the pandemic would affect TES prediction accuracy; and 3) whether TES would regain its pre-COVID-19 accuracy in the early post-pandemic period.Methods: We studied monthly volumes of four EDs with a combined annual census of approximately 250,000 visits in the two years prior to, during the 25-month COVID-19 pandemic, and the 14 months following. We compared the accuracy of four models of TES forecasting by measuring the mean absolute percentage error (MAPE), mean square errors (MSE) and mean absolute deviation (MAD), comparing actual to predicted monthly volume.Results: In the 23 months prior to COVID-19, the overall average MAPE across four forecasting methods was 3.88% ± 1.88% (range 2.41–6.42% across the four ED sites), rising to 15.21% ± 6.67%during the 25-month COVID-19 period (range 9.97–25.18% across the four sites), and falling to 6.45% ± 3.92% in the 14 months after (range 3.86–12.34% across the four sites). The 12-month Holt-Winter method had the greatest accuracy prior to COVID-19 (3.18% ± 1.65%) and during the pandemic (11.31% ± 4.81%), while the 24-month Holt-Winter offered the best performance following the pandemic (5.91% ± 3.82%). The pediatric ED had an average MAPE more than twice that of the average MAPE of the three adult EDs (6.42% ± 1.54% prior to COVID-19, 25.18% ± 9.42% during the pandemic, and 12.34% ± 0.55% after COVID-19). After the onset of the pandemic, there was no immediate improvement in forecasting model accuracy until two years later; however, these still had not returned to baseline accuracy levels.Conclusion: We were able to identify a TES model that was the most accurate. Most of the models saw an approximate four-fold increase in MAPE after onset of the pandemic. In the months following the most severe waves of COVID-19, we saw improvements in the accuracy of forecasting models, but they were not back to pre-COVID-19 accuracies.

Introduction Methods Results Conclusion Delirium affects 15% of older adults presenting to emergency departments (EDs) but is detected in only one‐third of cases. Evidence‐based guidelines for ED delirium screening exist, but are underutilized. Frontline staff perceptions about delirium and time and resource constraints are known barriers to ED delirium screening uptake. Early adopters of ED delirium screening can offer valuable lessons about successful implementation.We conducted semi‐structured interviews with clinician‐administrators leading ED delirium screening initiatives from 20 EDs in the United States and Canada. Interviews focused on experiences of planning and implementing ED delirium screening. Interviews lasted 15 to 50 minutes and were digitally recorded and transcribed. To identify factors that commonly impacted implementation of ED delirium screening, we used constructs from the Consolidated Framework for Implementation Research (CFIR), an Implementation Science framework widely used to evaluate healthcare improvement initiatives.Overall, notable facilitators of successful implementation were having institutional and ED leadership support and designated clinical champions to longitudinally engage and educate frontline staff. We found specific examples of factors affecting implementation drawn from the following seven CFIR constructs: (1) intervention complexity, (2) intervention adaptability, (3) external policies and incentives, (4) peer pressure from other institutions, (5) the implementation climate of the ED, (6) staff knowledge and beliefs, and (7) engaging deliverers of intervention, that is, frontline ED staff.Implementing ED delirium screening is complex and requires institutional resources as well as clinical champions to engage frontline staff in a sustained fashion. [ABSTRACT FROM AUTHOR]

Aim Background Design Method Findings Conclusion Implications for the Profession and Patient Care Impact Reporting Method Patient or Public Contribution To explore the barriers and facilitators influencing emergency department clinicians' adherence to the Australian Peripheral Intravenous Catheter (PIVC) Clinical Care Standard, using the Behaviour Change Wheel (BCW).Suboptimal PIVC practices are frequently linked to a range of patient‐important adverse outcomes. The first Australian Peripheral Intravenous Catheter Clinical Care Standard was introduced in 2021, aiming to standardize practice. However, a recent national survey revealed a lack of adherence to the Standard among emergency department clinicians.A qualitative descriptive study.The study was conducted across two Australian emergency departments in 2023. Utilizing purposive sampling, semi‐structured interviews were conducted. The analysis incorporated both deductive and inductive approaches, mapping the findings to the BCW.Interviews with 25 nurses and doctors revealed nine key subthemes. The main barriers were the stressful environment, insufficient education and training, and the absence of a feedback mechanism. The main facilitators were recognition of suboptimal practice, belief in the importance of patient engagement, and the desire to improve practice.Multiple complex factors have an impact on clinicians' adherence to the Standard. The identified interventions will serve as a guide for future implementation of the Standard.The findings inform healthcare organizations of the significance of implementing strategies to enhance clinicians' acceptance of the Standard. Clinicians should consider incorporating the multifaceted interventions developed in accordance with the BCW for future implementation projects.Promoting adherence to standards opens avenues to challenge suboptimal practice and has the potential to instigate a culture shift in the fundamental skills of frontline clinicians.The study is designed and reported according to the Consolidated Criteria for Reporting Qualitative Research checklist.No patient or public contribution. [ABSTRACT FROM AUTHOR]

Background: As with many countries worldwide, Singapore is experiencing a rapidly ageing population. Presentation of older persons for urgent but non-emergent conditions to the Emergency Department (ED) represents a growing group of patients utilising public healthcare emergency services and puts a strain on current ED resources. The medical conditions vary, and resources used has been poorly characterized. Methods: This is a single-center cross-sectional observational study of patients aged 55 to 75 years old who visited the ED with urgent conditions, Patient Acuity Category Scale (PACS) P2 or P3, who were subsequently discharged. The patients visited a public hospital in Singapore on four randomly selected weekdays in April 2023. The utilisation of hospital resources and manpower was studied. A formulated criteria was used to determine the appropriate site of care, such as an Urgent Care Centre (UCC), Primary Care Providers (PCP) clinic or the ED. Results: There were 235 eligible patients during the study period, with a mean age of 65.1 years of which a majority, 183 (77.9%) were allocated to patient acuity category scale P2. Most of the patients were walk-in patients with no referrals (169 (71.9%)). Based on the criteria, the majority of 187 (79.6%) of these patient may be safely managed at an outpatient setting; 71 (30.2%) patients by PCP, 116 (49.4%) patients may be managed by an UCC, with the remaining 48 (20.4%) requiring ED care. Conclusion: Our findings indicate that a significant portion of discharged older ED adults with urgent but non-emergent conditions may be adequately managed at outpatient medical services that are appropriately resourced. More research is needed on healthcare initiatives aimed at developing the capabilities of outpatient medical services to manage mild to moderate acute conditions to optimise ED resource allocation. [ABSTRACT FROM AUTHOR]

ABSTRACT Self‐harm and suicide ideation are global health concerns, significantly impacting culturally and linguistically diverse (CALD) populations. Emergency departments (EDs) play a role in intervening following such presentations, yet there is limited research focusing on the CALD population's use of these services in Australia. This study aimed to explore patterns in ED use for self‐harm and suicide ideation, comparing CALD and non‐CALD persons in terms of service use, presentation themes and likelihood of repeat presentations. This was a cross‐sectional analysis of data from presentations for self‐harm and suicide ideation to the ED of a major metropolitan hospital in Victoria, Australia, from 2012 to 2019. The study used thematic analysis of triage notes, recurrent event analysis and logistic and linear regressions to compare CALD and non‐CALD presentations. CALD presentations comprised 1.3% (n = 202) of the total (n = 15 606). CALD presentations were more likely to occur during business hours, less likely to be triaged as urgent and more likely to result in ward admission. Occupation stressors were more common in CALD presentations. A lower likelihood of repeat presentations was observed among CALD persons. The study also highlighted the limitations of current data collection practices in capturing the full spectrum of CALD presentations. This study found variability in the recording of CALD status, warranting further investigation into how data collection in EDs may be improved. Increased ward admission rate and lower likelihood of repeat presentation by CALD persons also indicate that further research is required to understand help‐seeking and clinical decision‐making in the CALD population. [ABSTRACT FROM AUTHOR]

Background: Colorectal cancer (CRC) is globally the third most prevalent cancer and a leading cause of cancer-related deaths. In Alberta, Canada, a significant portion of CRC diagnoses occur following emergency department (ED) presentations. Gaps remain in understanding patient's perspectives on CRC diagnosis after an ED visit. The aim of this study was to examine the experiences and perspectives of a group of patients diagnosed with CRC subsequent to an ED visit in Alberta and their close contacts. Methods: We conducted a qualitative study using in-depth, semi-structured interviews with patients diagnosed with CRC after an ED visit at the Rockyview General Hospital, Calgary, and their close contacts, from November 2022 to June 2023. Interviews focused on symptom recognition, healthcare interactions, and the decision-making process leading to an ED visit. They were conducted in-person or over the phone, and analysed using thematic analysis. Results: Eighteen participants (12 patients and 6 close contacts) were interviewed, revealing four main themes: (1) variability in symptom recognition and interpretation; (2) inconsistencies in primary care consultations; (3) factors influencing decision-making leading to an ED visit; and (4) recommendations for expedited diagnosis outside of EDs. Conclusion: The findings highlight the complexity of the diagnostic journey for CRC patients in Alberta, pointing to significant gaps in symptom recognition and response by patients and healthcare providers. Improved diagnostic protocols and targeted support for healthcare providers, as well as approaches to address systemic delays may help streamline the diagnostic journey. Future research should focus on exploring innovative interventions to address the identified barriers to timely CRC diagnosis. [ABSTRACT FROM AUTHOR]

Introduction: To reduce mortality, the Taiwan government has vigorously promoted free cancer screening and preventive health screening services. Cancers are usually advanced by the time they are discovered in the emergency department. Through this study, we aimed to understand the characteristics of cancer patients diagnosed through the emergency department and thus identify high-risk populations by comparing cancer staging and survival rates in patients diagnosed in the emergency department and those diagnosed in the non-emergency department. Methods: The retrospective study enrolled a total of 389,043 patients over the age of 20 who were newly diagnosed with one of the five major cancers (including lung cancer, colorectal cancer, breast cancer, prostate cancer, and oral cancer) between 2008 and 2017 and analyzed their diagnostic pathway, cancer stage at diagnosis, and survival time. Results: Of the study participants, 59,423 patients (about 15.3%) were diagnosed with cancer through the emergency department. We found that a sizable proportion of older people and patients with low education and low incomes were diagnosed through emergency department visits, and those with a health condition comorbidity severity of 3 had the highest proportion diagnosed by the emergency department, advanced stages at diagnosis, and risk of death. These can be classified as high-risk groups. In addition, 76.4% of patients diagnosed in the emergency department had advanced cancer, and the risk of death was 1.46 times higher than that of patients diagnosed in the non-emergency department. Although cancer screening is available, it does not reduce the proportion of patients with advanced cancer who are diagnosed through or at the time of diagnosis in the emergency department. Conclusions: The present study found that the government's cancer screening did not affect the proportion or number of cancers diagnosed through emergency department visits. Therefore, the government should focus on more cancer screening, health education in high-risk groups, and strengthening the link between emergency and oncology departments to reduce the risk of death for patients diagnosed through emergency department visits. [ABSTRACT FROM AUTHOR]

Background/objectives: The race-sex differences in emergency department (ED) disposition decisions have been reported widely. Our objective is to identify demographic and clinical subgroups for which this difference is most pronounced, which will facilitate future targeted research on potential disparities and interventions. Methods: We performed a retrospective analysis of 93 987 White and African-American adults assigned an Emergency Severity Index of 3 at 3 large EDs from January 2019 to February 2020. Using random forests, we identified the Elixhauser comorbidity score, age, and insurance status as important variables to divide data into subpopulations. Logistic regression models were then fitted to test race-sex differences within each subpopulation while controlling for other patient characteristics and ED conditions. Results: In each subpopulation, African-American women were less likely to be admitted than White men with odds ratios as low as 0.304 (95% confidence interval (CI): [0.229, 0.404]). African-American men had smaller admission odds compared to White men in subpopulations of 41+ years of age or with very low/high Elixhauser scores, odds ratios being as low as 0.652 (CI: [0.590, 0.747]). White women were less likely to be admitted than White men in subpopulations of 18 to 40 or 41 to 64 years of age, with low Elixhauser scores, or with Self-Pay or Medicaid insurance status with odds ratios as low as 0.574 (CI: [0.421, 0.784]). Conclusions: While differences in likelihood of admission were lessened by younger age for African-American men, and by older age, higher Elixhauser score, and Medicare or Commercial insurance for White women, they persisted in all subgroups for African-American women. In general, patients of age 64 years or younger, with low comorbidity scores, or with Medicaid or no insurance appeared most prone to potential disparities in admissions. [ABSTRACT FROM AUTHOR]

Introduction: Sepsis is a severe medical condition that can be life-threatening. If sepsis progresses to septic shock, the mortality rate increases to around 40%, much higher than the 10% mortality observed in sepsis. Diabetes increases infection and sepsis risk, making management complex. Various scores of screening tools, such as Modified Early Warning Score (MEWS), Simplified Acute Physiology Score (SAPS II), Sequential Organ Failure Assessment Score (SOFA), and Acute Physiology and Chronic Health Evaluation (APACHE II), are used to predict the severity or mortality rate of disease. Our study aimed to compare the effectiveness and optimal cutoff points of these scores. We focused on the early prediction of septic shock in patients with diabetes in the Emergency Department (ED). Methods: We conducted a retrospective cohort study to collect data on patients with diabetes. We collected prediction factors and MEWS, SOFA, SAPS II and APACHE II scores to predict septic shock in these patients. We determined the optimal cutoff points for each score. Subsequently, we compared the identified scores with the gold standard for diagnosing septic shock by applying the Sepsis-3 criteria. Results: Systolic blood pressure (SBP), peripheral oxygen saturation (SpO2), Glasgow Coma Scale (GCS), pH, and lactate concentrations were significant predictors of septic shock (p < 0.001). The SOFA score performed well in predicting septic shock in patients with diabetes. The area under the receiver operating characteristics (ROC) curve for the SOFA score was 0.866 for detection within 48 h and 0.840 for detection after 2 h of admission to the ED, with the optimal cutoff score of ≥ 6. Conclusion: SBP, SpO2, GCS, pH, and lactate concentrations are crucial for the early prediction of septic shock in patients with diabetes. The SOFA score is a superior predictor for the onset of septic shock in patients with diabetes compared with MEWS, SAPS II, and APACHE II scores. Specifically, a cutoff of ≥ 6 in the SOFA score demonstrates high accuracy in predicting shock within 48 h post-ED visit and as early as 2 h after ED admission. [ABSTRACT FROM AUTHOR]

Background: Bleeding in early pregnancy is a common emergency department (ED) presentation. Although variability in approaches has been demonstrated, research is relatively uncommon on practices and outcomes. This study investigated the influence of clinical pattern of care, utility, and contribution of pelvic examination aimed at diagnosing and managing bleeding in early pregnancy at three Canadian EDs. Methods: After obtaining informed consent, data were collected from adult women who were pregnant and from treating ED physicians using a structured questionnaire. We defined the change in management based on the initial clinical plan at the time of the initial physician assessment in the ED and any subsequent changes made after the pelvic examination was performed. Patient telephone follow-up was supplemented by linking with provincial administrative data for births. Univariable and multivariable binary logistic regression analyses were performed to identify factors associated with a change in patient management following pelvic examination in the ED. Results: Overall, 200 women were enrolled. The mean age was 31 years, patients had been bleeding for a median of 1 day and stayed in the ED for a median of 5 h. Of these, 166 (83.0%) received a pelvic examination, including speculum examination and/or bimanual palpation. Pregnancy outcome data were available for 192 pregnancies; 107 (56%) experienced a miscarriage. Factors significantly associated with a change in management after pelvic examination in the univariate logistic regression analysis were brown/dark-red bleeding per vaginam (physician determined), tachycardia, right lower quadrant tenderness, and bimanual palpation. In the multivariate logistic regression analysis, brown/dark-red bleeding per vaginam was independently associated with a reduced likelihood of a change in management after pelvic examination (aOR = 0.37; 95% CI: 0.14–0.98). Conclusion: Among women presenting to the ED with bleeding in early pregnancy prior to 20 weeks gestation, only brown/dark-red vaginal bleeding, potentially indicative of bleeding resolution, significantly independently influenced the baseline odds of a change in management after pelvic examination. Until the debate on the utility of pelvic examination in the ED for this presentation is resolved, physician preferences and shared decision making with patients should guide practice regarding speculum examination/bimanual palpation for the management of bleeding in early pregnancy. [ABSTRACT FROM AUTHOR]

Background: Fentanyl is an opioid analgesic frequently used in the emergency department (ED) and is usually administered without knowing the QTC values of the patients or being monitored. However, the effect of fentanyl on QTC, prolongation or shortening, has not been elucidated. This study aimed to determine the effect of fentanyl on QTC. Methods: This is a prospective observational study in the ED of a tertiary hospital on patients who received intravenous fentanyl for procedures other than intubation. ECG was performed before and at 1, 5, 15, 30, and 60 min after the initiation of fentanyl administration, and QTC value was calculated. Primary outcomes were QTC prolongation, defined as an increase in the QTC to ≥ 500 ms or any increase in QTC by ≥ 60 ms. Results: The study included 109 patients. Of these, 60 patients were male, and the median age was 40. Compared with the baseline QTC value, statistically significant prolongation was detected at the 5th, 15th, 30th, and 60th minutes, with the maximum prolongation at 30 min, and the median was 13.08 ms. Most patients with QTC prolongation were female and over 40 years of age. Clinically, none of these patients developed malignant arrhythmias during the 60-minute monitored observation period. Conclusion: Fentanyl prolonged the QTC value statistically significantly. Although no patient developed malignant arrhythmia clinically, our results suggest that this QTC-prolonging effect should be considered when using fentanyl in patients at risk of torsades. [ABSTRACT FROM AUTHOR]

Background: Opioid related overdose morbidity and mortality continue to significantly impact rural communities. Nationwide, emergency departments (EDs) have seen an increase in opioid use disorder (OUD)-related visits compared to other substance use disorders (SUD). ED-initiated buprenorphine is associated with increased treatment engagement at 30 days. However, few studies assess rural ED-initiated buprenorphine implementation, which has unique implementation barriers. This protocol outlines the rationale and methods of a rural ED-initiated buprenorphine program implementation study. Methods: This is a two-year longitudinal implementation design with repeated qualitative and quantitative measures of an ED-initiated buprenorphine program in the rural Mountain West. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework outlines intervention assessments. The primary outcome is implementation measured by ED-initiated buprenorphine protocol core components. Reach, adoption, and maintenance are secondary outcomes. External facilitators from an academic institution with addiction medicine and prior program implementation expertise partnered with community hospital internal facilitators to form an implementation team. External facilitators provide ongoing support, recommendations, education, and academic detailing. The implementation team designed and implemented the rural ED-initiated buprenorphine program. The program includes OUD screening, low-threshold buprenorphine initiation, naloxone distribution and administration training, and patient navigator incorporation to provide warm hand off referrals for outpatient OUD management. To address rural based implementation barriers, we organized implementation strategies based on Expert Recommendations for Implementing Change (ERIC). Implementation strategies include ED workflow redesign, local needs assessments, ED staff education, hospital leadership and clinical champion involvement, as well as patient and community resources engagement. Discussion: Most ED-initiated buprenorphine implementation studies have been conducted in urban settings, with few involving rural areas and none have been done in the rural Mountain West. Rural EDs face unique barriers, but tailored implementation strategies with external facilitation support may help address these. This protocol could help identify effective rural ED-initiated buprenorphine implementation strategies to integrate more accessible OUD treatment within rural communities to prevent further morbidity and mortality. Trial Registration: ClinicalTrials.gov National Clinical Trials, NCT06087991. Registered 11 October 2023 – Retrospectively registered, https://clinicaltrials.gov/study/NCT06087991. [ABSTRACT FROM AUTHOR]

Objectives: This study aims to analyze the clinical features, symptoms, laboratory findings, and treatment approaches of patients presenting to the emergency department with elevated INR due to warfarin overdose. Methods: The study was conducted retrospectively from August 1, 2023, to June 1, 2024, in the emergency department of a tertiary hospital in a city with a population of 5 million. Patients aged 18 and over with an INR value of 3.5 or above were included. Data were obtained from electronic health records and patient files. Statistical analyses were performed using IBM SPSS Statistics. Results: A total of 121 patients were included in the study. The mean age was 71.85±12.28 years, with 53.7% female and 46.3% male. The most common diagnoses were atrial fibrillation (33.1%) and valve replacement (31.4%). The main reasons for emergency admission included general condition disorder (22.3%) and abdominal pain (16.5%). The bleeding rate was 47.9%, with the gastrointestinal system being the most common bleeding site (49.2%). The mean INR value was 9.27±5.45. Vitamin K was administered to 47.1% of patients and fresh frozen plasma to 28.1%. The discharge rate was 38.8%, and the mortality rate was 2.5%. Conclusions: Patients presenting to the emergency department with warfarin overdose are at significant risk of severe bleeding, requiring careful management. Close monitoring and accurate dose adjustments are essential, especially in elderly and comorbid patients. Antidotes such as vitamin K, fresh frozen plasma, and prothrombin complex are effective in managing bleeding complications. Future studies should aim to standardize and enhance the effectiveness of these treatment protocols. [ABSTRACT FROM AUTHOR]

'Ramping' is a commonly used term in contemporary Australian healthcare. It is also a part of the public and political zeitgeist. However, its precise definition varies among sources. In the published literature, there are distinctions between related terms, such as 'entry overload' and 'Patient Off Stretcher Time Delay'. How ramping is defined and how it came to be defined have significance for policies and procedures relating to the described phenomenon. Through examination of the history of the term, insights are obtained into the underlying issues contributing to ramping and, accordingly, associated possible solutions. [ABSTRACT FROM AUTHOR]

This document provides an analysis of nonpowder firearm-related eye trauma in the United States. The study examined data from 2013 to 2022 and found that there were approximately 16,756 emergency department visits for these injuries during that time. Children and males were the most affected, with BB guns being the most common cause of eye injuries. Contusions and abrasions were the most common diagnosis. While there has been a decrease in overall rates of these injuries, there has been an increase in adult cases in recent years. The article suggests implementing regulations and safety measures, such as age requirements, background checks, and protective eyewear, to prevent these injuries. It also recommends the establishment of a national database to support research and legislative efforts. [Extracted from the article]

Aims: The aim of this work is to describe opioid initiation and long‐term use after emergency department (ED) visits or hospitalizations in New South Wales, Australia, by patient, admission and clinical characteristics. Methods: This is a population‐based cohort study, including all hospitalizations and ED visits between 2014 and 2020, linked to medicine dispensings, deaths and cancer registrations (Medicines Intelligence Data Platform), among adults with no opioid dispensings in the previous year. Outcome measures were opioid initiations (dispensed within 7 days of discharge) and long‐term use (90 days of continuous exposure, 90–270 days after initiation). Results: The cohort included 16 153 096 admissions by 4.2 million opioid‐naïve adults; 39.0% were ED presentations without hospital admission, 16.8% hospital admissions via ED and 44.2% direct hospital admissions. Opioids were initiated post‐discharge for 6.2% of ED, 8.3% of hospital via ED and 10.0% of direct hospital admissions; of these 1.0%, 2.5% and 0.5% progressed to long‐term opioid use, respectively. Initiation was lowest in obstetric admissions without surgery (1.0%), and highest among trauma admissions (25.4%), obstetric admissions with surgical intervention (19.8%) and non‐trauma surgical admissions (12.0%). Long‐term use was highest among medical admissions via ED (3.5%), trauma admissions (2.3%) and ED alone (1.0%). From 2014 to 2020, overall opioid initiations decreased 16% from 8.7% to 7.2%, and long‐term opioid use decreased 33% from 1.3% to 0.8%. Conclusions: Both opioid initiation and long‐term use decreased over time; however, the higher rates of long‐term use following trauma, and medical admissions via ED, warrant further surveillance. Strategies supporting appropriate prescribing and access to multidisciplinary pain services will facilitate best practice care. [ABSTRACT FROM AUTHOR]

Background: Emergency department triage is a vital and complex decision‐making process. There is limited knowledge about nurses' experiences with triage decision support systems in emergency departments. Aim: This study was conducted to examine nurses' experiences with a computer‐based triage decision support system in the emergency department. Study Design: This is a qualitative and phenomenological study. Data were collected through interviews from 14 triage nurses who used a triage decision support system in the emergency department of a university hospital. The nurses were recruited for semi‐structured interviews. All interviews were recorded on a voice recorder and then transcribed. Data were analysed with the inductive content analysis method. The interviewer asked comprehensive questions about the nurses' experiences with the triage decision support system. Results: Three main and 11 sub‐themes were elicited as a result of the analysis of the in‐depth interviews: (a) the facilitating the triage decision theme, which included help in case of a dilemma, team collaboration, monitoring/supervision, and error reduction sub‐themes; (b) the contribution to professionalism theme, which included ease of learning and teaching triage, professional autonomy, creating a database, and evidence‐based practice sub‐themes; (c) the areas that need improvement theme, which included reducing screen clicks, the effect of the hospital automation system performance, and clinical descriptors not included in the algorithm sub‐themes. Conclusion: Triage nurses stated that the decision support system was beneficial and facilitated decision‐making. The decision support system enabled triage nurses to make their own decisions using their clinical knowledge and experience, without a restriction on their professional autonomy, and this was perceived positively. It was emphasized that this system could be a support tool in educating nurses new to triage. However, nurses stated that the pace of the decision support system was affected by the performance of the hospital automation system and that the large number of steps used for electing items caused a waste of time. They also added that these were technical areas that needed improvement. Relevance to Clinical Practice: The study provides important data that will help healthcare organizations and professionals better understand the emergency department nurse triage decision support system and gain a versatile, comprehensive, and general understanding. [ABSTRACT FROM AUTHOR]