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

Introduction: Emergency department (ED) surge events, defined as the episodic clustering of high-acuity patients that transiently overwhelms available clinician capacity, are associated with delays in care and potential patient harm. Existing crowding metrics do not quantify real-time clinician-level workload. This paper describes the development and preliminary feasibility evaluation of a novel acuity-weighted metric—the cumulative weighted-average acuity level (CWAAL)—to detect physician-level surge conditions in real time.

Methods: This multiphase observational feasibility study was conducted at two rural community EDs. The CWAAL is defined as the sum of weighted acuity scores for all active patients under a single clinician’s management: it incorporates a feasibility threshold derived by combinatorial enumeration. The primary outcome was door-to-doctor time (DDT); secondary outcomes included length of stay (LOS) and CWAAL distribution. The DDT comparisons at Hospital B (n = 4 surge events per condition) used the Mann-Whitney U test. All data were obtained from the practice of a single physician.

Results: We evaluated a single emergency physician across 354 patients on 10 study dates at two rural community EDs, tracking 11 surge events and one proof of concept. A CWAAL feasibility threshold of ≤ 12 (±1)—equivalent to four simultaneous Level 3 patients (~120 minute demand within a 60-minute window)—emerged consistently across both sites. At Hospital B, surge-period DDTs were substantially lower with advanced practice clinician (APC) coverage than without (median, 31.5 minutes [interquartile range {IQR}, 24.7–38.0] vs 107.7 minutes [IQR, 85.7–133.5]); Mann-Whitney U = 0, P = .03, 2-tailed exact; rank-biserial r = 1.0), with complete distributional separation across eight surge events. All APC-supported events occurred at CWAAL ≤ 12; all unsupported events at CWAAL > 12. A proof-of-concept application on May 28, 2024, demonstrated operational feasibility; supplemental staffing reduced the physician’s weighted acuity burden by 31 points and normalized DDT and LOS.

Conclusion: In this development cohort, the physician reached functional care capacity at cumulative weighted average acuity level = 12 (four simultaneous Level 3 patients; ~120 minutes demand within a 60-minute physician-hour). Complete separation of APC-supported and unsupported outcomes across eight events supports this novel acuity-weighted metric as a meaningful operational signal. Formal prospective validation across independent datasets is required before generalizing. 

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Introduction: Medical students are sometimes used as embedded simulation participants (ESP) to facilitate ultrasound training on live volunteers. There is little guidance on how to safeguard the autonomy and dignity of medical student ESPs serving in this role. Based on real student experiences, we used four cases to illustrate the ethical dilemmas that can arise when ESPs are used, including the examination of sensitive body areas, risk for coercion, discovery of incidental findings in a public and professional setting, and social media posting of training events. Through these cases, we explore and articulate the relevant ethical obligations educators have to obtain informed consent, sensitively address incidental findings, and ensure the psychological and physical safety of ESPs.

Methods: We developed interventions and procedures at our institution to address the obligation to promote ESP autonomy and bodily dignity, including a comprehensive consent form, ombudsperson role, and restrictions surrounding photography and social media posting of educational events.

Results: These interventions were implemented in January 2024 in the emergency department of a large academic medical center affiliated with a medical school. Since implementation, 96 ESPs have participated in 16 discrete educational events. There has been anecdotal positive reception of these interventions. Recruiting and training individuals for the ombudsperson role carried some challenges.

Conclusion: Proactive measures are necessary to support the autonomy and safety of medical student ESPs. There are practical challenges associated with recruitment, training, and implementation of the ombudsperson role. We hope that other institutions who use medical student ESPs will consider incorporating similar practices to promote the psychological and bodily safety of their volunteers.

Introduction: Initiation of buprenorphine reduces mortality in people with opioid use disorder. However, patients who decline hospital transport after overdose may not be connected to treatment. To augment treatment engagement, prehospital buprenorphine pilot programs began in 2019. To date, few studies have looked at these programs nationally. Our objective was to evaluate national prehospital buprenorphine usage.

Methods: We conducted a cross-sectional evaluation of emergency medical service (EMS) encounters involving prehospital buprenorphine administration using the 2020-2023 National EMS Information System Public Release Research datasets. Our primary outcome was trends in prehospital buprenorphine usage. Quarterly rates of prehospital buprenorphine were evaluated using joinpoint regression to identify inflection points. The secondary outcome was patient demographics and encounter characteristics, which were analyzed using descriptive statistics.

Results: Of all EMS encounters with patient contact in the dataset (N = 167,221,959), there were 2,180 encounters where buprenorphine was administered (62% male [n = 1,349], mean age 37 years, standard deviation [SD] 10), with a significant increase per year (2020: n = 33; 2023: n = 1,574). Approximately half (52%; n = 1,125) of prehospital buprenorphine administrations occurred during 9-1-1 responses. Most encounters occurred in the South Atlantic region (4 administrations/100,000 encounters) and urban areas (72%; n = 1,572). Nearly all EMS crews were advanced life support (ALS) level of care (paramedic: 53% [n = 1,155]; ALS-community paramedic: 46% [n = 1,008]). Initial dosages of administered buprenorphine were 8 milligrams (mg) (45%; n = 973), 16 mg (36%; n = 786), or 24 mg (7%; n = 160). Most patients (80%; n = 1,746) had documented improvement with only four (0.2%) worse after administration. Few 9-1-1 encounters (16%; n = 180) resulted in hospital transport by EMS. Only 7% (n = 82) of 9-1-1 prehospital buprenorphine encounters had documented naloxone administration prior to buprenorphine dosing. There was a significant increase in number of buprenorphine administrations in quarter 2 of 2022 (slope increase of 54 administrations [95% CI, 20-89] per quarter versus 1 administration [95% CI, –1 to +3] per quarter from 2020-2022 quarter 1).

Conclusion: Rates of prehospital buprenorphine have increased significantly between 2020 and 2023. Buprenorphine administration largely resulted in documentation of improvement in patient condition. With continued high rates of opioid-related deaths, prehospital buprenorphine may be considered by EMS agencies to prevent deaths from subsequent opioid use and connect patients to treatment.

Introduction: Alcohol withdrawal syndrome (AWS) is a frequent cause of emergency department (ED) visits, and some patients return soon after discharge. Identifying factors associated with short-term ED return may inform targeted interventions. Our primary objective was to identify factors associated with 72-hour ED return and 30-day hospital admission among patients discharged after treatment for AWS.

Methods: We conducted a retrospective review of 318 ED encounters for AWS at a single academic medical center from January 1, 2020, to December 31, 2023. Demographic, psychiatric, housing, insurance, and discharge pharmacology variables were collected. We evaluated ED pharmacologic treatment strategy and discharge taper prescriptions. The primary outcome measure was 72-hour ED return, and the secondary outcome measure was hospital admission within 30 days. We compared groups using chi-square, Shapiro-Wilk, Fisher exact, and Mann–Whitney U tests. Variables with significant univariate associations were included in multivariable logistic regression, and results were reported as odds ratios (OR) with 95% confidence intervals. 

Results: Fourteen patients (4.4%) returned within 72 hours, and 32 patients (10.1%) were admitted within 30 days. On multivariable logistic regression, schizophrenia (OR, 8.59; 95% CI, 2.07-35.61), Medicaid insurance (OR, 4.43; 95% CI, 1.39-14.14), and anxiety (OR, 3.53; 95% CI, 1.10-11.39) were independently associated with increased 72-hour ED return. Homelessness was independently associated with higher 30-day admission (OR, 3.19; 95% CI, 1.26-8.07). Discharge tapers were not associated with either outcome.

Conclusion: Among patients discharged after ED treatment for alcohol withdrawal syndrome, Medicaid insurance, anxiety, schizophrenia, and homelessness were associated with short-term return or admission. These findings suggest that social and psychiatric vulnerability may contribute to short-term ED reuse following discharge after AWS treatment. These results highlight opportunities to strengthen follow-up pathways and to address social determinants of health. Larger, multicenter studies are needed to clarify whether these associations are specific to AWS or reflect broader patterns of ED utilization.

Introduction: Psychostimulant detection rates among emergency department (ED) patients presenting with suspected substance intoxication are low and are influenced by limited access to confirmatory testing, insufficient clinical information, and variability in physician experience. These challenges often result in high false-positive rates and unnecessary resource use. We hypothesized that machine learning (ML) algorithms could maintain reliable diagnostic performance across a temporal validation cohort and perform comparably to physicians with varying experience levels.

Methods: This multicenter study prospectively enrolled ED patients with suspected substance intoxication between March 2019 and January 2020. We chronologically partitioned data into a training set (March–October 2019) and a temporal validation cohort (November 2019–January 2020) to assess model generalizability. After determining psychostimulant intoxication via liquid chromatography-mass spectrometry from urine samples, we trained the ML algorithms using the confirmed positive cases. The primary outcome was the diagnostic discrimination of the models, measured by the area under the receiver operating characteristic curve (AUC) in the temporal validation cohort. Secondary outcomes included model accuracy, the Youden index, and a comparative assessment of sensitivity and specificity relative to five physicians of varying experience levels.

Results: Among 1,382 patients (mean age 43.8 [standard deviation 19.2] years; 55.3% male), 302 patients (21.9%) had confirmed psychostimulant intoxication, primarily involving (meth)amphetamines (134 [44.4%]), cathinones (107 [35.4%]), and ketamine (97 [32.1%]). In the temporal validation cohort (n = 382), the ML models demonstrated consistent performance, with AUCs ranging from 0.786 to 0.836. The primary outcome was met by the top-performing extreme gradient boosting (XGB) model (AUC, 0.836, 95% CI, 0.785-0.882; accuracy, 0.866 (95% CI, 0.838-0.895); and Youden index, 0.590 (95% CI, 0.480-0.694). To evaluate secondary outcomes, the XGB model’s predictive accuracy was evaluated against 5 emergency physicians. The model surpassed the junior emergency physicians in both specificity (0.910 vs 0.633-0.867) and sensitivity (0.681 vs 0.500-0.633); its specificity was comparable to that of the senior emergency physicians (0.900-0.933).

Conclusion: Machine learning models provide reliable diagnostic utility for identifying psychostimulant intoxication, achieving performance comparable to senior emergency physicians. While moderate sensitivity (0.389–0.708) limits their role as standalone rule-out tools, their high specificity provides a standardized tool to assist clinical decision-making and reduce diagnostic uncertainty in the fast-paced ED setting. 

Introduction: Asthma exacerbations commonly require nebulized albuterol in the emergency department (ED). High-efficiency devices (vibrating mesh, breath-enhanced/actuated) may shorten treatment time compared with traditional jet nebulizers. We compared four commonly used nebulizer devices on treatment time and ED outcomes.

Methods: We conducted a prospective observational study of a convenience sample of patients at a high-volume, urban Level I trauma center ED (February 2019–March 2023; paused during COVID-19). Patients ≥ 3 years of age receiving clinician-ordered nebulized albuterol were eligible. Exclusions included patients with a history of chronic obstructive pulmonary disease or congestive heart failure, inability to follow commands or hold the device, and need for positive-pressure ventilation. Respiratory care practitioners used one of four devices already in use in this department: Westmed miniHEART Hi-Flo jet (Mini), Aerogen Ultra (vibrating mesh), Monaghan AeroEclipse II (breath-actuated), or Salter Labs NebuTech (breath-enhanced). The Mini group received a single 15-mg dose; others received 5-mg increments up to 15 mg with reassessment. Our primary outcome measure was the shortest time to complete delivery of the planned albuterol dose to the patient. Secondary outcomes included hospital admission and changes in asthma security scores and peak expiratory flow. We used analysis of variance post-hoc tests and adjusted linear/logistic regression. Both males and females were included; sex-stratified analyses were not prespecified.

Results: We enrolled 296 patients (Mini, n = 90; Aerogen, n = 67; AeroEclipse, n = 65; NebuTech, n = 74), 78 (26.3%) of whom were pediatric patients 3-18 years of age (Mini, n = 22; Aerogen, n = 20; AeroEclipse, n = 14, and NebuTech, n = 22). Time to complete albuterol differed by device, with mean treatment times in minutes (95% CI): Mini, 60.6 [55.9–65.3]; Aerogen, 12.3 [10.9–13.7]; AeroEclipse, 8.7 [7.7–9.7]; and NebuTech, 7.9 [7.0–8.8]. Adjusted models showed 82%, 88%, and 88% relative reductions vs Mini (all P < .01). Admission rates did not differ in total percentage (Mini, 11.1 [10]; Aerogen, 14.9 [10]; AeroEclipse, 16.9 [11]; and NebuTech, 6.8 [5] (all P > .05). Adults had lower odds of admission than pediatrics (odds ratio 0.38; 95% CI, 0.18–0.79; P = .01), with a total of 36 (12.1%) patients requiring admission, two pediatric. Asthma severity and improvements in peak expiratory flow were similar across devices, with mean post-treatment values (asthma severity score and peak expiratory flow): Mini, 5.5 and 301.1; Aerogen, 5.6 and 292.7; AeroEclipse, 5.9 and 248.5; and NebuTech, 5.7 and 301.1 (all P > .01).

Conclusion: In a real-world ED cohort, vibrating-mesh and breath-enhanced/actuated nebulizers delivered albuterol > 80% faster than a traditional jet device, potentially saving at least 45 minutes per treatment per patient, without differences in admission rates or clinical response. Adopting faster devices may improve workflow and throughput without compromising patient outcomes.

Introduction: Inhaled nitrous oxide (iNO) offers rapid onset analgesia with a favorable safety profile yet remains underused for shoulder dislocation reductions in the emergency department (ED). The objective of this study was to evaluate the use and outcomes of iNO for shoulder reduction in the ED, including whether intravenous (IV) access was required, whether successful reduction could be accomplished without additional analgesic or sedative medications under procedural sedation, and the rate of adverse effects from iNO.

Methods: We conducted a retrospective chart review of shoulder dislocation reductions using iNO at two high-volume EDs over three years (2019–2022). Data collected included age, sex, indication, procedural success, IV placement, medications administered, and adverse events and was stored in a password-protected database. The primary endpoint was successful reduction with iNO as the primary procedural analgesic; secondary endpoint was occurrence of any adverse events.

Results: Of 138 patients, 125 (90.6%; 95% CI, 0.84-0.95) achieved successful reduction with iNO alone without escalation to procedural sedation; 102 patients (74%) did not require IV access. Adverse events were rare (2/138 or 1.4% [95% CI, 0.02-0.05]): one patient experienced transient agitation (a known side effect of N-methyl-D-aspartate antagonism), and one had vomiting. Both were self-limited without hemodynamic changes.

Conclusion: This retrospective case series, the largest of its kind to date examining iNO for shoulder dislocation reduction, demonstrated a 90.6% success rate with minimal adverse events and reduced resource utilization compared to procedural sedation. These findings support further prospective investigation of iNO for shoulder dislocation as well as other orthopedic reductions and painful ED procedures.

Introduction: Emergency department (ED) boarding is a well-documented crisis associated with adverse patient outcomes, healthcare worker burnout, and moral injury. Although prior work has documented operational and educational impacts, including reductions in resident productivity and procedural exposure, less is known about how sustained boarding shapes professional identity formation. We sought to explore how sustained ED boarding shapes the learning experiences and professional identity formation of emergency medicine (EM) residents, as perceived by both residents and the attending physicians who train them.

Methods: Using a constructivist paradigm, we conducted a qualitative study using semi-structured interviews with residents and attending physicians from a 4-year EM residency program with rotations across 5 clinical sites, between July and August 2025. Two researchers independently coded transcripts and iteratively refined a shared codebook, continuing until additional interviews were unlikely to add new insight, guided by the concept of information power. We used reflexive thematic analysis, treating researchers’ clinical and analytic judgment as a resource for identifying patterns of meaning, and prioritized participants’ own construction of meaning over the frequency of any single idea, consistent with an interpretive phenomenological approach.

Results: We interviewed 13 emergency physicians: 6 residents and 7 attending physicians (range: 1–30+ years after residency). Three overarching themes emerged: (1) Educational challenges and opportunities—boarding fragments diagnostic ownership, narrows the acuity spectrum, and limits authentic undifferentiated encounters, although attending physicians adapt through structured hypotheticals and micro-teaching); (2) Shifts in the clinical environment—operational and structural adaptations create educational dead space, constrain the therapeutic alliance, and generate role ambiguity around boarded patients); and (3) Moral strain and suffering—moral injury and combined suffering is not peripheral to training but embedded within it, shaping how residents interpret professional responsibility and integrity. The three themes exist in a triangular relationship, with suffering at the foundation.

Conclusion: Boarding appeared to function as a formative context for professional identity formation, not merely a disruptive one. Residents described learning systems-level practice, advocacy, and emotional regulation, often through loss and moral injury, alongside attending physicians navigating the same. These findings suggest that recognizing boarding as a structural condition of training may reorient the responsibility of graduate medical education: formalizing adaptive teaching strategies, creating structured opportunities to process moral strain, and committing to advocacy that treats boarding as the educational crisis it is.

Introduction: Advanced emergency ultrasound (AEMUS) fellowships recently experienced an unexpected decrease in the number of positions filled in the match. Our study aimed to characterize this trend over an eight-year period.

Methods: We performed a cross-sectional observational study of AEMUS fellowships participating in the National Resident Matching Program (NRMP) from the 2019–2026 match cycles, cross-referencing the publicly available database from the Society of Clinical Ultrasound Fellowships. The primary outcome was both the proportion of AEMUS fellowship positions filled and a program complement fill percentage. Secondary outcomes included stratification by geography and duration since program establishment.

Results: We included a total of 138 of the 141 programs listed in the NRMP Match. From 2019 to 2026, there was a 28.2% increase in the number of programs and a 34.5% increase in available positions. There was a general increase in the percentage of positions filled from 2019 to 2022, with 53.7% (87/162) of positions filled to 74.4% (145/195), peaking at 81.1% (137/169) in 2021. This upward trend reversed in 2023 with a decrease to 65.1% (142/218). The percentage of positions filled has continued to decrease through 2026, with a fill rate of only 56.0% (122/218). In the eight years of NRMP data, 97 of the 138 programs (70.3%) went unfilled at least once. Programs participating in the Match for a longer period had a statistically significant higher fill percentage, with 27 programs in the 1- to 4-year group with a total fill percentage of 46.0%, 32 programs in the 5- to 7-year group with a fill percentage of 59.0%, and 79 programs in the ≥ 8-year group with a fill percentage of 72.8% (P < .01) using a Kruskal-Wallis test. Spearman correlation analysis found no association between geographic proximity and likelihood of a program being fully filled.

Conclusion: This cross-sectional study of NRMP data showed a decrease in the percentage of positions filled for adult AEMUS fellowships starting in 2023, which continued through 2026. Programs with greater longevity exhibited higher fill percentages, showing resilience in the face of this pattern.

Introduction: Since the COVID-19 pandemic, many emergency medicine (EM) residencies have transitioned to virtual interviews, providing less in-person exposure for applicants. Away rotations offer applicants the opportunity to gain in-person exposure to residency programs beyond the virtual interview environment. Whether the away rotation is more important now and leads to higher rotator match rates in the virtual recruitment era remains unclear and warrants investigation. Our objective was to determine the percentage of EM interns who completed an in-person rotation at the residency program in which they matched and compare this to pre-COVID-19 match rates.

Methods: This was a multicenter pilot study of EM residency programs. We recruited a convenience sample of academic programs from the eight Society for Academic Emergency Medicine (SAEM) US geographic regions. Inclusion criteria included academic EM programs that conducted virtual-only interviews post-COVID-19. We collected data via a survey form for the 2017-2024 application years regarding the number of matched interns who completed an in-person rotation at the program and the number of matched interns who were “home” versus “away” rotators. The first three years were defined as pre-COVID and the last three as post-COVID. The 2020-2021 academic year was excluded given the elimination of most away rotations during this cycle. We compared proportions of matched interns before and after COVID-19.

Results: Eleven of 13 invited programs (representing seven of eight SAEM regions) participated in our analysis. Pre-COVID, 95 of 384 interns (24.7%; 95% CI, 20.5-29.4%) completed a rotation at their respective residency program. Post-COVID, this decreased by 2.86% (absolute risk difference; 95% CI, –6.13% to 4.02%; McNemar’s P = .06) to 84 of 384 (21.9%; 95% CI, 17.8-26.3%). Focusing solely on “away” rotators, 48 of the matched interns (12.5%; 95% CI, 9.4-16.2%) completed a rotation at their residency program pre-COVID compared to 47 interns (12.2%; 95% CI, 9.1-15.9%) post-COVID (P = .82). The absolute risk difference for the away rotators was 0.7% (95% CI, -10.6% to 9.1%, P = .82).

Conclusion: In this pilot study, we found no statistically significant difference in the proportion of matched interns who completed an in-person rotation in the pre- versus post-COVID-19 era. 

Academic emergency departments (EDs) host off-service residents (OSRs) from various specialties. While OSRs contribute meaningfully to patient care, they often face unique challenges during their ED rotations, including limited preparation, heightened stress, and unmet personal expectations. Despite a standardized curriculum endorsed by the American College of Emergency Physicians, guidance on how to foster meaningful educational experiences for OSRs remains sparse. This perspective offers a structured approach grounded in self-determination theory (SDT), which emphasizes autonomy, competence, and relatedness as essential to intrinsic motivation and effective learning. By aligning educational strategies with SDT principles, emergency medicine educators can enhance engagement, support learner development, and create lasting interprofessional collaboration. Ultimately, this learner-centered approach not only enriches the OSR experience but also strengthens the role of the ED as a dynamic, inclusive learning environment for all trainees.

Introduction: Efficient triage in emergency departments (ED) is crucial for timely patient care, as evidence indicates that time to triage could affect treatment outcomes. Sex differences have been observed in different healthcare areas. The objective of this study was to determine whether sex differences exist in a patient’s time to triage and the magnitude of any observed differences at presentation to the ED of a Jerusalem hospital.

Methods: This retrospective study used anonymized data from adult ED visits between January 1 to September 30, 2024, at an ED in Jerusalem. Our primary outcome measure was the mean time to triage, defined as the interval between documented patient arrival and the first encounter with a triage nurse. Our secondary outcome measures included the proportion of patients triaged within 15 minutes, stratified by sex, ED division, and Emergency Severity Index (ESI) level.

Results: The study analyzed 30,447 adult ED visits over nine months. Mean time to triage was 10.9 minutes for women versus 10.3 minutes for men (absolute difference, 0.6 minutes; P < .001). Women were less likely to be triaged within 15 minutes (75.2% versus 76.9%; absolute difference, 1.7%; P < .001). Median time to triage was 6.0 minutes (interquartile range [IQR]) for men, 1.0-15.0 vs 7.0 minutes (IQR, 1.0-15.0) for women. Among patients with ESI levels 3-5, women had lower odds of triage within 15 minutes (odds ratio [OR], 0.78; 95% CI, 0.73–0.84; P < .001), while no significant sex differences were observed for ESI levels 1-2 (OR 1.30; 0.90–1.88; P = .17). Differences were most pronounced in ED triage to the ambulatory care area (absolute difference, 1.8%; OR, 0.95) and minimal in acute care (absolute difference, 0.5%; OR, 0.84), with no significant difference in the shock-trauma unit. Both sexes had similar triage rates within 60 minutes (99.2%).

Conclusion: Although we found statistically significant sex differences in time to triage, the absolute difference of 0.6 minutes is not clinically meaningful. The near-universal triage within 60 minutes suggests that early triage prioritization differences do not translate into clinically significant delays. Within this ED, triage processes function similarly for men and women. Future research should evaluate downstream processes (eg, time to physician evaluation) to determine aspects of ED care that may demonstrate clinically important sex-based disparities.

Introduction: Emergency department (ED) crowding harms patient care and strains hospital operations. Forecasting daily patient arrivals can help ED medical directors, department chairs, and hospital administrators plan staffing and bed capacity in advance, rather than reacting after a surge has already occurred. This study compared five computer-based forecasting methods, including three machine learning models (eXtreme gradient boosting [XGBoost], light gradient boosting machine [LGBM], and long short-term memory [LSTM]) and two traditional statistical models (autoregressive integrated moving average [ARIMA] and seasonal ARIMA [SARIMA]), to determine which most accurately predicts ED patient volume seven days in advance, using eight years of daily visit data from an academic freestanding ED.

Methods: This retrospective study analyzed 3,202 consecutive days of daily patient volume (March 27, 2017, to December 31, 2025) from an academic freestanding ED with approximately 31,102 annual visits. Each model used the preceding 365 days of data to forecast the subsequent 7 days, repeated across the study period to reflect the weekly cycle by which most EDs plan staffing. Our primary measure of accuracy was mean absolute error (MAE), defined as the average number of patients per day by which a forecast missed the actual volume. Secondary measures included root mean squared error (RMSE), mean absolute percentage error (MAPE), the coefficient of determination (R², a score from 0 to 1 reflecting how well predictions tracked actual day-to-day volume), and the percentage of forecasts accurate within 5, 10, 15, and 20 patients, thresholds selected for their relevance to staffing decisions. The best-performing model on initial metrics, XGBoost, served as the reference model for statistical comparison using the Diebold-Mariano (DM) test, which determines whether an observed difference in accuracy between two models is statistically meaningful or attributable to chance.

Results: Among 453 rolling weekly forecast windows, SARIMA, XGBoost, and LGBM demonstrated the lowest absolute errors and best forecasting of patient volume, with MAE values of 9.60 (95% CI, 9.29–9.91), 9.61 (95% CI, 9.31–9.91), and 9.64 (95% CI, 9.33–9.94) patients/day, respectively; these three models therefore missed the actual daily patient count by approximately 9 to 10 patients, on average. Models ARIMA and LSTM were less accurate, with mean MAE values of 10.54 (95% CI, 10.21–10.87) and 12.01 (95% CI, 11.63–12.39) patients per day. Relative to the XGBoost reference (MAPE 13.82%), ARIMA (MAPE 14.93%) and LSTM (MAPE 17.27%) showed a marked decrease in predictive accuracy. For operational planning, the top-performing models (SARIMA, XGBoost, and LGBM) correctly predicted daily volume within a margin of 20 patients in 90.3% to 90.6% of instances, while LSTM performed less well and reached this threshold in only 83.3% of forecasts. Statistical testing confirmed these differences were unlikely due to chance, with XGBoost significantly outperforming ARIMA (DM = −6.09, P < .001) and LSTM (DM = −6.96, P < .001).

Conclusion: Models SARIMA, XGBoost, and LGBM performed comparably well, and all three would provide reliable, operationally useful forecasts for ED staffing and resource allocation decisions. A traditional statistical method, SARIMA, which is simpler and less resource-intensive to implement, performed as well as the newer machine learning methods evaluated in this study. This finding suggests that hospitals do not necessarily need to invest in more complex artificial intelligence tools to obtain accurate ED volume forecasts.

Introduction: Emergency medical services (EMS) redirection is used to manage emergency department (ED) strain, but whether it reflects operational conditions is unclear. We compared associations of prespecified ED operational measures, including visit volume, patient flow times, admissions, boarding, and left-early measures, with redirection activation and total daily redirection minutes.

Methods: We performed a retrospective study at a single urban tertiary care center over 392 consecutive days from April 7, 2021 through May 3, 2022. Redirection temporarily routed ambulances away from the study hospital and was activated centrally by EMS. New York City’s 9-1-1 system included about 500 ambulance units and over 60 hospitals. The primary outcome was activation, defined as any redirection during a calendar day. The secondary outcome was total redirection minutes among days with redirection. Multivariable logistic regression evaluated activation, and negative binomial regression evaluated duration.

Results: Redirection occurred on 250 of 392 days (63.8%). Median daily duration was 47 minutes (interquartile range 23-78). Higher ED visit volume was associated with activation (odds ratio [OR] 1.14 per 10 patients; 95% CI, 1.02-1.27). Longer door-to-room time was associated with activation (OR 1.42 per 5 min; 95% CI, 1.04-1.92) and duration (incidence rate ratio 1.022 per min; 95% CI, 1.002-1.042). Boarding time and admission count were not associated with either outcome.

Conclusion: Emergency department visit volume was associated with activation but not duration, while door-to-room time was associated with both. Evaluating redirection as a single outcome may obscure differences between activation and cumulative duration.

Introduction: Women remain underrepresented in emergency medicine leadership roles, in part due to sex-based stereotypes that undervalue leadership traits traditionally associated with women, such as collaboration and empathy. Agentic traits like assertiveness are often perceived as requisite for leadership, while communal skills are overlooked. Leadership self-efficacy, an individual’s belief in their ability to successfully perform leadership roles, is a key predictor of leadership emergence.

Methods: Our team developed a 90-minute didactic session featuring a panel of diverse women leaders followed by an interactive case-based exercise, delivered at the Society for Academic Emergency Medicine 35th Annual Meeting in 2024. The intervention was evaluated using a pre- and postsurvey based on an adapted Leadership Self-Efficacy Scale measuring six domains of leadership self-efficacy. Eighteen participants completed both the pre- and postsession surveys, providing 18 matched pre–post pairs for analysis. Participants rated their confidence on a seven-point Likert scale. Our outcome of interest was the change in mean self-efficacy score for each domain on this seven-point scale, assessed with paired t-tests.

Results: All six leadership domains showed increased mean scores postintervention. Dimension 1 (Leading Change) increased significantly (mean change +0.72/7, P = .001), as did Dimension 2 (Choosing team/Delegating) (mean change +0.61/7, P = .004). Dimensions 3–6 showed positive but nonsignificant trends.

Conclusion: This single-session intervention was associated with increased leadership self-efficacy, particularly in the domains of leading change and team-building. The combination of role model exposure and interactive case practice may be a useful approach for empowering women physicians. This innovation can be adapted for implementation at other academic institutions.

Introduction: Prehospital emergency care (PEC) systems vary widely in structure, capacity, and stage of development, and existing evaluation tools are not tailored to the contextual needs of Southeast Asia. To address this gap, the Prehospital Emergency Care System Evaluation Tool (PECSET) was developed as a 32-element, consensus-derived framework to support system assessment, prioritization, and quality improvement. The objective of this study was to evaluate the prospective acceptability of the PECSET framework among Southeast Asian prehospital stakeholders using the theoretical framework of acceptability (TFA) and to identify regional variation in implementation priorities.

Methods: We conducted a cross-sectional survey of PEC professionals from the Philippines, Thailand, Vietnam, Indonesia, and Malaysia between April 2023 and June 2024. Participants were recruited from six resuscitation training conferences and attended a standardized two-hour educational session before completing an anonymous survey mapped to TFA constructs. We assessed differences between countries using Pearson chi-square tests. Our primary outcome measure was acceptability scores across five TFA domains (affective attitude, intervention coherence, opportunity costs, self-efficacy, and perceived effectiveness). Secondary outcomes included identification of high-priority implementation elements.

Results: Participants (N = 274; 66% response rate) included physicians (46%, n = 126), prehospital professionals (30%, n = 82), and medical directors (15%, n = 41). Intervention coherence was high: 92% to 100% of participants were likely or extremely likely to use PECSET for quality improvement. However, geographic variation existed; a small subset in Indonesia and Vietnam (n = 6) reported they were “unlikely” to use the tool, compared to none in Thailand, Malaysia, and the Philippines (P = .04). Regarding self-efficacy, while 100% (n = 274; 95% CI, 98-100%) reported confidence in application, only 20% (n = 55; 95% CI,15-25%) were “extremely confident.” Affective attitude was positive, with 97% (n = 266) intending to integrate the tool; only Vietnam (n = 4; 5% [95% CI, 2-10%]) and Indonesia (n = 2; 2% [95% CI, 0-13%]) indicated hesitation (P = .24). Secondary outcomes identified “layperson public awareness and education programs” as the top implementation priority across all five nations, although priorities varied.

Conclusion: The Prehospital Emergency Care System Evaluation Tool demonstrated high acceptability among potential end-users across Southeast Asia, indicating readiness for broader implementation and future evaluation of feasibility, fidelity, and system-level impact. As a stakeholder-informed evaluation framework, PECSET offers a practical approach to strengthening PEC systems in Southeast Asia and beyond.

Introduction: The risk of medical errors increases for the approximately 689,000 unidentified, noncommunicative patients who present to emergency departments annually. The concomitant rise in hospital admissions, lengths of stay, and mortality will likely persist unless approaches to identifying noncommunicative patients are developed and adopted. Facial recognition technology could provide a solution where scanning the face reliably provides access to identification and medical history of patients who self-enroll in the application database. Our objective was to compare paramedics’ ability to identify noncommunicative patients and make related clinical decisions using a cloud-based facial-recognition application vs standard practice.

Methods: We conducted a double-blind, randomized controlled study with 90 participating firefighterparamedics in a simulated patient encounter. Our primary outcome was patient identification. Secondary outcomes included identification of key medical information, appropriateness of treatment decisions, and transport to the patient’s preferred hospital. We uploaded facial photographs and simulated medical profiles to a secure cloud-based app. Participants used a tablet to scan the patient’s face (standardized patient or actor). Successful matches returned identifying information, medical history, emergency contacts, preferred hospital, and primary care physician contact information. The 48 experimental participants had access to this patient information, while the 42 controls did not, even if they scanned the face. Standardized patients (SP) portrayed a noncommunicative urosepsis patient. Participants reported their findings to the facilitators and evaluated the technology on a 5-point Likert scale.

Results: We analyzed 90 study participants (48 experimental, 42 control), of whom 40/48 (83.3%) experimental group identified the SP compared with 9/42 (21.4%) control group (OR [odds ratio], 13.87; 95% CI, 5.03-38.25; P < .001). Identification of important medical information of the SP by the study participants occurred in 30/48 (62.5%) in the experimental group versus 4/42 (9.5%) in control (OR, 15.83; 95% CI, 4.84-51.76; P < .001). Correct transport decision to the preferred hospital occurred in 27/48 (56.3%) experimental participants compared with 10/42 (23.8%) controls (OR, 4.11; 95% CI, 1.65-10.23; P = .02). Overall, 80% of participants reported that the technology would benefit their day-to-day clinical work.

Conclusion: The use of a cloud-based facial-recognition application significantly improved firefighter-paramedics’ ability to identify noncommunicative patients and access critical medical information, with an appropriate transport decision to the patient’s preferred hospital. 

Introduction: In urinary tract infections (UTI) sex-related differences in comorbidities, antimicrobial resistance, and outcomes have been described, but it remains unclear whether these disparities reflect sex-related biological mechanisms or are primarily explained by age and comorbidity, especially in emergency settings. Our objective was to evaluate sex-related differences in microbiology, antimicrobial resistance, and outcomes among adults with potentially multidrug-resistant UTIs presenting to the emergency department (ED), and to determine whether sex independently predicts multidrug-resistant infections and outcomes after adjustment for age and comorbidity.

Methods: We conducted a prospective multicenter study enrolling all adult patients with suspected or confirmed UTIs admitted to one of the eight EDs involved from February 2023–July 2024. Our primary outcome was the prevalence of multidrug-resistant UTIs and whether sex independently predicted multidrug-resistant infection after adjustment for age and comorbidity. Secondary outcomes included hospitalization, adequacy of empirical antibiotic therapy, clinical response at 7 days, and 7-day and 30-day all-cause mortality. Demographic, clinical, and microbiological data were compared by sex. To account for baseline differences in age and comorbidity burden (Charlson Comorbidity Index), multivariable logistic regression models were applied to identify independent predictors of multidrug-resistant infection, hospitalization, and 30-day mortality.

Results: We included 679 patients (358 males, 321 females). Mean age was 70.1 years (standard deviation 17.9) in males and 63.1 years (21.4) in females (P < .001). The Charlson Comorbidity Index was higher in males (2.50 [2.45]) than in females (1.85 [2.32]) (P = .01). Multidrug-resistant infection occurred in 107/321 females (33.5%) and 166/358 males (46.5%) (P = .02). Adequate empirical therapy was achieved in 213/321 females (66.2%) and 221/358 males (61.8%) (P = .10). Hospitalization occurred in 176/321 females (54.9%) and 175/358 males (48.8%) (P = .09). Seven-day mortality was 14/321 females (4.5%) and 28/358 males (7.9%) (P = .05), while 30-day mortality was 32/321 females (9.9%) and 50/358 males (14.0%) (P = .05). After adjustment for age and comorbidity, male sex remained independently associated with multidrug-resistant infection (adjusted odds ratio 1.45; 95% CI, 1.03–2.10, P sex = .02; P age = .01).

Conclusion: Male sex was independently associated with multidrug-resistant urinary tract infections in the emergency department, even after adjustment for age and comorbidity. These findings highlight the need for sex- and risk-based approaches to empirical therapy and antimicrobial stewardship in acute care settings.

Introduction: Efforts to increase influenza vaccine acceptance must consider the importance of patient education and familiarity with vaccinations and influenza in the emergency department (ED), particularly for populations without another primary source of healthcare. This is the first study, to our knowledge, to assess in-depth perceptions regarding the influenza vaccine and identify barriers and facilitators to influenza vaccination among COVID-19 unvaccinated adult ED patients.

Methods: We conducted a qualitative idiographic interview study from July 12, 2021, to September 24, 2021, at four EDs in urban cities across the United States. We recruited adult ED patients (18 years and older) unvaccinated for COVID-19, without a primary care clinician, who were fluent in either English or Spanish. The primary finding was a detailed understanding of patient perceptions regarding the influenza vaccine, with secondary findings assessing influenza vaccination rates, barriers and facilitators to being vaccinated, sources of information, and future vaccination intentions. We used a content analysis approach to identify themes around patient experiences, concerns, barriers, information sources, and future intentions regarding influenza vaccination.

Results: Of 65 participants interviewed, 48 discussed the influenza vaccine and were included in this analysis. Among these participants, the median age was 34 years, 21 (43.8%) were women, and 14 (29.2%) were Hispanic. We found three core themes influencing influenza vaccine hesitancy: 1) previous experiences with influenza illness and/or the vaccine; 2) knowledge about the influenza vaccine; and 3) confidence in vaccine safety and effectiveness. In our cohort, 10 (20.8%) participants demonstrated knowledge of the purpose and mechanism of the influenza vaccine. In addition, 14 (29.2%) patients suggested they would accept the vaccine if offered, while 18 (37.5%) patients stated they did not plan to receive the influenza vaccine and/or expressed strong hesitancy due to concerns about lack of vaccine effectiveness, fear of side effects, and lack of concern regarding influenza illness.

Conclusion: Our findings identify an important barrier that could be overcome by ED-based vaccine education, particularly for underserved patient populations. Interventions to increase influenza vaccine uptake could focus on overcoming hesitancy related to prior experiences and understanding of vaccine safety and effectiveness.

Introduction: Patients frequently board overnight in the emergency department (ED) while awaiting medical admission, sometimes in hallway care spaces. Prior literature suggests that timing of boarding may matter; a single overnight stay in the ED may be associated with increased mortality and adverse events, especially for older adults. Given the deliriogenic ED environment, these effects may be magnified in the hallway. However, little is known about the effects of prolonged hallway stays. We evaluated whether an overnight stay in the ED hallway, compared to an ED room, was associated with increased delirium and adverse outcomes for geriatric patients.

Methods: We conducted a retrospective multisite cohort database study of patients aged 65 years and older admitted to a general medicine service January 1, 2022, to December 31, 2023, who spent an entire night (midnight to 8 am) in the ED prior to admission. We compared those who spent the entire night in the ED hallway with those who were in ED rooms. Our primary outcome was a composite outcome for incident delirium and severe agitation (defined by the International Classification of Diseases, 10th Rev, code for delirium, positive nursing screen, use of parenteral antipsychotics, and/or physical restraints, since delirium was not routinely screened for at these sites). Secondary outcomes included hospital length of stay (LOS), inpatient and 30-day mortality, and 30-day ED revisit and readmission. We implemented mixed-effect regression models and adjusted for confounders.

Results: A total of 8,576 patients met inclusion criteria, including 1,231 patients (14%) in the hallway group. Overall, 847 patients (9.9%) developed incident delirium and severe agitation: 160 (13%) of the hallway group and 687 (9%) of the non-hallway group. An overnight stay in the ED hallway was not associated with delirium and severe agitation (OR, 1.06, 95% CI, 0.58–1.94; P = .84), but increased ED LOS was independently associated with delirium and severe agitation (OR, 1.01; 95% CI, 1.0–1.01 per hour; P = .01). There was no association between an overnight stay in the hallway and secondary outcomes except increased hospital LOS (OR 1.01, 95% CI, 1.00–1.01 per hour; P = .01).

Conclusion: An overnight in the ED hallway care space was not associated with increased delirium and severe agitation for geriatric patients, but prolonged ED LOS was associated with this outcome. Hospital systems should consider prioritizing geriatric patients for expedited transfer from the ED to inpatient units, and prospective research with consistent delirium screening is needed to rigorously evaluate the safety of hallway care for older adults.

Introduction: Racial disparities in healthcare persist, with evidence suggesting that bias contributes to inequities in care and outcomes for Black patients. Racial concordance between patients and clinicians has been proposed as one strategy to improve patient satisfaction and health outcomes, but its impact in acute care settings such as the emergency department (ED) remains underexplored. The objective of this study was to assess how racial concordance between patient and clinician, together with patient perceptions of how race affected their care, influence patient satisfaction with care in the ED.

Methods: This secondary analysis used data from a previously published text message–based survey of patients discharged from two EDs between August and September 2021. Patients were categorized as not completely discordant if at least one clinician (physician, advanced practice clinician, or nurse) shared their self-identified race. The primary outcome was patient ratings of experience with ED care (scored 0 = poor to 5 = excellent). Multivariable ordinal logistic regression was used to assess associations between racial concordance, perceived impact of race on care, and experience ratings.

Results: Of 516 respondents, 195 (37.8%) were classified as not completely discordant with at least one emergency clinician. Not completely discordant patients reported significantly lower experience ratings (scored 0 to 5) compared to racially discordant patients (median, 4 [3-5] vs 5 [3-5]; P = .01). In multivariable ordinal logistic regression, racial concordance was not independently significant in patient experience.

Conclusion: Contrary to expectations, in our population, racial concordance was not significantly associated with satisfaction in ED care. In the adjusted analysis, perceived negative impact on care due to race was the strongest independent predictor of lower overall satisfaction. These findings suggest that how patients perceived the role of race in their care may be more influential than simply patient-clinician concordance in the acute care setting. Further research is needed to investigate these factors in more diverse patient-clinician population and other ED settings to help inform policies focused on advancing health equity.

Introduction: Emergency department (ED) food insecurity (FI) screening traditionally identifies insufficient access to food but does not account for diet quality. We evaluated the incremental yield of adding a nutrition insecurity (NI) screener to routine FI screening.

Methods: This single-center observational study enrolled adult ED patients from April–September 2025. Participants completed the 2-item Hunger Vital Sign and a 1-item NI screener. Our primary measure was incremental yield of NI screening beyond FI screening, defined by the number of NI-positive/FI-negative patients identified. Secondary outcome measures included FI and NI prevalence, screening concordance, and number needed to screen. Screening fidelity was supported through structured training of research associates and standardized phrasing.

Results: Of 1,120 patients, 13.6% (95% CI, 11.6–15.7%) screened positive for FI and 11.4% (95% CI, 9.7–13.5%) for NI. While the measures showed substantial agreement (κ = 0.67), they identified significantly different populations (McNemar P = .01). Specifically, 28 patients (2.5%) screened NI-positive but FI-negative, yielding an 18.4% relative increase in identified at-risk patients compared to only screening for FI.

Conclusion: Dual screening identified a clinically relevant NI-only subgroup whose diet-quality barriers were not captured by FI screening alone. Incorporating NI into ED social needs assessments may improve identification of diet-related risk and guide medically tailored interventions.

Introduction: The Indiana University School of Medicine launched two new community-based residency programs at Indiana University Health Bloomington (IUH-B) in July 2026. Prior to the launch, this research explored community members’ attitudes, expectations, and concerns regarding the introduction of resident physicians to the emergency department (ED). 

Methods: This study was conducted from June to July 2025 at IUH-B. Using a convergent mixed-methods design, we evaluated a convenience sample of adult patients and accompanying family members in the emergency department (ED). Data collection included a 16-item electronic survey and semi-structured interviews. 

Results: The survey was completed by 39 adult participants, and 40 completed the qualitative interview. Most participants (59%) were aware of the residency programs, and nearly all (95%) agreed that residents would improve the quality, access, and modernity of healthcare in Bloomington, with very few expressing concerns about resident involvement. Overall, 97% of respondents stated support for the expansion of additional physician training programs locally. Comfort with or support for residency programs was not significantly influenced by prior experience with residents or awareness of the new programs. Thematic analysis shows that participants value residents who are competent, personable, and attentive listeners, while emphasizing the importance of strong supervision by attending physicians. Overall, participants are optimistic that new residency programs will bring more clinicians and up-to-date medical practices to the Bloomington area. 

Conclusion: Participants viewed the implementation of a new residency program positively, agreeing with proposed benefits and expressing minimal concerns. To ensure successful integration, further community initiatives should focus on educational outreach regarding the specific roles and training levels of emergency medicine residents, and prepare for implementation of trainees.

Introduction: Cannabis is one of the most commonly used psychoactive substances worldwide, with 20% of adults in the U.S. reporting using cannabis at least once in the past year. Nicotine dependence is reported in 9% to 10% of adults in the U.S.1 This study aims to investigate the relationship between cannabis use and cigarette smoking on mortality, cardiovascular outcomes, suicide, cancer of the lung and bronchus, and reactive airway disease in emergency department (ED) patients.

Methods: This retrospective, propensity score–matched study used the TriNetX database to analyze records of 120,689,106 patients from 69 healthcare organizations in the U.S. between 2005 and 2022. The first cohort consisted of adult patients and was grouped based on diagnosis of cannabis-related disorders (CRD) within five years before or one month after an ED visit. The second cohort consisted of adult patients with a diagnosis of “nicotine dependence, cigarettes” within five years before to one month after an ED visit. The outcomes evaluated were all-cause mortality, stroke, myocardial infarction, suicide, cancer of the lung and bronchus, and reactive airway disease (asthma/chronic obstructive pulmonary disease [COPD]) within three years after the ED visit. Patients who previously experienced these outcomes or belonged to both cohorts were excluded from the study. We performed 1:1 greedy nearest-neighbor propensity score matching for demographics and seven preexisting conditions associated with mortality.

Results: There were 1,682,117 patients identified with ED visits and CRD or cigarette smoking. After propensity score matching, there were a total of 651,232 adult patients with CRD (n = 325,616) or cigarette smoking (n = 325,616) within five years prior or one month after an ED visit. Patients with CRD were associated with a significantly higher mortality rate (2.35% vs 2.16%; relative risk [RR] 1.09; 95% CI, 1.05-1.12; P < .001), stroke (0.45% vs 0.28%; RR 1.59; 95% CI, 1.47-1.73; P < .001), myocardial infarction (0.53% vs 0.35%; RR 1.51; 95% CI, 1.40-1.63; P < .001) and suicide (0.62% vs 0.35%; RR 1.77; 95% CI, 1.65–1.90; P < .001) within 3-years of the ED visit compared to patients smoking cigarettes. Individuals with CRD were associated with a significantly lower rate of lung and bronchus cancer (0.16% vs 0.31%; RR 0.53; 95% CI, 0.48–0.59; P < .001) and reactive airway disease; asthma (6.30% vs 7.37%; RR 0.86; 95% CI, 0.84–0.87; P < .001) and COPD (1.65% vs 3.05%; RR 0.54; 95% CI, 0.52-0.56; P < .001) than those with cigarette smoking.

Conclusion: We found that cannabis use was associated with higher risks of mortality, stroke, myocardial infarction, and suicide for ED patients when compared to cigarette smoking. Cannabis-related disorder was associated with lower rates of reactive airway disease and lung and bronchus cancer when compared to those with cigarette smoking.

Introduction: Whether the use of computed tomography (CT) in pediatric minor head trauma varies by documented language preference (English vs non-English), independent of race, is not well understood. Our objective was to identify factors associated with head CT use among children with minor head trauma in an institutional Pediatric Emergency Care Applied Research Network (PECARN)-based pathway.

Methods: This single-center retrospective cohort study included patients 2 to 14 years of age presenting with minor head trauma, January 2019 to June 2022, who were classified as low, intermediate, or high risk using PECARN criteria. Our primary outcome measure was a three-level clinical pathway: no CT and no traumatic brain injury (TBI); clinical TBI without CT; or CT performed. Secondary outcomes were CT positivity and short-term clinical outcomes. Multinomial logistic regression assessed associations between pathway and language preference, age, headache, weighted observed symptom score (OSS), and race (White vs non-White).

Results: Among 1,167 patients, 319 (27.3%) underwent CT, 132 (11.3%) had clinical TBI diagnosis without CT, and 716 (61.4%) had neither; 430 (36.8%) were classified intermediate risk—the subgroup in which the imaging decision is most discretionary. Non-English language preference was associated with lower adjusted odds of CT in the intermediate-risk subgroup (adjusted odds ratio [aOR], 0.48; 95% CI, 0.24-0.92; P = .03) but not in the full cohort (aOR, 0.78; 95% CI, 0.50-1.22; P = .27). Within the intermediate-risk subgroup, OSS was strongly associated with CT use (aOR, 3.65; 95% CI, 2.67-5.00; P < .001) and headache with clinical TBI without CT (aOR, 4.94; 95% CI, 1.64-14.90; P = .005), whereas race was not independently associated with CT use (aOR, 1.36; 95% CI, 0.82-2.25; P = .48). Language preference was not associated with CT positivity among scanned patients (aOR, 1.10; 95% CI, 0.44-2.72; P = .84), and short-term outcomes did not differ by language (all P > .35).

Conclusion: Documented non-English language preference was independently associated with lower use of head CT in PECARN intermediate-risk children; race was not after adjustment for clinical severity. Yield and short-term outcomes did not differ by language preference among imaged patients; however, imaging selection precludes conclusions about mechanism.

Introduction: Unspecified headache is a common discharge diagnosis in the pediatric emergency department (ED). While diagnostic uncertainty and limited access to specialty evaluation may contribute to repeat ED visits in this population, longitudinal utilization data are limited. Study objectives were both to determine the incidence of repeat headache-related ED visits in children discharged from the ED with unspecified headache and to identify predictors of ED return (eg, prior headache-related ED or neurology utilization).

Methods: This preliminary, prospective longitudinal cohort study included 76 children (ages 8–17 years) discharged from the ED with an unspecified headache diagnosis. We assessed headache-related ED and outpatient neurology visits both six months after the index visit (ie, ED enrollment) and, retrospectively, 12 months before the index visit. The sample included children insured through a Medi-Cal–based Physician-Hospital Consortium, who receive care exclusively within an integrated healthcare network, and other children in the hospital network, allowing capture of all ED and clinic utilization data. Our primary outcome was incidence of headache-related ED utilization postindex visit. Pain characteristics were self-reported during the index visit. Chi-square, Mann-Whitney U, and logistic regression analyses examined factors associated with incidence of headache-related ED returns.

Results: Nearly 12% (n = 9) of children returned to the ED for a headache 6 months following the index visit. Across the 18-month study, 22.4% had at least one headache-related ED visit outside the index visit, 64.7% (n = 11) of whom had >2 headache-related ED encounters. A prior headache-related ED visit or prior neurology visit was significantly associated with returning to the ED after the index visit (20.0% vs 3.0%; risk difference = 17.0%; 95% CI, 0.9%-48.0%; P = .03, and 37.5% vs 1.5%; risk difference = 28.7%; 95% CI, 3.2%-60.9%; P = .02, respectively). Children with more than two headache-related ED visits during the 18-month study reported higher pain intensity (7.00 [SD, 1.38] vs 5.79 [SD, 2.09]; mean difference = -1.21; 95% CI, -2.20 to -0.22; P = .02). In logistic regression analyses, prior neurology utilization was the only variable significantly associated with headache-related ED return (OR, 15.31; 95% CI, 1.08-216.34; P = .04).

Conclusion: A considerable proportion of children discharged with unspecified headache returned to the ED for headache. Emergency department and neurology utilization and pain intensity were linked to return ED visits. Larger, longitudinal studies are needed to further clarify these findings.

Introduction: Emergency medicine has evolved beyond episodic acute care to encompass a growing range of clinical, social, and system-level responsibilities. This scholarly perspective proposes the Patient Rights Index in Emergency Medicine (PRI-ED), a conceptual framework designed to organize recurring domains through which emergency departments promote access to care, patient safety, relief of suffering, autonomy, and dignity.

Methods: The PRI-ED was developed through iterative domain generation informed by clinical observation, professional experience, and targeted review of peer-reviewed literature, policy analyses, and professional organizational reports. No primary data collection, systematic review, formal consensus process, or empirical validation was performed.

Results: We identified 12 domains that represent recurring clinical, operational, and system-level challenges encountered in emergency medicine. These domains were organized within a standardized framework linking domain-specific objectives, intervention strategies, measurable indicators, and relevant policy or funding mechanisms.

Conclusion: The PRI-ED is a proposed conceptual framework for organizing and evaluating domains in which emergency medicine intersects with access, safety, autonomy, relief of suffering, and dignity. The framework is intended to inform future implementation, evaluation, and policy discussion and requires feasibility testing and outcome validation before effectiveness can be determined. 

Introduction: Emergency departments (EDs) face escalating pressures from rising patient volumes, workforce shortages, and documentation burdens. Digital health technologies have shown promise individually, but most are implemented in isolation, limiting their collective impact. This narrative review synthesizes evidence for six digital health technologies applicable to the ED and proposes a three-pillar framework for their coordinated implementation, positioning the ED as a convergence point for health system digital transformation.

Methods: We searched PubMed and Google Scholar for peer-reviewed literature published from 2018 through July 2026 on ambient artificial intelligence (AI) documentation, telehospitalist programs, virtual nursing, remote patient monitoring, virtual specialty consultation, and postdischarge transitional care, prioritizing systematic reviews and meta-analyses. Fifty-one sources met inclusion criteria and were synthesized. We organized the technologies into three functional pillars: streamlining clinical workflows; expanding workforce capacity; and extending continuity of care. Outcomes included clinical, operational, and implementation measures. Experience from Houston Methodist, a nine-hospital health system, is presented as an illustrative example separate from the literature synthesis.

Results: Of the 51 sources, 23 (45.1%) addressed streamlining clinical workflows, 16 (31.4%) expanding workforce capacity, and 12 (23.5%) extending continuity of care. Overall, 22 (43.1%) were ED-specific: 10, five, and seven within the respective pillars. Ambient AI documentation included 13 sources (seven ED-specific); telestroke included one ED-specific source. Evidence maturity varied by technology and setting. In non-ED settings, meta-analyses reported shorter documentation time with ambient AI documentation (standardized mean difference, -0.72; 95% CI, -0.99 to -0.45), lower hospital mortality with tele-intensive care (risk ratio, 0.74; 95% CI, 0.58-0.96), and lower odds of 30-day readmission with low-complexity post-discharge interventions (odds ratio [OR], 0.78; 95% CI, 0.66-0.92). Emergency department-specific evidence remained largely observational; one meta-analysis showed no mortality difference with telestroke (OR, 1.16; 95% CI, 0.94-1.43), while one systematic review found no demonstrable benefits from telephone follow-up post-ED discharge.

Conclusion: Current evidence supports individual digital health technologies in and around the ED. Based on implementation science principles and institutional experience, we propose that coordinated implementation across the three pillars may offer advantages over isolated deployments, a hypothesis warranting prospective comparative evaluation.

Introduction: Chest pain accounts for approximately six million emergency department (ED) visits annually in the United States. Early detection of acute occlusive myocardial infarction (OMI) is challenging, especially in patients without classic ST-elevation on initial electrocardiography (ECG). Regional wall motion abnormalities (RWMA) often precede ECG changes and can be sensitive indicators of acute coronary occlusion on transthoracic echocardiography (TTE). However, the accuracy of emergency physician-performed TTE for RWMA detection has not been well defined. In this review we aim to determine how accurate emergency physicians are in detecting RWMAs.

Methods: We conducted a systematic review of studies including adult ED patients who underwent cardiac ultrasound performed or interpreted by emergency physicians, with test characteristics compared to cardiology-performed or interpreted echocardiography as the reference standard. Primary outcomes were sensitivity and specificity for RWMA detection. Secondary outcomes included likelihood ratios, and area under the receiver-operator curve (AUC). Risk of bias was assessed using QUADAS-2, and evidence certainty was evaluated using GRADE methodology.

Results: The search identified 2,463 studies, of which 32 underwent full-text review; nine studies including 1,191 participants from the US, Turkey, and Iran are included. Sonographers across studies ranged from medical students and residents to fellowship-trained and senior emergency physicians with varying levels of prior ultrasound and RWMA-specific training. Pooled sensitivity and specificity for RWMA detection were 86% (95% CI, 76-93%) and 85% (95% CI, 70-94%), respectively, with an AUC of 0.918. Pooled positive and negative likelihood ratios were 5.42 (95% CI, 2.51-11.68) and 0.17 (95% CI, 0.09-0.33), respectively. Four of the nine studies were judged to have a high risk of bias in at least one domain. Substantial heterogeneity was observed in the secondary univariate analyses (>80%). The overall certainty of evidence was moderate.

Conclusion: Emergency physician-performed or interpreted cardiac ultrasound demonstrates high accuracy for detecting RWMAs compared with cardiology-performed or interpreted echocardiography. Although heterogeneity was observed across studies, the overall certainty of evidence was moderate. Structured training and standardized protocols may optimize diagnostic performance.

Introduction: Toxic mushroom exposures can occur through multiple mechanisms, including consumption as a delicacy, foraging, and use for psychoactive properties. Recent evidence suggests that psylocibin mushroom use is increasing in the United States. However, information on trends in mushroom poisonings in Florida is limited. This study aims to characterize trends in psychoactive and nonpsychoactive mushroom exposures reported to the Florida Poison Information Center Network (FPICN) over an 11-year period.

Methods: This is a retrospective review of all mushroom exposures reported to the FPICN between 2014 to 2024. Our primary outcome was to evaluate the annual trend of psychoactive and nonpsychoactive exposures. Secondary outcomes included identifying patient demographics, exposure intent, clinical effects, and medical outcomes associated with each exposure type. Psychoactive mushrooms were defined as belonging to groups 2 (muscimol), 4 (muscarine and histamine), and 6 (psilocybin and psilocin) in the National Poison Data System coding manual. We performed statistical analyses using chi-square and Mann–Whitney tests, and joinpoint regression models.

Results: A total of 2,995 mushroom exposures were reported. Psychoactive mushrooms comprised 15.6% (n = 467) of exposures and were more likely to involve males (72.5%, P < .001) and intentional ingestions (80.9%, P < .001). Joinpoint regression analysis showed that from 2014 to 2018, the rate of psychoactive mushroom exposures did not change significantly (annual percentage change [APC] = −1.5%; 95% CI, −35.9% to 19.3%; P = .88). In contrast, from 2018 through 2024, exposure rates increased significantly by an average of 34.4% per year (APC = 34.4%; 95% CI, 27.0%–60.4%, P < .001). These trends were standardized to overall poison center call volume. There were three deaths: a 67-year-old male (intentional–suspected suicide); an 81-year-old male (unintentional); and a 44-year-old female (unintentional), all involving mushrooms of unknown category.

Conclusion: Psychoactive mushroom exposures in Florida have increased substantially since 2018, particularly among adolescents and adults, and were more commonly associated with intentional use. These findings may reflect changing cultural attitudes and increased accessibility. Further research is needed to better understand the evolving landscape associated with psychoactive mushroom use.

Introduction: The number of peer-reviewed biomedical journals has more than tripled over the past 20–25 years increasing the demand for quality peer reviewers. This demand and the lack of available formal training in peer review have resulted in a shortage of qualified peer reviewers. In response to this shortage, the Western Journal of Emergency Medicine Special Issue in Education (Special Issue) developed a formal mentored peer-review (MPR) program that provides a learning experience in peer review to educate fellows through legitimate participation while contributing to the editorial process of the journal. The latter serves as the basis of this study.

Methods: The impact of the MPR program on the Special Issue’s reviewer pool served as the primary outcome of this study. This was accomplished by tracking the number of participating fellowships and their graduates who subsequently provided independent peer reviews for the sponsoring journal. Comparisons of MPRs generated by education fellows and their fellowship directors to those generated by our nonmentored faculty reviewers served two secondary outcomes: the quality of peer reviews and time from peer review offer to submission of the requisite peer reviews.

Results: Over a period of five years, 82 fellows mentored by 43 fellowship directors submitted 147 MPRs. Of the 60 MPR graduates (35%), 21 were retained as independent peer reviewers. Based on a five-point editorial scoring scale (5 being excellent) mentored peer reviews received significantly higher editorial ratings (4.13 [SD 0.8]) than nonmentored faculty reviews (traditional reviewers) (3.33 [1.04]) and independent reviews by program graduates (3.61 [0.84]] (P < .001). We evaluated two peer-review turnaround periods. The first was the time from the initial two offers to review until two offers had been accepted. Instances where the first two offers were randomly made to MPRs were compared to offers to nonmentored faculty reviewers. The latter group took 60.2 (32.0) days compared to the MPR group, which averaged 17.2 (16.7) days (P < .001). The second interval measured the time from reviewer acceptance of the peer review until they submitted their completed review. There was no difference between the time in days between MPRs (10.4 [7.9]) and nonmentored faculty (9.4 [8.1]) in submitting reviews that had been accepted.

Conclusion: The mentored peer-review program contributed to increasing the Special Issue’s reviewer pool with reviews of higher quality. In addition, by inviting two mentored peer-reviewers initially as compared to nonmentored faculty reviewers, the time frame for obtaining two secured peer-reviewers was significantly reduced. These findings demonstrate that a formalized approach to learning peer review by partnering with academically oriented fellowships has the potential to improve the availability of peer reviewers, the quality of peer reviews, and efficiency in the editorial review process.

Introduction: Emergency department (ED) vertical patient pathways (VPP) assign patients to a dedicated care area with chairs, avoiding the use of traditional ED beds. The effect of reassigning a dedicated vertical emergency physician (EP) onto an established rotational patient assignment (RPA) system, which prospectively assigns arriving patients to EP queues, is unknown. We sought to describe operational outcomes and staff satisfaction with trialing this role.

Methods: We conducted a single-center, hypothesis-generating exploratory pilot at a 56-bed tertiary-care ED in which one 8.75-hour EP shift on five Mondays was repurposed into an 8.75-hour dedicated VPP role within a chair-based vertical patient care area while the rotational patient assignment system remained in place; three prior comparable Mondays served as comparison. Primary outcome was discharged-patient ED length of stay (LOS); secondary outcomes included VPP upgrades to a bed, patient numbers seen by the dedicated shift, and staff satisfaction. We report descriptive analyses.

Results: We analyzed 529 discharged-patient encounters: 199 (37.6%) during the preintervention period and 330 (62.4%) during the postintervention period. Median ED LOS for discharged patients did not demonstrate a consistent directional change, decreasing by seven minutes (3.1%) in the overall ED (226 vs 219 minutes) and increasing by 18.5 minutes (13.0%) among patients initially evaluated via the VPP (142.5 vs 161 minutes). The dedicated VPP EP saw three more patients per shift (21.4%; median 17 vs 14), and VPP upgrades fell from 15/68 (22.1%) to 5/130 (3.8%). Timeliness and communication were rated favorably by 4/4 VPP physician respondents and 10/12 and 16/17 registered nurse/allied health respondents, respectively; 3/4 VPP physician respondents vs 1/29 non-VPP physician respondents supported continuing the model.

Conclusion: Reassigning an existing EP to a dedicated vertical EP role within an ongoing rotational patient assignment system was not accompanied by shortened discharged-patient length of stay. Fewer VPP upgrades and a modest increase in patients seen by the dedicated shift were observed, but patient selection and acuity limit interpretation. Staff reported favorable teamwork within the vertical space, whereas non-VPP physicians reported less manageable workloads and little support for continuing the model.