Greenslade J, Parsonage W, Stephensen L
… +11 more, Parsons R, Perez S, Starmer K, Starmer G, Gaikwad N, McPhail SM, Hall E, Brownlee E, McCormick E, Cullen L, Limit of Detection in the Emergency Department (LEGEND) investigators
Ann Emerg Med
· 2026 Apr · PMID 41405523
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STUDY OBJECTIVES: The Limit of Detection in the Emergency Department (LEGEND) rule-out strategy integrates high-sensitivity cardiac troponin assay concentrations with shared decision making to rapidly assess emergency pa...STUDY OBJECTIVES: The Limit of Detection in the Emergency Department (LEGEND) rule-out strategy integrates high-sensitivity cardiac troponin assay concentrations with shared decision making to rapidly assess emergency patients with suspected acute coronary syndrome (ACS). We hypothesized that the LEGEND rule-out strategy would reduce length of stay (LOS), increase the proportion of patients safely discharged within 4 hours, reduce cardiac testing, and decrease hospital representations, while maintaining patient safety. METHODS: We conducted a stepped-wedge cluster randomized controlled trial in 4 Australian emergency departments from August 2019 to July 2020. We included adult patients presenting with suspected ACS. We randomized sites to implement the LEGEND strategy. The primary outcome was LOS. Secondary outcomes included discharge from hospital within 4 hours, cardiovascular tests, representations, index, and 30-day events. RESULTS: The study included 9,944 patients, 5,347 in the standard care and 4,597 in the intervention arm. For patients in the LEGEND cohort (presentation troponin ≤2 ng/L), the mean LOS was 3.6 hours shorter in the intervention arm than the standard care arm (95% confidence interval [CI] 2.5 to 4.6 hours). The proportion of patients safely discharged within 4 hours increased by 22.9% (95% CI 19.5% to 26.3%), and cardiac testing decreased by 7.8% (95% CI 4.6% to 11.1%). There were no differences in representations, index events, or 30-day events. CONCLUSION: The LEGEND rule-out strategy safely ruled out acute myocardial infarction, reduced hospital LOS, increased the proportion of patients discharged within 4 hours, and reduced cardiac testing.
Hawk KF, Venkatesh AK, Rothenberg C
… +7 more, Sharma D, Goyal P, Lin Z, Mendez-Hernandez C, Sharma P, Sambell M, Weiner SG
Ann Emerg Med
· 2026 Mar · PMID 41369633
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STUDY OBJECTIVE: We sought to characterize changes in the proportion of key capabilities related to the emergency care of patients with opioid use disorder among emergency departments (EDs) participating in all years of...STUDY OBJECTIVE: We sought to characterize changes in the proportion of key capabilities related to the emergency care of patients with opioid use disorder among emergency departments (EDs) participating in all years of the 2020 to 2024 the American College of Emergency Physicians Emergency Quality Network Opioid Initiative. METHODS: At the beginning of each annual quality improvement collaborative, EDs completed an online survey regarding capabilities on services for patients presenting to their ED with opioid use disorder or opioid overdose, including provision of outpatient naloxone after overdose, presence of a clinician who prescribes buprenorphine in the ED, an adopted protocol for buprenorphine initiation, and use of clinical support tools to guide opioid use disorder treatment. RESULTS: A total of 174 unique EDs participated in all E-QUAL opioid collaboratives from 2020 to 2024. More than half of participating EDs were rural and saw less than 20,000 visits per year. EDs reported an increase in the naloxone provision to patients presenting after opioid overdose from 39.1% (68/174) in 2020 to 89.7% (156/174) in 2024. The number of EDs reporting a clinician who prescribes buprenorphine in their ED also increased (16.7% [29/174] in 2022 to 52.87% [92/174] in 2024). Protocols for ED-initiated buprenorphine and use of clinical support tools to guide the treatment of opioid use disorder remained similar (4.0% [7/174] to 5.8% [10/174] and 46.0% [80/174] to 48.9% [85/174]). CONCLUSIONS: These trends demonstrate increasing acceptance and incorporation of naloxone provision after opioid overdose and ED clinicians who prescribe buprenorphine among a group of mostly rural, small community EDs participating in a quality improvement-based learning collaborative.
Shi AC, Taylor T, Huang CC
… +4 more, Singhal AB, Goldstein JN, Bevers MB, Hou PC
Ann Emerg Med
· 2026 May · PMID 41369631
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STUDY OBJECTIVE: Blood pressure (BP) control is thought to be critical in acute intracerebral hemorrhage management. Here, we investigated whether reducing systolic BP ≤150 mm Hg within 2 hours of emergency department (E...STUDY OBJECTIVE: Blood pressure (BP) control is thought to be critical in acute intracerebral hemorrhage management. Here, we investigated whether reducing systolic BP ≤150 mm Hg within 2 hours of emergency department (ED) arrival is associated with improved outcomes and assessed the effect of excessive BP lowering ("overshooting") on functional recovery. METHODS: We conducted a retrospective cohort study of adult patients with spontaneous intracerebral hemorrhage (ICH) who presented to 2 academic medical centers between 2017 and 2023. We assessed the associations between blood pressure (BP) indicators, including BP control (≤150 mm Hg within 2 hours) and overshooting (<120 mm Hg), and the modified Rankin scale (mRS) score at discharge, dichotomized as a good (0 to 3) or poor (4 to 6) outcome, using logistic regression adjusted for ICH score, time from last seen well, and arrival BP. RESULTS: Among 420 included patients, 323 (76.9%) had arrival BP>150 mm Hg. Of these, 62.8% received antihypertensive medications within 1 hour of ED arrival, and 71.2% achieved goal BP within 2 hours. Achieving goal BP within 2 hours of ED arrival was associated with worse outcomes (OR 2.32, 95% CI 1.17 to 4.57). Overshooting within 6 hours was associated with worse outcomes (OR 2.55, 95% CI 1.27 to 5.13). Antihypertensive medication type (bolus versus infusion) did not influence overshooting risk. CONCLUSIONS: Although successful early BP reduction is common in ICH care, excessive lowering is also common and is associated with worse functional outcome. Caution is warranted to avoid overshooting during acute BP management.
Westafer LM, Walsh P, Helderman R
… +5 more, Strokes N, Greineder CF, Barnes GD, Vinson DR, Stubblefield WB
Ann Emerg Med
· 2026 Jul · PMID 41351603
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STUDY OBJECTIVES: To explore physicians' interpretation and decisionmaking when encountering computed tomographic pulmonary angiogram (CTPA) reports communicating diagnostic uncertainty about the presence of pulmonary em...STUDY OBJECTIVES: To explore physicians' interpretation and decisionmaking when encountering computed tomographic pulmonary angiogram (CTPA) reports communicating diagnostic uncertainty about the presence of pulmonary embolism (PE). METHODS: We conducted semistructured interviews from February 1 to June 3, 2024 among purposively sampled emergency medicine and hospital medicine physicians in the United States. Interviews were recorded, transcribed, and analyzed in an iterative process using reflexive thematic analysis. RESULTS: We analyzed interviews from 25 emergency physicians and 17 hospitalists. The median age was 41 years and 33% identified as women. Participants were diverse in practice setting and years of practice. Central themes included a lack of organized approach to diagnostic uncertainty, a perception that empiric anticoagulation would represent "erring on the side of caution," a tendency to defer additional testing and ascertainment of diagnostic certainty to downstream decision makers, and a disinclination to engage in repeat testing due to time pressures and local culture. Although many participants expressed support for the general idea of standardized communication of diagnostic uncertainty, most resisted its quantification in the context of CTPA reports. Many voiced concern that quantification of uncertainty left them without a clear course of action. CONCLUSION: Although diagnostic uncertainty regarding the presence of PE is commonly encountered in CTPA reports, most physicians report a lack of an organized approach to this scenario, often defaulting to empiric anticoagulation and deferring additional diagnostic testing. Future efforts are needed to develop data-driven guidance for encountering diagnostic uncertainty in radiographic imaging reports for PE.
Ann Emerg Med
· 2026 May · PMID 41351602
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STUDY OBJECTIVE: Diagnosis of deep neck space infections is challenging in children due to subtle symptoms and examination findings. However, delays in diagnosis can contribute to increased morbidity in pediatric deep ne...STUDY OBJECTIVE: Diagnosis of deep neck space infections is challenging in children due to subtle symptoms and examination findings. However, delays in diagnosis can contribute to increased morbidity in pediatric deep neck space infection. We aimed to determine (1) the most frequent discharge diagnoses associated with emergency department (ED) visits in the 10 days before deep neck space infection diagnosis and (2) use cohorts of pediatric ED visits with these frequent diagnoses to determine factors associated with return admission with deep neck space infection. METHODS: Cross-sectional analysis of ED and inpatient visits for ages less than 18 years from the State Emergency Department and State Inpatient Datasets from 2018-2019. We linked deep neck space infection admissions (identified by primary International Classification of Diseases, Tenth Revision diagnosis J390) to 10-day antecedent ED visits and identified the most frequent discharge diagnoses in these visits. We then analyzed cohorts of ED encounters with these frequent discharge diagnoses: 1) localized neck symptoms (pain, mass, or torticollis), and 2) pharyngitis or tonsillitis; and compared patient and hospital characteristics of visits with and without a subsequent 10-day admission for deep neck space infection using descriptive statistics. Firth logistic regression was used to assess patient and hospital predictors of a deep neck space infection revisit. RESULTS: Among 799 pediatric deep neck space infection admissions included in the study, 146 (18.3%) patients had more than or equal to 1 treat-and-release ED visits in the 10-day window before deep neck space infection admission. In the cohorts of ED treat-and-release visits for pharyngitis/tonsillitis (n=419,660) and localized neck symptoms (n=54,779), 10-day return visits for deep neck space infection were rare, representing 0.01% and 0.07% of visits, respectively. ED visits with neck imaging were associated with deep neck space infection revisit for both cohorts. Predictors of deep neck space infection in the localized neck symptoms cohort also included younger age and an ED diagnosis of fever, whereas in the pharyngitis cohort, deep neck space infection revisit was associated with ED diagnosis of localized neck symptoms, and negatively associated with a diagnosis of upper respiratory infection or respiratory symptoms. CONCLUSIONS: In ED encounters where patients were discharged with neck pain/mass or torticollis, younger age and a diagnosis of fever were associated with a subsequent deep neck space infection admission. Among ED patients discharged with pharyngitis/tonsillitis, absence of upper respiratory infection/respiratory diagnosis, and neck pain/mass/or torticollis were associated with increased risk of return admission for deep neck space infection. Increased clinical suspicion for deep neck space infection (as manifested by laboratory findings/neck imaging at initial ED visit) was associated with increased risk of deep neck space infection revisit, representing an area for future research. Findings should be validated in datasets with more detailed clinical documentation.
Talan DA, Moran GJ, Machado-Aranda D
… +9 more, Chiang WK, Faine BA, Fleischman R, Hoyt DB, Jones AE, Sabbatini A, Yealy DM, Yu JT, Saltzman DJ
Ann Emerg Med
· 2026 Jun · PMID 41348058
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For more than 100 years, physicians and patients considered appendicitis a surgical emergency requiring hospitalization for urgent removal of the obstructed and inflamed appendix to prevent rupture and sepsis. With the a...For more than 100 years, physicians and patients considered appendicitis a surgical emergency requiring hospitalization for urgent removal of the obstructed and inflamed appendix to prevent rupture and sepsis. With the advent of modern imaging, uncomplicated appendicitis is identifiable, and later evidence showed that surgical delay does not increase the risk of appendiceal perforation. Perforation appears to be a separate disease, with uncomplicated appendicitis likely related to infection, which sometimes self-resolves. Most recently, studies compared nonoperative treatment of uncomplicated appendicitis with antibiotics and observation followed by selective surgery to urgent appendectomy, including 4 multicenter trials involving more than 2,000 adults and 2,000 children. The results led the American College of Surgeons to endorse nonoperative treatment of uncomplicated appendicitis as a safe alternative treatment. Furthermore, emergency department discharge and outpatient management appears feasible in as many as 90% of nonoperative treatment of uncomplicated appendicitis-treated patients. We review methods and results of these trials and evaluate implications for emergency care.