Thomas AL, Rupp JD, Suszanski J
… +6 more, Storrow AB, Kline JA, Birrenkott DA, Kabrhel C, Wrenn JO, Stubblefield WB
Ann Emerg Med
· 2026 Jun · PMID 42313044
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STUDY OBJECTIVE: Assessment of right ventricular dysfunction facilitates risk stratification of emergency department (ED) patients with pulmonary embolism (PE). We evaluated the accuracy of emergency physician-interprete...STUDY OBJECTIVE: Assessment of right ventricular dysfunction facilitates risk stratification of emergency department (ED) patients with pulmonary embolism (PE). We evaluated the accuracy of emergency physician-interpreted point-of-care ultrasound (POCUS) compared with cardiologist-interpreted consultative echocardiography for right ventricular dysfunction in patients with PE. METHODS: We developed a retrospective cohort using a regular expression algorithm to identify PE+ patients. Patients were included if they received both an ED POCUS and a cardiologist-interpreted consultative echocardiogram. Right ventricular dysfunction on POCUS was defined as RV size greater than left ventricular size, decreased RV systolic function by tricuspid annular plane systolic excursion, or both. Right ventricular dysfunction on consultative echocardiography was categorized as absent, mild, or moderate to severe using this verbiage to describe the presence of RV dilation, reduced RV function, or both. We report test characteristics (sensitivity and specificity), and agreement as inter-rater reliability coefficients (kappa) of POCUS stratified by right ventricular dysfunction severity and emergency residency training level. RESULTS: In a 194-patient cohort with 97 emergency physician ultrasound operators, POCUS was 76.8% sensitive and 85.9% specific for the identification of right ventricular dysfunction compared with consultative echocardiography. There was 81.4% agreement, overall (kappa=0.63, 95% CI, 0.51 to 0.75). POCUS accuracy improved when right ventricular dysfunction was interpreted as moderate to severe on consultative ultrasound. Inter-rater reliability declined through residency training. CONCLUSION: POCUS is 76.8% sensitive and 85.9% specific for right ventricular dysfunction in ED patients with PE compared with consultative echocardiography. There is moderate agreement between modalities. Accuracy and agreement improve when right ventricular dysfunction is moderate to severe.
Ann Emerg Med
· 2026 Jun · PMID 42313043
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Emergency medicine is practiced under conditions in which decisions and conversations often precede diagnostic or prognostic certainty. In this context, palliative care is frequently misconceived as a late intervention r...Emergency medicine is practiced under conditions in which decisions and conversations often precede diagnostic or prognostic certainty. In this context, palliative care is frequently misconceived as a late intervention rather than a clinical stance applicable during uncertainty. This perspective posits that palliative care in the emergency department should be understood as an approach grounded in early recognition of unmet needs, communication under uncertainty, and deliberate clinical presence. Drawing on the experience of a physician training in palliative care, the article explores how "staying" with patients and families before certainty emerges constitutes meaningful emergency care and supports proportionate decisionmaking in acute settings.
Haimovich AD, Erion-Barner G, Nathanson LA
… +9 more, Cohen C, Orcutt R, Desai S, Rubins D, Hwang U, Taylor RA, Shapiro NI, Ouchi K, Schonberg MA
Ann Emerg Med
· 2026 Jun · PMID 42313042
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STUDY OBJECTIVES: To compare end-of-life predictions as measured by the physician-answered surprise question (SQ), "Would you be surprised if this patient died in the next 6 months?"), the Geriatric End-of-Life Screening...STUDY OBJECTIVES: To compare end-of-life predictions as measured by the physician-answered surprise question (SQ), "Would you be surprised if this patient died in the next 6 months?"), the Geriatric End-of-Life Screening Tool (GEST) artificial intelligence (AI) model, and a new collaborative GEST+SQ model for predicting 6-month mortality in older emergency department (ED) patients. METHODS: This was a single-site prospective cohort study (Nov 2022 to June 2023) at a tertiary academic ED of patients aged 65 years and older. Answers to the SQ were collected within the electronic health record at ED disposition and GEST scores were calculated from available records using laboratory, vital signs, demographic and historical data. Six-month mortality was adjudicated via electronic health record and state records. SQ and GEST were compared using sensitivity and specificity. A new logistic regression model was developed combining SQ and GEST (GEST+SQ) and compared with GEST alone, using area under receiver-operating characteristic curves (ROC-AUC) for discrimination and expected calibration error for calibration. We modeled a sequential screening pathway where low- and high-risk patients received only GEST screening, whereas intermediate-risk patients received both GEST and SQ, reporting the proportion of patients for whom adding the SQ to GEST would change a theoretical referral to intervention. RESULTS: From 9,256 eligible patients, 3,479 had SQ responses (37.6%), with 13.3% 6-month mortality. When matching GEST sensitivity to SQ (83.8%), GEST had greater specificity than the SQ (61.5% [56.7 to 67.1] vs. 50.8% [49.1 to 52.6]). At matching specificity (50.8%), GEST sensitivity (90.0% [87.0 to 92.7]) exceeded the SQ (83.8% [80.3 to 87.0]). GEST had an receiver-operating characteristic - area under the curve (ROC-AUC) of 0.79 (0.77 to 0.81), whereas the GEST+SQ model had ROC-AUC of 0.80 (0.78 to 0.82). The GEST+SQ model had significantly improved expected calibration error of 0.01 (0.01 to 0.02) for GEST+SQ vs. 0.042 (0.03 to 0.05) for GEST alone. In a sequential screening pathway, as few as 5% of patients required SQ screening following GEST risk scoring. CONCLUSION: GEST modestly outperformed the SQ for predicting 6-month mortality. A GEST+SQ collaborative model did not improve discrimination (ROC-AUC) over GEST alone, but improved calibration. Sequential screening using GEST and then the SQ for intermediate-risk patients could decrease physician screening burden by 95% relative to manual, SQ-only screening. Collaborative approaches integrating automated tools with targeted physician input may enhance ED mortality risk assessment while reducing clinician effort.
Fatuzzo S, Koziatek CA, Graulty C
… +11 more, Ruggiero M, Kim JG, Smalley S, Keeley K, Wang Y, Offenbacher J, Smith SW, Wittman I, Caspers C, Jamin C, Genes N
Ann Emerg Med
· 2026 Jun · PMID 42287283
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STUDY OBJECTIVES: Clinical demands in the emergency department (ED) may contribute to decision and attention fatigue as clinician time-on-shift increases, impacting patient care. Emergency department pharmacists review o...STUDY OBJECTIVES: Clinical demands in the emergency department (ED) may contribute to decision and attention fatigue as clinician time-on-shift increases, impacting patient care. Emergency department pharmacists review orders and intervene to correct problems related to safety and appropriateness. This study's objective was to evaluate and characterize the rate of pharmacist interventions on ED medication orders. We hypothesized that pharmacist interventions would increase with clinician time-on-shift. METHODS: We performed a retrospective study of 2 EDs within a single health system between January 2022 and November 2023. Medication and pharmacy intervention details were extracted and linked to clinician schedules, pharmacist schedules, and ED crowding scores. Mixed-effects logistic regression modeling identified factors associated with pharmacist interventions. RESULTS: Pharmacists intervened on 9,054 (1.5%) of 622,171 medication orders placed by 308 clinicians. Pharmacy intervention rate increased with clinician time-on-shift (odds ratio 1.04 for each hour; 95% confidence interval 1.03 to 1.05), with meaningful variation in this effect between individual clinicians. Stratified by clinician type (attendings, residents, or physician assistants) and shift timing (overnight versus daytime shifts), the association between time-on-shift and pharmacy intervention rate remained positive. Stratified by site (A versus B), the association was positive at site A but not at site B. CONCLUSION: The likelihood of orders requiring pharmacist interventions increased as ED clinicians' time-on-shift increased. This association was consistently observed across differing clinician types and shift timing, but variable across the 2 sites of the study. Clinical staffing models and quality of care could be improved by addressing stressors and fatigue accumulation informed by this analytical model.
Ann Emerg Med
· 2026 Jun · PMID 42287282
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STUDY OBJECTIVE: To compare a rule-based computable phenotype designed to identify patients with opioid use disorder in the emergency department (ED) with a large language model, using expert physician review as the refe...STUDY OBJECTIVE: To compare a rule-based computable phenotype designed to identify patients with opioid use disorder in the emergency department (ED) with a large language model, using expert physician review as the reference standard. METHODS: We conducted a retrospective study of randomly sampled adult ED encounters (January 1, 2023 to October 17, 2024) at a single academic health system. We drew a stratified random sample based on whether encounters met a preexisting rule-based phenotype for identifying opioid use disorder. The phenotype incorporated diagnosis codes, medications for opioid use disorder, urine toxicology results, addiction consultations, and keyword matching. With zero-shot prompting, a large language model (ChatGPT 4.1) classified opioid use disorder using ED notes from the index visit. Two board-certified emergency physicians independently determined the presence of opioid use disorder by full chart review; discrepancies were adjudicated by a third reviewer. Using inverse probability weighting based on the sampling fractions, we estimated sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS: Among 302 encounters, weighted opioid use disorder prevalence was 5.6% (95% confidence interval [CI], 4.0 to 7.0%). The structured phenotype demonstrated sensitivity 0.84 (95% CI, 0.42 to 0.97) and specificity 0.964 (95% CI, 0.96 to 0.97) (positive predictive value 0.58; negative predictive value 0.99). The large language model demonstrated sensitivity 0.81 (95% CI 0.70-0.88) and specificity 0.996 (95% CI, 0.993 to 0.998) (positive predictive value 0.92; negative predictive value 0.99). Specificity was significantly higher for the large language model (P<.0001). CONCLUSION: Both approaches demonstrated strong diagnostic performance. Although the structured phenotype showed slightly higher sensitivity, the large language model achieved higher specificity and positive predictive value, suggesting potential to reduce false-positive alerts in ED workflows. Prospective validation in other populations is needed.
Dutta S, Guan-Ting You J, Dunham L
… +4 more, Cash R, Meeker M, White BA, Joseph JW
Ann Emerg Med
· 2026 Jun · PMID 42283666
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STUDY OBJECTIVE: Emergency physicians experience substantial documentation burden, contributing to physician burnout. Human scribes reduce documentation workload but are expensive and pose staffing challenges. Ambient ar...STUDY OBJECTIVE: Emergency physicians experience substantial documentation burden, contributing to physician burnout. Human scribes reduce documentation workload but are expensive and pose staffing challenges. Ambient artificial intelligence (AI) scribes offer a potential alternative by automating note generation from clinician-patient conversations using AI. We compared ambient AI and human scribes against encounters with no scribe on emergency physicians' documentation time and clinical productivity. METHODS: This retrospective cross-sectional observational study evaluated emergency department encounters from January 2025 to September 2025 at 4 hospitals within a large integrated health care system. Encounters were categorized as ambient AI scribe, human scribe, or no scribe. Patient demographics, documentation time, work relative value units (wRVUs), and shift data were extracted. Attending documentation time was modeled using median quantile regression with standard errors clustered at the physician level and controlling for encounter-level variables. Clinical productivity measured as total wRVUs per shift hour was modeled using generalized estimating equations adjusting for physician and shift-level variables. RESULTS: Among 198,178 emergency department encounters, 8,489 (4.3%) used ambient AI scribes, 15,947 (8.0%) used human scribes, and 173,742 (87.7%) had no scribe. Median patient age was 49 years (interquartile range 30 to 68 years), and 53.1% were female. Compared with encounters with no scribe, ambient AI scribes were associated with a 1.6-minute reduction in adjusted median attending documentation time per note (95% confidence interval 0.3 to 2.9), whereas human scribes were associated with a 3.3-minute reduction (95% confidence interval 2.3 to 4.3). Total wRVUs per shift hour did not differ among groups. CONCLUSION: Ambient AI and human scribes were associated with reduced physician documentation time. Clinical productivity did not differ between study groups.
Berdahl CT, Schiff GD, Venkatesh AK
… +7 more, Seferian EG, Torbati SS, Ptacek MP, Carrascoza-Bolanos J, Qureshi N, Nuckols TK, Multidisciplinary ED Diagnostic Excellence Panel
Ann Emerg Med
· 2026 Jun · PMID 42274436
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STUDY OBJECTIVE: To develop definitions of (1) diagnostic excellence and (2) missed diagnostic opportunity to guide research and quality/safety programs in the emergency department (ED). METHODS: We used a modified RAND/...STUDY OBJECTIVE: To develop definitions of (1) diagnostic excellence and (2) missed diagnostic opportunity to guide research and quality/safety programs in the emergency department (ED). METHODS: We used a modified RAND/UCLA panel method, which is a modified Delphi panel that is designed to measure consensus among clinical experts. First, we identified existing definitions of diagnostic error and related terms and extracted conceptual components (eg, accuracy and timeliness). Second, we recruited 11 multidisciplinary panelists, selected for diversity in professional role, clinical setting, geography, and diagnostic error exposure. Third, panelists rated conceptual components on validity, relevance to the ED, and overall importance using a 1 to 9 scale. Conceptual components with final-round median ratings ≥7 on all dimensions were selected for inclusion in narrative definitions. RESULTS: Diagnostic excellence in the ED is "the use of optimal, evidence-based practice to attain an accurate and timely explanation about a patient's condition based on the information available at the time and communicate that explanation to the patient/family. Diagnostic excellence is patient-centered and equitable. Diagnostic excellence includes avoidance of divergent practices. It leads to better choices in management, prevents missed opportunities, and reduces the risk of preventable patient harm." A missed diagnostic opportunity is "a measurable divergence from optimal, evidence-based practice that may lead to: an inaccurate or delayed explanation of a patient's condition, despite information available at the time, or a failure in shared communication related to the diagnosis with the patient/family. A missed diagnostic opportunity may lead to suboptimal management, preventable patient harm, or inequitable outcomes." CONCLUSION: Future work should study implementation of these definitions into ED diagnostic research and quality/safety programs.
Ramraj R, Chen E, Huang X
… +7 more, Haddad G, McCann-Pineo M, Young E, Li T, Becker L, Rolston D, Jafari D
Ann Emerg Med
· 2026 Jun · PMID 42274435
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STUDY HYPOTHESIS: Early defibrillation is crucial in improving out-of-hospital cardiac arrest (OHCA) survival. The use of emergency medical services (EMS) equipment is associated with shorter time to first emergency depa...STUDY HYPOTHESIS: Early defibrillation is crucial in improving out-of-hospital cardiac arrest (OHCA) survival. The use of emergency medical services (EMS) equipment is associated with shorter time to first emergency department (ED) rhythm analysis/defibrillation. METHODS: This is a single-center, retrospective, video review-based study conducted between October 2018 and February 2024. It includes video-recorded patients with OHCA aged 18 and older and excludes patients with traumatic arrests and out-of-hospital return of spontaneous circulation (ROSC). Groups were based on EMS versus ED monitors/defibrillators/pads use for initial ED rhythm analysis. The primary and secondary outcomes were time to first ED rhythm analysis and time to first ED defibrillation, respectively. The exploratory outcomes were time of ED bed transfer, rates of ROSC, survival to hospital admission/discharge, and neurologic outcome. RESULTS: Of 223 OHCA patients included, 75 (33.6%) were grouped into EMS and 148 (66.4%) into ED. Out-of-hospital shockable rhythms were reported in 26.5% of EMS and 10.5% of ED groups. The EMS group had a shorter median time to first ED rhythm analysis (143-second difference, 95% confidence interval [CI] 116 to 169) and first ED defibrillation (131.5-second difference, 95% CI 8 to 272). In exploratory analysis, the EMS group had longer time to ED bed transfer (15.0-second difference, 95% CI 0 to 21) and more frequent defibrillation in the ED (18.0% difference, 95% CI 4.2 to 31.8). Forty-four patients survived to hospital admission and 8 survived to hospital discharge. CONCLUSION: Initial ED rhythm analysis using EMS equipment may be associated with shorter time to initial rhythm analysis.
Ünlü L, Griese JA, Minotti B
… +14 more, Carpenter CR, Appenzeller-Herzog C, Sterzer P, Christ M, Azad N, Nordstrom K, Skinner C, Alsma J, Stiebel V, Kurzhals S, Abdalla Maia IW, Bingisser R, Wilson MP, Nickel CH
Ann Emerg Med
· 2026 Jun · PMID 42233919
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STUDY OBJECTIVE: Medical screening (often termed "medical clearance") is often performed to exclude acute medical conditions in psychiatric emergency department (ED) presentations. This scoping review aims to map and app...STUDY OBJECTIVE: Medical screening (often termed "medical clearance") is often performed to exclude acute medical conditions in psychiatric emergency department (ED) presentations. This scoping review aims to map and appraise the currently available literature on medical screening of adult (18 years and older) patients with psychiatric complaints in the ED. METHODS: We searched Medline, PsycInfo, EMBASE, and Web of Science from inception to April 2025, supplemented by citation searching and expert consultation. Eligible studies of any design included adult patients with psychiatric complaints presenting to general EDs and reported on medical screening practices. Key study characteristics were charted from all eligible articles. Original research articles and society statements underwent thematic analysis. RESULTS: Of 9,128 records screened, 145 publications met inclusion criteria, including 62 original research articles, 74 nonoriginal publications, and 9 society recommendations. Among original research articles with primarily retrospective study design (59.7%) on 34,836 patients and 1,149 health care professionals, we identified 8 themes: laboratory testing (38, 62.9%), history taking (22 studies, 35.5%), vital signs (21, 33.9%), physical examination (19, 30.6%), diagnostic imaging (13, 21.0%), medical screening tools (10, 16.1%), electrocardiography (9, 14.5%), and system-level factors (8, 12.9%). Nonoriginal publications were tabulated. Most society recommendations discouraged routine laboratory testing of psychiatric ED presentations and called for collaboration between emergency medicine and psychiatry stakeholders. None of the society recommendations perfectly adhered to either the National Academy of Medicine recommendations for creating trustworthy guidelines or Grading of Recommendations Assessment, Development and Evaluation methodology. CONCLUSIONS: Medical screening practices can be categorized into 8 distinct themes, with the greatest amount of data available for laboratory testing, history taking, and vital sign assessment. Studies are predominantly retrospective and high-quality prospective assessments of the diagnostic accuracy of medical screening practices are warranted.