Adelgais KM, Remick KE, Hewes HA
… +6 more, Crady R, Alter R, Gausche-Hill M, Schmuhl P, Genovesi AL, Shah MI
Ann Emerg Med
· 2026 Jul · PMID 41721808
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STUDY OBJECTIVE: The National Prehospital Pediatric Readiness Project aims to optimize pediatric out-of-hospital care by emergency medical services (EMS). The current report details the findings of the first national ass...STUDY OBJECTIVE: The National Prehospital Pediatric Readiness Project aims to optimize pediatric out-of-hospital care by emergency medical services (EMS). The current report details the findings of the first national assessment of pediatric readiness among US EMS agencies. METHODS: We performed a cross-sectional study of data collected from 911-responding EMS agencies in the United States via a scored web-based survey developed based on national guidelines for out-of-hospital care. The survey contained 207 questions across 8 domains of out-of-hospital readiness: education, equipment, safety, family-centered care, pediatric coordination, interaction with systems, policies, and quality improvment. The primary outcome was the Prehospital Pediatric Readiness Score (range 0-100); secondary outcomes were median domain scores and the effect of a pediatric emergency care coordinator on scores. RESULTS: Overall, 6,989/15,293 (46%) agencies responded; 2,661 (38%) reported having a pediatric emergency care coordinator. Median Prehospital Pediatric Readiness Score was 65.5 (interquartile range [IQR] 50.9 to 78.8). Domain scores were highest for equipment (median 12.0, IQR [12 to 12], range 0 to 12), policies (11.5, IQR [10 to 12], range 0 to 13), and safety (11.5, IQR [7 to 14], range 0 to 14) and lowest for family-centered care (5.8, IQR [2 to 8], range 0 to 10), quality improvement (5.7, IQR [3 to 9], range 0 to 12), and interactions with systems (4.9, IQR [3 to 7], range 0 to 10). Presence of a pediatric emergency care coordinator was associated with a perfect score in all domains. CONCLUSION: A national assessment of EMS agencies revealed strengths and gaps in pediatric readiness. Pediatric emergency care coordinators are associated with higher readiness scores. Future work should address barriers to pediatric readiness and the effect of higher readiness on patient outcomes.
Sax DR, Warton EM, Mark DG
… +4 more, Vitale-McDowell TJ, DiLena DD, Rauchwerger AS, Reed ME
Ann Emerg Med
· 2026 Jun · PMID 41721807
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STUDY OBJECTIVE: Assess how emergency department (ED) mistriage is associated with timeliness of ED care and patient outcomes. METHODS: This was a retrospective cohort study of ED encounters from 2016 to 2020, across 21...STUDY OBJECTIVE: Assess how emergency department (ED) mistriage is associated with timeliness of ED care and patient outcomes. METHODS: This was a retrospective cohort study of ED encounters from 2016 to 2020, across 21 EDs. Using operational measures of triage accuracy, we assessed how assigned Emergency Severity Index (ESI) matched downstream intensity of care and resource use. Patients with a mismatch between ESI assignment and downstream resource use were classified as undertriaged high-acuity or overtriaged low acuity, whereas those with no mismatch were classified as true low-, mid-, or high-acuity. The primary outcome was delay in care; secondary outcomes included ED length of stay, intensive care unit admission (ICU), and short-term mortality. RESULTS: Among 5,315,081 adult ED encounters, mean age was 51.7 years, 2,962,827 (56%) were women, and 590,566 (11.1%), 800,966 (15.1%), 2,336,012 (44.0%), 1,137,444 (21.4%), and 450,093 (8.5%) were Asian, Black, Non-Hispanic White, Hispanic, and other, unknown or multi-race, respectively. Undertriaged high-acuity patients had higher comorbidity burdens, high-risk medication use, and recent health care use compared with true mid- and high-acuity patients. In adjusted analyses, mistriage, both under- and overtriage, was associated with small delays in care. Undertriaged high-acuity patients had an 8-minute delay in care compared with true high-acuity patients. Overtriaged low-acuity patients had a 3-minute delay in care and a 42-minute longer total ED length of stay compared with true low-acuity patients. CONCLUSION: Mistriage was associated with small delays in care. Early identification of critically ill patients remains a triage priority, and the use of patient history data may help support accurate triage.
Preiksaitis C, Alvarez A, Winkel M
… +9 more, Karamatsu M, Brown I, Sama N, Morris L, Lee JY, Gubbels A, Wahl E, Frye A, Rose C
Ann Emerg Med
· 2026 May · PMID 41665590
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STUDY OBJECTIVES: To describe real-world adoption of an ambient artificial intelligence (AI) scribe in the emergency department (ED) and compare documentation time and note characteristics between ambient and standard en...STUDY OBJECTIVES: To describe real-world adoption of an ambient artificial intelligence (AI) scribe in the emergency department (ED) and compare documentation time and note characteristics between ambient and standard encounters using electronic health record audit logs. METHODS: We performed a retrospective observational study of adult ED encounters at a tertiary academic medical center. Attending physicians could optionally use an ambient AI scribe to generate notes from patient-clinician conversations. We included single-attending encounters in core ED zones and excluded visits with human scribes. Electronic health record audit logs provided documentation of time during and after the shift, total electronic health record time, and note length. We summarized adoption by physician, zone, and acuity and compared medians between ambient and standard encounters. RESULTS: Among 8,740 eligible encounters, 976 (11.2%) used ambient AI. Thirty-five of 92 attendings (38%) used the tool, and a small group of high-frequency users accounted for most ambient encounters. Ambient use clustered in telemedicine and vertical-care zones (chair-based ambulatory care) and in lower-acuity patients, as well as those not requiring interpreters. Median on-shift documentation time was 2:45 min for ambient encounters versus 3:50 min for standard encounters (difference -1:05; -28%). Median total electronic health record time was 8:39 min versus 10:21 min (-16%), and ambient notes were shorter overall. CONCLUSION: Early ED implementation of ambient AI scribes showed low but highly skewed adoption, with physicians favoring lower acuity, noninterpreted encounters. When used, ambient AI was associated with shorter on-shift documentation time, total electronic health record time, and note length.
Ann Emerg Med
· 2026 Feb · PMID 41665589
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Hurricane Helene struck Western North Carolina in September 2024, leaving an entire region without power, clean water, or internet connectivity for more than a week. A small, rural, community hospital and its emergency d...Hurricane Helene struck Western North Carolina in September 2024, leaving an entire region without power, clean water, or internet connectivity for more than a week. A small, rural, community hospital and its emergency department, which normally sees 84 patients per day, suddenly became the sole source of medical care for an estimated 200,000 residents and experienced a 70% surge in patient volume. Although structural damage to the hospital was limited, the complete loss of digital connectivity rendered electronic medical records, laboratory information systems, radiology, pharmacy, and routine communication tools inoperable. Forced back into an analog system of care, clinicians rapidly redesigned workflows: in-person huddles replaced digital messaging, point-of-care testing replaced central laboratory processing, radiologists interpreted imaging in real time at the scanner, and paper charting was used. When patients dependent on powered medical devices such as oxygen concentrators and left ventricular assist devices overwhelmed emergency department space, the hospital created a staffed medical device shelter in a nearby high school. Paper medication administration records and take-home medication packs were developed to allow safe discharge despite pharmacy closures. This experience revealed that, in modern hospital disaster planning, uninterrupted internet access is a critical contingency to plan for. Backup generators cannot compensate for the loss of digital connectivity. Hospitals should prepare for extended digital outages by maintaining point-of-care diagnostics, physical copies of critical order sets, and plans for alternative care locations for medically fragile patients. Here, we share lessons learned from the connectivity outages during Hurricane Helene and its aftermath, and how small, rural hospitals can serve as community anchors during prolonged infrastructure failure.
Brown R, Min J, Fein J
… +2 more, Wright M, Cullen D
Ann Emerg Med
· 2026 Jul · PMID 41636668
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STUDY OBJECTIVE: The emergency department (ED) is a key setting for social care, but there is limited guidance for implementation. This study compares ED social care approaches and elucidates caregiver perspectives on so...STUDY OBJECTIVE: The emergency department (ED) is a key setting for social care, but there is limited guidance for implementation. This study compares ED social care approaches and elucidates caregiver perspectives on social care delivery. METHODS: This was a secondary analysis of a mixed-method randomized controlled trial comparing the effect of social risk screening on resource desire. Caregivers of pediatric (0 to 25 years) patients in a pediatric ED were randomized to receive the following: (1) a social risk screener, (2) a "resource menu" to indicate desired assistance, or (3) no assessment. All arms received electronic resources and optional individualized navigation. Differences in resource desire were assessed with risk differences and univariate logistic regression. We interviewed a purposive sample to explore perceptions of social care until thematic saturation was reached and analyzed transcripts using thematic analysis. RESULTS: Of 1,996 families recruited (63.6% publicly insured), a higher proportion reported desire for resources in the menu arm compared to the screening arm (39.6% vs 31.7%). Among 441 follow-up survey participants, 45.8% used and 36.7% shared the resources. The likelihood of engaging with navigation increased with the number of desired resource domains (odds ratio 2.6, 95% confidence interval 2.2 to 3.0). The 33 interview participants offered implementation recommendations: (1) maintain situational awareness, (2) concisely communicate procedures, (3) provide resources after acute needs are addressed, and (4) offer longitudinal follow-up. CONCLUSION: Our findings support offering resources rather than screening for risk and a tiered social care structure that prioritizes preferences: electronic resources provided to all, tailored resources for those requesting assistance, and resource navigation for those who desire it.
Wood AJ, Rosendale N, Crowe R
… +2 more, Kelly JD, Guterman EL
Ann Emerg Med
· 2026 Jul · PMID 41632058
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STUDY OBJECTIVE: Timely out-of-hospital recognition and management of neurologic emergencies-including status epilepticus, stroke, intracerebral hemorrhage, and traumatic brain injury-are critical to improving patient ou...STUDY OBJECTIVE: Timely out-of-hospital recognition and management of neurologic emergencies-including status epilepticus, stroke, intracerebral hemorrhage, and traumatic brain injury-are critical to improving patient outcomes. However, the influence of social risk factors on the delivery and quality of emergency medical services (EMS) care in these time-sensitive conditions remains poorly understood and may contribute to long-term morbidity and mortality. This study examines the association between community-level social vulnerability and out-of-hospital identification of neurologic emergencies. METHODS: This retrospective cohort study used data from the ESO Data Collaborative research dataset from January 2019 through December 2022. The dataset covers EMS agencies across the United States that participated in the ESO Data Collaborative research dataset, which includes a health data exchange linking EMS and emergency department encounters. EMS encounters initiated via 911 calls for patients of all ages diagnosed in the emergency department with status epilepticus, stroke, intracerebral hemorrhage, or traumatic brain injury, as determined by primary International Classification of Diseases-10 codes, were included for analysis. Social vulnerability was measured at the census tract level using the Social Vulnerability Index, categorized in quintiles. Our primary outcome was EMS identification of the neurologic emergency, defined as an out-of-hospital impression or treatment protocol consistent with the emergency department diagnosis. RESULTS: Among 69,842 EMS encounters, 35,729 (51.2%) were for stroke, 23,607 (33.8%) for traumatic brain injury, 5,911 (8.5%) for intracerebral hemorrhage, and 4,595 (6.6%) for status epilepticus. Patients in the most socially vulnerable census tract quintile had a 33% greater risk of EMS not identifying the neurologic emergency (risk ratio [RR] 1.33; 95% confidence interval [CI] 1.23 to 1.43) compared to the least vulnerable quintile. Condition-specific analyses showed social vulnerability was associated with an increased risk of not identifying stroke (RR 1.31; 95% CI 1.22 to 1.41) and traumatic brain injury (RR 1.17; 95% CI 1.03 to 1.32). No significant association was found for status epilepticus (RR 0.90; 95% CI 0.73 to 1.10) or intracerebral hemorrhage (RR 1.09; 95% CI 0.99 to 1.20). CONCLUSION: Higher neighborhood social vulnerability was associated with lower rates of out-of-hospital neurologic emergency identification, particularly stroke and traumatic brain injury. Targeted strategies are needed for equitable out-of-hospital recognition and response for time-sensitive neurologic conditions.
Atzema CL, Cox JL, Cheung CC
… +4 more, Coll-Vinent B, Benjamin EJ, Jackevicius CA, Vinson DR
Ann Emerg Med
· 2026 Apr · PMID 41603838
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The European Society of Cardiology and the American College of Cardiology/American Heart Association/American College of Clinical Pharmacy/Heart Rhythm Society both recently updated their guidelines on the management of...The European Society of Cardiology and the American College of Cardiology/American Heart Association/American College of Clinical Pharmacy/Heart Rhythm Society both recently updated their guidelines on the management of atrial fibrillation, whereas the Canadian Cardiovascular Society/Canadian Heart Rhythm Society published their most recent guidelines in 2020. Compared with previous iterations, all three guidelines are more specific in their recommendations with respect to emergency department (ED) care. Although the principles that underpin each group's recommendations are similar, some of the details vary, which could lead to clinician confusion. In addition, no publication has compared all 3 on the care that is specific to emergency medicine, nor contextualized them with the recommendations made by 2 national emergency medicine groups. In this Concepts paper, we compare and contrast the different guidelines as they apply to the practice of emergency medicine, highlighting differences as well as the underlying rationale provided by each group. We also provide practical insights for implementation in the ED setting.
McCarthy D, Borrayes L, Hopper E
… +6 more, Lutz CL, Teigman A, Siegel R, Solorzano C, Irizarry E, Friedman BW
Ann Emerg Med
· 2026 Jan · PMID 41603837
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STUDY OBJECTIVE: To determine, when performing a sphenopalatine ganglion block (SPGB) for emergency department (ED) patients with headache, whether larger doses of bupivacaine result in greater rates of sustained headach...STUDY OBJECTIVE: To determine, when performing a sphenopalatine ganglion block (SPGB) for emergency department (ED) patients with headache, whether larger doses of bupivacaine result in greater rates of sustained headache relief than lower doses. METHODS: This was a randomized, 4-armed study conducted in 2 EDs. Eligible patients were those with a moderate or severe primary or secondary headache. We randomized patients to unilateral (UL) or bilateral (BL) transnasal SPGB with 0.5% bupivacaine and also to high dose (3 mL) or low dose (1 mL) bupivacaine. Thus, participants could have received 1 mL, 2 mL, 3 mL, or 6 mL of bupivacaine. No attempts were made to blind study participants or investigators. We did not use a sham procedure. We assessed pain using the descriptors severe, moderate, mild, or none. The primary outcome was sustained headache relief, defined as achieving a headache intensity of mild or none within 2 hours of medication administration and maintaining a level of mild or none for 48 hours after the procedure without the use of any rescue analgesic medications at any time during the 48 hours. The secondary outcome was the request to receive the same medication during a subsequent visit to the ED for headache. The minimum clinically important between-group difference was an absolute risk reduction of 15% to 20%. RESULTS: In total, 2,494 patients were screened for eligibility, and 220 were randomized. Of the 2,494 patients, 1,612 (65%) refused participation because they preferred a route of administration other than nasal. Rates of sustained headache relief were as follows: 3 mL BL, 17/54 (31%); 3 mL UL, 15/44 (34%); 1 mL BL, 23/65 (35%); and 1 mL UL, 9/48 (19%). When compared to the 1 mL UL dose, neither the 3 mL BL (95% CI for difference of 13% -4% to 29%) nor the 3 mL UL dose (95% CI for difference of 15% -2% to 33%) resulted in more sustained relief. Rates of wish to receive again were 3 mL BL, 35/53 (66%); 3 mL UL, 26/ 44 (59%); 1 mL BL, 36/62 (58%); and 1 mL UL, 33/45 (73%). There were no statistically significant differences among the groups regarding wish to receive again. The intervention was generally well tolerated, with minor procedure-related adverse events reported in ≤10% of participants in each arm. CONCLUSION: Among ED patients with headache treated with a SPGB, larger doses of bupivacaine do not result in more sustained headache relief than smaller doses.
Baker AH, Li J, Douglas KE
… +2 more, Monuteaux MC, Chung S
Ann Emerg Med
· 2026 Jul · PMID 41575405
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STUDY OBJECTIVE: Pediatric data on health care utilization following disasters are limited, with most studies focused on adults. This study evaluated changes in pediatric emergency department (ED) volumes, hospital admis...STUDY OBJECTIVE: Pediatric data on health care utilization following disasters are limited, with most studies focused on adults. This study evaluated changes in pediatric emergency department (ED) volumes, hospital admissions, and diagnoses following Major Disaster Declarations by the Federal Emergency Management Agency. METHODS: This was a retrospective observational analysis of patients aged ≤18 years presenting to a Pediatric Health Information System-participating ED between 2010 and 2023. We paired each Pediatric Health Information System ED with any major disaster that occurred within 50 miles of the ED. For each ED-disaster pair, we analyzed changes in weekly ED visits, admissions, and diagnoses for weeks 1 to 4 after the disaster. We report mean counts (SD) and percent changes (95% confidence interval), stratified by the 5 disaster types (severe storm/flood, snow/ice storm, fire, tornado, and earthquake). RESULTS: Across 288 Major Disaster Declarations over 14 years, there were 409 ED-disaster pairs. For all disaster types, ED visits and admissions showed modest week 1 declines followed by a return to baseline levels. Tornadoes were associated with consistent decreases in ED visits over all 4 weeks, whereas snow/ice storms, severe storms/floods, and earthquakes demonstrated early decreases followed by recovery. Fires were associated with sustained increases, particularly for respiratory diagnoses. Admissions declined after tornadoes, with smaller decreases after snow/ice storms and earthquakes, whereas remaining stable after severe storms/floods and fires. CONCLUSION: Pediatric ED utilization generally declined modestly after most disasters but increased following fires, driven by respiratory presentations. Declines likely reflect disruptions in access and care seeking, whereas fire-related surges highlight distinct respiratory effects. Preparedness efforts should incorporate event and diagnosis-specific trends to support continuity of operations and capacity for brief surges when they occur.