Academic Emergency Medicine[JOURNAL]
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200 papers
Lock and Protect, Reducing Access to Adolescent Means of Suicide: A Pilot Feasibility Study.
Blanchard AM, Tejada J, Pettway S … +8 more , Cornell E, Hoffmann JA, Patel SR, Chernick LS, Betz ME, Auerbach RP, Asarnow J, Dayan PS
Acad Emerg Med · 2026 May · PMID 42101340 · Full text
BACKGROUND: Providing lethal means counseling to caregivers is an underutilized component of emergency department (ED)-based suicide prevention. We assessed the feasibility and acceptability of Lock and Protect, a web-ba...
BACKGROUND: Providing lethal means counseling to caregivers is an underutilized component of emergency department (ED)-based suicide prevention. We assessed the feasibility and acceptability of Lock and Protect, a web-based lethal means counseling decision aid, among caregivers of adolescents who presented to the ED for self-injurious and/or suicidal thoughts and behaviors. METHODS: We conducted a pilot feasibility study of caregiver-adolescent dyads in a pediatric ED. Adolescents were 13-17 years old with current suicidal ideation, suicide attempt, or non-suicidal self-injury. Caregivers received the Lock and Protect intervention plus usual care while their child was in the ED. Feasibility was measured via enrollment rates, duration of time caregivers interacted with Lock and Protect, and tool completion rates. Caregiver acceptability was measured with the Ottawa Acceptability Scale. Follow-up assessments measured changes in home storage at 2- and 4-weeks after enrollment. RESULTS: Of 47 caregivers screened and eligible, 40 enrolled (85.1%), of whom 39/40 and 1/40 reported home access to medications and firearms, respectively. Caregivers found Lock and Protect respectful of their family values about medications (100%) and firearms (97.5%). Almost all caregivers (95.0%) reported the length was "just right" and 92.5% reported the amount of information was "just right". All caregivers completed the tool in the ED, using it for a mean of 8 min (SD = 3.4 min). All would recommend the tool to others. Ottawa Acceptability Scale scores demonstrated that 95.0% of caregivers found the options in Lock and Protect realistic, and 97.5% found the tool useful for changing home medication access. Follow-up was completed for 77.5% of caregivers, with 20/31 (64.5%) reporting safer home storage of medications. CONCLUSIONS: Lock and Protect, a web-based lethal means counseling decision aid, was feasible to administer in the pediatric ED and acceptable to caregivers of adolescents at risk for suicide.
Guardian Presence in Research Conducted on Children With Blunt Abdominal Trauma in the Emergency Department.
Ugalde IT, Badawy M, McCarten-Gibbs KA … +7 more , Yen K, Ishimine P, Atigapramoj NS, Chaudhari PP, Tancredi DJ, Kuppermann N, Holmes JF
Acad Emerg Med · 2026 May · PMID 42089861 · Full text
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Overlooking Barriers to Safe and Effective Emergency Department Discharge.
Hagerman TK, Mowbray FI, Lang T … +7 more , Nour M, Rammal JK, Odeesho S, Farhat S, Klausner H, Siddiqui M, Miller J
Acad Emerg Med · 2026 May · PMID 42089838 · Publisher ↗
BACKGROUND: Physician awareness of a patient's social and functional barriers to effective and safe care after discharge from the emergency department (ED) is crucial. Yet, limited data exist evaluating the ability of re...
BACKGROUND: Physician awareness of a patient's social and functional barriers to effective and safe care after discharge from the emergency department (ED) is crucial. Yet, limited data exist evaluating the ability of resident physicians to identify these barriers. METHODS: We performed a prospective cohort study of patients age ≥ 18 at a single urban ED with an emergency medicine (EM) residency program from 10/2024 to 5/2025. A research team member assessed barriers with each patient, including transportation access, difficulty affording medications, need for assistance with activities of daily living (ADL), and lack of a primary care provider. We measured health literacy and cognitive function with the Rapid Estimate of Adult Literacy in Medicine-Revised and Mini-Cog, respectively. Patient report or measurement of barriers (criterion standard) was matched to written survey data completed by the EM resident caring for the patient. We calculated sensitivity of resident identification of barriers and measured agreement using Cohen's kappa. RESULTS: The sample included 234 patients with complete barrier data cared for by 40 EM residents. Patients consistently reported barriers at higher rates than physicians. Physicians had poor sensitivity for accurate identification of patient barriers. For example, 20.4% of patients reported they had no primary care physician (PCP) and 9.8% of residents reported their patient had no PCP [sensitivity 26.1% (95% CI 14.3-41.1), κ = 0.25]. Limited health literacy was identified in 59.0% of patients and reported by 37.6% of residents [sensitivity 44.7% (95% CI 35.7-53.9), 57.7% agreement]. Abnormal cognition was present in 53.6% of adults age ≥ 65 and reported by 16.7% of residents [sensitivity 27.3% (95% CI 13.3-45.5), 58.6% agreement]. CONCLUSIONS: Patients report barriers to effective care transitions after ED discharge at higher rates than resident physicians identify these barriers. Poor agreement between patient-reported and physician-identified challenges suggests a need for enhanced training, systematic screening, and interdisciplinary collaboration.
How Often Are Emergency Patients Diagnosed With Diabetic Ketoacidosis Despite Not Meeting Laboratory Criteria?
Griffey RT, Haas N, Schneider RM … +4 more , Suarez D, Kline JA, Ancona R, Cruz-Bravo P
Acad Emerg Med · 2026 May · PMID 42089584 · Publisher ↗
OBJECTIVES: Emergency department (ED) patients with hyperglycemia, acidosis, and/or ketosis may have diabetic ketoacidosis (DKA) or any of several well-described conditions. Though the diagnosis of DKA is based on specif...
OBJECTIVES: Emergency department (ED) patients with hyperglycemia, acidosis, and/or ketosis may have diabetic ketoacidosis (DKA) or any of several well-described conditions. Though the diagnosis of DKA is based on specific laboratory criteria, DKA often presents with mixed clinical pictures, making a strictly laboratory diagnosis problematic. When laboratories fail to meet criteria, patients may nevertheless be diagnosed with DKA. The extent of this is not reported. METHODS: We conducted a retrospective observational study at an urban academic ED (01/01/2019-02/28/2023) of adult patients with point of care (POC) glucose > 300 mg/dL and POC ketone > 1.1 mmol/L and/or an ED diagnosis of DKA. We present the proportion whose initial laboratories met DKA criteria based on one of two laboratory definitions, the proportion whose initial laboratories did not meet criteria but who were nevertheless diagnosed with DKA, and the frequencies of non-DKA diagnoses potentially explaining these laboratory abnormalities. Analyses were descriptive. RESULTS: Of 1676 patients included, 883 (53%, 95% CI: 50, 55) met lab criteria for DKA. Of 740 screening positive by POC testing whose initial labs did not meet DKA criteria, 229 (31%, 95% CI: 28, 34) were diagnosed with DKA. Primary ED diagnoses of the remaining 511 included: hyperglycemia (196, 38%), starvation ketosis (58, 11%), hyperosmotic hyperglycemic state (11, 2%), and other ketosis (9, 2%), while 67 (13%) had a primary diagnosis of infection, 1 (< 1%) metabolic acidosis and 169 (33%) an unrelated diagnosis. CONCLUSION: In this single center study of patients screening positive for DKA or given an ED diagnosis of DKA, 53% met laboratory criteria for DKA, and of those not meeting criteria, 31% were nevertheless diagnosed with DKA. This suggests that emergency physicians use criteria beyond laboratory values to diagnose DKA and supports the idea that DKA is ultimately a clinical rather than a purely laboratory-diagnosed condition.
Characteristics and Short-Term Outcomes of Patients With Acute Pulmonary Embolism Requiring Intubation.
Dhar IT, Baltsen CD, Birrenkott DA … +6 more , Freitas MF, Bor B, Granfeldt A, Andersen A, Lyhne MD, Kabrhel C
Acad Emerg Med · 2026 May · PMID 42084455 · Publisher ↗
BACKGROUND: Patients with severe pulmonary embolism (PE) may experience hemodynamic instability with intubation and mechanical ventilation. However, the characteristics and outcomes of intubated PE patients have not been...
BACKGROUND: Patients with severe pulmonary embolism (PE) may experience hemodynamic instability with intubation and mechanical ventilation. However, the characteristics and outcomes of intubated PE patients have not been previously described in the literature. METHODS: We conducted a retrospective cohort study of patients requiring activation of our hospital's Pulmonary Embolism Response Team (PERT) from 2012 to 2021 who were intubated within 24 h of their acute PE diagnosis. Our primary outcome was peri-intubation hemodynamic instability and death occurring within 30 min. Our secondary outcome was peri-intubation hemodynamic instability and death within 3 h of intubation. RESULTS: We included 51 patients. Within 30 min of intubation, seven (14%) patients had a new or increased vasopressor requirement, four (8%) suffered cardiac arrest, and 1 (2%) required ECMO. Within 3 h, 26 (51%) patients had a new or increased vasopressor requirement, six (12%) suffered cardiac arrest, and five (10%) required ECMO. Patients with a central PE (n = 29, 57%) were more likely to experience peri-intubation hemodynamic instability (OR 3.4, 95% CI [0.95, 13], p = 0.048). Patients who had right ventricular strain on CT (OR 3.7, 95% CI [1.01, 15], p = 0.043) or echocardiogram (OR 8.0, 95% CI [1.9, 42], p = 0.0014) were also more likely to experience hemodynamic instability. CONCLUSION: Peri-intubation hemodynamic deterioration occurs in more than half of patients with acute PE, and severe events, like cardiac arrest, are common. Physicians should be cautious when intubating PE patients. Further research is needed to identify optimal strategies to treat PE patients who require intubation.
Standardized Workload Assessment Metric for Pediatric Emergency Departments (SWAMPED): Multicenter Derivation and Evaluation of a Task-Level Workload Measure.
Meckler G, Bone JN, Principi T … +9 more , Wright B, Gravel J, Mater A, Singh D, Görges M, van Rooij T, Hurley KF, Doan Q, for Pediatric Emergency Research Canada (PERC)
Acad Emerg Med · 2026 May · PMID 42084450 · Full text
BACKGROUND: Physician workload in pediatric emergency departments (PEDs) is associated with patient safety, quality of care, and clinician well-being, but is commonly inferred from proxy measures such as visit volume, ac...
BACKGROUND: Physician workload in pediatric emergency departments (PEDs) is associated with patient safety, quality of care, and clinician well-being, but is commonly inferred from proxy measures such as visit volume, acuity, or throughput metrics that incompletely capture the contextual and cognitive demands of clinical care. The Standardized Workload Assessment Metric for Pediatric Emergency Departments (SWAMPED) was developed to quantify workload at the level of discrete clinical tasks. We derived workload estimates and evaluated the reliability, precision, and contextual responsiveness of SWAMPED. METHODS: We conducted a multicenter cross-sectional study of PED physicians at tertiary children's hospitals within the Pediatric Emergency Research Canada network. Participants independently scored 46 care components using the NASA Task Load Index, a validated multidimensional instrument that measures perceived workload associated with a specific task (in this case a clinical care component) accounting for six domains of effort (mental, physical, time, effort, performance, and frustration). Six extrinsic patient and systems-level modifiers were assessed for their impact on component-level workload. We assessed score distributions, interrater agreement using intraclass correlation coefficients (ICC), precision of component estimates, and extrinsic modifiers' effects using mixed-effects models. RESULTS: Sixty-two physicians from 11 sites participated. Interrater agreement across care components was good (ICC: 0.69, 95% CI: 0.60-0.78). Mean workload scores varied across care components (range 22.1-99.5) with high precision (95% CI margin of error of 2.5-6.5 points; relative margin 5%-10%). Most components demonstrated increased workload in the presence of extrinsic modifiers, while intrinsic physician characteristics were not associated with significant differences in workload scores. CONCLUSIONS: SWAMPED generated reliable and precise, task-specific workload estimates and demonstrated sensitivity to clinically relevant contextual modifiers. This approach enables quantitative assessment of physician workload at the task level and provides a foundation for future investigations linking workload to clinical outcomes, clinician performance, and health system planning.
Initial 12 mg Versus 6 mg Adenosine for Supraventricular Tachycardia in the Emergency Department.
Sert ET, Kokulu K, Yürük O … +2 more , Akar EH, Topuz MA
Acad Emerg Med · 2026 May · PMID 42057249 · Full text
OBJECTIVES: This study aimed to compare the efficacy and safety of an initial 12 mg versus 6 mg adenosine dose for sinus rhythm conversion in patients presenting with supraventricular tachycardia (SVT) in the emergency d...
OBJECTIVES: This study aimed to compare the efficacy and safety of an initial 12 mg versus 6 mg adenosine dose for sinus rhythm conversion in patients presenting with supraventricular tachycardia (SVT) in the emergency department (ED). METHODS: This prospective observational study was conducted between February 2025 and January 2026. Adult patients (≥ 18 years) presenting to the ED with hemodynamically stable SVT confirmed by 12-lead electrocardiography (ECG) were included. Patients were categorized into two groups according to the initial adenosine dose administered (6 mg vs. 12 mg). To address potential selection bias, 1:1 propensity score matching (PSM) was performed. The primary outcome was successful first-dose sinus rhythm conversion. Secondary outcomes included adenosine-related adverse effects and SVT recurrence during the ED stay. RESULTS: A total of 142 patients were analyzed (n = 71 per group). First-dose conversion was significantly higher with 12 mg compared with 6 mg (83.1% vs. 52.1%). In the PSM cohort (n = 104), the 12 mg dose maintained its superior efficacy (82.7% vs. 53.8%). The PSM-adjusted odds ratio for successful conversion was 4.12 (95% confidence interval [CI]: 1.85-9.14), with a number needed to treat (NNT) of 3.8 (95% CI: 2.5-8.3). SVT recurrence was numerically lower in the 12 mg group (1.4% vs. 9.9%). Adverse effects were similar between groups. CONCLUSIONS: An initial 12 mg adenosine dose was associated with higher first-dose sinus rhythm conversion than 6 mg, while adverse effects were similar between groups.
Characteristics Associated With Community Violence Prevention Programs in US Hospitals: A Cross-Sectional Survey Analysis.
Ashok VA, Yun K, Klebanoff MJ … +3 more , Kaufman E, Aysola J, Richmond TS
Acad Emerg Med · 2026 Apr · PMID 42050826 · Full text
BACKGROUND: Violence is a social determinant of health, and hospitals are well-positioned to promote patient well-being by addressing its root causes. Understanding factors associated with hospital engagement in communit...
BACKGROUND: Violence is a social determinant of health, and hospitals are well-positioned to promote patient well-being by addressing its root causes. Understanding factors associated with hospital engagement in community violence prevention can guide intervention development and capacity building. OBJECTIVE: To examine hospital and county-level factors associated with the presence of community violence prevention programs (CVPPs) in U.S. hospitals. METHODS: This cross-sectional study linked data from the 2022 American Hospital Association Annual Survey with county-level socioeconomic and demographic data from the US Census Bureau and all-cause homicide rates from the US Centers for Disease Control and Prevention. The sample included general medical and surgical hospitals with Medicare identification numbers. Survey-adjusted logistic regression assessed associations between hospital CVPP presence and all-cause homicide. Our response variable was whether or not the hospital had a CVPP, and our explanatory variable was county-level all-cause homicide rates. We adjusted for hospital characteristics and county-level socio-demographics. RESULTS: Of 4,374 hospitals, 990 (22.6%) reported having CVPPs. Compared to those without CVPPs, hospitals with CVPPs were more likely to be nonprofit (85.0% vs. 62.9%), large (> 500 beds; 16.9% vs. 4.7%), have more annual ED visits (51,873.9 vs. 26,224.5), and be urban (81.1% vs. 51.8%) (all p < 0.001). They also more frequently offered outpatient psychiatric (86.1% vs. 46.9%), substance use (74.4% vs. 23.2%), and pain management (93.1% vs. 65.2%) services. In adjusted models, homicide rates were not associated with CVPP presence (aOR = 1.01, 95% CI [0.99, 1.04]). CVPP presence was independently associated with nonprofit ownership, larger size, trauma designation, and lower social deprivation in urban counties. CONCLUSIONS: Hospital and community characteristics, rather than homicide rates, predict CVPP presence. CVPPs are concentrated in larger, urban, well-resourced hospitals rather than in areas with the highest homicide rates, highlighting potential misalignment between program placement and community need.
Characteristics of Adolescents With Elevated Suicide Risk Presenting to the ED With Physical Health Complaints.
Krass P, Sanders RA, Ross AM … +4 more , Dalton EM, Joshi P, Fein JA, Doupnik SK
Acad Emerg Med · 2026 Apr · PMID 42050822 · Full text
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Age-Specific Clinical Biomarker Ranges in Acute Head Injury, Non-TBI Trauma, and Healthy Control Subjects in the Emergency Department.
Mayes KD, Van Meter TE, Mirshahi N … +8 more , Boyd S, Sandsmark D, Rascovsky K, Diaz-Arrastia R, Weppner J, Peacock WF, Kuehl DR, HeadSMART II Investigators
Acad Emerg Med · 2026 Apr · PMID 42048067 · Full text
OBJECTIVES: Blood-based biomarkers for traumatic brain injury (TBI) are increasingly integrated into diagnostic algorithms, but their interpretation may be confounded by age-related neurological changes. This study quant...
OBJECTIVES: Blood-based biomarkers for traumatic brain injury (TBI) are increasingly integrated into diagnostic algorithms, but their interpretation may be confounded by age-related neurological changes. This study quantified the relative effects of age and TBI on biomarker concentrations to determine whether age-related variation approaches or exceeds that associated with injury. METHODS: Serum biomarkers were analyzed from 762 adults enrolled in the HeadSMART II and HeadSMART Geriatric studies, including healthy controls (n = 88), non-head trauma controls (n = 99), and mild TBI patients (GCS 13-15, n = 575). Participants were categorized by age (18-40, 41-64, 65-74, ≥ 75 years). Six TBI-relevant biomarkers (glial fibrillary acidic protein [GFAP], brain-derived neurotrophic factor [BDNF], neurogranin [NRGN], α-synuclein [SNCA], suppression of tumorigenicity 2 [ST2], and von Willebrand factor [vWF]) were quantified using validated immunoassays (BRAINBox Solutions). Biomarker levels were compared using two-way ANOVA, and the relative effects of age and injury were estimated using Cohen's f. RESULTS: Age significantly influenced several biomarkers. GFAP showed strong age-related increases, with significant elevations across age strata (p < 0.001), exceeding the effect of head injury alone. vWF also increased significantly with age (p < 0.001), while ST2 did not show a main effect of age (p = 0.404), although age interacted with group (p < 0.001). SNCA demonstrated modest age effects (p = 0.001), particularly in older trauma and TBI participants. NRGN showed no significant age-related changes (p = 0.454), and BDNF exhibited age effects within interaction terms (p < 0.001). Overall, age-associated effect sizes for GFAP and vWF were comparable to, or greater than, those of head injury. CONCLUSIONS: Age exerts substantial influence on circulating biomarker concentrations, particularly GFAP and vWF, often rivaling or exceeding TBI-related changes. Diagnostic algorithms that fail to adjust for age may risk misclassification, especially among older adults, underscoring the need for age-normalized biomarker interpretation.
Diagnostic Accuracy of Examination, Brain-Type Natriuretic Peptide, and Imaging for Volume Overload.
Long B, White C, Gottlieb M
Acad Emerg Med · 2026 Apr · PMID 42048048 · Publisher ↗
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Association Between American Society of Anesthesiologists Physical Status Classification System and Remimazolam Sedation Outcomes.
Brynning CH, Busch SP, Krarup AL … +1 more , Melgaard D
Acad Emerg Med · 2026 Apr · PMID 42043412 · Full text
BACKGROUND: Remimazolam (RM) is an ultrashort-acting benzodiazepine with pharmacodynamic properties ideal for procedural sedation in emergency departments (EDs). This study evaluated the safety of RM when used for proced...
BACKGROUND: Remimazolam (RM) is an ultrashort-acting benzodiazepine with pharmacodynamic properties ideal for procedural sedation in emergency departments (EDs). This study evaluated the safety of RM when used for procedural sedation of American Society of Anesthesiologists (ASA) I-III patients in the ED. AIMS: To compare the occurrence of no or mild/moderate respiratory complications during procedural sedation in patients with ASA scores I, II, and III. Secondarily, to compare clinical characteristics of RM sedations between the ASA groups. METHODS: This qualitative improvement study was conducted in 2024 and 2025 at a Danish Level 1 trauma center. RM was administered to ASA I-III patients ≥ 12 years of age as procedural sedation by emergency medicine physicians or nurses educated in airway management, RM sedation, and adverse events. Safety was measured by the occurrence of respiratory problems graded as none, mild, moderate, or severe. RESULTS: Of the 540 patients sedated with RM, 95%-100% in ASA I-III had no or mild/moderate respiratory complications, with ASA I and III being the safest groups (p < 0.014). ASA III patients had the most potential airway risks, but still experienced fewer severe respiratory complications than ASA II patients (4.7% vs. 1.3%, p = 0.014). The RM dose was found to be age-, gender- and ASA score-dependent. CONCLUSIONS: RM showed great potential for procedural sedation and was safe for procedural sedation of ASA I-III patients in the ED, with few serious respiratory complications, even in high doses and with high-risk profiles.
Addressing Frailty in the Emergency Department: Early Outcomes of a Geriatric Rapid Access Clinic.
Kaab A, Kokorelias KM, Kim K … +1 more , Romanovsky L
Acad Emerg Med · 2026 Apr · PMID 42043332 · Full text
OBJECTIVES: Older adults represent a growing proportion of emergency department (ED) visits, with an increased risk of adverse outcomes following discharge, particularly when frailty is present. Access to post-ED geriatr...
OBJECTIVES: Older adults represent a growing proportion of emergency department (ED) visits, with an increased risk of adverse outcomes following discharge, particularly when frailty is present. Access to post-ED geriatric follow-up is often delayed, leaving patients without timely support and increasing their risk of ED revisits and subsequent hospital admissions. This study evaluates a novel Geriatric Rapid Access Clinic (Geri-RAC) designed to provide expedited, specialized follow-up for high-risk older adults discharged from the ED. METHODS: A retrospective chart review was conducted of all patients who attended the Geri-RAC at a large academic hospital in Toronto from January 2023 to July 2024. Older adults identified as high-risk in the ED were referred to the clinic. Patient outcomes included ED revisit rates and anticipated hospital admission avoidance; data on clinic performance indicators, patient characteristics, and accessed supports were also measured. RESULTS: Thirty-three patients attended the Geri-RAC during the 19-month pilot. Mean age was 82.6 years, with 81.8% having a Clinical Frailty Scale score ≥ 4. Functional limitations were present in 69.7% of patients. Median wait time from ED referral to appointment was 7 days. Cognitive testing was conducted in 78.7% of attendees and medication de-prescribing was initiated in 48.5%. Most patients (87.9%) were newly connected to support services, averaging 2.6 ± 2.1 service linkages per patient. 45.5% of patients received new specialist referrals. The 7-, 30-, and 90-day ED revisit rates were 0%, 12.1%, and 24.2%, respectively. Admission avoidance was anticipated in 42.4% of cases. CONCLUSIONS: The Geri-RAC provided timely access to post-ED follow-up and multidisciplinary care for frail older adults. Early findings highlight the potential for this model to enhance ED discharge planning, facilitate structured care transitions, and decrease reliance on emergency services in this high-risk population.
Correction to "Severe Hyponatremia in the Emergency Department. Incidence of Cerebral Edema and Risk of Osmotic Demyelination Syndrome".
Acad Emerg Med · 2026 Apr · PMID 42043325 · Publisher ↗
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Medication Management of Early Pregnancy Loss in an Urban Texas Emergency Department.
Cline L, Sandfeld E, Brunkal H … +4 more , Fischer M, Gilbert A, Fine L, Ager EE
Acad Emerg Med · 2026 Apr · PMID 42043301 · Full text
BACKGROUND: Among patients with early pregnancy loss (EPL) without medication complications or need for urgent surgical evacuation, treatment should largely be guided by patient preference. However, evidence describing m...
BACKGROUND: Among patients with early pregnancy loss (EPL) without medication complications or need for urgent surgical evacuation, treatment should largely be guided by patient preference. However, evidence describing medication management for EPL in the emergency department (ED) setting is limited. We examine the occurrence of medication management of EPL with misoprostol in an urban Texas ED, describe associated clinical outcomes, and identify patient and clinical factors associated with offering this treatment. METHODS: This was a retrospective study of patients with confirmed EPL at a single urban academic ED in Texas from November 1, 2022, to May 31, 2024. Data were collected via relevant EHR review. Eligible patients were identified via ICD-10 codes and reviewed using a structured abstraction tool. We identified patients who received expectant or medication management with misoprostol and reported clinical outcomes using descriptive statistics. An exploratory multivariable logistic regression was used to identify characteristics predictive of patients being offered misoprostol. RESULTS: During the study period, 181 patients met our inclusion criteria. Most patients (n = 154; 85.1%) received expectant management. Misoprostol was offered to 44 patients (24%); 27 patients (15.0%) received the medication, all of whom had an OB consult. Seven-day return ED visits were low in both the expectant (n = 18; 11.5%) and medication (n = 2; 7.4%) management groups. Of the 18 patients managed expectantly with a 7-day return ED visit, six received misoprostol during the second visit. OB consultation strongly predicted patients being offered misoprostol (aOR 15.1; 95% CI 4.8-47.61). CONCLUSION: Medication management was rarely provided to ED patients with confirmed EPL; OB was consulted for all patients who received misoprostol. Return ED visits were rare among patients managed expectantly and with misoprostol. Several patients received misoprostol during a return ED visit, which may suggest a missed opportunity for medication treatment of EPL during initial ED presentation.
Multi-Factorial and Multi-Component Fall Prevention Interventions Initiated From the Emergency Department: A Systemic Review and Meta-Analysis.
Southerland LT, Mowbray FI, Tarnovsky IA … +9 more , Lo AX, Lee S, Harper K, Ryer SV, Maddow CL, Carpenter CR, Malsch AJ, Ragsdale L, Liu SW
Acad Emerg Med · 2026 Apr · PMID 42032852 · Full text
BACKGROUND: Fall risk screening and prevention interventions initiated from the Emergency Department (ED) are endorsed by current national guidelines. We aimed to evaluate the effectiveness of ED-based multi-factorial an...
BACKGROUND: Fall risk screening and prevention interventions initiated from the Emergency Department (ED) are endorsed by current national guidelines. We aimed to evaluate the effectiveness of ED-based multi-factorial and multi-component interventions to prevent falls. METHODS: We conducted a systematic review and meta-analysis of interventions for fall prevention initiated in the ED for older patients (age ≥ 60 years). Multi-component and multi-factorial interventions were included. We excluded studies without a control or comparison group. The published literature was searched from 2019 to May 2024. Risk of bias was assessed with the Newcastle Ottawa tool for observation studies and the Cochrane Risk of Bias v2 for randomized trials. A meta-analysis was completed for the outcomes with multiple studies. RESULTS: The search resulted in 6312 abstracts with 2571 duplicates, for 3741 unique citations. A total of 18 studies were included in the systematic review; 5 were rated as high risk of bias/low quality. The articles were heterogenous in the intervention type (8 multi-factorial and 8 multi-component), setting (ED focused vs. outpatient), intervention components (i.e., nurses, physicians, therapists), and size (103-1435 participants). The interventions did not decrease risk of falls at 3 months (risk difference 0.05 95% CI [0.00; 0.09]), 6 months (0.07 [-0.04; 0.18]) or 12 months (-0.02 [-0.11; 0.07]). ED revisits at 1 month (-0.01 [-0.03; 0.00]), 3 months (-0.04 [-0.14; 0.06]), and 12 months (0.02 [-0.05; 0.25]) were also unchanged. Mortality and hospitalization rates were also unaffected. Improvement in functional status was noted in 4 of 5 studies reporting this outcome. CONCLUSIONS: Multi-factorial and multi-component fall prevention interventions initiated from the ED did not decrease falls or recurrent healthcare use. These interventions may improve functional status in older adults at fall risk. Comparisons are limited by the heterogeneity in types of interventions, intervention compliance, and timing of outcomes.
Preemptive Anticoagulation for Patients With Suspected Pulmonary Embolism in the Emergency Department: An International Survey of Emergency Physicians.
Grewal K, Stubblefield WB, Casey SD … +5 more , de Wit K, Vinson DR, Thompson C, Hugli O, Emergency Advisory and Research International Board on Thrombosis (EARTH)
Acad Emerg Med · 2026 Apr · PMID 42026840 · Full text
BACKGROUND: Guidelines recommend therapeutic anticoagulation for select patients with suspected pulmonary embolism (PE) while awaiting confirmatory imaging. International practice regarding preemptive anticoagulation in...
BACKGROUND: Guidelines recommend therapeutic anticoagulation for select patients with suspected pulmonary embolism (PE) while awaiting confirmatory imaging. International practice regarding preemptive anticoagulation in the emergency department (ED) is not well understood. We aimed to describe emergency physician use of preemptive anticoagulation in patients with suspected PE and identify characteristics associated with its use. METHODS: We conducted an international survey of emergency physicians. The survey was distributed between November 2024 and May 2025. Physicians were asked about use of preemptive anticoagulation, factors associated with use, knowledge of international guidelines, and availability of local protocols. A clinical vignette examined decision making surrounding initiation of preemptive anticoagulation. Multivariable logistic regression models were used to examine factors associated with (1) sometimes/always using preemptive anticoagulation and (2) with use in the vignette. RESULTS: There were 413 responses (27.6% response rate) from 13 countries. Among respondents, 23.1% reported never providing preemptive anticoagulation, 73.9% reported sometimes using it, and 2.9% reported always using it. Over two-thirds of respondents were unaware of recommendations for using preemptive anticoagulation and half reported their institution did not have protocols for preemptive anticoagulation. In multivariable regression, more clinical experience (OR: 1.81, 95% CI: 1.38-2.38), higher self-rated knowledge about PE (OR: 2.05, 95% CI: 1.03-4.06), and more concern for cardiovascular deterioration (OR: 3.21, 95% CI: 1.88-5.49) were positively associated with sometimes/always using preemptive anticoagulation. More concern for bleeding was associated with a lower odds of sometimes or always using preemptive anticoagulation. In the vignette, respondents with institutional protocols for preemptive anticoagulation had higher odds of starting preemptive anticoagulation and those with more concern for bleeding had lower odds of starting it. CONCLUSION: Use of preemptive anticoagulation for patients with suspected PE was low. Most physicians were unaware of guidelines supporting its use and do not have institutional protocols to guide use of preemptive anticoagulation. Implementation and use of institutional protocols may increase guideline-directed preemptive anticoagulation in select patients.
The Downstream Effects of Prehospital Opioid Dosing in Older Adults: A Retrospective Cohort Study.
McGuire SS, Brown CS, Palmer AK … +7 more , Jeffery MM, Mullan AF, Stanich JA, Bower SM, Liedl CP, Rentz LC, Bellolio F
Acad Emerg Med · 2026 Apr · PMID 42023551 · Publisher ↗
BACKGROUND: Older adults experience age-related physiological changes that alter the pharmacokinetics and pharmacodynamics of certain medications, which may necessitate reduced dosing. Our objective was to assess emergen...
BACKGROUND: Older adults experience age-related physiological changes that alter the pharmacokinetics and pharmacodynamics of certain medications, which may necessitate reduced dosing. Our objective was to assess emergency department (ED) and hospital outcomes of older patients administered opioids by emergency medical services (EMS) clinicians. METHODS: Retrospective cohort study of adults ≥ 65 years who received an opioid between 2019 and 2024 within a health system-affiliated EMS agency. We excluded patients with an advanced airway and those with no documented weight. Maximum single and cumulative weight-based opioid dosages were classified as low, therapeutic, or high. Outcomes were measured in the ED/hospital and compared using Poisson regression with Huber/White standard errors, adjusted for age, sex, vitals, Glascow Coma Scale, emergency severity index, and chief concern. Results were reported as adjusted risk ratios (aRRs). RESULTS: A total of 6406 patients, including 747 (11.7%, 95% CI: 10.9-12.5) with a high opioid dose, 3663 (57.2%, 95% CI: 56.0-58.4) with a therapeutic dose, and 1996 (31.2%, 95% CI: 30.0-32.3) with a low dose, were included. Receipt of a high maximum single opioid dose versus a low/therapeutic dose (excluding patients receiving a concomitant sedative) was associated with increased risk of altered responsiveness (aRR = 1.28, 95% CI: 1.03-1.58) and delirium (aRR = 2.43, 95% CI: 1.08-5.45) in the ED/hospital setting. When 311 (4.9%) patients who received a concomitant sedative were included, patients who received a high opioid dose similarly had an increased risk of altered responsiveness (aRR = 1.28, 95% CI: 1.06-1.56) and delirium (RR = 2.65, 95% CI: 1.25-5.59), compared to a low/therapeutic dose. There was no difference in outcomes of hypoxia, death within 30 days, or ED length of stay between dose groups. CONCLUSION: Prehospital administration of high opioid doses to older patients was associated with increased rates of altered responsiveness and delirium. These findings highlight how out-of-hospital care can impact a patient's ED and hospital course.
Association of Early Steroid and Antibiotic Therapy With Airway Outcomes in Adult Epiglottitis: A 10-Year Multicenter Retrospective Cohort Study.
O'Brien J, Muccio DR, Schrock JW
Acad Emerg Med · 2026 Apr · PMID 42023439 · Full text
BACKGROUND: Adult epiglottitis is an uncommon but potentially life-threatening condition requiring rapid recognition and airway-focused management, yet evidence regarding early medical therapy is limited. We evaluated te...
BACKGROUND: Adult epiglottitis is an uncommon but potentially life-threatening condition requiring rapid recognition and airway-focused management, yet evidence regarding early medical therapy is limited. We evaluated temporal trends in adult epiglottitis and examined associations between early corticosteroid or antibiotic therapy and clinically important outcomes. METHODS: We conducted a retrospective cohort study of adults (≥ 18 years) presenting to U.S. emergency departments with acute epiglottitis between 2014 and 2024 using the TriNetX Research Network. Cases were identified using the ICD-10 code J05.1; patients with preexisting tracheostomy were excluded. Early therapy was defined as systemic corticosteroid or parenteral antibiotic administration within 24 h of presentation. The primary outcome was endotracheal intubation; secondary outcomes included ICU admission, 30-day ED recidivism, and 30-day mortality. Propensity score matching (1:1) and multivariable Cox proportional hazards models were used to estimate risk ratios (RRs) and hazard ratios (HRs). RESULTS: The annual incidence proportion of adult epiglottitis increased from 0.002% in 2014 to 0.005% in 2024 (RR per year 1.09; 95% CI 1.08-1.10), with the steepest rise among adults aged 60-74 years. In matched cohorts, early corticosteroid therapy was associated with lower risks of intubation (RR 0.48; 95% CI 0.26-0.88) and ICU admission (RR 0.71; 95% CI 0.55-0.92). Early antibiotic therapy demonstrated similar associations for intubation (RR 0.54; 95% CI 0.34-0.85) and ICU admission (RR 0.72; 95% CI 0.60-0.86). In adjusted Cox models, early steroids (HR 0.33; 95% CI 0.25-0.44) and early antibiotics (HR 0.50; 95% CI 0.34-0.75) were independently associated with lower hazards of intubation. Older age, comorbidities, and hypoxia were strong predictors of airway compromise. CONCLUSIONS: Adult epiglottitis incidence has increased over the past decade, particularly among older adults. Early corticosteroid and antibiotic therapy were independently associated with lower risks of intubation and ICU admission, supporting current clinical practice favoring timely medical therapy in adults with suspected epiglottitis.
Comparative Evaluation of Machine Translation Accuracy of Emergency Department Discharge Instructions: A Non-Inferiority Study.
Rodriguez G, Hernández P, Kirwan C … +2 more , Dunham L, Dutta S
Acad Emerg Med · 2026 Apr · PMID 41989065 · Publisher ↗
BACKGROUND: Patients with limited English proficiency (LEP) face disproportionate risks at emergency department (ED) discharge. Professional interpretation improves outcomes, but real-time written translations remain dif...
BACKGROUND: Patients with limited English proficiency (LEP) face disproportionate risks at emergency department (ED) discharge. Professional interpretation improves outcomes, but real-time written translations remain difficult to provide in many EDs. Modern transformer-based large language models (LLMs) may offer improved translation quality compared with older systems, yet their performance on ad hoc provider-written ED discharge instructions is not well established. METHODS: We conducted a blinded cross-sectional non-inferiority study of English-language ED discharge instructions translated into Spanish, Brazilian Portuguese, and Simplified Chinese comparing Google Translate and ChatGPT-4o versus professional medical interpreters. Fifty-three randomly selected provider-written instructions (100-500 words, preserving spelling/grammar errors) were translated, yielding 477 unique translations. Professional medical interpreters, blinded to translation method, independently scored each translation on fluency, adequacy, meaning, and severity on a five-point Likert scale. Inter-rater reliability between the professional interpreter evaluations was calculated. A 0.5-point non-inferiority margin was pre-specified, and adjusted mean Likert rating differences generated by mixed effects models for each accuracy dimension were compared between translation methods for each language. The proportion of clinically significant translation errors was compared between methods, as was the ability of evaluators to guess the translation method. RESULTS: Inter-rater reliability was high across languages. Both machine translation methods were non-inferior to professional interpreters for adequacy, meaning, and severity in Spanish and Portuguese, and for all four domains in Chinese. For fluency, Google Translate and ChatGPT-4o were inferior in Spanish and Portuguese but non-inferior in Chinese. The frequency of clinically significant errors did not differ significantly by translation method. Evaluators, blinded to method, frequently misidentified machine translations as professional. CONCLUSIONS: In this multi-language evaluation of real-world ED discharge instructions, Google Translate and ChatGPT-4o were non-inferior to professional interpreters for most domains of translation accuracy.
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