Griffey RT, Bollam N, Schneider RM
… +3 more, Kwok ESH, Ancona R, Kocher KE
Acad Emerg Med
· 2026 Feb · PMID 41689235
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BACKGROUND: Opioid-related adverse events (AEs) resulting in or following an ED visit are well described. Less is known about AEs due to opioid administration in the ED, whose detection is limited by the high frequency o...BACKGROUND: Opioid-related adverse events (AEs) resulting in or following an ED visit are well described. Less is known about AEs due to opioid administration in the ED, whose detection is limited by the high frequency of administration and poorly specific surveillance methods. We studied the use of the ED Trigger Tool (EDTT) for detection of AEs from high-risk opioid administration in the ED. METHODS: This is a secondary analysis of a multicenter retrospective study of the EDTT for two selected triggers: M2- ≥ 3 doses of hydromorphone administered and M18- opioid + benzodiazepine administration. We applied the EDTT to an 18-month extract of data from three sites and reviewed a balanced sample of ~3000 records/site using a two-tiered approach, characterizing opioid-related AEs by occurrence, type, and severity. Analysis is descriptive. RESULTS: A total of 13,601/450,852 visits (3.0%) across three sites included one of these triggers: M2 (6447; 1.4%); M18 (6201; 1.4%); or both (853; 0.2%). In our sample of 8719 records, 458 (5.3%) included at least one of these triggers (78 with M2, 347 with M18, and 33 with both). Reviewer agreement was high (Kappa = 0.94). We identified 124 opioid-related ED AEs among 120 triggered visits (26.2%): M2 (37/78 visits; 47.4%); M18 (76/347 visits; 21.9%), and both (7/33 visits; 21.2%). There were no site differences in opioid-related ED AE detection. Common AEs included hypotension, hypoxia, allergic reactions, and delirium, mostly resulting in temporary harm but 30% requiring urgent intervention. CONCLUSIONS: In our sample, 5% of visits included high-risk opioid administration, of which 26% included an opioid-related AE. AE rates were similar across sites, with expected variability in type and severity across triggers and sites. The EDTT is a useful approach for AE detection. Triggers focusing on high-risk opioid administration may have a more favorable yield as a surveillance strategy.
Lee S, Lo AX, Hogan TM
… +9 more, van Oppen JD, Gettel CJ, Lapointe-Shaw L, Seidenfeld J, Hirata K, Aliberti MJR, Healy HS, Liu SW, Geriatric ED Guidelines Writing Group
Acad Emerg Med
· 2026 Feb · PMID 41677306
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OBJECTIVES: Pain is common among patients presenting to the emergency department (ED) but is frequently underdetected and undertreated in older people living with dementia (PLWD). This systematic review examined whether...OBJECTIVES: Pain is common among patients presenting to the emergency department (ED) but is frequently underdetected and undertreated in older people living with dementia (PLWD). This systematic review examined whether dementia-specific pain assessment tools improve pain management compared with usual care in the ED. METHODS: We conducted a systematic review and have reported the methods and results following PRISMA (PROSPERO: CRD420251044828). Eligible studies included randomized, quasi-experimental, and observational designs enrolling ED patients aged ≥ 65 years with dementia or cognitive impairment. Interventions were pain assessment tools developed for PLWD, and comparisons were with standard pain scales. Primary outcomes were patient-reported outcome measures and analgesia administration; secondary outcomes included repeated pain scores, ED revisits, functional decline, mortality, and adverse events. Five databases (Ovid MEDLINE, Embase, Cochrane Library, CINAHL, PsycInfo) and two clinical trial registries were searched without language or date restrictions on April 22, 2025, and December 16, 2025, respectively. Two reviewers independently screened, extracted data, and assessed risk of bias using Cochrane RoB-2. RESULTS: Of 987 records identified, 18 underwent full-text review, and one study met eligibility criteria. Fry et al. (2017) conducted a multicenter, cluster-randomized controlled trial of 602 older adults with suspected long bone fractures, comparing the Pain Assessment in Advanced Dementia (PAINAD) tool with standard pain scales. No significant differences were observed in median time to first analgesia (83 vs. 82 min, p = 0.42) or proportion receiving analgesia within 60 min (28% vs. 32%, p = 0.19). Evidence certainty was rated very low. CONCLUSIONS: Evidence on dementia-specific pain assessment tools in the ED is extremely limited. Available data suggest PAINAD does not improve timeliness of analgesia, underscoring the urgent need for rigorous studies to guide pain management for PLWD in the ED.
Wang G, Hooper CD, Gunaga S
… +9 more, Lee S, Coates WC, Campbell RL, Goldberg E, Bellolio F, Ouchi K, van Oppen JD, Liu SW, GED Guidelines Qualitative Study Group
Acad Emerg Med
· 2026 Feb · PMID 41673986
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BACKGROUND: One in five emergency department (ED) visits is by older adults aged 65+ years. Clinical practice guidelines are needed to optimize patient care by translating the best available evidence into actionable reco...BACKGROUND: One in five emergency department (ED) visits is by older adults aged 65+ years. Clinical practice guidelines are needed to optimize patient care by translating the best available evidence into actionable recommendations to guide person-centered management for this medically complex and growing patient population. Our objective was to understand contributors' experiences and share best practices to inform other guideline working groups. METHODS: We conducted a qualitative study based on thematic analysis with an interpretivist paradigm in June-July 2025, using semi-structured interviews of Geriatric Emergency Department (GED) Guidelines 2.0 contributors to understand their experiences. Interviews were transcribed, independently reviewed by team members, and reflexively coded to identify themes. RESULTS: We interviewed 18 participants. Four main themes emerged: (1) motivations for participation, (2) varying opportunities to be involved, (3) personal benefits, and (4) challenges for improvement. Participants contrasted the strengths of shared learning and development with the burdens of organization and coordination. CONCLUSION: Contributors to the GED Guidelines 2.0 reported a positive experience. They joined because they wanted to contribute to better care of older patients and to achieve personal and professional goals. Many cited that their roles aligned with their strengths and expertise. They also gained skills and knowledge on systematic reviews and benefited from networking. Future groups planning a similar process should consider having multiple levels of leadership, experts in systematic reviews, regular reminders, and creative incentives to improve the process and foster improved networking opportunities within their disciplines.
Sinvani L, Perrin A, Huebschmann AG
… +14 more, Basile M, Groton S, Barnaby D, Sanchez G, Chiuzan C, Chua V, Slotnick S, Porreca K, Romano K, Kwiatek S, Cary K, Garg N, Sud P, Makhnevich A
Acad Emerg Med
· 2026 Feb · PMID 41660681
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BACKGROUND: Delirium is missed in over 75% of older adults presenting to the Emergency Department (ED). The study aimed to determine the efficacy of the ED Delirium Detection Program (ED-DDP) to improve delirium detectio...BACKGROUND: Delirium is missed in over 75% of older adults presenting to the Emergency Department (ED). The study aimed to determine the efficacy of the ED Delirium Detection Program (ED-DDP) to improve delirium detection while evaluating implementation outcomes. METHODS: The ED-DDP consisted of a train-the-trainer model where delirium champions (DCs) trained ED nurses to perform delirium screening using an electronic health record (EHR)-embedded Brief Confusion Assessment Method (bCAM). The ED-DDP was implemented across 3 diverse EDs using a stepped-wedge cluster randomized trial, consisting of control, implementation, and intervention periods. The RE-AIM (Reach, Efficacy, Adoption, Implementation, Maintenance) framework guided outcome assessments. Efficacy was defined as delirium detection between control and intervention periods. Implementation outcomes were assessed via quantitative (surveys, training logs, EHR) and qualitative (semi-structured interviews) methods. RESULTS: Across the 3 ED sites, 94.4% (n = 17/18) of DCs completed delirium training and 94.4% scored ≥ 80% on the post-workshop assessment (Implementation/Fidelity). Over 90% (91.1%, n = 195/214) of nurses agreed to receive training by DCs (Adoption); the average score during nurse bCAM spot checks was 73.3% (Implementation-Fidelity). After ED-DDP implementation, the odds of delirium screening were 11.5 times higher (95% CI: [6.0, 22.3], p < 0.001), when adjusting for time and site clustering (Penetration); screening varied from 6% to 80% across the 3 sites (Reach). The proportion of older adult encounters with a positive delirium screen increased from 0% to 2.2% (p = 0.002; Efficacy). Qualitative data revealed that although DCs and nurses thought delirium screening was a priority for patient care quality and safety, competing priorities were a barrier to consistent and accurate screening (Maintenance). CONCLUSIONS: Although a comprehensive ED delirium training program successfully increased delirium screening, detection remained low. These findings suggest that sustainable delirium detection in the ED requires not only robust training but also deeply embedded workflow solutions and clear post-detection action pathways.
Acad Emerg Med
· 2026 Feb · PMID 41645916
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BACKGROUND: Prolonged emergency department waiting times are associated with increased mortality among older patients. In January 2025, the ED of Linkoping University Hospital, Sweden, implemented a low-resource routine...BACKGROUND: Prolonged emergency department waiting times are associated with increased mortality among older patients. In January 2025, the ED of Linkoping University Hospital, Sweden, implemented a low-resource routine to expedite the workup of older patients living with frailty by prioritized physician assessment and subsequent workup. AIM: To investigate if a frailty alert using the Clinical Frailty Scale followed by prioritized clinical assessment influences ED operating metrics. DESIGN: This was an observational before and after study of a pre-implementation group (control) and a post-implementation group (intervention) between October 2024 and February 2025. SETTING/PARTICIPANTS: Consecutive patients aged > 64 years, with a documented CFS assessment during the ED visit at the Linkoping University Hospital, Sweden, who consented to participation, were included. METHOD: Standard ED operating metrics, Time to physician, ED length of stay (LOS), and admission rates were compared between a pre-implementation group and a post-implementation group. RESULTS: A total of 542 ED visits were analyzed (248 pre-implementation, 294 post-implementation). Time to physician was shorter in the post-implementation group at 31 min (IQR 15, 65) versus 44 min (IQR 20, 94) (p < 0.001). ED LOS was reduced from 352 (IQR 266, 515) to 319 (IQR 240, 458) minutes (p = 0.014). The admission rate was unchanged at 59% and 60% (p = 0.4). CONCLUSION: Frailty alerts based on the CFS with prioritized workup reduced ED LOS and time to physician in older patients living with frailty in this single center study and may be a low-resource intervention to reduce the risks of adverse events in the ED. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT06869148.
Grabinski Z, Smalley S, Olinde A
… +10 more, Ballentine A, Creary K, Caruso L, Wiegner M, Mathews C, Belotti L, Byland LM, Wang Y, Patel K, Smith SW
Acad Emerg Med
· 2026 Feb · PMID 41636659
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BACKGROUND: Optimal emergency contraception (EC) can prevent approximately 95% of rape-related pregnancies. However, time to presentation, weight, and BMI influence efficacy of EC, and disparities in access to care, race...BACKGROUND: Optimal emergency contraception (EC) can prevent approximately 95% of rape-related pregnancies. However, time to presentation, weight, and BMI influence efficacy of EC, and disparities in access to care, race and ethnicity, language, and socioeconomic status may modify rape-related pregnancy risk. We aimed to increase effective EC administration and eliminate potential health disparities in all sexual assault (SA) survivors managed in the emergency department (ED). METHODS: We conducted a 5-year retrospective review evaluating race and ethnicity, language, selected socioeconomic indicators, and obesity factors in EC administration. We implemented a quality improvement (QI) initiative over 2 years across three urban EDs, with interventions focused on care standardization (e.g., pharmaceutical changes, electronic health record optimizations, and checklists), multimodal and inter-disciplinary education, and sustainability of change (e.g., quality assurance reviews and bi-directional feedback). Statistical process control charts (SPCs) were used to evaluate temporal changes in EC administration to SA survivors. The Pearson Chi-squared was used to analyze differences across race and ethnicity groups in pre- and post-intervention cohorts. We estimated rape-related pregnancy preventions based on estimated pharmaceutical efficacy and previously reported marginal risks of pregnancy. RESULTS: Through two QI improvement cycles, within a pre-initiative cohort of 291 patients and post-initiative cohort of 156 patients, we increased any EC administration from 73.7% to 100% and effective EC from 44.1% to 100%, both of which were sustained for 14 months. Differences in effective EC administration across race and ethnicity groups pre-initiative (p = 0.005) were eliminated post-initiative (p = 0.840). An estimated 2.7-9.1 rape-related pregnancies were prevented in our post-initiative cohort. CONCLUSIONS: We achieved sustained effective EC administration to SA survivors and eliminated race and ethnicity disparities. Multi-modal interventions focusing on care standardization, education, and sustainability demonstrated success in patient preventative health goals and health equity.
Love JS, Tapper AR, Pasao MA
… +3 more, Moser JS, Samuels-Kalow ME, Lin MP
Acad Emerg Med
· 2026 Feb · PMID 41630142
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STUDY OBJECTIVE: To report on first-job compensation packages and negotiation practices among a sample of recent emergency medicine (EM) research fellowship graduates, describe gender differences in negotiation behaviors...STUDY OBJECTIVE: To report on first-job compensation packages and negotiation practices among a sample of recent emergency medicine (EM) research fellowship graduates, describe gender differences in negotiation behaviors, and explore perceived barriers and facilitators to early research career success. METHODS: We conducted a national qualitative study using semi-structured interviews with EM research fellowship graduates from 2019 to 2023. Participants were recruited via the Society for Academic Emergency Medicine and National Clinician Scholars Program fellowship directories and alumni networks. Interviews focused on participants' first academic job search post-fellowship and were analyzed using thematic analysis with an inductive and deductive coding approach. Themes were developed through consensus coding and interviews continued until thematic saturation was reached. RESULTS: Seventeen participants completed interviews of 30-60 min in duration; 53% were women, 53% identified as white, and 59% had a first job in the Northeast. Most received one to two job offers and reported varied start-up packages, clinical hours, and non-clinical effort. A majority (59%) did not negotiate their job offers. Participants cited lack of transparency about compensation and institutional expectations as the primary barrier to negotiation. Mentorship-particularly from senior researchers-was described as a key facilitator of early-career success and a major factor influencing job acceptance decisions. Negotiation, when it occurred, more commonly focused on non-clinical effort than salary or start-up funding. Participants emphasized that increased research effort and mentorship were essential to productivity and career sustainability. CONCLUSION: Most EM fellowship graduates did not negotiate key elements of their first academic job offer, often due to a lack of accessible information. Mentorship and protected time for research were the two biggest drivers of job acceptance and perceived productivity. Greater transparency and standardized employment offers-or formal negotiation training in the absence of the latter-may help build a more productive and sustainable pipeline of EM physician-scientists.
Goldberg EM, Keene S, Bounds M
… +9 more, Resnik L, Berry SD, Roberts S, Leroux A, Gomez-Picazo J, Magdaleno M, Nelson A, Mor V, Merchant RC
Acad Emerg Med
· 2026 Jan · PMID 41603307
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BACKGROUND: Emergency department (ED) visits by older adults for falls are an opportunity to initiate fall prevention interventions. The GAPcare II trial tested an effective ED-based fall prevention program at two health...BACKGROUND: Emergency department (ED) visits by older adults for falls are an opportunity to initiate fall prevention interventions. The GAPcare II trial tested an effective ED-based fall prevention program at two health systems. Our objective was to assess successful completion of intervention processes across sites including consultation completion rates, time to consultation, consultation duration, and types of recommendations made. PARTICIPANTS AND SETTING: Community-dwelling adults ≥ 65 years old presenting to three EDs (two in Rhode Island, one in Colorado) within 7 days of an accidental fall who were expected to be discharged and were without mobility-limiting injuries. METHODS: GAPcare II was a randomized controlled trial conducted from August 2021 to January 2025. Participants were randomly assigned to intervention (pharmacy and physical therapy (PT) consultations) or usual ED care arms. Pharmacists reviewed medications for fall risk and recommended modifications. Physical therapists performed validated mobility/balance assessments and provided recommendations for assistive devices, outpatient services, and disposition. RESULTS: Of 852 eligible ED patients, 196 were enrolled (96 intervention, 100 control). Participants' median age was 78 years, 68% were female, and 83% were white. In the intervention arm, 93% received pharmacy consultations and 83% received PT consultations. Median time from initial consultation request to bedside evaluation was 24 min (pharmacy) and 47 min (PT). Pharmacists recommended changing medication timing (26%), stopping fall-risk medications (19%), and dose adjustments (18%). Physical therapists recommended assistive devices (66%), outpatient services (36%), and skilled nursing facility admission (25%). ED length of stay did not differ between the intervention and usual care arms (4.6 vs. 4.4 h, p = 0.90). CONCLUSIONS: The GAPcare II trial demonstrated that an ED-based fall prevention program is feasible to implement across two health systems with varied operations, volume, and staffing with similar results. Consultations generated actionable recommendations and did not prolong ED length of stay.
Amagasa S, Utsumi S, Uematsu S
… +3 more, Ramgopal S, Berg RA, Okubo M
Acad Emerg Med
· 2026 Jan · PMID 41587366
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BACKGROUND: The optimal sequence of epinephrine administration and advanced airway management (AAM) successfully delivered during pediatric out-of-hospital cardiac arrest (OHCA) is unclear. Our objective was to determine...BACKGROUND: The optimal sequence of epinephrine administration and advanced airway management (AAM) successfully delivered during pediatric out-of-hospital cardiac arrest (OHCA) is unclear. Our objective was to determine whether the sequence of first successful epinephrine administration and first successful AAM is associated with survival and functional outcomes in pediatric OHCA. METHODS: We performed a secondary analysis of the Resuscitation Outcomes Consortium Epidemiologic Registry-Cardiac Arrest, a prospective database from 10 US and Canadian regions (2011-2015). We included children (age < 18 years) with non-traumatic OHCA who received epinephrine and/or AAM (endotracheal intubation or supraglottic airway). Our exposure was the sequence of first successful epinephrine administration versus first successful AAM (epinephrine-first or AAM-first). The primary outcome was survival at hospital discharge. Secondary outcomes were a favorable functional outcome at discharge (modified Rankin Scale ≤ 3) and return of spontaneous circulation (ROSC) at hospital arrival. We adjusted for group differences using inverse-probability-of-treatment weighting derived from a propensity score and compared outcomes with logistic regression. RESULTS: Of 886 eligible patients, 297 (33.5%) received AAM as the first successful intervention, 558 (63.0%) received epinephrine as the first successful intervention, and 31 (3.5%) received these at the same recorded second. There was no significant difference in survival at discharge between the epinephrine-first and AAM-first groups (odds ratio [OR], 1.03; 95% confidence interval [CI], 0.69-1.52). Relative to the AAM-first group, the epinephrine-first group was associated with higher odds of ROSC at hospital arrival (OR, 1.38; 95% CI, 1.06-1.80) but lower odds of favorable functional outcome at hospital discharge (OR, 0.32; 95% CI, 0.13-0.76). CONCLUSIONS: In this large observational study of pediatric OHCA, the observed sequence of first successful epinephrine administration and first successful AAM was not associated with survival to hospital discharge.
Wagner KD, Chase B, Anderson J
… +4 more, Andres Reyes MS, Harding RW, Fiuty P, Page K
Acad Emerg Med
· 2026 Jan · PMID 41578137
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BACKGROUND: The increasing prevalence of methamphetamine-associated "overdoses" in the surveillance literature necessitates a better understanding of self-reported symptoms associated with acute methamphetamine toxicity...BACKGROUND: The increasing prevalence of methamphetamine-associated "overdoses" in the surveillance literature necessitates a better understanding of self-reported symptoms associated with acute methamphetamine toxicity events. This study describes and compares the prevalence, self-reported symptoms, and behavioral correlates of acute methamphetamine toxicity, opioid overdose, and mixed drug overdose events. METHODS: We surveyed 420 people who use drugs in Nevada and New Mexico. Participants reported on their experiences of acute methamphetamine toxicity, opioid overdose, and mixed drug overdose events, including symptoms and healthcare utilization. We conducted descriptive analyses and compared demographics, drug use behaviors, and health indicators across groups experiencing different types of events. RESULTS: Of 217 participants reporting any event, 24% experienced only methamphetamine toxicity, 35% only opioid overdose, 5% only mixed drug overdose, and 36% multiple types. Methamphetamine toxicity events were characterized by anxiety (43%), heart pounding (34%), and rapid heart rate (33%), while opioid overdoses primarily involved loss of consciousness (86%). The methamphetamine-only group reported significantly lower prevalence of recent use of various substances and less frequent naloxone availability. CONCLUSIONS: Acute methamphetamine toxicity events present distinctly from opioid overdoses, with implications for emergency recognition and response. Lower naloxone availability among people who use methamphetamine is concerning given the prevalence of polydrug use. These findings underscore the need for targeted interventions addressing methamphetamine-related harm reduction efforts.