Shah FI, Lew G, Lee R
… +6 more, Reich K, Crowder K, VandenBerg S, McGillivray M, Blanchard IE, Goodarzi Z
Acad Emerg Med
· 2026 Feb · PMID 41201290
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INTRODUCTION: Emergency medical services (EMS) providers are often first responders to agitated older adults, providing critical clinical care and transport. However, significant knowledge gaps persist in our understandi...INTRODUCTION: Emergency medical services (EMS) providers are often first responders to agitated older adults, providing critical clinical care and transport. However, significant knowledge gaps persist in our understanding of agitation management for older adults in the prehospital setting. AIMS: To describe the barriers and facilitators to the management of agitation in older adults and the reduction of restraint use by EMS providers. METHODS: In-depth semi-structured qualitative interviews (n = 30) took place with EMS providers employed in Alberta, Canada. The theoretical domains framework (TDF) served as a guiding structure for the development of the interview guide. Framework analysis was used to analyze the qualitative data: a line-by-line thematic analysis was used to identify codes/themes, which were then mapped onto the TDF, and behavior change wheel. RESULTS: Six major thematic categories were identified. EMS providers reported inadequate training and support, especially for managing agitation in older adult populations. Restraints are used as a safety measure for patient and provider safety, and as a last resort once other agitation management strategies have been exhausted. EMS providers report a complex decision-making matrix of balancing the risks, benefits, and ethical considerations of restraint use, which is often collaborative and integrates EMS protocols. Common barriers to effective agitation management in EMS, as well as non-restraint agitation management techniques are also discussed. CONCLUSION: The present study is the first in-depth exploration of EMS provider experiences regarding the management of agitation and chemical and physical restraints in older adults.
Benabbas R, Zehtabchi S, Wakai A
… +6 more, Allen R, deSouza IS, Richards RJ, Curley D, Dunne E, Sinert R
Acad Emerg Med
· 2026 Feb · PMID 41201260
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BACKGROUND: Syncope places a significant burden on emergency departments (EDs), often prompting extensive testing to exclude life-threatening conditions. However, the diagnostic utility of troponin, B-type natriuretic pe...BACKGROUND: Syncope places a significant burden on emergency departments (EDs), often prompting extensive testing to exclude life-threatening conditions. However, the diagnostic utility of troponin, B-type natriuretic peptide (BNP), transthoracic echocardiography (TTE), and outpatient cardiac monitoring remains unclear. METHODS: This systematic review assessed the diagnostic accuracy of these tests in adults presenting with syncope. The research question was: In ED patients with syncope, does TTE, cardiac biomarkers (troponin, BNP), or outpatient arrhythmia monitoring, compared with no testing, improve outcomes within 30 days? Primary outcomes included adverse events (death, arrhythmias, structural/ischemic heart disease, and select non-cardiac causes such as pulmonary embolism or aortic dissection) for biomarkers and diagnostic yield for TTE and monitoring. Sensitivity, specificity, and likelihood ratios (LR+ and LR-) were calculated for biomarkers, while diagnostic yield with 95% CI was reported for TTE and monitoring. Risk of bias was assessed using JBI and QUADAS-2. RESULTS: The database searches identified 1759 citations. After applying inclusion and exclusion criteria, 41 studies (21,557 patients) were included. Significant heterogeneity among the included trials (all with I > 90%) precluded meta-analysis. For BNP, LR+ ranged 1.4-47 and LR- 0.06-0.4; for troponin, LR+ 1.9-11.2 and LR- 0.2-0.9. TTE diagnostic yield was 0%-29% overall and 8%-28% in high-risk groups. Outpatient monitoring yielded 1%-59% overall and 12%-42% in high-risk patients. CONCLUSION: In ED patients with syncope, the diagnostic accuracy and yield of cardiac biomarkers, TTE, and outpatient monitoring show substantial variability, largely due to differences in patient populations, outcome measures, and study methodologies. Based on the existing evidence, these modalities in isolation cannot be recommended for routine use in syncope evaluation. Among these tests, the diagnostic yield of TTE and outpatient monitoring is greater in patients with cardiac risk factors and could potentially contribute to a more accurate diagnosis.
Meeker MA, Bongiorno DM, Cullen D
… +2 more, Schiavoni KH, Samuels-Kalow M
Acad Emerg Med
· 2026 Feb · PMID 41199471
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INTRODUCTION: Emergency departments (EDs) are increasingly required to screen for social risk and social need, but existing tools are long, hindering their utility in clinical settings, and resulting in incomplete survey...INTRODUCTION: Emergency departments (EDs) are increasingly required to screen for social risk and social need, but existing tools are long, hindering their utility in clinical settings, and resulting in incomplete surveys. However, strategies for streamlining screening tools remain unclear. This work aimed to guide future development of an ED-based screener by using a health system's ten-item social risk/social need questionnaire to (1) compare differences in patient populations by questionnaire completeness, (2) observe patterns of responses (e.g., what questions cover the same constructs and can potentially be eliminated), and (3) test for variation in social risk/social need measurement by age. METHODS: This cross-sectional study evaluated patients who responded to at least one question in the social risk/social need questionnaire in our regional health system from February 2019 to March 2023. Descriptive analyses examined patients stratified by questionnaire completeness: lower response (< 60%) versus higher response (≥ 60%). Within the higher response group, factor analysis extracted social risk/social need constructs and the strength of the association between each questionnaire item and its corresponding social risk/social need construct. RESULTS: Among 330,109 individuals, 248,808 (75%) completed the survey. In the lower response group (28,985; 9%), more patients were caregivers of children ≤ 4 years (18,231; 63%) and had commercial insurance (21,009; 72%) compared to the higher response group (23,873; 8% and 149,814; 50%, respectively). Factor analysis revealed a three-factor structure of the social risk/social need framework which we labeled: core resources, housing, and ability to work. From the magnitude of factor loadings, the items with the strongest indication of social risk/social need were paying for utilities, upcoming housing instability, and unemployment. CONCLUSION: In this health system, incomplete social risk/social need questionnaires are common. To improve response rates, the social risk/social need framework elucidated by our factor analysis will guide the development of a consolidated questionnaire for the EDs.
Hodgkin D, Thomas CP, Davis MT
… +4 more, Wicks JJ, Greenfield SF, Meisel ZF, Horgan CM
Acad Emerg Med
· 2026 Feb · PMID 41193942
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BACKGROUND: The US is experiencing an epidemic of opioid misuse and mortality. Effective treatments are available, including medications for opioid use disorders (MOUD), but they are greatly underused due to a variety of...BACKGROUND: The US is experiencing an epidemic of opioid misuse and mortality. Effective treatments are available, including medications for opioid use disorders (MOUD), but they are greatly underused due to a variety of barriers. In response, some US hospitals have established programs to identify emergency department (ED) patients with opioid use disorders (OUD) and begin treatment with MOUD ("ED induction"). For this model to be widely adopted, financial sustainability for hospitals is critical. Little is known about the financial aspects of ED-based treatment models, including insurance billing and reimbursement. OBJECTIVES: Our study addressed the following questions about ED-based induction of OUD treatment: (1) Which components of this model are billable to insurers? (2) How do hospitals fund the components that are not billable? (3) Does ED-based induction generate savings that could help fund that service? METHODS: We conducted a qualitative study, involving semi-structured interviews with officials at selected US hospitals. Potential interviewees were identified using a snowball sampling approach. We conducted 12 interviews across 10 states, mostly with urban teaching hospitals. RESULTS: Key findings include, (1) medication costs are often billable to insurers, but costs of key para-professional staff like peer navigators are not, requiring the hospital to absorb their salaries. Even some billable costs are reimbursed at low rates which challenge sustainability. (2) To fund non-billable components, hospitals typically rely on time-limited grant funding, including the federal 340B drug rebate program. (3) Several interviewees anticipated cost savings to their hospitals from reduced use of ED services by patients who had no (or low-paying) insurance. DISCUSSION: These findings indicate that some hospitals are able to sustain ED-based induction of MOUD using time-limited grant funding. However, wider dissemination of this model will likely require more stable funding streams, such as Medicaid reimbursement, paying adequate rates, and coverage of personnel.
Ohle R, Roy D, Baraku E
… +9 more, Patel K, Savage DW, McIsaac S, Singh R, Lelli D, Tse D, Johns P, Yadav K, Perry JJ
Acad Emerg Med
· 2026 Feb · PMID 41181898
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BACKGROUND: Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo, yet it remains underdiagnosed and undertreated in emergency departments (EDs). Despite evidence-based guidelines recommending b...BACKGROUND: Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo, yet it remains underdiagnosed and undertreated in emergency departments (EDs). Despite evidence-based guidelines recommending bedside diagnostic maneuvers (Dix-Hallpike and supine roll test) and canalith repositioning maneuvers (CRMs), these are infrequently utilized, leading to unnecessary imaging, prolonged symptoms, and increased healthcare utilization. OBJECTIVE: This study aimed to implement an educational strategy to improve the diagnosis and treatment of BPPV in the ED by increasing adherence to guideline-based practices. METHODS: We conducted a multicenter interrupted time series study from August 2020 to September 2023. The intervention, developed using the CAN-Implement framework, included online training, quick-reference tools, and a mobile app. Due to the COVID-19 pandemic, in-person training was canceled. The primary clinical outcome was the proportion of patients receiving the appropriate CRM based on positional test results. Implementation outcomes included fidelity, appropriateness, adoption, penetration, and system impact, reported using the Standards for Reporting Implementation Studies (StaRI) guidelines. RESULTS: We included 1682 patients (1252 pre-intervention, 430 post-intervention). There was no significant change in the primary outcome (appropriate CRM use, OR = 1.08, 95% CI: 0.76-1.40). However, selective CT use improved (OR = 1.29, 95% CI: 1.09-1.49), supine roll testing increased from 14.2% to 23.5%, and neurology consults decreased from 7.1% to 4.0%. Documentation of diagnostic test descriptors improved, while neurological exam documentation declined. CONCLUSION: The intervention did not significantly increase appropriate CRM use but led to improvements in selective imaging, neurology consultation, and horizontal canal testing. Provision of educational tools alone was insufficient to overcome identified environmental barriers. To effectively improve BPPV management in the ED, future efforts should combine hands-on training with system-level supports and workflow integration.
Acad Emerg Med
· 2026 Feb · PMID 41157894
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OBJECTIVE: Cluster-randomized trials (also called group-randomized trials) are increasingly common in emergency care research. In such trials, groups of participants are allocated to different interventions based on natu...OBJECTIVE: Cluster-randomized trials (also called group-randomized trials) are increasingly common in emergency care research. In such trials, groups of participants are allocated to different interventions based on naturally occurring "clusters," such as clinics, hospitals, or emergency medical services agencies. In this methodological review, we introduced key terminology and features of cluster-randomized trials, described common rationales for cluster-randomization and its most common limitations, and offered brief advice for conducting and critically appraising cluster-randomized trials in emergency care research. RESULTS: Researchers elect to use cluster-randomization when individual participant randomization is not preferred or not possible. Common reasons include a desire to limit contamination between study groups, logistical convenience relating to trial administration or study procedures, or the use of an intervention that is naturally group-oriented, such as an educational intervention or clinical decision support tool that is directed toward influencing clinician behaviors. Although cluster-randomization has advantages in these contexts, this approach also comes with some notable weaknesses, such as inflated sample size requirements, greater difficulty in blinding participants and researchers, and an increased risk of baseline imbalances between comparator groups. When reading and critically appraising cluster-randomized trials, emergency clinicians should consider whether researchers have appropriately justified group over individual randomization, accounted for different levels of clustering and the degree of correlation between participants within clusters (intracluster correlation), and appropriately consented various levels of participants to study participation. CONCLUSIONS: Cluster-randomized trials are frequently used in emergency care research, especially as researchers are increasingly evaluating educational or electronic health record interventions that are naturally group-oriented or have a high risk of contamination. After reading this review, emergency medicine clinicians and researchers will have a foundational understanding of key cluster trial features and will be able to assess the quality and limitations of emerging evidence.
Yang DH, Sherak R, Chin M
… +9 more, Pagano E, Tyrrell JD, Sullivan T, Henderson R, Jubanyik K, Dodington J, Rhodes D, Gawel M, Sangal RB
Acad Emerg Med
· 2026 Feb · PMID 41147845
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OBJECTIVE: To determine if the utilization of an Electronic Health Record-integrated clinical pathway increased the provision of recommended medical and forensic care to adult sexual assault survivors in the ED. METHODS:...OBJECTIVE: To determine if the utilization of an Electronic Health Record-integrated clinical pathway increased the provision of recommended medical and forensic care to adult sexual assault survivors in the ED. METHODS: This was a retrospective chart review of 552 adult survivors of sexual assault who received care at a health care system in the Northeast between January 1, 2020, and December 31, 2022. Our six outcomes were the proportion of patients who were offered a consultation with a sexual assault advocate, the proportion of patients who had the sexual assault forensic evidence kit collected, pregnancy test ordered, emergency contraception ordered, HIV post-exposure prophylaxis ordered, and sexually transmitted infection prophylaxis ordered. Primary analysis compared the impact of the pathway on outcomes before and after the implementation. Secondary analysis included the impact on outcomes of pathway use compared to non-pathway use after implementation. RESULTS: The pathway was used in 128 (51%) patient encounters after it was implemented. Offering consultation with a sexual assault advocate and ordering HIV post-exposure prophylaxis improved post-implementation compared to pre-implementation. In the post-implementation period, there was an improvement in recommended medical and forensic care across all outcomes, including offering an advocate, collecting forensic evidence, ordering STI prophylaxis, HIV PEP, pregnancy tests, and emergency contraception. Patients were less likely to have a SAFE kit collected if the pathway was not used compared to pre-implementation. CONCLUSIONS: Pathway usage led to improved medical and forensic care of sexual assault survivors. Implementation of Electronic Health Record-integrated clinical pathways requires active use of the pathway rather than indirect learning from the presence of the pathway.
Briggs B, Smith L, Yates N
… +2 more, Green R, Cline D
Acad Emerg Med
· 2026 Feb · PMID 41147831
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BACKGROUND: Alcohol withdrawal syndrome (AWS) significantly contributes to ED resource utilization. While phenobarbital is increasingly used as an alternative to benzodiazepines, data comparing their impact on ED utiliza...BACKGROUND: Alcohol withdrawal syndrome (AWS) significantly contributes to ED resource utilization. While phenobarbital is increasingly used as an alternative to benzodiazepines, data comparing their impact on ED utilization remain limited. We evaluated whether phenobarbital monotherapy improves ED operational outcomes compared to benzodiazepines or combination therapy. METHODS: We conducted a single-center, retrospective cohort study of 1178 adults at a regional academic medical center from January 1, 2020, to December 31, 2023. Patients ≥ 18 years old who were treated with intravenous (IV) phenobarbital, IV benzodiazepines, or both for AWS in the ED were included. The primary outcome was hospital admission. Secondary outcomes included ED length of stay, return visits within 72 h of index visit, and 30-day hospital readmission. A formalized data abstraction process was utilized. Analyses used chi-squared or Kruskal-Wallis tests and logistic regression to estimate odds ratios with 95% confidence intervals. RESULTS: Of 777 eligible encounters, 459 (59.1%) resulted in admission. Admission rates were 74.0% for benzodiazepine-only encounters, followed by combination therapy (62.4%), and lowest for phenobarbital-only (52.1%; OR 0.44, 95% CI 0.30-0.66, p < 0.0001). Among discharged patients (318 encounters), median ED LOS was shortest in the phenobarbital-only group (5.8 h), versus 7.6 h for benzodiazepine-only and 10.3 h for combination therapy (p < 0.0001). Logistic regression analysis revealed treatment with phenobarbital alone was independently associated with discharge, while increasing age, increasing heart rate, and treatment with benzodiazepines alone were independently associated with hospitalization. CONCLUSIONS: Phenobarbital monotherapy for AWS was associated with lower admission rates, shorter ED LOS, and fewer IV medication administrations compared to benzodiazepine-based regimens. Return visit rates were similar across all groups. These findings are exploratory, underscoring the need for prospective studies to confirm these associations.
Lee S, Khoujah D, Eagles D
… +11 more, Kennedy M, Lo AX, Nickel CH, Arendts G, Ragsdale L, Seidenfeld J, de Wit K, Luciani-Mcgillivray I, Carpenter CR, Liu SW, Geriatric Emergency Department Delirium Guidelines 2.0 Writing Team
Acad Emerg Med
· 2026 Feb · PMID 41146403
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OBJECTIVES: This portion of the Geriatric Emergency Department (GED) Guidelines 2.0 focuses on delirium in the emergency department (ED). METHODS: A multidisciplinary group applied the Grading of Recommendations Assessme...OBJECTIVES: This portion of the Geriatric Emergency Department (GED) Guidelines 2.0 focuses on delirium in the emergency department (ED). METHODS: A multidisciplinary group applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and develop recommendations related to older ED patients with possible delirium. RESULTS: The GED Guidelines 2.0 Delirium Work Group derived six evidence-based recommendations for risk stratification, diagnosis, and brain imaging. To reduce universal screening, the Delirium Risk Score may be used to identify older adults at low risk for delirium, though the evidence certainty is very low. In adults over 65 admitted to ED observation units, Zucchelli's risk assessment tool (threshold ≥ 4) may stratify delirium risk, also with very low certainty. For adults over 75, the REDEEM Score may be used to identify low- or high-risk individuals, again with very low certainty. For diagnosis, 4AT, bCAM, CAM-ICU, mCAM, AMT-4, or RASS may be used to rule delirium in or out, based on very low certainty. The Delirium Triage Screen (DTS) may be used to rule out, but not to rule in, delirium, also with very low certainty. For diagnostic imaging, there is very low certainty of evidence to recommend for or against obtaining a head CT as part of the evaluation for older ED patients with delirium. All recommendations are conditional, reflecting very low certainty of evidence due to the lack of high-quality ED-based studies and comparative effectiveness research. CONCLUSION: Rigorous ED-based research is needed to strengthen evidence and guide delirium care for older adults in geriatric emergency medicine.
Moloney E, O'Donovan MR, Burke D
… +4 more, Healy A, Larkin M, O'Keeffe A, O'Caoimh R
Acad Emerg Med
· 2026 Feb · PMID 41103247
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BACKGROUND: Emergency Department (ED) Triage identifies patients with urgent needs. Frailty is not routinely identified and older patients presenting atypically may be inappropriately triaged as low priority. The introdu...BACKGROUND: Emergency Department (ED) Triage identifies patients with urgent needs. Frailty is not routinely identified and older patients presenting atypically may be inappropriately triaged as low priority. The introduction of a frailty modifier at triage is recommended in international guidelines, but is not yet widely-adopted. METHODS: A Frailty Trigger was developed following a systematic review and two-round eDelphi. To investigate diagnostic test accuracy for frailty, we recruited consecutive adults aged ≥ 70 attending a university hospital ED between December 2021 and February 2022, comparing the Trigger to the Clinical Frailty Scale (CFS), Variable indicative of Placement (VIP), and PRISMA-7. An independent comprehensive geriatric assessment (CGA) determined frailty status. RESULTS: In total, 313 adults aged ≥ 70 years were available, median age 78 ± 9 years and 46% were female. Half (51%) were frail based on the CGA. The Frailty Trigger had excellent diagnostic accuracy for frailty, Area Under the Curve (AUC) of 0.822, 95% confidence interval (CI): 0.780-0.865, similar to the VIP (AUC 0.820, p = 0.937), although significantly lower than the PRISMA-7 (AUC 0.896) and CFS (AUC 0.946). Mean administrative time was 25.5 s (SD ±10.9 s). Scoring positive on the Frailty Trigger was associated with increased length of stay (LOS), median 6.4 versus 2.3 days (p < 0.001). After adjustment for age, sex, and co-morbidity, a positive score was associated with reduced survival at 1 year (Hazard Ratio 2.2; 95% CI 1.15-4.33, p = 0.017). CONCLUSION: When applied as part of ED triage, the Frailty Trigger showed excellent diagnostic accuracy for frailty when compared to validated screens and was quick to use. It predicted LOS and mortality. Studies are required to examine feasibility and its effect on frailty pathways from triage.