BACKGROUND: Dizziness and vertigo are common emergency department (ED) presentations, but only 2%-5% receive a serious diagnosis, such as stroke or transient ischemic attack (TIA). Due to the lack of reliable validated p...BACKGROUND: Dizziness and vertigo are common emergency department (ED) presentations, but only 2%-5% receive a serious diagnosis, such as stroke or transient ischemic attack (TIA). Due to the lack of reliable validated prediction tools, many undergo unnecessary imaging and consultations, highlighting the need for improved risk stratification. OBJECTIVE: To develop machine learning (ML) models that predict serious diagnoses in ED patients presenting with dizziness or vertigo. METHODS: This multicenter cohort study included 6637 ED patients with dizziness, vertigo, or imbalance from September 2014-December 2022. The primary outcome was a serious diagnosis-stroke, TIA, vertebral artery dissection, or brain tumor-within 30 days, adjudicated by a blinded committee. Data were split 80/20 into training and test sets. Four ML models (decision tree, LASSO logistic regression, random forest, XGBoost) were trained on 17 variables using 5-fold cross-validation and evaluated alongside the Sudbury Vertigo Risk score. Performance was assessed using area under the curve (AUC) and diagnostic accuracy measures. Computed tomography (CT) and referral rates were hypothetically compared pre- and post-model application. RESULTS: Among 6637 patients (mean age 78.1; 57.8% female), 3.3% had a serious diagnosis. All ML models demonstrated strong discrimination, with AUCs ranging from 0.92 to 0.97. At a 5% predicted probability threshold, sensitivities ranged from 53%-97% and specificities from 84% to 96%. Logistic regression with LASSO demonstrated a favorable balance between discrimination (AUC: 0.97, sensitivity: 97% and specificity: 91%), although confidence intervals overlapped substantially across models. In a hypothetical model-based analysis, ML-guided classification corresponded to projected reductions in CT utilization and referrals ranging from 53%-85% and 11%-73%, respectively. CONCLUSIONS: Select ML models demonstrated discrimination comparable to the Sudbury Vertigo Risk Score while potentially improving specificity and reducing projected resource utilization. These tools show promise, but external validation is needed.
Acad Emerg Med
· 2026 Jun · PMID 42363580
·
Publisher ↗
BACKGROUND: Distinguishing central causes of dizziness from peripheral causes in emergency department (ED) patients is a challenging clinical problem. The Sudbury Vertigo Risk Score is a clinical prediction model that su...BACKGROUND: Distinguishing central causes of dizziness from peripheral causes in emergency department (ED) patients is a challenging clinical problem. The Sudbury Vertigo Risk Score is a clinical prediction model that supports decision-making by predicting central causes of dizziness. However, its predictor "benign paroxysmal positional vertigo (BPPV) diagnosis" may introduce uncertainty and limit clinical usability. Therefore, we developed a modified model in which this predictor was replaced with variables that can be assessed through patient history. METHODS: We retrospectively included consecutive patients aged ≥ 15 years who presented with dizziness to an ED between April 2013 and March 2023. The outcome was dizziness due to central lesions, defined as abnormalities identified on neuroimaging and judged by a relevant specialist to be the cause of dizziness. We developed a modified model using multivariable logistic regression in which "BPPV diagnosis" was replaced with two predictors-"trigger (provoked by changes in head position)" and "history of dizziness"-while retaining the other original predictors. We evaluated discrimination using the area under the receiver operating characteristic curve (AUROC) and calibration using a calibration plot. We compared efficiency and safety between the modified model and the Sudbury model. RESULTS: Among 3606 patients, a total of 2958 were eligible. Dizziness due to central lesions was identified in 155 patients (5.2%). The AUROC was 0.85 (95% CI, 0.82-0.88) for the Sudbury model and 0.81 (95% CI, 0.77-0.85) for the modified model. The modified model showed calibration comparable to that of the original model. Safety and efficiency were 0.0% (95% CI, 0.0%-0.5%) and 26.8% (95% CI, 25.2%-28.4%) for the Sudbury model, and 0.9% (95% CI, 0.4%-2.1%) and 18.7% (95% CI, 17.3%-20.1%) for the modified model. CONCLUSION: The modified model showed comparable performance after replacing BPPV diagnosis with predictors that can be more easily assessed through patient history.
Glober N, Kuhn D, Martin L
… +4 more, Stewart L, Tanner-Lauderbaugh P, Sparzo J, McCarroll M
Acad Emerg Med
· 2026 Jun · PMID 42340089
·
Publisher ↗
BACKGROUND: Emergency department (ED) overcrowding is a routine challenge for most hub hospitals, reported by more than 90% of ED medical directors several times each week. Alternate treatment locations are permissible w...BACKGROUND: Emergency department (ED) overcrowding is a routine challenge for most hub hospitals, reported by more than 90% of ED medical directors several times each week. Alternate treatment locations are permissible within the Emergency Medical Treatment and Labor Act (EMTALA) regulations (with patient consent) as long as hospitals screen and stabilize any patient presenting to an ED. METHODS: This pilot study explored the feasibility and patient acceptability of offering financial compensation to low-acuity patients who agreed to transfer from an overcrowded ED to critical access hospitals. RESULTS: Four eligible patients requiring medical-surgical admission participated. Transfers included travel vouchers of $300-$500. All transfers were completed safely without retransfer or complications, and all patients were discharged home. The aggregate Net Promoter Score was +75, indicating strong satisfaction. CONCLUSIONS: Findings suggest that modest financial incentives may support patient-approved interfacility transfers, ease ED overcrowding, and enhance utilization of underused hospitals while complying with EMTALA. Further study of this model is warranted.
DeAngelis J, Vargas G, Weiss RE
… +11 more, Winskill C, Suh EH, Sacco DL, Wood N, Nishijima DK, Storrow AB, Schimmel J, Poterucha TJ, Elias PA, Beltre N, Probst MA
Acad Emerg Med
· 2026 Jun · PMID 42340085
·
Publisher ↗
BACKGROUND: Syncope is common in the Emergency Department (ED) and can be associated with structural heart disease (SHD). Transthoracic echocardiography (TTE) is commonly ordered to assess for SHD. OBJECTIVE: To external...BACKGROUND: Syncope is common in the Emergency Department (ED) and can be associated with structural heart disease (SHD). Transthoracic echocardiography (TTE) is commonly ordered to assess for SHD. OBJECTIVE: To externally validate the previously developed ROMEO score, which identifies patients with syncope who are at very low risk of significant findings on TTE. DESIGN: Secondary analysis of a multicenter, prospective, observational cohort study. SETTING: One community and five academic EDs in the United States. PARTICIPANTS: Adults (≥ 40 years old) presenting to the ED with syncope or presyncope, without a serious ED diagnosis. INTERVENTIONS: Receipt of TTE within 30 days of the index visit. MEASUREMENTS: Our primary outcome was the rate of significant findings on TTE within 30 days of the index ED visit. We calculated the sensitivity, specificity, negative and positive predictive values (NPV, PPV), and the area under the curve (AUC) of the ROMEO score. RESULTS: We enrolled 1287 patients, of whom 427 underwent TTE. 88 (20.6%) had a significant finding. A ROMEO score of zero had a sensitivity of 98.9% and a NPV of 98.6%. The specificity and PPV were 20.2% and 24.3%, respectively. The AUC was 0.83 (95% CI: 0.79 to 0.87). LIMITATIONS: Given the rate of non-enrollment of screened patients, there is potential for selection bias. Our study sample was biased toward urban, academic centers; the results may not apply to community settings. CONCLUSIONS: The ROMEO score demonstrates strong predictive performance and may be useful to help clinicians identify patients who are unlikely to benefit from TTE. TRIAL REGISTRATION: ClinicalTrial.gov identifier: NCT04533425.
Acad Emerg Med
· 2026 Jun · PMID 42313763
·
Publisher ↗
BACKGROUND: Although guidelines support outpatient management for low-risk pulmonary embolism, U.S. emergency department (ED) adoption remains low, partly due to limited contemporary evidence. Direct oral anticoagulant (...BACKGROUND: Although guidelines support outpatient management for low-risk pulmonary embolism, U.S. emergency department (ED) adoption remains low, partly due to limited contemporary evidence. Direct oral anticoagulant (DOAC) era studies are small or European and typically classify all sPESI > 0 as high risk. More granular U.S. outcomes are needed to inform which patients can be safely discharged. OBJECTIVES: To characterize 30-day all-cause mortality by sPESI in patients with an acute PE treated with a DOAC. DESIGN: Retrospective cohort study. SETTING: United States Veterans Affairs (VA) Health System, 2015 to 2024. PARTICIPANTS: Adult patients diagnosed with an acute PE in a VA ED were prescribed a DOAC within one day. EXPOSURE: Hospital admission. MAIN OUTCOMES: 30-day all-cause mortality. RESULTS: A total of 6,427 first-time acute PEs were treated with a DOAC. Thirty-day mortality rates by sPESI were: sPESI 0: 0.0%, sPESI 1: 0.4%, sPESI 2: 1.8%, sPESI 3: 3.8%, sPESI 4: 8.8%, sPESI 5: 21.1%, and sPESI 6: 25.0%. Of 3,799 patients with sPESI < 2, 2,578 (67.9%) were hospitalized with a median length of stay of 24 h. After adjusting for covariates, odds of 30-day all-cause mortality were similar regardless of admission vs. ED discharge (OR 1.32, 95% CI 0.40, 4.36, p = 0.65). CONCLUSIONS: In this large U.S. DOAC-era cohort, patients with sPESI 0 or 1 had very low 30-day mortality, and hospitalization did not appear to improve outcomes. Despite this, two-thirds were admitted. These findings support expanding outpatient management of acute PE and reducing short-stay, low-value hospitalizations if no other indication for admission exists.
Janes M, Wood N, Strong E
… +3 more, Smith L, Snyder E, Yilmaz S
Acad Emerg Med
· 2026 Jun · PMID 42307487
·
Publisher ↗
BACKGROUND: Older adults with cancer frequently present to the emergency department (ED) with complex care needs, yet palliative care remains underutilized. We aimed to characterize palliative care utilization and advanc...BACKGROUND: Older adults with cancer frequently present to the emergency department (ED) with complex care needs, yet palliative care remains underutilized. We aimed to characterize palliative care utilization and advance care planning (ACP) among older adults with cancer presenting to the ED and examine associated outcomes. METHODS: We conducted a retrospective chart review of a random sample of 200 patients aged ≥ 65 years with cancer who presented to the ED at a tertiary academic center in 2022. Data included demographics, oncologic factors, ED encounter characteristics, palliative care utilization, ACP documentation, and outcomes. Analyses were descriptive, with exploratory associations evaluated using chi-square tests and logistic regression. RESULTS: Patients were older (mean age 74.3 years), and had frequent ED use, averaging 3.1 visits annually (SD = 1.9). Most were White (88.5%), male (52.5%), married (54.0%), and had a solid tumor malignancy (77.5%), with 28.5% receiving palliative-intent treatment. ED encounters frequently resulted in hospitalization (60.0%), with 18.3% of hospitalized patients requiring ICU admission. Palliative care consultation occurred in 2.5% of patients in the ED and 16.5% overall. ACP documentation increased from 65.5% at presentation to 75.0% following the encounter, largely driven by new MOLST completion and changes in code status. Mortality was high, with 24.4% dying during hospitalization and 49.0% within 6 months of the ED encounter. Among those who died within 6 months, 66.3% had not received palliative care consultation. In exploratory analyses, palliative care consultation, intensive care interventions, and ED visit frequency were associated with mortality. CONCLUSIONS: Older adults with cancer presenting to the ED experience high rates of hospitalization, intensive care use, and short-term mortality, yet palliative care remains underutilized. Although ACP documentation increased during acute care encounters, these changes often occur with clinical deterioration. The ED offers an opportunity to identify unmet palliative care needs and facilitate earlier integration.
Alexander AB, LaRoche KJ, Cromer R
… +2 more, Edmonds BT, Freedman L
Acad Emerg Med
· 2026 Jun · PMID 42246485
·
Full text
BACKGROUND: The Dobbs decision enabled widespread state abortion bans, creating legal ambiguity for clinicians managing reproductive emergencies in the ED. While impacts on obstetricians are documented, less is known abo...BACKGROUND: The Dobbs decision enabled widespread state abortion bans, creating legal ambiguity for clinicians managing reproductive emergencies in the ED. While impacts on obstetricians are documented, less is known about how these laws influence emergency medicine practice. We explored how ED clinicians navigate care for patients with vaginal bleeding under Indiana's restrictive abortion ban. METHODS: We conducted a team-based ethnographic study at an urban academic ED and Level 1 Trauma Center in Indiana between August 2023 and October 2024. Data included six weeks of site-based observations and semi-structured interviews with 20 emergency clinicians. Interviews explored clinical decision-making, documentation practices, and perceptions of legal risk following implementation of the abortion ban. Transcripts and field notes were analyzed using an iterative, consensus-based qualitative coding process informed by ethnographic methods. RESULTS: Three interrelated themes shaped clinician decision-making: knowing, documentation, and reporting. Clinicians described altered approaches to history-taking, particularly around self-managed abortion, balancing medical relevance against concerns for patient stigma and legal harm. Documentation practices were characterized by uncertainty and fear, with many clinicians intentionally limiting chart detail to protect patients while simultaneously worrying about medico-legal vulnerability. Knowledge of state-mandated reporting requirements varied widely, contributing to anxiety, misinterpretation of the law, and defensive clinical behaviors. Across themes, clinicians reported persistent tension between ethical obligations to patient safety and autonomy and perceived pressure to ensure legal self-protection. Robust institutional support was identified as a critical mitigating factor. CONCLUSIONS: Indiana's abortion ban has introduced legal uncertainty into emergency care for patients with vaginal bleeding, reshaping clinician behavior around information gathering, documentation, and reporting. These shifts risk delayed or defensive care, erosion of patient trust, and widening inequities in time-sensitive emergency settings. Clear institutional guidance, interdisciplinary collaboration, and legal support are essential to safeguard evidence-based emergency care and uphold ethical practice in restrictive reproductive policy environments.
Vieira da Silva HF, Watanabe ET, Tavares MC
… +3 more, Ramos Bicalho AC, Ferraro LSD, Simões E Silva AC
Acad Emerg Med
· 2026 Jun · PMID 42246462
·
Publisher ↗
BACKGROUND: Urethral catheterization is the standard method for obtaining sterile urine in nontoilet-trained children, but the conventional blind technique frequently results in futile attempts ("dry taps") on empty blad...BACKGROUND: Urethral catheterization is the standard method for obtaining sterile urine in nontoilet-trained children, but the conventional blind technique frequently results in futile attempts ("dry taps") on empty bladders. Point-of-care ultrasound (POCUS) offers the clinical advantage of confirming adequate urine volume to prevent mucosal trauma and procedural distress. However, its routine implementation may be limited by operator training requirements and potential workflow delays while waiting for bladder filling. Therefore, this study aims to evaluate the efficacy of real-time POCUS-assisted versus standard blind urethral catheterization in pediatric patients. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) adhering to PRISMA guidelines (PROSPERO: CRD420251247483). We searched PubMed, Embase, and CENTRAL for trials comparing POCUS-guided versus standard catheterization in children aged ≤ 36 months. The primary outcome was the first-attempt success rate. The certainty of evidence was evaluated using the GRADE approach. RESULTS: Three trials comprising 337 participants were included. POCUS-assisted catheterization significantly increased first-attempt success compared to the conventional technique (89.7% vs. 72.5%; RR 1.25, 95% CI 1.08-1.45, p = 0.0022), yielding a Number Needed to Treat (NNT) of 6. Furthermore, ultrasound guidance significantly reduced the rate of "dry taps" (3.6% vs. 23.9%; RR 0.25, 95% CI 0.13-0.47, p < 0.0001), representing an NNT of 5 to prevent one futile attempt. The certainty of evidence for the primary outcome was rated as moderate. Secondary descriptive outcomes indicated higher caregiver satisfaction, lower perceived patient discomfort, and comparable overall workflow times despite required waiting periods for bladder filling. CONCLUSIONS: Real-time POCUS significantly improves first-attempt catheterization success and drastically reduces futile attempts in young children. Furthermore, it enhances caregiver satisfaction and minimizes patient distress without intrinsically delaying emergency department workflow. These highly actionable findings support the integration of ultrasound guidance into routine pediatric emergency care.