This prospective, single-centre exploratory study enrolled 45 consecutive selected adults with non-traumatic OHCA (NT-OHCA) of unclear aetiology who were eligible for TEE. Of all enrolled patients, 43 completed standardised TEE image acquisition, while 2 cases with TEE-unrecognisable aetiology were excluded from aetiological analysis. The per-protocol analysis finally included 41 patients in whom TEE was successfully completed. Certified emergency physicians performed simplified TEE examinations (five standard views) during active resuscitation. Door-to-TEE interval, diagnostic yield, TEE-guided interventions and clinical outcomes were recorded according to Utstein guidelines.

TEE yielded diagnostic-quality images in all patients (43/43), with a median door-to-TEE time of 13 min (IQR: 6.5–22). Reversible aetiologies were identified in 39.0% (16/41), most commonly acute aortic dissection (50.0%, 8/16), followed by massive pulmonary embolism (25.0%), hypertrophic cardiomyopathy (18.8%) and hypovolaemia (6.3%). TEE guided interventions in 56.3% (9/16) of identified cases. Return of spontaneous circulation (ROSC) and 28-day survival rates were 41.5% and 12.2%, respectively, with no significant differences between aetiology-identified and unidentified groups (ROSC: 37.5% vs 44.0%, p>0.05; 28-day survival: 6.3% vs 16.0%, p>0.05). Sensitivity analysis of the 43-case complete imaging cohort and the total 45 enrolled cases further verified the stability and reliability of the diagnostic results.

During mechanical cardiopulmonary resuscitation, TEE rapidly identified suspected aetiologies in 39% (16/41) of NT-OHCA cases, notably revealing frequent acute aortic dissections. Lacking a comparator group, TEE’s feasibility as a complementary tool requires further controlled investigation.

We conducted a retrospective derivation and internal validation cohort study. Adult patients presenting to the EDs of Toulouse University Hospital with AKI of any Kidney Disease: Improving Global Outcomes (KDIGO) stage between 1 July and 31 December 2019 were eligible. Included patients were randomly assigned in a 2:1 ratio to a derivation cohort (DC) and an internal validation cohort (VC). The primary outcome was obstructive AKI, defined as hydronephrosis identified on imaging and requiring either urological intervention or Foley catheter insertion. A risk stratification decision tree was developed (Kidney Injury Tree For Identification of obSTructive Origin (KIT-FISTO) model).

The prevalence of obstructive AKI was 9% in the DC (64/727) and 7% in the VC (27/364). Patients presenting with lumbar, flank or hypogastric pain were classified as ‘high risk’ in each cohort, with a corresponding obstructive AKI risk of 55% (95% CI 45% to 64%) and 54% (95% CI 39% to 69%), respectively. Patients without pain but with a history of urinary tract surgery, abdominal cancer, a solitary functional kidney or prostatic hyperplasia were classified as ‘moderate risk’, with obstructive AKI risks of 4% (95% CI 1% to 10%) and 2% (95% CI 0% to 12%), respectively. All remaining patients (>70%) were classified as ‘low risk’, with an observed obstructive AKI risk of 0% (95% CI 0% to 1%). ‘Low risk’ classification had a sensitivity of 98% (95% CI 92% to 100%) and 96% (95% CI 81% to 100%), respectively.

The KIT-FISTO was derived and internally validated to predict obstructive AKI in ED, but requires external and prospective validation before implementation.

Six electronic databases were searched from inception through 31 May 2024, for ED-based studies on ADP implementation in adults with suspected cardiac chest pain. Eligible study designs included randomised controlled trials, controlled clinical trials, cohort studies, before/after studies and observational studies. Two reviewers independently screened articles for relevance and inclusion, with disagreements resolved by third-party adjudication. The primary outcome was the proportion of studies providing sex-disaggregated or gender-disaggregated analyses for key ED outcomes; secondary outcomes included the accuracy of sex and gender reporting per Canadian Institutes of Health Research definitions.

From 19 455 records, 211 studies were included, predominantly prospective cohort designs (39%), with most data collected in ED settings (87%). While 95% reported participant sex, 76% did so appropriately; fewer than 20% considered sex or gender explicitly in their analyses or ADP applications. Gender was reported less frequently (37%) and reporting was largely inaccurate (92%). No studies presented sex-disaggregated or gender-disaggregated analyses for key ED outcomes (eg, length of stay, consultations, admissions, major adverse cardiac events). Regression analyses failed to identify significant increases in sex/gender reporting following major international sex-based and gender-based policy initiatives.

Our findings highlight a critical need for improved and consistent integration of sex and gender in ED cardiac research. While most studies recognise the importance of sex differences, few explicitly addressed them, and even fewer considered the complexity of gender identities meaningfully. Future research should examine sex-specific and gender-specific troponin cut points, investigate at-risk groups and report disaggregated analyses of ED-relevant outcomes.

CRD42022380813.

This observational retrospective cohort study was conducted in the two EDs of a University Hospital between 1 January and 31 December 2021. Adult patients for whom a blood culture was collected during ED visit were included. The primary endpoint was bloodstream infection. A multivariate analysis using backward stepwise logistic regression was performed to identify risk factors for bloodstream infection and derive the aGe, cOmplaint, Temperature and Hemodynamic for bloodstream Infection Classification (GOTHIC) score. Diagnostic accuracy of the score was evaluated in the derivation and validation cohorts.

6740 visits were analysed, including 4493 patients in the derivation cohort and 2247 patients in the validation cohort. The prevalence of bloodstream infection was 11% (n=512) and 10% (n=234) in each cohort, respectively. The GOTHIC score included seven factors associated with bloodstream infection: age ≥75 years (OR=2.90; +1 point), tachycardia >90 beats per minute (OR=1.51; +1 point), systolic blood pressure <100 mm Hg (OR=1.90; +1 point), diastolic blood pressure <60 mmvHg (OR=1.41; +1 point), fever >38°C (OR=2.14; +1 point), isolated fever as chief complaint at triage (OR=1.62; +1 point) and protective chief complaint (dyspnoea, COVID-19 symptoms or vaso-occlusive crisis) (OR=0.47; –1 point).

We propose a simple risk score for bloodstream infection that can be easily calculated using seven variables assessable at triage.

We conducted a prospective multicentre study. We recorded NE time, the 28-day all-cause mortality rate, the time to achieve a mean arterial pressure (MAP) >65 mm Hg, net fluid balance and lactate clearance. These parameters were compared between survivors and non-survivors. Cox regression analysis was used to determine their association with mortality.

A total of 138 patients were included in the study. Non-survivors had a longer median NE time (98.5 min (IQR 60.0–131) vs 49.5 min (IQR 25.5–75.0), p<0.001) and a longer duration to reach the target MAP (80 min (IQR 30.0–217.5) vs 60 min (IQR 25.0–117.5), p=0.013) compared with survivors. In the multivariable Cox regression analysis, NE time remained a predictor of 28-day all-cause mortality (adjusted HR=1.335, 95% CI 1.034 to 1.722, p=0.026). NE time exceeding 1 hour (adjusted HR=2.60, 95% CI 1.40 to 4.84, p=0.003) and 2 hours (adjusted HR=2.96, 95% CI 1.49 to 5.87, p=0.002) associated with increasing the risk of 28-day mortality.

NE time was associated with the 28-day all-cause mortality in sepsis patients. Commencing NE therapy within the first 60 min following the onset of hypotension was associated with a reduced risk of 28-day all-cause mortality.

TCTR20221103005.

Six electronic databases were searched for peer-reviewed research articles from inception to April 2025, alongside citation tracking. Eligible studies reported quantitative associations between offload delay and patient outcomes. Two reviewers independently extracted data and assessed risk of bias using the MASTER scale for observational studies. Narrative synthesis and causal inference principles guided data interpretation.

Four observational studies (three cohort, one case-control) met inclusion criteria from 420 screened articles, encompassing over 3 26 474 patients across Australia and Canada. Only one study reported a statistically significant increase in 30-day mortality with longer offload times, whereas the others found no difference or inconsistent effects. Three studies consistently reported longer emergency department (ED) length of stay in delayed patients. One study found a modest increase in 30-day repeat ambulance attendance. No studies assessed time to treatment or clinical deterioration. Definitions of offload delay varied widely (≥15 min to≥60 min), study populations differed in acuity and case mix, and risk adjustment was limited, with only one study incorporating pre-handover physiological measures. Risk of bias was moderate to high across all studies, largely due to incomplete control for baseline illness risk and system-level confounding, since higher-acuity patients are often prioritised for rapid offload.

Ambulance offload delays are consistently associated with prolonged ED stays, underscoring their significant operational burden on already strained health systems. However, direct evidence of clinical harm associated with offload delay remains unclear, largely due to methodological limitations and inconsistent definitions. Future research employing rigorous causal inference methods is urgently needed to determine whether ambulance offload delays directly contribute to adverse patient outcomes, thereby informing policies to strengthen timely and high-quality patient care.

James Lind Alliance (JLA) methodology was employed. The scope included unscheduled emergency care provided to children and young people irrespective of setting. An independent JLA facilitator chaired monthly steering group meetings with equal input from parents and healthcare professionals. Two online surveys were employed to generate a list of evidence uncertainties and then to prioritise research questions from key stakeholder groups (patients, carers and healthcare professionals). An online workshop subsequently used an adapted nominal group technique to reach a consensus on the top list of research priorities.

655 questions were submitted in Survey 1 by 338 respondents (35% patients and carers and 65% healthcare professionals). After merging questions by topic and removing out-of-scope questions, 70 summary questions proceeded to evidence reviews; three were found to have been sufficiently answered. Further merging of summary questions resulted in 46 indicative research questions for Survey 2, which received 542 complete responses (26.6% patients and carers, 73.4% healthcare professionals). The 18 highest-ranking questions were brought to the consensus workshop, in which 12 patients/carers and 15 healthcare professionals reached consensus on the 10 highest priority research questions.

This refreshed PEM prioritisation study has identified the top 10 research priorities reflecting the views of patients, carers and a range of health professionals across the UK and Ireland. These priorities will be used to drive the PEM research agenda for the next decade.

Consecutive patients were included in a multicentre, prospective cohort study conducted between 1 November 2021 and 15 May 2022 in six trauma networks served by West Midlands and Yorkshire Ambulance Services. Electronic data from ambulance service patient report forms were linked to data from the Trauma Audit and Research Network trauma registry. The accuracy of prehospital triage decisions (conveyance to an MTC with pre-alert) against a bespoke MATTS reference standard to define major trauma was calculated. This was compared with optimal undertriage/overtriage trade-off indicated by previous economic modelling. Additional analyses investigated theoretical triage tool accuracy based on recorded data irrespective of hospital destination, examined important injury subgroups, evaluated alternative reference standards and described triage tool use.

In total, 38 010 injured patients were included, with 2.2% prevalence of major trauma. The MATTS triage tool demonstrated 55.3% sensitivity (95% CI 51.8% to 58.7%) and 94.3% specificity (95% CI 94.1% to 94.6%). There was evidence of triage tool use in a minority of patients (6.3%), with senior clinical advice sought in 9.3% of patients. Theoretical triage tool sensitivity was 51.1% (95% CI 47.6% to 54.5%) with specificity 93.6% (95% CI 92.7% to 94.4%). Agreement between the theoretical triage tool result and the observed triage decision was good (absolute agreement 90.4%, Gwet’s agreement coefficient 1 (AC1) statistic 0.89, 95% CI 0.89 to 0.89). Accuracy varied across different ages, mechanisms of injury subgroups and alternative reference standards for major trauma.

The MATTS triage tool achieved an appropriate undertriage/overtriage trade-off compared with previously established targets. However, documented adherence to MATTS was low. Dedicated training and further evaluation are necessary prior to national wider implementation.

In this prospective blinded study, 309 patients with suspected lower-extremity DVT presenting to a tertiary emergency department between November 2022 and October 2024 were evaluated. All patients underwent compression ultrasonography performed by trained emergency physicians followed by radiologist-performed Doppler ultrasonography as the reference standard. Diagnostic performance was assessed using sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) with 95% CIs. Interobserver agreement was evaluated using Cohen’s kappa coefficient.

DVT was confirmed in 33/309 patients (10.6%). Emergency physician-performed compression ultrasonography demonstrated a sensitivity of 97.0% (95% CI 84.2 to 99.9) and specificity of 99.3% (95% CI 97.4 to 99.9). The PPV was 94.1% (95% CI 80.3 to 99.3) and the NPV was 99.6% (95% CI 98.0 to 100). Interobserver agreement between emergency physicians and radiologists was excellent across evaluated venous segments, with Cohen’s kappa values of 0.926 (95% CI 0.880 to 0.971) for the femoral vein, 0.907 (95% CI 0.855 to 0.958) for the saphenofemoral junction and 0.973 (95% CI 0.947 to 0.999) for the popliteal vein. The median workflow-based time-to-diagnosis was 1 hour (IQR 0.75–1.5) for emergency physician-performed ultrasound and 4 hours (IQR 3–6) for radiologist-performed ultrasound.

Compression ultrasonography performed by trained emergency physicians demonstrated high diagnostic accuracy and excellent agreement with radiologist-performed Doppler ultrasonography in patients with suspected DVT. Bedside ultrasound was also associated with shorter workflow-based time-to-diagnosis. These findings support further evaluation of whether earlier bedside diagnosis may translate into clinically meaningful outcomes such as reduced emergency department length of stay and improved patient flow.

This study is a retrospective chart review of trauma entries. Given its...]]> 2026-05-21T09:00:18-07:00 info:doi/10.1136/emermed-2025-215778 hwp:master-id:emermed;emermed-2025-215778 British Association for Accident and Emergency Medicine 2026-05-21 Letter http://emj.bmj.com/cgi/content/short/emermed-2024-214819v1?rss=1 Objective

The provision of aid services in the context of disasters can also give rise to a range of physical and psychological issues among healthcare professionals. Such circumstances have the potential to negatively impact both their well-being and professional performance. However, their difficulty in expressing all of their experiences makes it difficult to understand this situation in depth. This study aims to explore in depth the experiences and mental challenges faced by Turkish health professionals during the Libyan flood disaster.

This was a qualitative study involving 10 health workers who had been involved in disaster response following the floods. The flood occurred on 10 September 2023. Data were collected between March and August 2024 through semi-structured interviews conducted either online or face-to-face in the participants’ homes. This timeframe enabled participants to articulate both their immediate reactions to the disaster and its longer-term effects on their personal and professional lives. An interpretive phenomenological approach was employed using Colaizzi’s phenomenological analysis technique.

The analysis revealed four principal themes. First, healthcare professionals emphasised the essential knowledge and skills required to provide effective care and treatment in the context of the flood. Second, they reported substantial physical challenges in the disaster zone, such as limited resources and disrupted infrastructure. Third, they described the profound mental challenges they faced, including stress, fear and emotional exhaustion. Finally, participants highlighted various coping strategies they employed to manage these difficulties and sustain their professional performance.

The study revealed that Turkish healthcare professionals who volunteered after the floods in Libya experienced not only physical challenges such as lack of resources, infrastructure problems and security concerns, but also psychological challenges such as secondary trauma and burnout. Furthermore, it was observed that not only professional knowledge and skills but also the capacity to cope with traumatic experiences are decisive in the effectiveness of disaster response processes. The study underscores the necessity for the implementation of psychosocial support and training programmes for professionals, with the objective of accelerating both individual and societal recovery processes following disasters.

A comparative cradle-to-grave life-cycle assessment was conducted at a Dutch ED. Data for material use, waste, packaging, transport, energy consumption, and staff and patient travel are included. Carbon footprints were calculated using SimaPro software with the ReCiPe 2016 method. The study compared the carbon footprints of the VFC pathway and standard pathway, identified key contributors, and performed a sensitivity and uncertainty analysis.

The VFC pathway resulted in a reduction of 2.8 (95% CI 2.1 to 3.9) kilograms of carbon dioxide equivalent greenhouse gas emissions (kg CO₂-eq) per treatment compared with the standard pathway, which equates to an annual decrease of 625 kg CO₂-equivalents in 230 patients seen in our hospital. Key contributors to the difference in annual emissions were travel movements (411.7 kg CO₂-eq), materials (126.5 kg CO₂-eq) and packaging (6.9 kg CO₂-eq). Sensitivity analysis revealed that eliminating follow-up visits could result in an annual reduction of 805 kg CO₂-eq, if all patients travelled by car.

The VFC pathway reduces the CO₂ emission of treating torus/greenstick fractures, primarily by decreasing patient travel, while patient satisfaction and material use do not increase. Broader adoption of a risk-sharing model, that is digitally supported, may reduce environmental impact across healthcare domains.

Eligible studies were searched through a literature query in PubMed and Web of Science in August 2024. Sodium correction rates and mortality data were extracted. The articles were grouped based on the threshold used to distinguish between slow and rapid correction. For each group, a random effects model was used for meta-analysis. The sodium correction rate thresholds were 8, 10 and 12 mmol/L/24 hours. Additionally, a random effects model was used to estimate the difference in osmotic demyelination syndrome (ODS) incidence.

11 retrospective studies with a total of 27 672 cases were included in the meta-analysis, each scoring at least 8* on the Newcastle-Ottawa quality assessment score. Mortality was significantly lower in the rapid correction group compared with the slow correction group for the 8 mmol/L/day threshold (OR: 0.398, p<0.001), for 10 mmol/L/day (OR: 0.489, p<0.001) and for 12 mmol/L/day (OR: 0.57, p<0.001). Overall incidence of ODS was low (0.085%), but it was higher in the rapid correction group (OR: 3.959, p=0.002).

Within all three thresholds of sodium correction, rapid correction was associated with improved survival. Although no causal relation can be concluded, a more liberal approach to sodium correction rate in hyponatraemia may be beneficial. However, osmotic demyelination remains a serious, although very rare, issue.

A retrospective cohort review of the English National Child Mortality Database between April 2019 and March 2024. Rates of death were corrected for population size using the 2021 census. Preinjury, injury and postinjury factors associated with death are reported descriptively.

145 CYP died of knife wounds. The mean age was 14.4 years (SD 4.2) and 90.3% (n=131) were male. The rates of death per 100 000 CYP, per year were highest in children of ‘Black/Black British’ ethnicity (1.40 (95% CI 1.03 to 1.86)), with an incidence rate ratio (IRR) of 13.29 (95% CI 8.23 to 20.00), compared with CYP of ‘White’ ethnicity. Children living in the most deprived areas, had a greater than seven times higher risk of death (IRR 7.48 (95% CI 3.22 to 17.29), compared to CYP living in the least deprived areas. Of the 57 cases available for detailed analysis, injuries to the chest and neck were responsible for the fatal injuries in 75.9% of cases (n=44) and 60.3% (n=35) died before reaching hospital. A thoracotomy was performed in 56.9% (n=33) of cases. Prior to death, 75.4% (n=43) had been known to social services and 57.9% (n=33) had experienced domestic violence and abuse. Neurodiversity or mental health concerns were reported in 50.9% (n=29) of CYP.

Death of CYP secondary to knife wounds occurred in all regions of England. Many children are exposed to adverse childhood experiences before death and known to statutory services. The identification of interventions to decrease the risk to children from knife violence remains a priority.

We prospectively collected prehospital data from patients with suspected sepsis in the ambulance service and supplemented the data with in-hospital findings. Prehospital data were used to calculate outputs of quick Sequential Organ Failure Assessment (qSOFA) and National Early Warning Score-2 (NEWS2). Outcomes were (1) sepsis severity after hospital admission, measured by Sequential Organ Failure Assessment (SOFA) score; (2) development of septic shock, defined by need for intravenous fluid resuscitation and pressors; and (3) 30-day all-cause mortality. Factors that predicted the three outcomes were identified with regression analysis. We performed receiver operating characteristic curve analysis to find the discriminatory abilities of prehospital scores.

We included 398 patients with a median age of 76 years and a 30-day all-cause mortality of 10.1%. Oxygen saturation, systolic blood pressure and qSOFA were associated with sepsis severity and septic shock; Glasgow Coma Score and male sex with sepsis severity and mortality; age with sepsis severity; ashen or marbled skin and focus of infection with septic shock; cyanosis, nursing home resident and comorbidity with mortality. No variable predicted all three outcomes. Area under the curve (AUC) for septic shock was higher for qSOFA than for NEWS2 (p=0.033). AUC for septic shock was higher for males than for females if NEWS2 score was used (p=0.049), indicating that NEWS2 is better at predicting shock among males compared with females.

While there may be a role for the use of prehospital scoring systems in patients who are critically ill on presentation, established clinical decision aids must be used with caution and predictive information is lost if the tools are applied alone.

Four bibliographical databases were searched, including: PubMed, MEDLINE, EMBASE and COCHRANE. Study selection, extraction and quality assessment were conducted independently by two reviewers via Covidence. Studies using a shared clinical decision tool were pooled to calculate sensitivity, specificity, likelihood ratios and false-positive rates using Meta-DiSc V.2.0. Univariate and, where possible, bivariate analyses generated forest plots and summary receiver operating characteristics curves. Heterogeneity was quantified by I², and methodological bias assessed via the Prediction model study Risk of Bias Assessment Tool (PROBAST).

From 626 records, 7 studies (6654 ED patients, Canada, Australia, USA) met inclusion. Of these, further analysis was undertaken of four validation studies. Two studies examined the Hess CDR reporting 98.3% sensitivity (95% CI 17% to 100%) and 47.6% specificity (95% CI 43.8% to 51.3%). Two studies examined the Rothrock CDR and reported 88.6% sensitivity (95% CI 80.1% to 93.7%) and 73% specificity (95% CI 17.7% to 97.2%). Hess had a negative likelihood ratio of 0.04 (95% CI 0 to 9.17) compared with Rothrock (0.156, 95% CI 0.06 to 0.38) and Rothrock had a positive likelihood ratio of 3.3 (95% CI 0.52 to 20.95) compared with Hess (1.9, 95% CI 1.67 to 2.11). Meta-analysis showed high heterogeneity with low bias as per PROBAST criteria.

A systematic review and meta-analysis of two chest X-ray decision rules for non-traumatic chest pain found the Hess et al rule more sensitive but unlikely to reduce imaging. Evidence is limited by few studies, high heterogeneity and retrospective cohorts. Neither rule is recommendable, highlighting the need for prospective derivation using established methodological standards.

We searched MEDLINE, Embase, CINAHL, Scopus, Web of Science and Cochrane Library for studies which examined the influence of language barriers on patient safety in paediatric emergency care as well as studies that evaluated interventions. Bibliographic database searches were executed on 18 December 2024; retrieved records were independently screened by two authors at title and abstract level followed by full text level. Data on study objectives, population characteristics, study design and their key findings were extracted.

1578 articles were identified, of which 33 were included and mapped according to (i) studies reporting safety risks linked to language barriers in paediatric emergency care (n=24) and (ii) existing interventions designed to mitigate these risks (n=9). Studies highlighted that language barriers can influence safety at multiple stages of the emergency care pathway, with discharge most frequently reported as a point of risk for paediatric patient safety. Interventions focused primarily on usage, uptake and documentation of professional interpreter services.

Addressing misunderstandings around follow-up and home-care advice during medical safety netting are priority areas for intervention. Future research should involve carer and clinical perspectives in exploring whether technology-enabled tools, including artificial intelligence, can safely mitigate language barriers in these situations.

To evaluate whether haematoma block provides a comparable procedural success rate to procedural sedation, and whether there is a difference in the likelihood of adverse events, in adult patients undergoing manipulation of distal radius fractures in the emergency department.

A structured search of MEDLINE and Embase databases was conducted using the Ovid interface. Studies comparing haematoma block with procedural sedation for manipulation of distal radius fractures in adults were included. Outcomes assessed included procedural success rate and adverse events. Seven studies met inclusion criteria, comprising four randomised controlled trials and three observational studies. Two studies were derived from the same dataset and were combined in the Best Evidence Topic (BET) table as one.

Across the included studies, there was no consistent evidence of a difference in procedural success between haematoma block and procedural sedation. The highest-quality evidence from two randomised controlled trials found no difference in radiographic outcome. Regarding the likelihood of adverse events when comparing haematoma block versus sedation, one study found less pain in the haematoma block group. None of the other studies detected a statistically significant difference.

In adult patients presenting to the emergency department with distal radius fractures requiring manipulation, the use of haematoma blocks appears to be associated with comparable procedural success rate to procedural sedation, without strong evidence of a difference in likelihood of adverse events.

This multicentre retrospective study, conducted in two EDs in Normandy, included adults (≥18years) presenting with non-rotatory vertigo, acute headache, altered consciousness, seizures, confusion, dizziness, syncope or presyncope without recent trauma who underwent CCT. Exclusion criteria were suspected stroke/transient ischemic attack (TIA) according to French guidelines, head trauma, brain cancer, hydrocephalus, recent stroke or minors. No follow-up was performed. The ECHS was calculated retrospectively and compared with CT findings.

Of the 600 included patients, the mean age was 62.4±18.7 years and 86 (14.3%) showed abnormalities on CT. The ECHS score demonstrated strong performance, with an area under the curve of 0.894 (95% CI 0.849 to 0.940). Using a threshold of ECHS≥1, we observed no false negatives, resulting in a sensitivity of 100% (95% CI 95.8% to 100%) and negative predictive value of 100% (95 % CI 98.2% to 100%). At this threshold, 48% of CCT scans could have been avoided without adverse outcomes.

The ECHS demonstrated high sensitivity for detecting CT abnormalities in this cohort, suggesting potential to reduce unnecessary scans in patients with a score of 0. However, prospective implementation studies are needed.

This retrospective study was conducted in the CCRU of a tertiary hospital and included adults (≥18 years) admitted from November 2015 until March 2020 and from July 2021 until December 2023. The primary outcome was the disposition category at CCRU discharge. Comparisons with a historical control group of critically ill emergency department (ED) patients prior to CCRU implementation were made.

2059 CCRU patients (median age 70 years; 57.4% male) were analysed. Patients were admitted to the CCRU from the ED (72.2%), wards (18%), emergency medical services (6.7%) or other sources (3.2%). Following a median CCRU length of stay of 2.7 (IQR 1.7–4.2) hours, during which 2 (IQR 1–4) critical care interventions per patient were delivered, 911 patients (44.2%) required ICU admission, while 978 (47.5%) and 74 (3.6%) patients were admitted to general wards or discharged home. 84 patients (4.1%) died in the CCRU. Compared with a historical control group, the ICU admission rate of ED patients (0.73 vs 0.56%, p<0.001) and the delay between ED presentation and ICU or CCRU admission decreased after CCRU implementation (1.87 (0.48–6.53) vs 0.85 (0.48–2.79) hours, p<0.001).

The CCRU at a large tertiary centre admitted critically ill patients with a wide range of emergencies. Following a short treatment period, during which several critical care interventions were delivered, less than half of CCRU patients required subsequent ICU admission. Comparisons with a historical control group suggest that CCRU implementation reduced the ICU admission rate and time to initiation of critical care for ED patients.

Emergency department clinicians across three acute care hospitals were invited to participate in 1:1 semi-structured interviews either face-to-face or by video call. Clinicians were asked to review five anonymised clinical cases and ‘think aloud’ about patient assessment strategies and interpretation of the Collaboration for the Diagnosis and Evaluation of Heart Failure (CoDE-HF) model outputs. Interviews were recorded, transcribed and coded. Codes were mapped onto the four domains of the unified theory of acceptance and use of technology model (performance expectancy, effort expectancy, social influences, facilitating conditions) which was used to identify barriers and facilitators to acceptance.

Facilitators to use were CoDE-HF’s ability to promote objective communication between colleagues and its role in reprioritising acute heart failure in cases where a diagnosis may have been missed. The method of presentation of model output (statements relating to the positive or negative predictive value of the CoDE-HF output score and visual traffic light system for the low-probability, intermediate-probability or high-probability categories) was viewed as facilitators, though the absolute numerical score was more difficult to interpret. Access to a computer and clinical sample processing time were the only potential organisational issues identified as barriers.

Clinicians reported that CoDE-HF could be a useful adjunct to clinical assessment of patients with breathlessness in the emergency department. Ease of model output interpretation is key to acceptance with interviews identifying a need to refine presentation of score information.

A qualitative meta-synthesis approach (following Enhancing Transparency in Reporting the Synthesis of Qualitative Research guidelines) was implemented to systematically review relevant qualitative studies. A comprehensive search was conducted across multiple databases, encompassing PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature; (CINAHL), PsycINFO, Web of Science, CNKI (China National Knowledge Infrastructure), Wanfang database and Scopus. The search duration was from database inception to March 2025.

In total, 22 studies complied with the inclusion criteria and were included in the meta-synthesis. Three main themes were identified: (i) needs for emergency palliative care (EPC) and current practice in emergency departments (EDs); (ii) emotional, ethical and communication experiences of nurses in providing PC in EDs; (iii) nurses’ perceived needs for training, support and system coordination. Across studies, EPC in the ED was described as occurring alongside acute life-saving care. Nurses’ experiences and attitudes towards EPC varied significantly, ranging from positive engagement to perceived incompatibility with their roles in emergency care.

This meta-synthesis highlights the complexity of providing PC in EDs and the urgency of implementing systematic interventions. To enhance the effectiveness and quality of EPC, it is necessary to provide systematic support and targeted strategies, thereby helping emergency nurses better meet the needs of patients at the end of life.

CRD420251008755.

This was a secondary analysis of the data from the Japan Association for Acute Medicine (JAAM)-OHCA Registry. Adult patients with OHCA without coma (Glasgow Coma Scale (GCS) Score ≥8) after ROSC between June 2014 and December 2019 were included. The primary endpoint was 30-day survival with good functional outcomes (Cerebral Performance Category Score of 1–2). Multivariable logistic regression analysis with a generalised estimating equation was performed to examine the factors associated with 30-day survival with good functional outcomes.

During the study period, 57 754 patients with OHCA were enrolled in the JAAM-OHCA Registry, of which 874 (1.5%) adult patients without coma after ROSC were analysed. Among them, the proportion of patients with 30-day survival with good functional outcomes was 76.0% (n=664), and the 30-day survival rate was 86.4% (n=755). Multivariable analysis revealed that younger age, witnessed cardiac arrest, shockable rhythms at the scene, GCS Motor Response (GCS-M) Score of 5 or 6 after ROSC, lower lactate levels and higher pH levels (pH≥7.10) were associated with 30-day survival with good functional outcomes.

Even among the patients with OHCA who achieved ROSC without coma, approximately a quarter of patients had poor functional outcomes. Older age, non-witnessed cardiac arrest, non-shockable rhythms at the scene, lower GCS-M Score after ROSC, higher lactate levels and lower pH levels predicted poorer outcomes.

This prospective cross-sectional study was conducted at a university hospital ED in Istanbul from December 2021 to January 2023. Participants were adults (>18 years) admitted to the green or yellow triage areas, representing non-urgent or moderately urgent conditions. Data were collected through a Personal Information Form and the Turkish Health Literacy Scale-32 (THLS-32), administered either face to face or online.

A total of 466 participants (mean age 30.3±12.9 years, 71.7% female) were included. Most participants were university graduates. The mean THLS-32 score was 30.35±10.11 (range 0–50), with only 13.9% (42–50 points) classified as having ‘excellent’ HL. Participants who reported relying on social media for health news and those who visited the ED due to ‘long waits for a hospital outpatient clinic’ had lower THLS-32 scores. There was no statistically significant association between HL and frequent ED attendance, age, gender or educational level.

Lower HL is associated with greater reliance on unverified information in social media for health news and ED attendance due to long outpatient waits. Our findings highlight the need for targeted HL and digital HL initiatives to reduce avoidable ED visits and strengthen healthcare navigation skills.

This study analysed data from the Heatstroke Study database (2017–2021) which included adult Japanese patients with heat-related illnesses. Acute neurological symptoms (Glasgow Coma Scale (GCS) <14 and/or seizures) were the primary exposure. Outcomes included in-hospital mortality and unfavourable functional outcomes (modified Rankin Scale (mRS) ≥3). Adjusted ORs with 95% CIs were estimated using multivariable logistic regression, adjusting for age, sex, preadmission mRS, Charlson Comorbidity Index, occurrence situation, body temperature and systolic blood pressure.

Among 2961 patients (median age 73.0 years, 69.4% were male), the in-hospital mortality was 5.4% (160/2961). The observed mortality was 10.9% (142/1303) in patients with acute neurological symptoms and 1.1% (18/1658) in patients without symptoms. Unfavourable functional outcomes occurred in 42.2% (455/1078) of patients with acute neurological symptoms and 10.4% (155/1492) of patients without symptoms. After adjustment, acute neurological symptoms were found to be significantly associated with in-hospital mortality (adjusted OR 7.33, 95% CI 4.50 to 12.64) and unfavourable functional outcomes (adjusted OR 5.15, 95% CI 4.14 to 6.44). A dose-dependent relationship was observed between GCS severity and mortality, with GCS 3–8 showing the highest risk compared with GCS 14–15 (adjusted OR 12.23, 95% CI 7.42 to 21.17).

Acute neurological symptoms, particularly impaired consciousness, were independently associated with mortality and unfavourable outcomes in heat-related illnesses. These findings emphasise the importance of neurological symptoms in severity classification for heat-related illnesses.

A systematic review and network meta-analysis were conducted. A comprehensive literature search in PubMed, Embase and Scopus was performed up to 31 December 2024. Pooled sensitivity, specificity and area under the receiver operating characteristic curve (AUC) were estimated. Network meta-analysis was used to compare diagnostic performance across G-FAST≥3, CPSS≥2 and CPSS≥3.

13 studies involving 12 414 patients were eligible for inclusion in the meta-analysis of G-FAST. G-FAST ≥3 demonstrated pooled sensitivity and specificity of 73.3% (95% CI 66.2% to 79.4%) and 74.3% (95% CI 65.3% to 81.6%), respectively, with an AUC of 0.80. In the network meta-analysis (six studies, 7012 participants), CPSS ≥2 showed the highest pooled sensitivity (79.0%, 95% CI 60.4% to 90.3%) and pooled specificity (66.1%, 95% CI 40.6% to 84.7%), whereas CPSS ≥3 demonstrated higher specificity (83.8%, 95% CI 63.6% to 93.9%) but reduced sensitivity (63.4%, 95% CI 40.1% to 81.7%). G-FAST ≥3 showed a more balanced performance between sensitivity (71.6%, 95% CI 51.4% to 85.7%) and specificity (76.4%, 95% CI 53.8% to 90.0%), with a numerically higher specificity than CPSS ≥2. Overall, there were no statistically significant differences in diagnostic performance among the scales.

G-FAST demonstrates moderate diagnostic accuracy for prehospital LVO detection, with performance comparable to traditional scales. Its use provides a feasible alternative for pre-hospital stroke triage, though further large-scale validation is warranted.

CRD42023477601.

This cohort study used prospectively collected nationwide registry data between January 2019 and June 2023. Adult patients with medical aetiology of OHCA who were transported by emergency medical services were included. The primary outcome was bystander CPR provision according to sex. The secondary outcome was the provision of bystander CPR based on DA-CPR administration status.

A total of 6487 patients with OHCA were included (median (IQR) age: 55 (52–64) years; male bystanders treated 3977 patients (61.3%)). The bystander CPR rate was lower when the patient and sex of bystander differed (male patient–male bystander, 85.0% vs male patient–female bystander, 79.2%; female patient–male bystander, 79.5% vs female patient–female bystander, 82.1%). Female bystanders were less likely to provide bystander CPR than male bystanders (adjusted OR (aOR): 0.83, 95% CI 0.73 to 0.95). The odds of a female bystander providing CPR to a male patient were significantly lower than those of a male bystander (aOR: 0.684, 95% CI 0.578 to 0.810). This difference was reduced when DA-CPR was administered (without DA-CPR, aOR: 0.673, 95% CI 0.475 to 0.952 vs with DA-CPR, aOR: 0.822, 95% CI 0.706 to 0.957).

An interaction between the patient and the sex of bystander was observed, particularly when the patient was a male and the bystander was a female. DA-CPR may serve as a potential intervention to help mitigate this disparity.

A retrospective review was undertaken of chest CT scans performed on children aged 0–17 years at KK Women’s and Children’s Hospital in Singapore. Patients were categorised as infants (<1 year old), children (1–9 years old) and adolescents (10–17 years old). Bilateral CWT at the second intercostal space (ICS) mid-clavicular line (MCL) and fourth ICS mid-axillary line (MAL) were measured radiographically. Adequacy of needle length is defined as CWT < needle length in >95% of cases.

588 CT scans (192 infants, 224 children, 172 adolescents) were reviewed. Mean CWT at the second ICS MCL was 12.61 mm (SD±4.14 mm), 15.62 mm (SD±4.88 mm) and 26.64 mm (SD±11.48 mm) for infants, children and adolescents, respectively. Mean CWT at the fourth ICS MAL is 14.95 mm (SD±5.25 mm), 16.49 mm (SD±5.89 mm) and 28.20 mm (SD±11.53 mm) for infants, children and adolescents, respectively. Adequate needle length was 25 mm, 32 mm and 50 mm for infants, children and adolescents, respectively, when inserted at the second ICS MCL.

In a Singaporean population, mean CWT at the second ICS MCL is thinner than mean CWT at the fourth ICS MAL for all age, sex, weight-for-length and body mass index categories. For successful NT at the second ICS MCL, a 25 mm needle is recommended for infants, 32 mm for children and 50 mm for adolescents.

We conducted a retrospective, population-based cohort study using data from the French National Out-of-Hospital Cardiac Arrest Registry for all OHCAs managed by mobile intensive care units between 1 July 2015 and 30 June 2016 in Nord-Pas-de-Calais. Age-adjusted and sex-adjusted standardised incidence ratios were smoothed with a Besag-York-Mollié Bayesian model. Spatial scan statistics identified incidence clusters. Cluster-level socioeconomic indicators, care processes and outcomes were compared

Incidence was mapped across 1541 municipalities. Among 2867 OHCAs, mean annual OHCA incidence was 68.8 per 100000 inhabitants (range <0.5 to >1.5 across municipalities). Two high-incidence clusters (relative risk between 1.61 and 1.68) and three low-incidence clusters (relative risk between 0.48 and 0.66) were detected. High-incidence clusters displayed greater deprivation and lower median income. Bystander basic life support was less frequent (26.7%) and 12-month survival lowest (1.4%) in the most deprived cluster.

Pronounced spatial inequality in OHCA burden exists within northern France. Municipalities with higher deprivation experience disproportionately higher incidence and poorer long-term survival. Targeted cardiopulmonary resuscitation training and strategic automated external defibrillator deployment should prioritise these vulnerable communities.

This open label, 1:1 parallel RCT using software-generated randomisation compared PENG block versus intravenous morphine (0.1 mg/kg) in patients aged ≥65 years who presented to the ED with femoral head, intertrochanteric, subtrochanteric and neck fractures with acute moderate-to-severe pain, defined as ≥5 on an 11-point Verbal Numeric Rating Scale (VNRS). The primary outcome was improvement in the VNRS score at 30 min. The secondary outcomes included the need for rescue therapy (intravenous fentanyl 0.5 µg/kg) and the incidence of adverse events.

A total of 34 patients were included in the final analysis, with 17 patients in each group. At 30 min, the median reduction in pain score was greater in the PENG block group than in the intravenous morphine group (–6 (IQR–6 to –5) vs –3 (IQR –5 to –2); p=0.001). Generalised estimating equation analysis accounting for repeated measures demonstrated that the PENG block was associated with a significantly more pronounced reduction in pain over time than intravenous morphine (adjusted β = –1.55; 95% CI –2.63 to –0.47; p=0.005). Rescue analgesia was required in 5.9% of patients receiving intravenous morphine, whereas no patients in the PENG block group required rescue therapy.

PENG block is a highly effective and safe alternative to intravenous morphine for managing acute hip fracture pain, particularly in older adults.

We prospectively interviewed all patients with delayed SAH diagnosis at Wessex Neurological Centre, UK, between 1 May 2018 and 30 April 2021. Interviews were structured detailing symptom onset, healthcare consultations and reasons for delays. Content analysis was used to develop a coding scheme, and statistical analysis was performed using analysis of variance, 2 and Fisher’s exact tests.

Of 550 cases of spontaneous SAH, 106 (19.3%) diagnoses were delayed.

85/106 (80.2%) patients did not seek immediate medical attention (15.5% of all SAH). The most common reasons were ‘waiting to see if symptoms would settle’ (18/85, 3.3% of all SAH) and ‘headaches not severe enough’ (15/85, 2.7% of all SAH).

48/106 (45.3%) reported diagnostic delays after seeking care (8.7% of all SAH), attributable to either misdiagnosis (36/48, 6.5% of all SAH) or errors in diagnostic testing (12/48, 2.2% of all SAH).

Patients who did not seek immediate medical attention were more likely to experience diagnostic delays after seeking care (OR 9.77, 95% CI 4.97 to 19.49, p<0.001). Among patients presenting late, diagnostic delays after seeking care occurred more frequently in Glasgow Coma Scale (GCS) 15 patients compared with GCS <15 (OR 5.3, 95% CI 1.4 to 19.5, p=0.011). 49/85 (57.6%) patients who delayed seeking care, and 21/36 (58.3%) misdiagnosed patients reported clinical thunderclap headache.

Prospective patient interviews capture data missed by retrospective chart review. This work has therefore identified important sources of delay in seeking care following the onset of SAH. Patients with delayed presentation were more likely to experience healthcare errors. These insights may help inform clinician awareness and public health initiatives aimed at earlier diagnosis.

A systematic literature search (PROSPERO CRD42023447238) of PubMed, Cochrane trials, Cochrane reviews, Embase, Web of Knowledge, Google Scholar and MEDLINE was performed from inception until February 2025. Any study that examined the management of ABD prehospitally was included. Randomised controlled trials, observational cohort studies and case series that were written in English were included. Methodological quality of included studies was interpreted using the ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) and GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.

From 6091 studies, 42 were included; none were high quality and 6 were moderate quality. Ketamine demonstrated the most effective sedation (range 79–98% of all patients included achieving adequate sedation as defined in the studies), although doses and methods of administration varied significantly. Midazolam generally showed a higher number of side effects than other drugs studied. Droperidol was not found to have a higher mortality than others, and no effect was seen on the QT interval.

Ketamine was found to be the most studied drug for treatment of ABD in the prehospital setting and is likely the most effective method of sedation at a dose of 5 mg/kg intramuscularly. Midazolam appears to have a higher risk of side effects, particularly respiratory-related, in comparison to other sedative agents. Conclusions are limited by the quality of evidence currently available and additional research is required to establish the most effective mode of administration and dose for this population group, as well as better definition of the presenting condition and outcome measures.

CRD42023447238.

The FALL-ER registry is a prospective, observational, multipurpose cohort including consecutive, community-dwelling patients age ≥65 years, attending the ED of five Spanish hospitals after a fall during 52 randomly selected days between 2014 and 2015. Variables necessary to operationalise the algorithm or a proxy when necessary were recorded. The primary outcome was a new fall within 6 months after the index visit. Survival and logistic regression analyses were conducted.

The cohort included 1241 patients (median age 80 years (IQR 73–85), 69.1% female). The algorithm allowed the classification of 1039 patients (88.7%) as high risk, 39 (3.3%) as intermediate risk and 93 (7.9%) as low risk of future falls. Overall, there were 134 patients (11.4%) who met the outcome and experienced a new fall within 6 months after the index ED visit. The cumulative probability of suffering a new fall was 13% (95% CI 10.8% to 15.1%), 17% (95% CI 4.8% to 29.1%) and 8.5% (95% CI 2.4% to 14.6%) in the high-risk, intermediate-risk and low-risk groups, respectively, without significant differences between groups (log-rank=0.422). Being classified as high risk had a sensitivity of 90% (95% CI 85% to 95%) and a specificity of 11% (95% CI 10% to 13%) for new falls.

A new fall-risk screening tool, based on the WFG algorithm, had poor discriminatory capacity in our ED cohort to predict new falls within 6 months of the index fall.

Qualitative study involving semistructured interviews with resident doctors in their 3rd year of training (ST3) in the UK. Participants included those who had undertaken Balint group sessions, ST3s who did not participate, and Balint group facilitators. Interviews were recorded, transcribed and analysed using reflexive thematic analysis.

12 participants were included between September 2023 and May 2024. They reported Balint groups to be a hugely positive part of their training. Participants developed a psychological toolkit and a supportive community to help manage the emotional and stress-related aspects of emergency medicine. This led to improved job satisfaction, which participants believed would enhance retention. Participants felt their ability to manage the emotional needs and challenges of their patients had improved. The groups were feasible to run but required planning and communication to facilitate release from clinical work.

Balint groups for ST3 emergency medicine resident doctors are feasible. Clinicians report benefits for themselves and perceived benefits for their patients. This supports continuing and developing the programme locally and piloting similar programmes in other professional groups and localities.

This is a post hoc analysis from the "Aiming towards evidence-based interpretation of cardiac biomarkers in patients presenting with chest pain using POC testing" (WESTCOR-POC) study which included 1494 consecutive patients with suspected acute coronary syndrome presenting to the ED at a moderately sized hospital in Norway. Patients were randomised to receive hs-cTn measurements at admission and after 1 hour either by POC or central laboratory testing. This post hoc analysis examines factors affecting the effectiveness of a POC-based ADP and predictors of non-ADP-concordant disposition. Both outcomes were assessed using regression models, with significance level set at p<0.05.

Overall, 36.1% of patients met the ADPs’ early discharge criteria, of which 66% were discharged. In effect-modification analyses, the effect of POC testing on ED LOS differed by concordance with ADP recommendations (interaction p=0.011), with a reduction among patients with ADP-concordant disposition (–14 min 95% CI –26 to –3), but no corresponding reduction among patients with discordant disposition (13.5 min, 95% CI –4.5 to 31.4). Factors predicting hospital admission despite ADP-recommended discharge were: age >60 years (OR 2.3, 95% CI 1.4 to 3.7, p=0.001), high triage category (OR 1.9, 95% CI 1.2 to 3.0, p=0.003) and suspected serious differential diagnosis (OR 5.9, 95% 3.5 to 9.9, p<0.001).

Our findings highlight the need for implementation strategies that support ADP concordant disposition decisions and ensure appropriate patient selection to realise the efficiency potential of POC hs-cTn testing in the ED.

A retrospective time-series analysis of PED visits and hospitalisations at Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Giannina Gaslini Children’s Hospital from 2002 to 2024 was conducted. Data on annual live births and residents aged ≤14 years were obtained from regional datasets. The incidence rates of PED visits and hospitalisations were calculated relative to births and the paediatric population. Trends were analysed using correlation coefficients, with sensitivity analyses excluding the COVID-19 years (2020–2021).

Over 23 years, 840 221 PED visits and 85 186 hospitalisations were recorded. Hospitalisations per 1000 PED visits decreased significantly (p<0.001). PED visits per 1000 live births increased significantly, both regionally (p<0.001) and provincially (p<0.001). Hospitalisations per 1000 paediatric residents aged ≤14 years declined significantly (p<0.001). After excluding the COVID-19 years, per-capita PED utilisation increased significantly, confirming a rising demand for emergency care despite demographic decline.

Despite reduced birth rates and a declining paediatric population, PED visits have increased disproportionately, driven by non-urgent cases. This discrepancy highlights systemic inefficiencies and behavioural determinants of inappropriate PED use, contributing to crowding. Comprehensive strategies, including enhanced primary care access, parental education, care integration and innovative organisational models, are necessary to ensure sustainable paediatric emergency care delivery.

Semi-structured interviews were conducted with 20 current and former EM ACFs from 12 universities in England and Wales. Interviews were analysed using thematic analysis following Braun and Clarke’s six-phase approach. A mixed inductive and deductive framework was applied. Reflexivity and positionality were addressed through multi-researcher coding and consensus development.

Six themes were identified: (1) Elements of surprise—structural ambiguity and unexpected barriers; (2) Unclear direction—limited guidance and inconsistent supervision; (3) Loneliness—professional isolation and detachment from clinical peers; (4) Engagement—enthusiasm linked to research alignment and supervisory support; (5) Repeated generic hurdles—difficulty balancing academic and clinical demands; (6) EM-specific hurdles—reduced exposure to key rotations and limited academic mentorship within EM. Fellows reported uncertainty about extensions to training and programme variability.

The EM ACF provides valuable entry into clinical academia; however, inconsistent structures, supervisory support and clarity in expectations hinder its full potential. Standardised induction, tailored supervision and flexible but transparent pathways are needed. These findings can inform policy, training programmes and institutional practices to better support the next generation of clinical academics in EM in the UK.

A retrospective cohort study using routine data for 3 EDs in England from July 2023 to May 2025 was performed. Direct, delay-related harm outcomes of medical patient boarding time were investigated: inpatient length of stay and 30-day re-admission and mortality rates. Indirect, crowding-mediated outcomes of medical patient boarding levels consisted of time in ED for non-admitted patients, ambulance handover times and Category 1, Category 2 and Category 3 ambulance response times. Mixed-effects regression analysis modelled each relationship while controlling for potential confounding.

The study examined 49 034 medical admissions, 210 334 non-admitted ED patients, 88 633 ambulance handovers and 146 278 ambulance responses. Medical patients, accounting for two-thirds of ED admissions, constituted 81% of total ED boarding time. Regression analysis showed that for a typical 25-bed ED, each additional five medical boarders was associated with an extra 7.9 min and 51.9 min ambulance response times for Category 2 and Category 3 calls and an extra 9.9 min of extra ambulance handover time. For admitted medical patients, each additional 4 hours of boarding time was associated with an extra 8.6 hours of inpatient length of stay and an 8.4% increase in the odds of 30-day mortality.

Boarding medical patients in the ED is associated with a significant increase in their risk of harm, including higher mortality and longer hospital stays. It also adversely affects other patients by delaying ambulances and reducing overall bed availability through extended inpatient stays.

Semi-structured interviews with 23 staff members across five ED sites in very high HIV prevalence areas were analysed thematically, informed by Normalisation Process Theory.

While there was some variation in staff knowledge and understanding of the programme, overall acceptance of the opt-out testing approach was found to be high. Training had a positive impact on staff understanding of the purpose of the intervention and the correct process, including the opt-out model. High workloads and competing priorities in EDs were significant barriers to testing. However, some specific systems and processes that facilitated the uptake of testing included automation and BBV champions. Giving the programme time to embed into practice and ensuring feedback loops and flexibility to ‘tweak’ the process was also essential to sustaining the programme.

To embed opt-out testing into emergency care, sites should implement automated test ordering, staff training, clear communication and dedicated champions, which can help to support earlier diagnosis, reduce inequalities and improve patient outcomes.

We designed an ambulatory pathway for suspected scaphoid fractures in the Emergency Department (ED) in which outpatient CBCT was requested by emergency medicine clinicians. A retrospective audit of current management of these patients was performed between 1 August 2022 and 31 October 2022 (prepathway period). A list of patients who underwent CBCT performed for the indication ‘suspected scaphoid or carpal bone fracture’ in the hospital was obtained and screened. Implementation of the pathway took place in February 2023 and was reviewed by continuous audit monitoring from 1 March 2023 to 31 May 2023 (postpathway period).

Prepathway implementation, 54 patients underwent CBCT. Following implementation of our pathway, the number of CBCTs performed in the hospital for this clinical indication increased to 111 (postpathway). The proportion of patients undergoing CBCT within 7 days increased from 11.1% (6/54) to 91.8% (102/111) (p<0.000). There was a 71.9% reduction in fracture clinic attendances (50/54 (92.6%) prepathway and 23/111 (22.5%) post pathway (p<0.000).

We successfully implemented an ambulatory pathway for suspected scaphoid fractures in the ED that significantly increased the proportion of patients with suspected scaphoid fractures undergoing early (<7 days) CBCT and definitive care.

Prospective multicentre cohort study across four hospitals in Oslo and Akershus, Norway (2019–2022). All adults with CK ≥5000U/L and/or myoglobin ≥1000ng/mL at emergency department presentation or within 72 hours thereafter were eligible, irrespective of admission. Primary outcome was AKI. Predictive performance of CK, myoglobin and the myoglobin-to-CK ratio was assessed using logistic regression and receiver operating characteristic (ROC) analysis.

In the 310 included patients, 108 (35%) developed AKI. In ROC analysis the myoglobin-to-CK ratio was the strongest predictor of AKI on admission (area under the curve (AUC) 0.84, 95% CI 0.79 to 0.89), followed by myoglobin (AUC 0.73, 95% CI 0.67 to 0.79); CK was a weak predictor (AUC 0.31, 95% CI 0.25 to 0.37). In quartile analysis, 72% of patients in the highest ratio quartile developed AKI, with a ratio ≥0.20 indicating risk. For myoglobin, 65% in the highest quartile developed AKI, with values ≥6372ng/mL indicating risk. ROC analysis identified optimised cut-offs of 0.48 for the ratio (sensitivity/specificity 79/82%) and 4489ng/mL for myoglobin (61/76%). Combined, these cut-offs increased sensitivity and negative predictive value to 89% (95% CI 81.3% to 94.4%) and 92% (95% CI 86.2% to 96.0%), respectively, suggesting potential for identification of both high-risk and low-risk patients at admission.

The myoglobin-to-CK ratio was the strongest early predictor of AKI. Combined with myoglobin ≥4489 ng/mL, a ratio ≥0.48 identified 89% of AKI cases and ruled out 92% of non-AKI cases, suggesting a potential admission-based tool for early AKI risk stratification in rhabdomyolysis.

NCT04118608.

A before-and-after sequential mixed-methods design was used. A community survey assessed changes in emergency care access among 191 participants at baseline and 270 postinterventions. Quantitative data were analysed using descriptive statistics and Pearson’s ² tests to assess preintervention and postintervention differences at a 5% significance level. Qualitative insights were obtained through three interviews with village leaders and healthcare providers, and one focus group with 10 community members, including members of the village health committee, at each phase. The primary outcome was perceived change in access, encompassing availability, acceptability, accommodation, affordability and physical accessibility. Secondary outcomes included awareness, satisfaction and perceived barriers. Qualitative data were analysed thematically.

Availability of emergency services increased from 61.0% to 84.4% (²=22.47, p<0.001), satisfaction from 12.0% to 88.5% (²=187.6, p<0.001) and awareness from 90.1% to 97.0% (²=9.03, p=0.003). Cultural barriers declined from 17.3% to 5.2% (²=18.56, p<0.001). Perceived affordability rose from 9.0% to 51.1% (²=56.91, p<0.001), however, cost remained a barrier, rising from 16.0% to 35.5% (²=4.81, p=0.028). Qualitative findings underscored greater awareness and trust in services but identified persistent financial barriers, particularly for high-cost treatments like antivenom. Health insurance coverage remained limited, with many relying on out-of-pocket payments.

The VEC model significantly improved awareness, satisfaction and access to emergency care in a rural PHC setting. Expanding insurance literacy and coverage, alongside cost transparency and future cost-effectiveness analyses, is recommended to support equitable national scale-up.

Semistructured interviews were conducted in September 2022 with HEMS clinicians from Essex & Herts Air Ambulance, and the feedback process was co-designed with the Essex Cardiothoracic Centre (Essex, UK). Using the COM-B model (Capability, Opportunity, Motivation-Behaviour), we conducted qualitative interviews with prehospitalists (seven paramedics, three prehospital doctors) to explore gaps in existing feedback processes and identify their information needs, then iteratively co-developed a structured feedback proforma with stakeholders.

Three themes emerged, specifically about weaknesses in current feedback and preferences for an improved system: (1) dissatisfaction with current ad hoc, ‘punitive’ approaches; (2) the educational and emotional importance of timely, targeted feedback; and (3) a strong preference for standardised, confidentiality-compliant delivery methods. The resulting feedback proforma included working diagnoses, key investigations completed, optimisation opportunities and patient outcomes (if already available), to be delivered within 24–48 hours of hospital admission.

Our study underscores the importance of stakeholder-driven development in shaping an effective prehospital feedback mechanism for OHCA aligned to clinicians’ needs. By exploring feedback preferences and mapping insights onto the COM-B model, we highlight how knowledge, context and motivation can all steer behavioural change. Further research is needed in diverse emergency medical service contexts to test its impact on clinical practice and patient outcomes.

A systematic search (PROSPERO registration: CRD420251042344) was conducted in English on EMBASE, MEDLINE, CINAHL and the Cochrane Library from inception to 1 May 2025. Grey literature sources (trial registries, conference abstracts, Google Scholar) were searched. Key resuscitation experts were contacted to identify unpublished or ongoing studies. The search strategy was peer-reviewed using the Peer Review of Electronic Search Strategies checklist. Eligible studies included randomised controlled trials (RCTs) contributing cohort data, observational studies and case series (≥10 patients) monitoring intra-arrest DBP or CPP in adult patients with cardiac arrest managed in prehospital or emergency department settings. Study selection involved two reviewers independently screening titles and abstracts, and full-text articles. Risk of bias was assessed using the Risk of Bias 2 and Risk of Bias in Non-randomised Studies of Interventions tools. This research received no funding.

15 studies (n=970 patients) across seven countries were included: 3 RCT-based prospective cohort studies and 12 observational studies. Meta-analysis was not performed due to heterogeneity in study designs. Aziz et al identified a DBP threshold of 35 mm Hg associated with ROSC (p<0.001), reporting a 5% increase in ROSC odds for every 1 mm Hg rise in DBP. This finding was supported by other observational studies reporting significantly higher maximum DBP values in patients with ROSC (34–56.5 mm Hg) compared with those without ROSC. Interventional studies aimed at augmenting DBP or CPP—including resuscitative endovascular balloon occlusion of the aorta—generally reported increases in ROSC, though studies were underpowered and at high risk of bias.

This review demonstrates an association between intra-arrest DBP and CPP and ROSC. DBP may provide a feasible clinical target, but definitive thresholds and their impact on survival to hospital discharge remain undefined.

CRD420251042344.

Retrospective analysis of 200 call recordings to the Scottish Ambulance Service January 2019–December 2020 during which dispatcher-assisted CPR instructions were provided. Potential barriers were coded inductively. Log rank tests were used to explore differences in ‘time to position patient flat’ and ‘time to initiate CPR’ depending on the presence/absence of potential barriers identified.

A random sample of 200 calls were selected from 11 275 potentially eligible calls. Patients in those calls were mostly male (61%), most aged 40–80s; callers were mostly female spouses. Time to position patient flat: median 40 s (IQR: 15.5–82.0), time to initiate CPR: median 50 s (IQR: 36–92). Between 1 and 11 potential barriers were identified in calls (median=4, IQR:2–6).

The most common barriers identified were communication (48%), emotion (45.5%) and physical challenges (38.5%). Various physical challenges, concern patient too heavy, concern that it was too late/futile, concern about physical ability, concern about doing harm and caller being ‘upset’ were significantly associated with delays to positioning the patient flat. Callers ‘not knowing how’ to do CPR; expressing concerns about doing harm, expressing anger and various physical challenges including concerns about ability were associated with delays in initiating CPR. Many significant barriers are potentially amenable to behavioural techniques.

Barriers to ‘positioning the patient flat’ and ‘initiating CPR’ are not the same. Concerns vary, and so identifying and addressing the specific concerns for individual callers at each stage might facilitate earlier CPR. Many of the issues delaying CPR are potentially modifiable with behavioural techniques.

We used a modified Delphi approach to achieve consensus among a multidisciplinary and geographically diverse expert advisory group. An initial list of 42 research questions was identified, with successive rounds of questionnaires conducted until there was a convergence of opinion or a point of diminishing returns was reached. The list was iteratively refined each round by advisory group members who ranked research questions and were given the opportunity to provide suggestions for potential additional questions and provide feedback regarding questions considered.

54 advisory group members participated in the modified Delphi approach. Over the course of two rounds, we identified 10 research questions as the highest priority for future investigation. These questions included topics addressing short- and long-term outcomes related to inadequate assessment and provision of sedation, patient-centered and family-centered outcomes, validity and reliability of clinically important outcome measures, most effective sedative regimens for children undergoing painful procedures, most effective sedative regimens for children undergoing non-painful procedures, most effective sedatives for minimal sedation/anxiolysis, effectiveness of novel sedation approaches, eliminating health disparities, clinician education and competency and the use of simulation to improve sedation outcomes.

The 10 research questions identified as highest priority can inform future work by researchers, funders, policymakers and other key decision makers who aim to meaningfully advance the provision of procedural sedation for children cared for in the emergency care setting.

180 patient attendances were randomly selected from attendances to Leeds General Infirmary and St Jame’s University Hospital EDs during April 2024. Data collection included both structured ECDS data and unstructured EPR entries. Both reviewers extracted the data using a standardised form to ensure consistency (AFJW...]]> 2026-01-09T09:00:25-08:00 info:doi/10.1136/emermed-2025-214901 hwp:master-id:emermed;emermed-2025-214901 British Association for Accident and Emergency Medicine 2026-01-09 Letter http://emj.bmj.com/cgi/content/short/emermed-2025-215647v1?rss=1 Objectives

Calcium administration in traumatic haemorrhage is a leading prehospital research priority.1 Previous studies have demonstrated that both trauma-related ionised hypocalcaemia (iHypoCa) and ionised hypercalcaemia (iHyperCa) are present on arrival in the emergency department, and both are associated with increased mortality and adverse outcomes.2–4 No studies have examined how early calcium disturbances occur and whether calcium disturbances are observed prehospital.2 This makes protocolised calcium replacement without ionised calcium (iCa) measurement challenging as it may undertreat some patients and overtreat others.4 5 All UK Helicopter Emergency Medical Services (HEMS) carry blood products and calcium replacement therapy; a small proportion of HEMS use iCa point-of-care testing (POCT).5 This study is hypothesis-generating and aims to identify whether trauma-related calcium disturbances occur before hospital arrival and whether POCT may have a role in detecting these.

This case series...]]> 2026-01-07T09:00:18-08:00 info:doi/10.1136/emermed-2025-215647 hwp:master-id:emermed;emermed-2025-215647 British Association for Accident and Emergency Medicine 2026-01-07 Letter http://emj.bmj.com/cgi/content/short/emermed-2024-214837v1?rss=1 Background

Emergency department (ED) utilisation and delays are a major public health concern internationally, with increased mortality with ED delays and overcrowding. The study aimed to assess how the population characteristics of ED catchment areas are associated with ED use and delays to admission or discharge, and how catchment presentation rates are associated with ED delays.

A cross-sectional study of presentations and delays to all 27 Scottish EDs for December 2023–February 2024. Catchment areas were defined for every ED in Scotland and population demographics for each, as Scottish Index of Multiple Deprivation (SIMD) and 8-fold Urban–Rural Classification (UR8). ED performance metrics for the study period were extracted from routinely reported data. Robust regression assessed the associations between catchment area demographics and ED delays, with negative binomial regression analysis of the association between catchment area demographics and presentation rates for the local population, reported as incidence rate ratio (IRR).

For each decile lower (more deprived) in median SIMD, monthly attendances increased by 10% (IRR 1.10, 95% CI 1.10 to 1.11). For each step more rural in the median UR8 of a catchment, the percentage of patients experiencing a delay to admission or discharge of over 4 hours reduced by 5.3% (95% CI 4.9% to 5.7%), and each step more deprived in median SIMD decile of a catchment area was associated with 4.8% more delays beyond 4 hours (95% CI 3.0 to 6.8%). There was no association between presentation rates and delay to admission or discharge.

EDs with more deprived catchment areas have higher presentation rates and greater delays in care. More rural EDs have fewer delays, which may mitigate some of the effects of geographical isolation in the provision of more timely care. In isolation, ED presentation rates are not associated with delays to care, adding to evidence that overall attendances are less important than other factors contributing to ED delays. Policymakers should consider the allocation of resources to best promote health equity.

Seven databases and the grey literature were searched up to May 2024. Comparative studies assessing interventions to reduce imaging in children with upper/lower extremity injuries implemented in the ED were eligible. Two independent reviewers screened for study eligibility, quality assessment and data extraction, with disagreements settled via third-party adjudication. Changes in imaging are reported as ORs with 95% CIs, using a random effects model.

From 9387 citations, eight unique studies enrolling 7793 children were included with the majority using a before–after design. Potential concerns for bias were documented due to a lack of reporting of key quality domains. Decision rules for ankle injuries successfully reduced radiography (OR=0.11; 95% CI 0.07 to 0.16, I²=38%). A decision rule for wrist injuries reduced imaging (OR=0.06; 95% CI 0.03 to 0.11); however, eight injuries were missed. Two studies implementing clinical guidelines reported decreases in radiographs per patient (p<0.001). One trial reported increased imaging in children assessed by triage nurses using an established clinical decision rule (OR=5.44; 95% CI 2.96 to 10.02), with 16 missed injuries identified.

Guidelines incorporating clinical decision rules, particularly decision rules for ankle injuries, can reduce radiography for children with extremity injuries in the ED. Further investigations are warranted to identify other extremity injuries, the components of the intervention and the most efficient clinicians to target.

CRD42016042875.

A retrospective study of all presentations (aged ≥12 years) to EMS between October 2021 and May 2023. EMS data were linked to VVED records. Surveys were distributed following VVED consultation to explore patient experience. Interrupted time-series analyses were used to evaluate the impact of VVED on non-transport rates and EMS reattendance within 24 hours. Multivariable logistic regression analyses were used to determine predictors of non-transport and EMS reattendance.

There were 914 747 EMS presentations within the study period, of which 30 433 (3.3%) were referred to VVED. Compared with those not referred, those referred to VVED were older with fewer vital sign derangements. Of VVED referrals, the median case time was 23 min shorter compared with cases not referred to VVED, and 74% were not transported. Compared with baseline, the VVED phase-in period was associated with a non-significant change in level (incident rate ratios (IRR): 1.03, 95% CI 0.99 to 1.06) and significant change in trend per 30 days (IRR: 1.01, 95% CI 1.01 to 1.02) for non-transports. Full implementation of VVED was associated with a step-reduction (IRR: 0.96, 95% CI 0.92 to 0.99) and downward trend per 30 days (IRR: 0.99, 95% CI 0.98 to 0.99). In both the VVED phase-in and full implementation periods, no associations were found for reattendance to EMS. After adjustment for clinical presentation and acuity, VVED referral was associated with a 16-fold (adjusted OR: 15.97 95% CI 15.53 to 16.43) increase in the odds of non-transport. Among the 8.9% of patients who responded to the survey, satisfaction of the VVED was high (91.1%).

The EMS-VVED referral pathway contributed to significant improvements in ambulance non-transports and case-time savings.

We conducted a cohort study of adults with STEMI activations from 2016 to 2020 using regional North Carolina STEMI registry data, which included eight rural emergency medical services (EMS) agencies and three percutaneous coronary intervention (PCI) centres. The primary outcome was EMS first medical contact to PCI in ≤90 min. By sex, we evaluated prehospital time intervals (dispatch, response, time-to-ECG, catheterisation laboratory activation, on-scene, transport and total EMS) and door-to-balloon time with clustered Wilcoxon rank-sum tests. We also evaluated agency and patient factors associated with timely reperfusion using generalised estimating equations.

Of the 365 patients included, 30.1% (110/365) were female with a mean age of 62.5±12.7. Fewer women received PCI within 90 min compared with men (43.6% vs 67.8%, p<0.001). Women also experienced significantly longer total EMS time (42.5 vs 40.0 min, p=0.049) and door-to-balloon time (48.5 vs 40.0 min, p=0.01). Other time intervals were similar. After adjustment, women without exertional symptoms, with diabetes or with hypercholesterolaemia had lower odds of timely reperfusion. Among men, lower odds of timely reperfusion were observed among those without pain, who had catheterisation lab activation between 17:00 and 07:00, who were older or who had farther transport.

In rural settings, women without exertional chest pain and those with comorbid conditions were less likely to have timely reperfusion. Women experienced significantly longer total EMS time and door-to-balloon time than men.

A qualitative study was undertaken using a constructivist approach based on applicability to learning in medical education and complex social environments. Kirkpatrick’s model of evaluation was used as a theoretical framework for determining effectiveness. Purposive sampling was used to guide recruitment, and semistructured interviews were undertaken with emergency practitioners involved in the VGRs programme. Interviews were transcribed and interpreted through iterative thematic analysis. Codes were developed deductively through critical literature review and inductively based on participant experiences.

12 interviews were conducted with facilitators, presenters and learners from both Uganda and the UK. Participants included senior doctors, residents, nurses and Ministry of Health representatives. Four core themes emerged: (1) VGRs can be used to support global emergency medicine education. Learning occurs through sharing experience, interaction and discussion. (2) Success depends on stakeholder engagement. (3) Technical factors can act as barriers and facilitators and are integral to effectiveness and (4) VGRs have impact beyond education including areas of multidisciplinary work and health system strengthening.

This study found that the VGR format is an effective method for online learning and has relevance to emergency care in all contexts. Factors were identified that have applicability to partnership programmes beyond emergency care including health system strengthening, specialty development and sustainability.

This retrospective study analysed adult non-traumatic OHCA cases in Vienna between January 2019 and December 2023. It assessed emergency medical service records and clinical patient data and reported incidences, return of spontaneous circulation (ROSC) rates, survival to hospital discharge and neurological outcome. Logistic regression assessed associations between outcomes and predictors, while Poisson regression examined incidence changes before, during and after COVID-19 lockdowns.

During the observation period, the Emergency Medical Service Vienna started CPR in a total of 7433 patients (77.1/100 000 population per year). Sustained ROSC was observed in 24.8%, survival to hospital discharge in 9.3% and a Cerebral Performance Category (CPC) Score of 1 or 2 in 6.8%, similar to prior data. However, patients with witnessed cardiac arrest of suspected cardiac aetiology and an initial shockable rhythm had a substantially higher rate of survival to hospital discharge (39%), and CPC of 1 or 2 (29.6%). Similarly, patients with CPC 1 or 2 before CPR had better outcomes than the overall cohort. During COVID-19, there was a decline in all outcome parameters.

Survival after OHCA in Vienna seems stable, but significant improvements in outcome parameters are seen in a ‘high outcome potential cohort’ over the last 15 years. This reaffirms the need to continue focusing on rapid initiation of bystander CPR and early defibrillation.

A single-centre validation study was conducted in a Dutch academic hospital. Step 1 involved forward and backward translation to produce a Dutch translation of the ED PREM (prototype). Step 2 involved establishing face and content validity of the Dutch prototype through cognitive patient interviews and researcher team consensus meetings. Step 3 involved administering the resultant Dutch pilot ED PREM to an ED population (n=527), to be able to perform psychometric analyses on this sample. Descriptive statistics and item reduction analyses were conducted prior to confirmatory factor analysis (CFA). CFA was used to confirm the structural validity of the Dutch ED PREM, and internal consistency was assessed.

The face and content validity of the prototype Dutch ED PREM was ‘good’ after 15 cognitive interviews and expert consultation. Over two-thirds of participants (357/527) completed the Dutch pilot ED PREM. Scores were high across all four domains. Several items were removed due to high ceiling effects and a large number of ‘not applicable’ responses. The final 18-item Dutch ED PREM showed acceptable model fit with CFA (²(df) 7519.55 (153), p<0.001, Root Mean Square Error of Approximation=0.090, Tucker-Lewis Index=0.942, Comparative Fit Index=0.951, Standardised Root Mean Square Residual=0.035). Internal consistency was high (Cronbach’s alpha ranged 0.85–0.97 per domain).

The final 18-item Dutch ED PREM showed good validity and reliability for measuring ED patient experience. It is suitable and feasible for use in clinical practice to assess and improve the person-centredness of emergency care.