Emergency Medicine Journal最新文献

Background: Young febrile infants are at high risk of invasive bacterial infections (IBIs). Clinical Decision Aids (CDA) such as the Step-by-Step and Paediatric Emergency Care Applied Research Network (PECARN) use Procalcitonin (PCT), limiting their application in settings without PCT access. This study aimed to test the performance of these CDAs in a UK cohort.

Methods: This was a planned analysis of the Febrile Infant Diagnostic Assessment and Outcome Study, a large, prospective multicentre observational study conducted across over 30 sites in the UK. Febrile infants (0-90 days of age) with complete biomarker data, who also underwent PCT testing, were included. Two CDAs, PECARN and Step-by-Step, were applied to the cohort, using their recommended low-risk criteria. The diagnostic performance of the CDAs was analysed.

Results: Of the 1527 infants who completed biomarker testing in the main study, 442 had PCT testing and were included, 22 (5%) were diagnosed with an IBI. PECARN and Step-by-Step CDAs demonstrated sensitivities of 1.00 (95% CI: 0.85 to 1.00) and 0.96 (95% CI: 0.77 to 1.00) respectively. The PECARN CDA performed with a specificity of 0.14 (95% CI: 0.11 to 0.18) identifying 14% of the participants as low-risk and did not misclassify any infants. The Step-by-Step CDA performed with a specificity of 0.15 (95% CI: 0.12 to 0.19) identifying 14% of the participants as low-risk and misclassifying one participant with IBI as low-risk.

Conclusion: Both PECARN and Step-by-Step CDAs demonstrated high sensitivity for detecting IBI in our cohort. While specificity was relatively low, these tools could potentially identify a subset of low-risk infants suitable for less intensive management.

Background: Hospitals responding to mass casualty incidents (MCIs) must rapidly scale up operations to accommodate high casualty counts, with little lead time. On 17 September 2024, 4000 pager devices were detonated across Lebanon, injuring 2323 individuals. This paper reports on a single-centre MCI response to this unprecedented hybrid warfare tactic, describing success features and identifying areas for improvement.

Methods: A qualitative analysis of 10 debrief meeting minutes held within 2 weeks of the incident, as part of the standard quality improvement process post-MCI response that included an after-action review conducted in accordance with the 2019 WHO guidelines. Group-based debriefs, facilitated by the emergency department (ED) chairperson, addressed different response elements and engaged relevant stakeholders. Conclusions were derived from the qualitative analysis of the meeting minutes.

Results: Our hospital received 182 casualties, 66% of whom were triaged to urgent-level care (yellow), 21% to delayed-level care (green) and 13% to immediate-level care (red), with 35 requiring emergent surgery within the first 12 hours. The MCI response was activated 34 min postincident, initiating security lockdown protocols, expedited patient registration, MCI triage protocol implementation, opening of surge areas and command centre activation. Key success features included: shifting from ED-based response to a whole-hospital mobilisation to accommodate the influx; early secondary triage of urgent-level (yellow) patients for immediate transfer to inpatient wards, resulting in 22.5% being managed in the inpatient setting; and optimised information system workflows for admission and order entry. Recommended improvements include simplifying operating theatre transfer workflows, shifting to paper-based documentation of assessments/interventions, optimising surgical and diagnostic prioritisation processes and developing minimal diagnostic imaging standards of care.

Conclusion: This study highlights key successes and challenges of a hospital response to a large hybrid-warfare MCI. Future research on reliability of key success features, specifically use of ED secondary triage protocols, is needed to support wider adoption. In addition, developing minimal imaging standards in MCIs is needed to reduce bottlenecks in this area.

Background: An acute scrotum is an urological emergency. One of its most important causes is testicular torsion, which can result in testicular necrosis unless quickly diagnosed and treated. Along with point-of-care ultrasound (POCUS), the Testicular Workup for Ischemia and Suspected Torsion (TWIST) score can be used to differentiate between testicular torsion and other causes of an acute scrotum. However, their diagnostic performance when undertaken by emergency physicians (EPs) and paediatricians in the emergency department (ED), as opposed to urologists/radiologists, is uncertain.

Methods: This retrospective observational study investigated patients aged ≤15 years with an acute scrotum who visited a paediatric tertiary care hospital's ED between March 2018 and August 2022. The diagnostic accuracy of the TWIST score and POCUS when performed by EPs and paediatricians to diagnose testicular torsion was calculated. Each TWIST score served as a cut-off. For practical purposes, a cutoff ≥3 points was used for sensitivity and the negative predictive value (NPV), and a cutoff ≥5 points was used for specificity and the positive predictive value (PPV). The final diagnosis served as the reference standard.

Results: Of 512 patients, 55 (11%) had testicular torsion. The TWIST score had 91% sensitivity (95% CI 80%-97%), 95% specificity (95% CI 93% to 97%), 63% PPV (95% CI 50% to 75%) and 99% NPV (95% CI 97% to 100%). When positivity was defined as either impaired testicular blood flow or the whirlpool sign, the sensitivity, specificity, PPV and NPV were 96% (95% CI 87% to 100%), 95% (95% CI 93% to 97%), 70% (95% CI 58% to 80%) and 100% (95% CI 98% to 100%) respectively.

Conclusion: Although the TWIST score and POCUS had high diagnostic accuracy for paediatric testicular torsion when performed by EPs or paediatricians in the ED, the non-negligible, false-negative rate indicated that the TWIST score should be used for risk stratification rather than as an exclusionary method.

Barriers to accessing healthcare, delays in diagnosis and suboptimal treatment have resulted in inequitable healthcare for people with learning disabilities. For people with learning disabilities, healthcare interactions are often unfamiliar and complex, and reasonable adjustments need to be made. Allowing more time for assessments, collaborating with caregivers and reducing personal triggers can help to overcome these challenges. However, despite this, there are some patients who require sedation to allow them to access certain investigations or interventions in a safe and tolerable manner.The Physician Response Unit (PRU) in North East London has developed a learning disability pathway offering prehospital oral dissociative sedation. The choice of combination oral ketamine and oral midazolam was informed by existing literature and expert clinician opinion. Traditional approaches involving intravenous or intramuscular routes can result in physical restraint and psychological distress. Alternatively, high strength parenteral preparations of ketamine and midazolam can be added to a small volume of drink and given to the patient by their carers under the supervision of the PRU team.In the first year of the pathway, 36 patients were referred and 9 patients went on to require prehospital oral dissociative sedations. There were no moderate, severe or sentinel events and only two minor adverse events. All the patients seen on the pathway were able to tolerate investigations or interventions that previously had been impossible to provide.

Background: Emergency medicine (EM) faces significant workforce challenges in sustaining clinical academic careers. Academic clinical fellowships (ACFs) offer protected research time, but little is known about how EM ACFs experience and navigate these posts.

Methods: 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.

Results: 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.

Conclusions: 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.

Background: Over the past two decades, paediatric emergency departments (PEDs) worldwide have experienced an increase in attendance, despite declining birth rates and enhanced access to primary care. This paradox suggests that the rising demand may be attributed to non-urgent conditions rather than genuine paediatric emergencies. Understanding the impact of demographic decline on PED utilisation is essential for effective health-service planning. This study assessed long-term trends in PED utilisation and hospitalisations in relation to declining birth rates in Liguria, Italy.

Methods: 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).

Results: 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.

Conclusions: 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.

Background: Previous studies have indicated that crowding within the emergency department (ED) is associated with longer lengths of stay in the ED and higher mortality. Boarding, the time patients spend waiting for an inpatient bed after ED assessment, represents a clinically unproductive delay and occupies scarce ED resources. We explore the association of medical patient boarding not only with their outcomes but also indirectly for other patients in the ED and those in and awaiting ambulances.

Methods: 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.

Results: 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. CONCLUSION : 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.