Western Journal of Emergency Medicine最新文献

Introduction: While research has begun to understand emergency department-based cardiac arrest (EDCA), consensus on what exactly constitutes EDCA remains unknown. In this study we aimed to explore the grouping of EDCA by using an unsupervised machine-learning algorithm and to investigate how these underlying clusters related to patient outcomes.

Methods: We retrieved electronic health record data from an ED in a tertiary medical center. The EDCAs were identified via the cardiopulmonary resuscitation log. We used k-means cluster analysis to group EDCAs and t-distributed stochastic neighbor embedding (t-SNE) for visualization. Primary outcomes were ED mortality and ED length of stay (LOS). The analyses were repeated using an independent ED data set, the Medical Information Mart for Intensive Care IV Emergency Department (MIMIC-IV-ED) dataset.

Results: From 2019 to 2022, there were 366 EDCA events. Cluster analysis identified three distinct clusters (Cluster 1 or immediate risk, n=54 [15%]; Cluster 2 or early risk, n=274 [75%]; Cluster 3 or late risk, n=38 [10%]). Cluster 1 patients had the shortest median time to EDCA (< 1 hour), followed by Cluster 2 (3 hours) and Cluster 3 (81 hours). Near cardiac arrest at triage was the most common cause of EDCA in Cluster 1, while respiratory illnesses and sepsis were more common in Cluster 3. The causes of EDCA in Cluster 2 were diverse, with predominantly cardiovascular and neurologic emergencies. The t-SNE revealed farther distances from Cluster 1 to the other two clusters, suggesting its most critical nature. Cluster 3 had the highest mortality (58%), followed by Clusters 1 (48%) and 2 (35%) (P = .01). Cluster 1 had the shortest median LOS (median, 4 hours), while Cluster 3 had the longest LOS (81 hours) (P < .001). In the independent data set, Cluster 1 remained, but Clusters 2 and 3 appeared to merge due to a shorter ED LOS overall.

Conclusion: We identified three novel clusters (immediate, early, and late risk) with distinct patterns in clinical presentation, putative causes of ED-based cardiac arrest, and ED outcomes. Understanding these clinical phenotypes may help develop cluster-specific interventions to prevent EDCA or intervene most appropriately. Cluster 1 patients may benefit from resuscitation efforts, and Clusters 2 or 3 patients can benefit from timely interventions for cardiac, respiratory, and neurologic emergencies. In addition, for patients with prolonged ED boarding, periodic monitoring with an early warning system may prevent a cardiac arrest event.

Introduction: Emergency department (ED) boarding negatively affects patient outcomes, increasing length of stay, hallway care, and mortality. Prior research found disparities in capacity metrics like hallway care based on patient race and ethnicity. However, whether boarding differs by demographics is not well characterized. We examined boarding variation by sociodemographic factors in a hospital with a standardized bed-prioritization process. We hypothesized that a structured inpatient assignment method may be associated with reduced boarding inequity.

Methods: This single-center, retrospective, cohort study included adult patients boarding in the ED after admission to the non-intensive care inpatient medicine service between February 2020-February 2023 at an urban, academic, tertiary-care hospital with > 110,000 annual ED visits. Primary outcome was time from admission order to inpatient bed transport. Patient demographics (age, sex, race/ethnicity, language, insurance, and housing status), visit characteristics (Emergency Severity Index, time, and day), and bed request features (telemetry, sitter need, and isolation precaution) were obtained via the medical record. We assessed for bivariate relationships between boarding time and demographics with descriptive statistics and analysis of variance using adjusted and unadjusted regression analyses with generalized estimating equations to account for patient-level correlation.

Results: In total, 22,291 encounters were included. Average age was 64 (SD ±19) years, and 47% were female. Approximately 12% identified as Hispanic, 70% as non-Hispanic White, and 10% as non-Hispanic Black. Most (97%) boarded ≥ 120 minutes. In adjusted analyses, patients with Medicaid waited an additional 85 minutes (95% CI 49-121), and patients with Medicare waited an additional 67 minutes (95% CI 32-103) compared to those with commercial coverage (both P < .001, respectively). Non-Hispanic Black patients boarded 14 minutes longer (95% CI 22-51), and non-English primary language speakers boarded 15 minutes longer (95% CI 17-47) than non-Hispanic White patients and English primary language speakers, respectively, although these two findings were not statistically significant.

Conclusion: Among adult patients admitted to the inpatient medicine service, non-commercial insurance such as Medicaid and Medicare was significantly associated with longer ED boarding, whereas race/ethnicity and primary language were not. Further study should determine whether these findings are replicated elsewhere, how this impacts patients, and whether targeted intervention can reduce inequities.

Introduction: The COVID-19 pandemic and related anti-Asian political rhetoric had a detrimental impact on the mental health of Asian American and Pacific Islander (AAPI) youth in the United States. Our objective was to quantify trends in suicide-related emergency department (ED) encounters among AAPI youth before and during the COVID-19 pandemic, using an intersectional lens of race and sex and to contextualize these trends on a timeline of political and social events (such as anti-Asian hate crimes) occurring during the same period in California.

Methods: Using data from the California State Emergency Department Database (SEDD) from 2018-2021, we evaluated changes in quarterly proportions of suicide-related ED encounters by age, race, and sex subgroups by comparing mean percentage change in proportions before and during the pandemic among patients 8-21 years of age. We evaluated changes in quarterly proportions of suicide-related ED encounters by age, race, and sex subgroups by comparing mean percentage changes as they related to events around the pandemic and spikes in anti-Asian hate crimes. To compare relative disparities during the periods, we used stratified adjusted mixed multilevel logistic regression, with White males as the reference group.

Results: The overall increase in suicide-related ED visits for all youth during this period was 49.5% (95% CI 46.7-52.2%), representing 2,637 more suicide-related ED visits in 2021 than 2018. The graphical observational analysis of changes in quarterly proportions of suicide-related ED visits showed some temporal correlation between spikes in rates among AAPI and American Indian and Alaska Native (AI/AN) females and specific events, such as anti-Asian hate crimes and school closings. The largest percentage increase was seen among females of all races, and in particular, AI/AN females (+58.1%, representing 471 more suicide-related ED visits in 2021 than 2018) and AAPI females (+57.5%, representing 1,545 more suicide-related ED visits in 2021 than 2018). During the pandemic, the adjusted odds of a suicide-related ED visit among AAPI females 13-17 years of age compared to White males was 2.01 (95% CI, 1.91-2.13). A total of 131 in-ED deaths occurred during the study period, with no significant year-to-year variation in the number of deaths.

Conclusion: Suicide-related ED visits increased for all youth during COVID-19, with the sharpest rise among AAPI and AI/AN females. Asian American and Pacific Islander females 8-12 and 13-17 years of age showed especially large increases. While causality cannot be inferred, patterns aligned with pandemic disruptions and anti-Asian hate crimes. Findings highlight the value of intersectional analysis to identify disproportionately impacted subgroups and inform future, culturally responsive suicide prevention efforts.

Introduction: Septic thrombophlebitis of the internal jugular vein (STIJV), or Lemierre syndrome, is a rare, life-threatening condition. Anticoagulant use for managing STIJV remains unclear due to ambiguous diagnostic criteria and a lack of robust evidence. We evaluated the clinical benefits and risks of anticoagulants in patients with STIJV.

Methods: In this retrospective study we used data from over 1,700 hospitals, retrieved from a nationwide Japanese database. We used multivariate logistic regression and propensity score matching to adjust for confounding variables (age, sex, Charlson Comorbidity Index, level of consciousness, use of mechanical ventilation, use of disseminated intravascular coagulation, admission to intensive care unit, history of diabetes, use of noradrenaline, diagnosis of acute renal failure, and diagnosis of cerebral infarction). We also conducted instrumental variable estimation to account for the impact of unmeasured covariates. The primary outcome was in-hospital mortality; the secondary outcomes were 90-day mortality, major bleeding events, and length of stay (LOS) in hospital.

Results: Among the 523 patients diagnosed with STIJV between April 1, 2014-March 31, 2022, 343 (65.6%) were excluded due to lack of appropriate treatment initiation for STIJV. Overall, 180 patients (34.4%) met the inclusion criteria; the data of 156 patients (31.1%) were ultimately analysed. Of these, 86 (55.1%) received anticoagulants, which neither significantly improved nor worsened survival outcomes. The in-hospital mortality was 3.39% and 1.69% and 90-day mortality was 2.54% and 1.69%, respectively, in patients who did and did not receive therapy, (P = .56 and .99, respectively). The adjusted odds ratio (AOR) for in-hospital and 90-day mortality was 0.858 (95% CI, 0.126-5.826, P = .88) and .991 (95% CI, .932-1.055, P = .79), respectively. The LOS was longer in those receiving anticoagulants (mean, 29.2 vs 21.8 days, AOR 11.7 days longer, 95% CI, 4.11-19.20, P < .01), potentially due to dose adjustment or clinical decision-making. Subgroup analysis comparing unfractionated heparin and direct Xa inhibitors showed similar in-hospital mortality outcomes: 4.54% in the unfractionated heparin group (AOR 2.361, 95% CI, 0.32-17.40; P = .40) and 3.03% in the direct Xa inhibitor group (AOR 0.444, 95% CI, 0.032-6.23; P = .55), respectively.

Conclusion: In the largest study of septic thrombophlebitis of the internal jugular vein to date, we found that early initiation of anticoagulation treatment was not statistically associated with survival. Therefore, anticoagulant use should be determined based on individual patient characteristics. Further research is warranted to improve the quality of evidence for this rare disease.

Introduction: In early 2025, the Accreditation Council for Graduate Medical Education (ACGME) announced proposed revisions to emergency medicine (EM) residency training to include substantial changes to the length of training programs, required rotations, and structured experiences. To date, no published national survey has sought to determine how these changes would impact individual programs.

Methods: Over a three-week period in April 2025, we anonymously surveyed program directors or their designees online through the Council of Residency Directors in Emergency Medicine listserv. Survey respondents were asked about the impact the changes would have on their programs and their overall opinions of the proposed 48-month minimum requirement.

Results: A total of 86 program directors responded to the survey (response rate of 29.9%) with representative samples from current three-year (83.7%, 72/86) and four-year (16.3%, 14/86) programs. Most program directors reported that they would have to make significant revisions in either structured experiences, required rotations, or both. Most survey respondents from three-year programs (52/72) do not support the proposed changes, whereas all respondents from four-year programs (14/14) do support the changes (P<.001).

Conclusion: Proposed program requirements may require modifications in both three- and four-year programs; 33 of the 86 program directors surveyed reported that would need more than one year to meet the requirements, if adopted. This raises the concern that programs may not be prepared to implement the revisions within the proposed timeline, potentially impacting resident education and the future EM workforce. The ACGME should consider a staged rollout of requirements to allow them to be thoughtfully implemented in a meaningful way.

Introduction: Hemorrhagic shock is a life-threatening condition and remains a leading cause of death worldwide. Current European guidelines lack recommendations for one fluid type over another in the management of hemorrhagic shock. This study explores the effectiveness and safety of colloids and crystalloids in resuscitation of hemorrhagic shock patients.

Methods: We conducted a systematic search in PubMed, Cochrane Cenral Register of Controlled Trials (CENTRAL), Scopus, Web of Science, ProQuest, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) up to January 3, 2024. We performed data analyses using Rstudio v.4.4.1 in Frequentist network meta-analysis with DerSimonian-Laird random-effects model. Subgroup and network meta-regression analyses was also performed in Bayesian methods. We analyzed safety aspects using meta-proportions with generalized linear mixed models models.

Results: A total of 3,693 patients from 23 randomized controlled trials were included in this study. Synthetic colloid demonstrated the lowest mortality rate (odds ratio 0.37, 95% CI, 0.15-0.93; P-score = .94) with the lowest fluid input requirement (mean difference -1.02; 95% CI, -1.62 to -0.41; P-score = .75). Subgroup and network meta-regression analysis revealed none of the covariates significantly influenced these two outcomes. Regarding safety aspects, isotonic crystalloid caused the most diverse adverse events, with acute respiratory distress syndrome (prop = 0.067) and overload syndrome (prop = 0.063) being the most common adverse events.

Conclusion: This study provides robust evidence favoring the initial use of synthetic colloid in the management of patients with hemorrhagic shock.

Introduction: Vagal maneuvers are first-line therapy for hemodynamically stable supraventricular tachycardia (SVT), yet the relative efficacy of the standard Valsalva Maneuver (SVM), modified Valsalva maneuver (MVM), carotid-sinus massage (CSM), and head-down deep breathing (HDDB) remains uncertain. We undertook a network meta-analysis (NMA) to define the optimal technique and explore age- and sex-related effect modification.

Methods: We searched nine databases from inception to January 2025 for randomized controlled trials involving adults (≥ 18 years of age) with stable SVT treated with at least two of the four maneuvers. Primary outcomes were conversion to sinus rhythm after a single attempt after multiple attempts, and by the end of the trial. Secondary outcomes were the need for rescue intravenous (IV) antiarrhythmic drugs and maneuver-related adverse events (AEs). Bayesian random-effects NMA generated risk ratios (RR) with 95% credible intervals (CrIs); surface under the cumulative ranking curve (SUCRA) quantified hierarchy. We performed consistency, publication bias, and sensitivity analyses, and network meta-regression for mean age and female proportion.

Results: Nineteen trials (n = 2,545) formed a connected network. The MVM was more than doubly effective for single-attempt conversion relative to the SVM (RR 2.71, 95% CrI, 2.26-3.31) and outperformed CSM (RR 6.57, 3.33-14.94) and HDDB (RR 1.30, 0.35-4.66); SUCRA = 88.7%. At the end of the trial, the MVM retained superiority over the SVM (RR 1.25, 1.03-1.56) and ranked the highest success rate (SUCRA = 81.3%). The MVM also reduced IV drug use vs the SVM (RR 0.64, 0.55-0.73) and CSM (RR 0.59, 0.37-0.90). No maneuver differed in multiple-attempt success or AEs. The HDDB technique was ranked highest in safety (SUCRA = 82.4%) but was supported only by a single, small study. Meta-regression showed no age or sex interaction. Inconsistency was minimal; the Egger test suggested small-study effects only for the IV-drug endpoint (P = .03).

Conclusion: The MVM provides the greatest likelihood of rapid sinus rhythm restoration and the least need for rescue pharmacotherapy without increasing AEs, supporting its adoption as the default vagal strategy for SVT. Larger, standardized trials are warranted to confirm safety differentials and long-term outcomes.

Introduction: The guaiac fecal occult blood test, originally designed for colorectal cancer screening, is frequently used in emergency departments (ED) to detect occult gastrointestinal (GI) bleeding. However, the test has low sensitivity and specificity, leading to potential false positives and negatives. This study evaluates the current practices and perceptions of emergency physicians and hospitalists regarding the utility of the guaiac test in the setting of suspected GI bleeding in the ED.

Objective: Our primary aim in this study was to evaluate the current practice and views of emergency physicians and hospitalists on the utility of the stool guaiac test in the ED.

Methods: We conducted a multicenter survey from January 3-April 3, 2024, across four hospital systems, targeting attending physicians in the ED and hospitalists. Participants were asked to rate their agreement with statements about the stool guaiac test on a scale of 1 (strongly disagree) to 5 (strongly agree).

Results: Response rates were 47/93 (50.5%) for emergency attendings and 9/18 (50%) for hospitalists. Emergency attendings were significantly less likely than hospitalists to agree that stool guaiac testing is important for evaluating GI bleeding (31% vs 67%, P < .001). More than half of emergency attendings (55%) reported often performing the test, while 44% of hospitalists reported frequently requesting it before accepting a patient. Although 70% of emergency attendings believed that guaiac results influence hospitalists' admission decisions (P = .02), 67% of hospitalists stated they would accept a patient with suspected GI bleeding even without a result. Despite rating the test as important, only 33% of hospitalists felt that stool guaiac testing frequently changes management during hospitalization. Overall, the groups showed distinct attitudes regarding the utility and impact of stool guaiac testing.

Conclusion: The guaiac fecal occult blood test remains widely used despite skepticism among emergency attendings regarding its importance. Hospitalists were more likely to request the test but acknowledged it rarely changes patient management. These findings highlight the need for re-evaluation of guaiac testing in acute care settings and improved communication between ED and inpatient teams. Further research should explore the clinical impact of removing routine stool guaiac testing.

Introduction: Resuscitation of critically injured patients requires effective team leadership. Poor communication is the leading cause of sentinel events. Closed-loop communication reduces error during trauma resuscitations. Nonetheless, previous studies show few verbal orders are audible. Verbal orders during trauma resuscitations have not been studied for completeness. In this project we aimed to assess whether verbal orders for medications and blood products during trauma resuscitations were complete, audible, and used closed-loop communication.

Methods: This was an observational assessment of a convenience sample of verbal orders that trauma captains gave for medications and blood products during the primary and secondary survey. It was conducted in an academic emergency department (ED) at an adult Level 1 trauma center. We assessed medication orders for the presence or absence of medication name, dose, and route. Blood orders were evaluated for the presence or absence of blood product (packed cells or whole blood) and type (O- or O+). We recorded orders as audible or inaudible. Closed-loop communication was recorded as present or absent. Orders were considered complete if they included all elements. We used descriptive statistics to analyze data.

Results: There were 186 verbal orders enrolled: 165 (88.7%) for medications and 21 (11.3% for blood products. For medication verbal orders, 77.9% (n=127) were audible, 73.6% (n=120) included the name, 62.0% (n=101) included the dose, 17.8% (n=29) included the route, and 73.5% (n=111) used closed-loop communication. Overall, 23 (14.1%) medication verbal orders were complete. Regarding verbal orders for blood, 16 (76.2%) were audible, three (14.3%) included the blood product, seven (33.3%) included the blood type, and 13 (61.9%) used closed-loop communication. Overall, 0% (n=0) of the blood product verbal orders were complete.

Conclusion: Audible, complete verbal orders, and closed-loop communication were underused during trauma resuscitations. Interventions to improve communication of verbal orders warrant evaluation in the ED.