Academic Emergency Medicine最新文献

Background: People with dementia are often hospitalized from the emergency department (ED) for conditions that could potentially be treated in the outpatient setting. In scenarios of clinical equipoise-where either admission or discharge may be appropriate-little is known about how emergency physicians make disposition decisions.

Methods: We conducted a qualitative study with attending emergency physicians at a single academic medical center. Interviews included open-ended questions about disposition decision-making in general as well as structured case scenarios using a think-aloud protocol. We used an inductive approach to code interview data and elucidate themes about the factors emergency physicians consider in disposition decisions for people with dementia in situations of clinical equipoise.

Results: We interviewed twenty-one physicians with an average of 10.5 years of clinical practice (range 5-21 years). Five themes emerged: (1) assessing availability of, reliability of, and burden faced by caregivers; (2) anticipating clinical trajectory and feasibility of outpatient follow-up; (3) identifying acute cognitive changes that may reflect serious underlying illness; (4) navigating medicolegal concerns; and (5) weighing potential harms of hospitalization. Among these, caregiver assessments and clinical trajectories were discussed most frequently, with physicians describing informal and variable approaches to caregiving assessments. While many physicians recognized the risk of discharging a delirious patient, few acknowledged that hospitalization itself could contribute to delirium or other harms. Overall, emergency physicians' decisions were shaped not only by patient characteristics, but by the surrounding health system's capacity to support timely and safe outpatient care.

Conclusions: ED disposition decisions for people with dementia often depend on caregiving context and health system constraints. Improving alignment of admission decisions with patients' and care partners' values and preferences may require structured approaches to assessing caregiver capacity and communicating risks of hospitalization. Health system investment in outpatient infrastructure and alternatives to admission may better support emergency physicians in making safe, patient-centered decisions.

Study objective: We evaluated the efficacy and safety of ultrasound-guided pericapsular nerve group (PENG) block for initial pain management in adult emergency department (ED) patients with hip fractures.

Methods: This prospective, randomized, double-blinded, controlled trial was conducted at a tertiary care academic ED. Adult patients (≥ 18 years) with traumatic hip fractures and Numerical Rating Scale (NRS) pain scores > 4 were randomized to ultrasound-guided PENG block with bupivacaine or sham procedure. Both groups received standard intravenous analgesia. The primary outcome was the difference in NRS scores over 3 h. Secondary outcomes included total rescue analgesia (morphine equivalents) and adverse events.

Results: Of 167 screened, 80 patients were enrolled (40 per group). Pain scores were significantly lower in the PENG block group at 30 min (mean difference [MD] -3.2; 95% confidence interval [CI]-4.2 to -2.2), 60 min (MD -3.1; 95% CI -4.1 to -2.1), and 120 min (MD -2.0; 95% CI -2.6, -1.4), compared with sham. Total rescue analgesia was significantly lower in the PENG block group (MD -4.6 mg morphine equivalents; 95% CI -6.2 to -3.1). No significant adverse events were reported, such as hematoma, quadriceps weakness, signs of local anesthetic systemic toxicity (LAST), or significant opioid-related adverse events.

Conclusion: In adult ED patients with hip fractures, ultrasound-guided PENG block significantly reduced pain scores and opioid requirements compared with sham, with no significant adverse events reported. PENG block may be an effective, opioid-sparing analgesic strategy for acute hip fractures in the ED.

Trial registration: Clinical Trial Registry-India: CTRI/2023/08/056595.

Background: Falls are a leading cause of morbidity among older adults. Although emergency departments (EDs) routinely screen for fall risk, few patients are connected to prevention programs after discharge. Digital tools could automate notification and referral, yet few have been developed or tested in acute care settings with ED end-users in mind.

Objective: To assess the feasibility, acceptability, and usability of ALERT-ED, a novel digital intervention designed to automate fall risk notification and referral.

Methods: We conducted semi-structured interviews with English- and Spanish-speaking ED patients aged ≥ 65, caregivers, and nurses across multiple hospitals within a large integrated healthcare system. ALERT-ED automatically embeds a QR code in the After Visit Summary of high fall risk ED patients, linking to a chatbot (Livi) that supports self-screening, fall education, and referral to community programs. Thematic analysis of interview transcripts informed optimization of the intervention ahead of a planned clinical trial.

Results: Interviews of 6 nurses, 12 patients, and 4 caregivers revealed seven themes: (1) feasibility depends on dissemination strategies and workflow alignment; (2) barriers include limited awareness and nursing time constraints; (3) acceptability improves trust, readability, and personalization; (4) expanding scope to enhance engagement; (5) privacy and artificial intelligence skepticism persist; (6) usability is high due to the QR interface; and (7) accessibility gaps remain for users with impairments.

Conclusion: ALERT-ED demonstrates strong feasibility, acceptability, and usability among older adults, caregivers, and ED nurses. By automating fall risk notification and referral, ALERT-ED offers a pathway for integrating public health interventions into emergency care.

Background: Transitions of care are high-risk periods for patient safety in the emergency department (ED), particularly for patients who are still in the diagnostic process and are discharged with diagnostic uncertainty. Care transitions must be improved for these patients, as one third of discharged ED patients have diagnostic uncertainty. Yet there are no validated measures that assess the quality of care transitions from the ED, limiting the ability to assess the impact of interventions. Thus, we developed and validated the ED Transitions (EDT) measure.

Methods: This mixed methods study was conducted across a large healthcare system in three phases: item generation, cognitive interviewing, and large-scale validation. Scale items were generated by experts and then iteratively refined using feedback from cognitive interviews (n = 11). The measure was then validated on a large sample of patients (n = 301) recently discharged from the ED. Exploratory structural equation modeling (ESEM) was employed to assess factor structure. Bivariate correlations were used to assess discriminant and convergent validity using the Care Transition Measure (CTM-3) and the Communication Assessment Tool-Teams (CAT-T).

Results: The measure was iteratively refined by way of an expert panel and cognitive interviews which resulted in a 15-item measure to be used for validation. The validation sample (n = 301) was 62% women, 49% White, and the majority having Medicare and/or Medicaid (68%). Sequential comparisons between confirmatory factor analyses and ESEM resulted in a final 10-item two-factor structure. Reliability was excellent (0.93), and bivariate correlations indicated positive correlations between the EDT, CTM-3, and CAT-T.

Conclusion: The EDT measure demonstrates content validity, structural validity, convergent validity, discriminant validity, and high internal consistency (i.e., reliability). This newly developed patient reported outcome measure can be used in future clinical and research work to better understand the impact of ED interventions on quality-of-care transitions for patients with diagnostic uncertainty.