Academic Emergency Medicine最新文献

Study objectives: Significant variability exists in patient populations and diagnostic capabilities among hospital-based emergency departments (HBEDs) and freestanding emergency departments (FSEDs). While high sensitivity cardiac troponin (hs-cTn) research has focused on HBEDs, its application in FSEDs remains unexplored. This study assesses the comparative, real-world effectiveness of a 0/1-h accelerated protocol (AP) using hs-cTn between HBEDs and FSEDs.

Methods: We conducted a pre-planned, secondary analysis of a stepped-wedge cluster randomized trial involving nine EDs within an integrated health system, from July 2020 to March 2021, comprised of five HBEDs and four FSEDs. The trial implemented a 0/1-h AP utilizing hs-cTnI to evaluate acute myocardial infarction (AMI). Adult ED patients with an ECG and cardiac troponin ordered were eligible, excluding those with STEMI, hs-cTnI > 18 ng/L, or trauma-related symptoms. The primary outcome was safe ED discharge, defined as discharge without death or AMI within 30 days.

Results: The trial included 32,609 patients, 26,957 in HBEDs and 5652 in FSEDs. Safe discharge from HBED occurred 53.7% (5935/11,062) of the time in the standard care arm and 50.3% (7991/15895) under the AP (aOR 1.04, 95% CI 0.94-1.15, p = 0.50). Safe discharge from a FSED occurred 86.0% (2102/2443) of the time in the standard care arm and increased to 95.0% (3049/3209) under the AP (aOR 1.48, 95% CI 1.03-2.13, p = 0.033). Overall, the observed association between the AP and safe discharge was stronger in FSEDs than in HBEDs ( $\Delta$ log(aOdds) 1.05, 95% CI (0.82, 1.29), p < 0.001).

Conclusion: Implementing a 0/1-h AP using hs-cTnI to evaluate for AMI was associated with higher rates of safe discharge in FSEDs compared to HBEDs.

Objective: The Global Emergency Medicine Literature Review (GEMLR) identifies impactful research in global emergency care. This 20th annual edition reviews GEM literature published in 2024 and highlights the growth of GEMLR over the years.

Methods: We conducted a scoping review of 2024 GEM articles through structured PubMed and gray literature searches. Reviewers and editors from 10 countries screened abstracts using predefined criteria for three domains: disaster and humanitarian response (DHR), emergency care in limited-resource settings (ECLRS), and emergency medicine development (EMD). Duplicates and articles lacking authorship equity or ethical oversight were excluded. Remaining publications were scored using tailored rubrics for original research (OR), review articles (RE), and gray literature (GRAY). The top 5% in each category were selected for critical appraisal. A retrospective summary of 20 years of GEMLR reviews was also completed.

Results: The search identified 46,714 PubMed and 12,575 gray literature articles. A total of 473 met inclusion criteria and were scored; 33 were selected as the top 5%, a decrease from 55 in 2023. Although the search string was unchanged, 2024 yielded ~10,000 fewer articles. Common themes included trauma, pediatrics, and clinical/triage protocols, with a new focus on mental health among clinicians and disaster victims. Over 20 years, 230 individuals have contributed 810 service-years to GEMLR. Nearly 75% of members were from the USA, while 32 (13.9%) were from LMICs and 27 (11.7%) from non-USA high-income countries. In total, 398,904 articles have been screened, 8476 scored, and 517 top articles narratively reviewed since 2005.

Conclusions: Over two decades, GEMLR has evolved into a large-scale, multinational, methodologically rigorous initiative, highlighting more than 500 high-impact GEM publications. In 2024, despite fewer articles screened, 33 top studies were identified across key domains. GEMLR emphasizes equitable LMIC representation, rigorous quality standards, and authorship equity, aiming to help shape the future of emergency care research.

Background: ED disposition decisions for older adults are complex and often uncertain, yet studies rarely capture emergency physicians' real-time perspectives.

Objective: To assess patient outcomes based on emergency physician-perceived need for admission.

Design: Single-site prospective cohort study conducted between July and November 2024.

Setting: A Boston-area academic tertiary care ED.

Participants: Patients aged 65 and older dispositioned by attending physicians, excluding patients who were handed off, left without being seen, or eloped.

Measurements: Physicians rated admission need using a 5-point Likert scale (2-4 considered marginal). Primary outcome was ED disposition stratified by rating. Secondary outcomes were hospital length-of-stay (LOS), 7-day ED return, and 30-day mortality.

Results: Of the 489 patients (mean age 76.9 years [SD 7.5], 51.1% female), 55.8% were non-marginal admissions, 26.0% were non-marginal discharges, and 18.2% were marginal dispositions. Patients with marginal dispositions had longer workup times than non-marginal admissions or discharges (3.3 vs. 2.8 vs. 2.4 h, p < 0.05). Thirty-day mortality was greater for non-marginal admissions (8.8%) than non-marginal discharges (1.6%, p = 0.01), but not significantly different than marginal dispositions (3.4%). Marginal admissions had shorter median LOS (3.1 vs. 5 days, p < 0.01) and higher early discharge rates (27.8% vs. 13.2%, p = 0.01) than non-marginal admissions. Marginal discharges had fewer 7-day returns than non-marginal discharges (0% vs. 11.7%, p = 0.04). For marginal cases, physicians discussed admission benefits more than risks (70.1% vs. 43.3%, p < 0.01) for marginal cases.

Limitations: Single-site and need for admission were reported contemporaneous with disposition decision.

Conclusions: One in six older adult ED dispositions was identified as marginal. These patients are potential targets for shared decision-making and alternative care pathways.

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: Older adults are at high risk for severe injuries and death from falls. Physical therapist (PT) and occupational therapist (OT) evaluations have been introduced into Emergency Department (ED) care to assist with fall risk evaluation and fall prevention care. An evaluation of current evidence was undertaken to inform the Geriatric ED Guidelines 2.0.

Methods: Systematic review of physical and/or occupational therapy evaluation for fall prevention in the ED. The intervention was evaluation by a rehabilitation therapist (PT, OT, or both) for fall prevention, fall assessment, or mitigation of fall risk factors. Studies that did not perform the evaluation during the ED or ED Observation Unit visit were excluded, such as referrals for home consultation. The published literature was searched using strategies created by a medical librarian and was implemented in Embase and PubMed in March 2025. Covidence was used for article collation and review. Risk of bias was assessed using the Cochrane Risk of Bias v2 and the Ottawa-Newcastle scale.

Results: The search resulted in 387 articles with 52 duplicates, for 335 unique citations. Ten articles on 6 datasets were included (4 abstracts and 6 published manuscripts). One article was at high risk of bias as very few intervention patients received therapist evaluation. The remaining 5 datasets had varied co-interventions in addition to PT and/or OT evaluations. PT or OT evaluation in the ED was associated with reduced ED revisits at 1, 2, and 6 months. Evaluations in the ED were not associated with increased hospital admission rates or ED length of stay. A meta-analysis was infeasible due to varied outcome timeframes.

Conclusions: PT and/or OT evaluations for fall prevention were associated with reduced subsequent ED revisits for older adults. However, the impact of co-interventions and heterogeneity limits strong conclusions.