BMC Emergency Medicine最新文献

Background: Emergency departments (EDs) are important access points for acute care in the U.S. healthcare system. However, persistent operational challenges, ranging from overcrowding to staffing shortages continue to threaten care quality and provider well-being. While existing literature has explored patient-level outcomes and system bottlenecks, the perspectives of ED leadership remain underexamined.

Objective: To explore how ED leaders across diverse facility types perceive, prioritize, and respond to operational challenges, and to identify context-sensitive strategies for improvement.

Methods: We employed a sequential explanatory mixed-methods design, combining survey data (n = 40) with semi-structured interviews (n = 8) of ED leaders representing rural, urban, and academic settings. Quantitative data were analyzed descriptively, while qualitative data underwent thematic analysis. Findings were triangulated to identify patterns across five operational domains: capacity management, staffing models, care coordination, digital integration, and patient experience.

Results: Leaders expressed near-universal satisfaction with triage protocols (94%) and onboarding practices (76%), signaling possible successful standardization. However, significant role-based and contextual divergences emerged, particularly around staffing adequacy, handoff quality, and revenue cycle awareness. Rural leaders reported greater innovation despite resource constraints, leveraging simplified protocols and creative staffing models. Strategic priorities such as space optimization and technology integration were often misaligned with operational realities, highlighting systemic implementation barriers.

Conclusion: ED leadership effectiveness hinges on adaptive strategies tailored to local contexts. While certain practices can be standardized, many require customization based on facility type, leadership role, and resource availability. These findings support a differentiated approach to ED improvement, one that balances evidence-based protocols with entrepreneurial adaptability and cross-professional collaboration.

Clinical trial number: Not applicable.

Background: Sepsis in older patients is associated with a high mortality rate, presenting a considerable clinical challenge. Existing mortality prediction scoring systems have demonstrated limited accuracy in this population. The Ramathibodi Older Sepsis Score (ROSS) was developed to address this limitation. However, temporal validation is necessary to assess its efficacy in predicting 28-day mortality.

Objective: This study aimed to validate the Ramathibodi Older Sepsis Score (ROSS) for predicting 28-day mortality in older sepsis patients in the emergency department (ED).

Methods: Data for the development cohort were retrospectively collected from August to December 2018, while data for the validation cohort were collected from January to June 2022. Seven prespecified prognostic factors for 28-day mortality were used to develop a predictive a predictive score and assess its performance.

Results: A total of 500 older sepsis patients were included in the validation cohort, and 599 patients were included in the development cohort. The predictive ability of the ROSS model in the validation cohort (Area under receiver operating characteristic curve; AuROC: 0.69, 95% CI: 0.61-0.77) decreased compared to the development cohort (AuROC: 0.87, 95% CI: 0.82-0.92); P < 0.01. This performance was compared with other scoring models: SIRS (AuROC: 0.50, 95% CI: 0.42-0.58; P < 0.01), qSOFA (AuROC: 0.70, 95% CI: 0.64-0.77; P = 0.75), NEWS2 (AuROC: 0.68, 95% CI: 0.60-0.76; P = 0.81), and REWS (AuROC: 0.66, 95% CI: 0.57-0.75; P = 0.51).

Conclusion: The temporal validation of the ROSS demonstrated moderate performance in predicting 28-day mortality in older sepsis patients, with AuROC values similar to qSOFA and NEWS2. Although ROSS did not outperform existing scores, it offers geriatric-specific insights and highlights the need for further validation.

Aim: Guided by the 2020 AHA quality targets for chest compressions, we used a manikin model to assess the effects of compression angle (90° vs. 100°) and audiovisual feedback on compression quality and rescuer fatigue.

Methods: This was a randomised, crossover, controlled trial. Four experimental groups were included: CCA90°, CCA90° with audiovisual feedback, CCA100°, and CCA100° with audiovisual feedback. Twenty-nine participants, following standardized training, performed 2-minute chest compression sessions on a manikin under each condition, with the order of scenarios randomized by lottery. Heart rate, blood pressure, and Borg Rating of Perceived Exertion (RPE) were recorded immediately before and after each session.

Results: Significant differences in mean chest compression depth were observed among the four groups (CCA90°: 49.6 ± 7.6 mm; CCA90° with audiovisual feedback: 51.3 ± 3.2 mm; CCA100°: 50.7 ± 8.3 mm; CCA100° with audiovisual feedback: 55.1 ± 4.5 mm; P < 0.001). However, both the CCA100° and CCA100° with audiovisual feedback groups had comparable medians (100%) but a lower overall distribution for Correct recoil rate (100 [92.8, 100]% and 98.5 [74.3, 100]%, respectively; P < 0.001) and for Correct hand position ratio (91.9 [23.7, 99.4]% and 89.1 [59.5, 99.8]%,respectively; P < 0.001) compared to the conventional CCA90° group. Changes in heart rate (P = 0.02) and RPE scores (P < 0.001) were greatest in the CCA100° with audiovisual feedback group, indicating a higher level of rescuer fatigue. No significant differences were observed among the four groups in terms of mean chest compression rate, accurate compression rate ratio, or change in mean arterial pressure.

Conclusion: The forward-leaning (100°) posture during CPR enhances chest compression depth; however, it may compromise correct hand positioning and complete chest recoil.

Background: The diagnostic utility of the D-dimer/pCO₂ ratio for pulmonary embolism (PE) risk stratification has not been fully established. This study evaluated its diagnostic performance among emergency department patients with positive age-adjusted D-dimer results undergoing computed tomography pulmonary angiography (CTPA).

Methods: This retrospective diagnostic accuracy study included 698 adult patients with positive age-adjusted D-dimer results, venous blood gas (VBG) pCO₂ measurements, and definitive CTPA interpretation. The D-dimer/pCO₂ ratio was calculated, and receiver operating characteristic (ROC) analysis was performed. Optimal and exploratory thresholds were assessed for overall PE detection and for excluding central PE. Robustness was tested using bootstrap validation and subgroup AUC comparisons. Decision curve analysis (DCA) was applied to evaluate clinical utility.

Results: PE was confirmed in 90 patients (12.9%). The ratio demonstrated good discrimination (AUC: 0.811, 95% CI: 0.775-0.847). At the optimal cut-off (44.91), sensitivity was 82.2% and specificity 71.1%, with a negative predictive value (NPV) of 96.4%. A lower cut-off (18.1) identified 91 patients with no observed PE (0/91; 95% CI upper bound for false negatives ≈ 4.0%). A higher threshold (61.25) identified 515 patients below this value, among whom no central PE was observed (0/515; 95% CI upper bound ≈ 0.7%). Discriminative ability was preserved across age groups (AUC range: 0.737-0.836). DCA showed modest, range-specific net benefit for incorporating the ratio within a low-to-intermediate threshold band.

Conclusion: In D-dimer-positive ED patients already being considered for CTPA, the D-dimer/pCO₂ ratio is an adjunctive imaging triage indicator rather than a stand-alone test and may help inform the imaging workflow in this defined context. These findings should not be extrapolated to D-dimer-negative patients or those with very high pretest probability.

Background: Patients with traumatic brain injuries (TBIs) have high mortality rates and poor outcomes. Predicting the need for urgent interventions, as well as mortality risk, is crucial for optimizing trauma management. This study aimed to identify and validate the reverse shock index multiplied by the Glasgow Coma Scale score (rSIG) as an assessment tool for predicting urgent interventions, critical care, and mortality in patients with isolated severe TBIs.

Methods: This retrospective nationwide validation study analyzed data from the Japan Trauma Data Bank between January 1, 2012, and December 31, 2021. The population was divided into derivation (2012-2018) and validation (2019-2021) cohorts. The primary composite outcome included blood transfusions within 24 hours of hospital arrival, craniotomy or craterization, intracranial pressure (ICP) monitoring, tracheal intubation, intensive care unit (ICU) admission, and in-hospital mortality. The optimal rSIG cutoff for predicting urgent interventions was determined using the Youden Index, and gray-zone analysis was performed as sensitivity.

Results: A total of 42,375 patients were analyzed (derivation cohort, n = 32,483; validation cohort, n = 9,892). The optimal rSIG cutoff point for predicting urgent intervention was 16.21. When applied to the validation cohort, the model demonstrated moderate discrimination (AUC 0.655, 95% CI 0.644-0.666). For predicting surgical intervention was 16.46, yielding as AUC 0.627 (95% CI 0.614-0.639), sensitivity of 53.2%, specificity of 72.1%, positive predictive value of 29.2%, and negative predictive value of 87.7%. Patients with abnormal rSIG values ( < 16.21) had significantly higher rates of urgent interventions, ICU admission, and in-hospital mortality (all p < 0.01). In the gray-zone analysis, rSIG values ≤6, 6-35, and ≥35 defined high-, moderate-, and low-risk groups, respectively; the high-risk group showed the greatest need for urgent trauma care and highest mortality (p < 0.001).

Conclusions: The rSIG may serve as a simple and practical indicator for predicting urgent interventions, critical care, and mortality in patients with isolated severe TBIs. Its simplicity and rapid calculability support its potential use as a triage tool in prehospital settings and as a clinical diagnostic aid in hospital environments.

Background: Enhancing disaster preparedness among women in vulnerable coastal regions is critical for reducing the impact of emergencies. Leveraging community members as change agents helps bridge knowledge gaps, shift attitudes, and improve emergency skills in resource-limited settings.

Objective: This study assessed the effectiveness of trained community change agents (CCAs) in improving disaster-related knowledge, attitudes, and cardiopulmonary resuscitation (CPR) skills among women.

Materials and methods: A quasi-experimental study involved 414 women from four coastal villages in Tamil Nadu, with 206 in the experimental group and 208 in the control group. Community change agents were trained in disaster-related knowledge, attitudes, and Cardio Pulmonary Resuscitation skills using the Coastal Disaster Readiness Package (CDRP). They then provided similar training to women in their communities, focusing on home disaster preparedness. Data was collected using a structured questionnaire and an observational checklist.

Results: The results indicated that women trained by Community Change Agents exhibited significant enhancements in disaster preparedness knowledge score relative to the control group, from pre-test 7.52 ± 3.71 to at 6-month post-test 16.43 ± 3.67, reflecting a 44.6% knowledge score gain. In contrast, the control group showed a minimal increase from 7.75 ± 3.66 to 9.01 ± 4.80. Attitude ratings were enhanced by 39.4% in the experimental group compared to a mere 0.6% in the control group. The experimental group observed significant gains in skills, rising scores from 13.44 at one month to 15.35 at six months (mean difference = 1.91, F = 45.95, p = 0.001). The control group, on the other hand, did not see any noteworthy improvements. Correlation analysis showed that there were moderate positive relationships between knowledge and attitude (r = 0.52, p = 0.001), knowledge and skill (r = 0.54, p = 0.001), and attitude and skill (r = 0.49, p = 0.001).

Conclusion: The study concludes that trained community change agents significantly improved disaster-related knowledge, attitudes, and CPR skills among women in coastal areas. The intervention effectively bridged preparedness gaps in a vulnerable population. Empowering local agents proved to be a practical and impactful strategy for enhancing community resilience.

Clinical trial number: Not Applicable.

Background: Lactate dynamics reflects restoration of tissue perfusion and has prognostic value in critical illness. However, the temporal evolution of lactate and its prognostic implications after out-of-hospital cardiac arrest (OHCA) have not been fully elucidated.

Methods: We retrospectively analyzed adult patients with OHCA with sustained return of spontaneous circulation (ROSC) at a tertiary medical center in Taiwan between 2016 and 2022. Serial lactate levels were measured at 2, 6, 12, and 24 h after ROSC. The primary outcome was a favorable neurological status at discharge, and a key secondary outcome was survival to discharge. Linear mixed-effects models were applied to evaluate longitudinal lactate trajectories and their associations with outcomes, accounting for repeated measures and adjusting for age, initial rhythm, bystander cardiopulmonary resuscitation (CPR), CPR duration, public location, witnessed status, targeted temperature management, percutaneous coronary intervention, and extracorporeal membrane oxygenation.

Results: Of the 496 included patients, 90 (18.1%) achieved a favorable neurological outcome and 241 (48.6%) survived to discharge. Lactate levels declined significantly over time in both groups (p < 0.001), but patients with favorable neurological outcomes and survivors showed a steeper decline between 12 and 24 h. Interaction analyses revealed significant time × outcome effects for neurological outcome at 12 h (β = - 0.33, 95% CI - 0.65 to - 0.001, p = 0.049) and 24 h (β = - 0.61, 95% CI - 0.91 to - 0.30, p < 0.001), and for survival at 12 h (β = - 0.38, 95% CI - 0.64 to - 0.13, p = 0.002) and 24 h (β = - 0.48, 95% CI - 0.72 to - 0.24, p < 0.001).

Conclusion: Serial lactate trajectories within the first 24 h after ROSC were strongly associated with survival and neurological recovery in OHCA patients. Modeling lactate as a continuous dynamic biomarker using LMM captured prognostic information beyond single time points and may help guide individualized post-resuscitation management.