Pakistan journal of pharmaceutical sciencesRoberto Lozano, Aragn Health Service, Zaragoza Zaragoza, Spain Spain
BACKGROUND: Spinal muscular atrophy (SMA) is a rare neuromuscular disorder treated with disease-modifying therapies such as risdiplam. In Spain, its use is regulated by a national pharmacoclinical protocol that requires structured monitoring. OBJECTIVES: To evaluate real-world use, protocol adherence and registry completeness of risdiplam in routine clinical practice. METHODS: A retrospective registry-based case series was conducted including patients with spinal muscular atrophy treated with risdiplam.Variables included age, SMA subtype, SMN2 copy number, diagnostic confirmation, treatment sequence and persistence. Protocol adherence was assessed according to national criteria. RESULTS: Ten patients were included in the study. SMA types II and III predominated, with one presymptomatic case. SMN2 copy number ranged from three to four in documented cases. Protocol adherence was confirmed in 70% of patients, while 30% lacked key eligibility variables. No off-protocol prescribing was identified. Treatment persistence was 100% and 60% of patients had previously received nusinersen. CONCLUSION: Risdiplam was used appropriately in accordance with protocol criteria. Registry incompleteness, rather than clinical deviation, was the main limitation and standardized data capture is essential for real-world evaluation.
Nursing in critical careNana Wu, Xia Chen, Jie Fu, Liwen Ding, Hong Zhou, Tiantian Xiao
BACKGROUND: Point-of-care ultrasound (POCUS) is increasingly used in paediatric and neonatal critical care, but evidence on nurse-led bedside POCUS remains limited and fragmented. AIMS: This scoping review aimed to map the evidence on nurse-led bedside POCUS in paediatric and neonatal critical care nursing practice, examine implementation factors and identify evidence gaps relevant to nursing research, education and clinical practice. METHODS: Following JBI methodology and PRISMA-ScR guidance, we searched PubMed, Embase, CINAHL, Web of Science, Cochrane Library and CNKI from inception to October 2025. Eligibility followed the PCC framework. Two reviewers independently screened records and extracted data using a standardized form. Study characteristics were synthesized descriptively, and implementation factors were deductively analysed using the COM-B framework. RESULTS: Thirty-four studies were included, mainly from the United States and China. Nurse-led POCUS applications included vascular access, respiratory assessment, catheter localization, cardiac or hemodynamic evaluation, bladder assessment and education or competency development. Outcomes included clinical (procedural success and diagnostic accuracy), process (timeliness and workflow efficiency) and nurse-related (competency, confidence and role development). Safety-related outcomes were the least reported. Implementation was influenced by training, equipment, protected time, institutional support, collaboration and patient safety concerns. The automatic motivation domain, referring to unconscious drivers such as habits and emotional responses, was not addressed by any study. CONCLUSIONS: Nurse-led POCUS is an emerging but unevenly developed component of paediatric and neonatal critical care. Brief training may support initial competency, but sustained implementation is constrained by underdeveloped quality assurance, unclear career pathways and limited attention to motivational processes. RELEVANCE TO CLINICAL PRACTICE: Future nursing research and clinical programmes may look beyond short-term training outcomes to consider competency standards, longitudinal supervision, quality assurance, educational approaches combining foundational POCUS training with structured workplace supervision and sustainable integration into routine care delivery.
Zhonghua jie he he hu xi za zhi = Zhonghua jiehe he huxi zazhi = Chinese journal of tuberculosis and respiratory diseasesC J Wei, Z S Cheng
The case fatality rate of severe pneumonia remains high, early and accurate etiological diagnosis is a prerequisite for precision antimicrobial therapy. Conventional culture techniques are limited by long turnaround times and low positivity rates. In recent years, novel detection systems such as microbiological rapid on-site evaluation(M-ROSE), point-of-care immunoloassays, multiplex PCR, and metagenomic sequencing have advanced rapidly, markedly shortening the time to pathogen identification. The integration of rapid detection assays for antimicrobial resistance genes has further facilitated precision antimicrobial therapy. Multi-omics analysis integrating the pathogen spectrum with host immune response status helps distinguish colonization from infection, thereby helping prevent antibiotic overuse. This article reviews techniques for pathogen and antimicrobial resistance gene detection together with strategies to distinguish colonization from infection to inform rapid bedside etiological diagnosis in severe pneumonia.
BMJ openAkshay Kumar, Catriona Marshall, Sonia Saraiva, William Lee, Suzanne Mason, Christopher D Burton, Christina Maria van der Feltz-Cornelis, Robert M West, Chris …
OBJECTIVES: To identify patient and attendance characteristics that predict persistent high use of emergency departments (EDs) in England and to quantify the relationship between these factors and the duration an individual remains a high user. DESIGN: Nationwide retrospective cohort study using a Cox proportional hazards model with random effects. SETTING: EDs across England, using linked national healthcare datasets including hospital admissions, General Practice (GP) prescribing data and mortality records from January 2016 to December 2019. PARTICIPANTS: The total national dataset comprised approximately 150 million ED attendances by 30 million adult patients (aged>18). From this, a random sample of 5 million individuals was analysed. In the 2017 calendar year, 1 766 208 individuals attended the ED, of which 91 034 (5.2%) met the criteria for high use (defined as five or more attendances within a 12-month period). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the length of time an individual remained in the 'high user' status. Predictors were measured using HRs to determine the likelihood of transitioning out of high-user status (where an HR<1.00 indicates a longer duration of high use). RESULTS: Several factors significantly predicted prolonged high-user status. Strong predictors (expressed as HRs) included: use of hypnotics and anxiolytics (HR=0.64), antipsychotics (HR=0.67), opioid analgesics (HR=0.73) and non-opioid analgesics (HR=0.74), being a 'burst' attender (HR=0.55), social deprivation (HR=0.81), leaving the department after refusing treatment (HR=0.77), leaving before being treated (HR=0.86) and having 'nothing abnormal detected' during the visit (HR=0.88). CONCLUSIONS: Persistent high ED use is strongly associated with prescriptions for analgesics and mental health medications, as well as specific attendance behaviours like 'burst' patterns and leaving without treatment. These findings suggest that healthcare providers should prioritise proactive care plans, enhanced mental health support and specialised pain management strategies to intervene before patients become long-term frequent users. Further research into the efficacy of these specific interventions for 'burst' attenders is warranted.
The American journal of case reportsFaisal J Alqahtani
BACKGROUND Ovarian torsion is an uncommon but time-sensitive gynecologic emergency in children. Diagnosis may be challenging because symptoms can be nonspecific and Doppler ultrasonography may demonstrate residual ovarian blood flow. Although oophoropexy may be performed to reduce recurrence, torsion can recur after fixation. CASE REPORT A 9-year-old prepubertal girl with a history of left ovarian torsion treated by laparoscopic detorsion and oophoropexy presented with 2 days of severe intermittent left-sided abdominal pain and 1 day of vomiting. She was afebrile and hemodynamically stable, without peritoneal signs. Transabdominal ultrasonography demonstrated an enlarged left ovary measuring 41×37×32 mm (approximately 27 mL), with diminished vascularity and faint internal flow on color and power Doppler imaging. Urgent laparoscopy confirmed recurrent left ovarian torsion of approximately 360°. The ovary was viable, and no ovarian cyst or adnexal mass was identified. Detorsion and utero-ovarian ligament plication were performed, preserving the ovary. At 8-week follow-up, ultrasonography demonstrated normalization of the left ovarian size to 16×14×24 mm (approximately 2.7 mL), with no adnexal lesion or pelvic free fluid. CONCLUSIONS Recurrent ovarian torsion can occur despite previous oophoropexy. Residual Doppler flow should not exclude torsion when clinical suspicion remains high. Prompt surgical evaluation can permit detorsion and ovarian preservation.
BMJ open qualityMohamed A Mansour, Ali Al-Kulabi, Minaam Abbas, Layth Qaraqe, Sade Uwaoma, Ahmad Al-Sukaini, Lora Young, Sue Deakin
INTRODUCTION: Managing musculoskeletal (MSK) injuries requires effective communication and collaboration between the emergency department (ED) and orthopaedic teams. A quality improvement project analysing virtual fracture clinic (VFC) referrals, staff challenges and the impact of the novel digital solution, Virtual Bones (VB), was undertaken at the West Suffolk Hospital. VB is a digital platform, available at the point of care, that guides clinicians in the assessment and management of MSK injury presentations in ED and referral to VFC. METHODS: VFC outcome data were collected between 2017 and 2022, with a 2-week focused data collection gathering diagnosis, ED processing times, patient leaflet distribution, VFC decisions and referral quality. An ED survey was distributed to explore staff challenges in the management of MSK injuries. Virtual Bones, a novel digital solution, was developed and deployed to enable clinicians to comprehensively digitalise MSK injury management pathways from first patient encounter to referral/discharge. Subsequent data collection cycles compared baseline to post deployment results. RESULTS: The Virtual Bones pilot (undertaken May-July 2023) involved 352 users, 2400 sessions and 56 700 page views. The initial 2-week cycle included 260 patients while the subsequent cycles included a total of 258. Mean ED processing times decreased from 166 to 122 min, with an up to 90 min reduction in the Foundation Doctors' group (p<0.0001). Inappropriately referred dischargeable injuries decreased from 23 to 10. Improper documentation decreased from 58% to 30% (p<0.0001). The VFC discharge rate increased from 39% to 48% (p=0.021). Patient information leaflet use increased from 27% to 41% (p=0.032). The ED staff survey demonstrated improved staff confidence in the revealed challenges, including navigating local guidelines, locating equipment, applying immobilisation devices and supplying information leaflets. CONCLUSION: Robust engagement with Virtual Bones, along with improved metrics, suggests that this digital solution effectively streamlined MSK injury pathways and helped staff manage challenges.
PloS oneNandakumar Ravichandran, Etimbuk Umana, Tomas Breslin, Aoife Cotter, Walter Cullen
Sepsis is a life-threatening condition associated with substantial morbidity and mortality worldwide. In Ireland, the majority of sepsis cases are community-acquired; however, patients presenting to emergency departments (EDs) with suspected severe infection remain poorly characterised, particularly those not captured in administrative datasets. This retrospective cross-sectional observational study will be conducted in the ED of Mater Misericordiae University Hospital, Dublin. Adult (non-maternity) ED presentations across eight predefined 24-hour sampling periods will be reviewed. Community-acquired acute infection will be identified through manual review of ED clinical documentation, and possible sepsis will be identified using the ED triage sepsis discriminator supported by clinical documentation. Data collected will include demographic characteristics, referral pathways, clinical presentation, and patient outcomes. Multivariable logistic regression will be used to identify factors associated with adverse outcomes, defined as intensive care unit admission or in-hospital mortality. This study will provide a detailed evaluation of ED presentations with suspected severe infection in Ireland, including patients not captured in existing national datasets. Findings will contribute to improved understanding of early sepsis recognition, referral pathways, and resource planning in emergency care.
Journal of medical Internet researchJessica Faiz, Caroline Gray, Allison Engstrom, Justine Seidenfeld, Anita A Vashi
BACKGROUND: Emergency departments (EDs) face persistent challenges related to overcrowding, boarding, ambulatory care access barriers, and workforce strain, contributing to compromised patient care and high rates of physician burnout. Virtual care has emerged as a potential strategy to alleviate pressure on emergency care systems. In 2020, the Veterans Health Administration (VA) launched the national Tele-Emergency Care (TEC) program, in which patients who call a call center can be connected to an emergency medicine clinician by phone or video. Although virtual care may help address ED capacity and clinician burnout, the perspectives of emergency medicine-trained clinicians remain limited. OBJECTIVE: The aim of this study is to examine the experiences of emergency medicine clinicians participating in VA's TEC program. METHODS: As part of a national mixed methods evaluation of TEC, we conducted semistructured interviews with clinicians delivering emergency care through TEC between February 2025 and June 2025. Participants (n=15) were recruited via multistage purposeful sampling from 4 of 18 regional TEC programs that varied in geography, volume, duration, and operational models. Interviews explored experiences of providing care in a virtual environment, including perceived benefits and challenges. We performed a descriptive qualitative analysis. RESULTS: We interviewed 14 physicians and 1 nurse practitioner with formal emergency medicine training. Interviewees described four primary themes: (1) clinical decision-making in a virtual environment; (2) development of the provider-patient relationship; (3) clinician job satisfaction and professional well-being; and (4) challenges. Participants reported that TEC provided perceived opportunities to avoid ED referrals, more focused patient interactions, and improved job satisfaction related to flexible virtual shifts. Reported challenges included filling primary care gaps and performing care coordination tasks. CONCLUSIONS: TEC represents an emerging model of emergency care delivery that clinicians perceive may expand access, prevent avoidable ED visits, and support clinician well-being while also introducing distinct clinical and operational challenges. Our findings can inform the implementation of similar emergency telehealth services in other health systems.
PloS oneMichelle Beattie, Lesley Campbell, Bev Fraser, Anna Terje
BACKGROUND: Drug-related harm is a major global public health concern, with opioids implicated in over 70% of drug-related deaths. Scotland reports the highest drug-related mortality rate in Europe, with remote and rural communities facing additional barriers to accessing harm reduction and treatment services. Assertive outreach is increasingly recognised as a key strategy to engage individuals at risk who are disconnected from traditional services. This study evaluates the use of a Trigger Checklist to identify and outreach individuals within 48 hours of referral in a rural Emergency Department (ED). METHODS: A realist evaluation explored how and why the Trigger Checklist works within the complexity of an ED setting. Guided by Pawson and Tilley's framework, the evaluation followed three stages: theory gleaning, refining, and consolidation. Initial programme theories were developed using literature and advisory group input, then refined through 13 realist interviews with ED clinicians and outreach workers (OW). Data were analysed using Context-Mechanism-Outcome (CMO) configurations and linked to middle-range theories. RESULTS: Three programme theories emerged: (1) Confident decision-making, where certainty, conversational aids, ethical reasoning, and outreach worker prompts influenced checklist use; (2) Trusting relationships, shaped by OWs' approachability, situational awareness, and mutual respect; and (3) Perceived value, driven by altruism, narrative feedback, and perceived reductions in ED visits. Relational coordination theory explained how shared goals, knowledge, and respect - reinforced by timely, accurate communication - enabled coordinated action. OW presence and recovery discussions were critical to foster confident and appropriate referrals among ED clinicians. CONCLUSIONS: The Trigger Checklist can support timely outreach potentially reducing drug-related harm in rural ED settings, but its success depends on relational dynamics, perceived value, and organisational integration. To avoid checklist fatigue or tokenistic use, it should be embedded with the support of OWs who foster trust. These relationships will enhance use of the checklist as a meaningful intervention within complex care systems.
JMIR human factorsMeghana Darla, Danielle Miltz, Khushboo Chandnani, Saptarshi Purkayastha, John W Diehl, Sivasubramanium V Bhavani
BACKGROUND: AI has the potential to enhance clinical decision-making in high-acuity settings such as intensive care units (ICUs) and emergency departments (EDs). However, despite promising performance, many AI-driven clinical decision support systems (AI-CDSSs) face poor adoption due to issues of trust, workflow disruption, and alert fatigue. Understanding the human factors that shape clinician acceptance is critical to guide safe and effective implementation of AI-CDSS in acute care. Theoretical frameworks, including the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model and the technology acceptance model (TAM), suggest that successful adoption requires addressing sociotechnical interactions among clinician trust, system design, organizational readiness, and task complexity, yet few empirical studies have applied these frameworks to AI-CDSSs in acute care settings. OBJECTIVE: This study aimed to evaluate emergency medicine and critical care clinicians' perceptions of AI-CDSSs and to identify key factors influencing adoption, including trust, design preferences, and workflow integration. METHODS: A SEIPS 2.0-informed mixed methods study evaluated ICU and ED clinicians from Emory Healthcare on perceptions of AI in clinical practice. An expert-reviewed survey (N=57) assessed clinician perceptions, trust, and implementation preferences. Semistructured interviews (n=11) included A/B testing of AI-CDSSs and clinical sepsis scenarios to explore decision-making in context. Transcripts were thematically analyzed using the Braun and Clarke framework in ATLAS.ti (version 26, ATLAS.ti Scientific Software Development). Quantitative data were analyzed descriptively. This study assessed clinician perceptions using mock alerts and hypothetical scenarios rather than real-world AI-CDSS deployment. RESULTS: Trust in AI varied significantly by patient acuity (Cochran Q=30.40, P<.001): stable patients (43/57, 75%, 95% CI 63%-85%), deteriorating patients (27/57, 47%, 95% CI 35%-60%), and critically ill patients in the ICU and undifferentiated patients in the ED (25/57, 44%, 95% CI 32%-57% for each scenario). Internal consistency was acceptable-to-good across three scales (Cronbach α: AI Perception=.891, Trust=.743, Implementation=.740; McDonald ω: AI Perception=0.895, Trust=0.782, Implementation=0.746). Barriers included overreliance, insufficient training, and data quality concerns. For the exploratory AI-CDSS design, clinicians preferred opt-in alerts (10/11, 91%), evidence-linked recommendations (7/11, 64%), and avoiding overt mention of increased AI acceptance (8/11, 73%). Thematic analysis yielded 36 themes across six domains: trust and transparency, alert usability, workflow fit, data concerns, training needs, and perceived clinical impact. Clinicians favored AI-CDSSs that preserved autonomy, minimized disruption, and provided transparent rationales. CONCLUSIONS: Adoption of AI-CDSSs in critical care is not solely a technical issue but a human-factors challenge centered on trust, transparency, and workflow compatibility. These findings support future testing of a phased implementation approach-beginning with lower-acuity applications where clinician trust is highest, then gradually extending to higher-acuity scenarios with enhanced transparency and override mechanisms. This graduated strategy addresses the critical interdependencies among people (trust), tools (design), organizations (training), and tasks (clinical complexity) identified in this study.
Southern medical journalPaul Park, Paul Koscumb, Nadia Ahmed, Jeremy Carter, Elizabeth Davis, T Preston Hill
OBJECTIVES: Diagnostic point-of-care ultrasound (POCUS) increasingly is recognized as a valuable bedside assessment tool; however, the most commonly cited barrier to starting a POCUS curriculum in Internal Medicine residency has been the lack of in-house experts. We propose collaborating with the emergency department because all of their faculty are POCUS trained during residency. METHODS: At the University of Texas Medical Branch, we partnered with the emergency department to create a hands-on core rotation starting in 2023 for all postgraduate year-1 residents to improve their skills, knowledge, and confidence with diagnostic POCUS. The residents watched didactic videos in addition to working with faculty and ultrasound technicians one to one for 2 weeks on live patients. RESULTS: The efficacy of the curriculum was evaluated using a pre- and postcourse knowledge quiz, a confidence survey, and a skills assessment. Out of 40 residents, 24 completed the written knowledge quiz and confidence survey, and 14 completed the skills assessment. Overall, the data showed significant improvement in all three evaluation methods. CONCLUSIONS: The success of starting a new POCUS curriculum depends heavily on the ability of the program to recruit expert educators, and that degree may vary by institution. We believe this study shows one way that success may be achieved.
Southern medical journalRowan Burns, Liela Meng, Mirinda Ann Gormley, Stella Self, Nathan Hudepohl
OBJECTIVES: Sepsis survivors are susceptible to health complications, substantially increasing the risk of emergency department (ED) and hospital readmissions. Few evaluations, however, have assessed the effectiveness of interventions targeted at decreasing readmissions among patients with sepsis. This study evaluated the effectiveness of a targeted intervention to decrease 72-hour ED readmission rates in patients with sepsis or pyelonephritis in a large ED in the US South. METHODS: This retrospective cohort study investigated 72-hour readmission rates from January 1, 2020 to December 31, 2023 for adults with an ED diagnosis of sepsis or pyelonephritis. An intervention to decrease ED readmissions was implemented on May 4, 2021. Monthly readmission rates were calculated as the proportion of patients readmitted within 72 hours of discharge following an ED visit with a discharge diagnosis of sepsis or pyelonephritis. Interrupted time series analysis was used to assess the differences in trends of monthly readmission rates prepolicy implementation, during policy implementation, and postpolicy implementation. RESULTS: Of 39,818 patients, 4907 (12.3%) had 72-hour readmissions. Preintervention, 72-hour readmissions increased by 0.00054 per admission per month (P = 0.30). At implementation, there was an immediate drop of 0.0017 in the monthly readmission rate (P = 0.75), and in postimplementation period, the trend reversed, with a sustained decrease of 0.00112 readmissions per admission per month (P = 0.04). There were sustained decreases in readmissions per admission per month of 0.00061 (P = 0.25) and 0.0033 (P = 0.02) for pyelonephritis and sepsis, respectively. CONCLUSIONS: This intervention was associated with a sustained decrease in readmissions per month for septic individuals seen in the ED. The authors did not report any financial relationships or conflicts of interest.
International journal of mental health nursingMichelle Glascott, Philip Hodgson, Wendy Hope, Nicola Clibbens, Luke Aston, Laura Fleming, Alison Innerd, Michael Graham
Adult acute mental health wards operate under sustained pressure, characterised by high patient acuity, workforce shortages and a focus on risk management that can limit opportunities for therapeutic engagement. Although physical activity is increasingly recognised as beneficial for mental and physical health, there remains limited evidence to guide its implementation within acute inpatient settings. The purpose of this study was to generate practice-relevant insights to inform the design and implementation of feasible physical activity interventions in adult acute mental health wards. A qualitative study was conducted using focus groups across two National Health Service mental health trusts in England. Thirty participants took part, including mental health nurses, multidisciplinary staff and people with lived experience of acute ward care. Data were analysed using reflexive thematic analysis within a multidisciplinary and lived-experience-informed research team. Three interrelated themes were identified. Barriers to implementation reflected the interaction between patient acuity, medication effects, restrictive practices, workforce pressures and ward organisation. Enablers and opportunities included nursing leadership, flexible and relational delivery approaches, staff participation and active involvement of patients in the design of activities and care planning. Participants also highlighted the importance of evaluation approaches that balance feasibility with meaningful patient-centred and ward-level outcomes, including staff wellbeing and ward atmosphere. Physical activity was perceived as both desirable and achievable when adapted to the realities of acute ward environments. These findings address an important evidence gap and can inform the development of context-sensitive, recovery-oriented physical activity interventions aligned with acute inpatient mental health nursing practice.
Giornale italiano di cardiologia (2006)Simona Giubilato, Francesca Musella, Carlotta Sorini Dini, Francesco Piroli, Nicola Gasparetto, Serena Guasti, Roberta Della Bona, Daniela Zabbia, Francesca Ca…
Point-of-care ultrasound (POCUS) is an imaging modality performed and interpreted by the treating physician at the bedside, with immediate integration of findings into clinical decision-making. Its rapid expansion in emergency medicine, critical care, and resource-limited settings has significantly improved diagnostic and therapeutic timeliness. However, this growth has highlighted the need to clearly define its scope of practice, standardize protocols, and distinguish POCUS from comprehensive consultative echocardiography. This review outlines the historical evolution of POCUS, from early trauma applications to structured protocols for shock, dyspnea, and cardiac arrest, and its current role in cardiopulmonary and hemodynamic monitoring of critically ill patients. Recent international guidelines are summarized, emphasizing POCUS as a distinct and complementary clinical tool rather than a replacement for formal imaging. Finally, future perspectives involving artificial intelligence and robotic ultrasound technologies are discussed, addressing their potential benefits and associated educational, organizational, and ethical challenges.
Emergency medicine Australasia : EMAJustin Boyle, Andrew Staib, Clair Sullivan, Sankalp Khanna, Ibrahima Diouf, Hamed Hassanzadeh, Jin Yoon, Vahid Riahi, Mahnaz Samadbeik, Emma Bosley, James Lind
OBJECTIVE: To identify evidence-based factors leading to the global challenge of hospital access block and inform strategies to improve emergency access performance. METHODS: A mixed methods approach was followed comprising an umbrella review of published systematic reviews, qualitative analysis of the perspectives of patients and healthcare workers, and quantitative analysis of contextual factors and 6 years of ambulance, emergency inpatient and ward movement records for the 25 largest public hospitals in Queensland, Australia. RESULTS: A key set of findings and recommendations were identified to improve emergency access that are practical and actionable. These comprise the introduction of inpatient discharge metrics and monitoring to shift focus from the front door of hospitals to the 'back door'; increasing support for primary care, community care, aged care, NDIS and vulnerable groups; maintaining demand-side strategies such as increasing inpatient-equivalent care alternatives (e.g., hospital in the home, acute care within nursing home services); investment in prehospital flow; improving hospital processes such as extended-hour discharge lounges; improving workforce; and revising funding policies. CONCLUSIONS: The study findings fill a gap in the evidence regarding challenges and recommendations for improving patient flow within hospital emergency departments and across the broader health system. Focussing efforts at the 'back end' of the inpatient journey is a critical step to improve emergency care outcomes.
International journal of mental health nursingLouise Doyle, Brian Keogh, Jean Morrissey, Agnes Higgins, Róisín Reilly, Kaitlyn McGeehan
Despite the availability of guidelines and protocols, service users' experiences of accessing care and treatment for self-harm and suicidal ideation at the Emergency Department (ED) are variable. There is a need to better understand what impacts service user experiences given the important role of the ED for accessing care and influencing future interactions with mental health services for people who experience self-harm and suicidal distress. This study aimed to identify the experiences of service users when presenting to the ED with self-harm and suicidal ideation. A descriptive qualitative approach was utilised encompassing in depth semi-structured interviews with 50 adult service users who attended EDs across the Republic of Ireland for self-harm and suicidal ideation. Data were analysed using reflexive thematic analysis. Findings are reported in accordance with COREQ guidelines and focus on three themes that were developed from the data: (1) Experiences of assessment, (2) Interpersonal interactions, (3) Discharge, onward referral and next steps to care. Participant experiences of care and treatment in the ED were largely negative with reports of an over-reliance on mechanistic assessments, poor interpersonal interactions and lack of support following discharge from the ED. The use of evidence-based protocols is important to ensure standardised and effective care and treatment of people attending the ED with self-harm and suicidal ideation. However, a relational approach needs to underpin their use to ensure that service users feel respected and listened to by all staff in the ED, and more positively inclined towards future help-seeking.
Emergency medicine practiceXin Qi, Annie Leamon, Christopher Baugh
The expanding use of antiplatelet agents, anticoagulants, and fibrinolytics has made bleeding emergencies more frequent and more complex. A structured, evidence-based approach enables emergency clinicians to identify life-threatening and critical-site bleeding, initiate resuscitation, establish which antithrombotic agent the patient received and when, and weigh the benefit of restoring hemostasis against the risk for thrombosis. This review synthesizes current guidelines and evidence on the evaluation and management of bleeding in patients receiving antithrombotic therapy, identifying areas of consensus and ongoing uncertainty. Coagulation assays, agent-specific reversal and hemostatic strategies, periprocedural management, and bleeding in pregnancy are addressed.
Pediatric emergency medicine practiceChad McCalla, Crick Watkins, Nicole J Prendergast, Adam B Johnson
Pediatric elbow injuries are a common complaint presenting to emergency departments. The unique anatomy and skeletal immaturity in children can make the elbow particularly difficult to evaluate and manage. Additionally, many healthcare institutions have limited or no access to pediatric orthopedic specialists, leaving management decisions to the clinician at the bedside. This review highlights the nuances of the pediatric elbow examination, addressing both acute and subacute (overuse) injuries. Common fracture types are reviewed, and key principles of x-ray interpretation are demonstrated, including recognition of normal variants and ossification centers. Management strategies are outlined, with an emphasis on identifying which patients can be safely managed without orthopedic consultation and which require more urgent care at a pediatric center with access to pediatric orthopedic specialists.
Emergency medicine Australasia : EMAHassan K Ahmad, Yu Xuan Kitzing, Victoria Bond, Jethro Worsam, Alvin Tan, Oliver Chen, Brindha Shivalingam, Radhika Seimon, Eliot Salmon, Michael M Dinh
OBJECTIVE: Evaluate the diagnostic accuracy of an artificial intelligence (AI) model for identifying urgent computed tomography brain (CTB) findings in consecutive emergency department (ED) patients and estimate the proportion eligible for expedited disposition. METHODS: We retrospectively analysed 3424 consecutive non-contrast CTB scans from adults presenting to a quaternary ED in 2024. The AI model (Harrison Enterprise CTB) classified each scan as "urgent" or "non-urgent." The reference standard was the index consultant radiologist report alone, classified independently by two emergency physicians with disagreements resolved by a blinded consultant radiologist tiebreak, all blinded to AI output. In a separate post hoc analysis, false negatives were re-adjudicated by a single unblinded assessor with access to the medical record and any subsequent imaging. RESULTS: Of 3424 scans, 253 (7.4%) had urgent findings on the reference standard. AI sensitivity was 85.4% (95% CI 80.0%-89.0%), specificity 69.1% (95% CI 67.0%-71.0%) and negative predictive value (NPV) 98.3% (95% CI 98.0%-99.0%). An estimated 64.0% of encounters were true negatives potentially eligible for expedited disposition. Of 37 false negatives, independent adjudication reclassified 24 as non-urgent, yielding a post hoc sensitivity of 94.3% and NPV of 99.4%. The 13 remaining cases were small or subtle findings. None of the 13 cases required urgent intervention during the index ED presentation. CONCLUSION: The AI model demonstrated high NPV for urgent CTB findings, with no false negative requiring urgent intervention during the index ED presentation. Preliminary results provide the safety rationale to proceed with a prospective trial aiming to incorporate this technology into ED workflows.
Emergency medicine Australasia : EMAVinay Gangathimmaiah, Rebecca Evans, Tarun Sen Gupta, Karen Carlisle
OBJECTIVE: Low-value diagnostic tests harm patients. Stewardship of tests can improve patient safety. Co-design and behavioural change theories can enhance the effectiveness of diagnostic stewardship interventions. This study aimed to co-design a theory-informed diagnostic stewardship intervention at a major-referral emergency department in Queensland, Australia. METHODS: A qualitative study was conducted at Townsville University Hospital Emergency Department. The Theoretical Domains Framework underpinned intervention design. Emergency clinicians ordering pathology tests were eligible for inclusion. A purposive sample of consenting participants was recruited. Data were collected via workshops facilitated by the lead author. Conversations were audio recorded and digitally transcribed. Data were managed with NVivo. Data were analysed by inductive and deductive approaches to generate codes, categories and themes. Thematic saturation and optimal stakeholder engagement influenced the final sample size. Trustworthiness was ensured via reflexivity, audit trail, thick description and participant validation. RESULTS: Seven workshops were conducted with 35 emergency physicians (18 male, 17 female) with a range of specialist experience (1-31 years). Urine culture was the diagnostic test of choice. Culture, complexity, and efficiency were identified as the major drivers of low-value urine cultures. Education, nudge, clinical champions, and audit/feedback were selected as intervention components. Credibility of change and workflow inefficiency were perceived as intervention challenges. CONCLUSION: Stakeholder engagement has enhanced perceived acceptability of this co-designed intervention for urine culture diagnostic stewardship. Behavioural change theories strengthen co-designed interventions by addressing context-specific drivers of low-value tests. Co-design and behavioural change theories can inform bespoke interventions to nurture a culture of diagnostic stewardship in emergency medicine practice.
Rhode Island medical journal (2013)Robert Bradshaw, Curtis Xu, David Cannata, Trent She, Zachary Boivin
BACKGROUND: Ghost scanning, performance of point-of-care ultrasound without image archival, can adversely affect patient care, billing, quality assurance, and result in medicolegal concerns. This study evaluated the Extended Focused Assessment with Sonography in Trauma (eFAST) ghost-scanning rate during trauma activations after placement of a low-cost visual reminder. METHODS: This single-center study was conducted from December 1, 2022 to November 30, 2023. Patients were included if they were the highest level of emergency department trauma activation. A ghost scan was classified as a documented eFAST examination in the electronic medical record nursing documentation without archived eFAST images in the picture-archiving and communication system. Six months of EMR review established a baseline ghost-scanning rate. Subsequently, a large label reminding clinicians to save images was placed prominently on the ultrasound machines for a six-month period with prospective chart review. The primary outcome was the absolute and relative difference in ghost-scanning rates after the label intervention. Differences between periods were analyzed using a two-tailed Mann-Whitney U test. RESULTS: A total of 325 trauma encounters were included. In the pre-intervention period, 66 eFAST examinations were identified among 143 encounters, of which 74.2% (49) were ghost scans. In the post-intervention period, 86 eFAST examinations were identified among 182 encounters, of which 54.7% (47) were ghost scans, representing a 19.5% absolute reduction (p = 0.013). CONCLUSION: The low-cost visual reminder was associated with a meaningful reduction in ghost scanning during eFAST examinations. Further investigation into similar interventions and their generalizability to other institutions is warranted.
Emergency medicine Australasia : EMAAmy Lee, Victoria Varley, Christopher Davis, Philip Jones, Steven Grant, Gerben Keijzers, Richard Pellatt
OBJECTIVE: This study describes the incidence of first-pass intubation without hypoxaemia in patients who underwent endotracheal intubation using ventilator assisted preoxygenation (VAPOX). METHODS: Retrospective cohort study of adult patients who underwent VAPOX assisted endotracheal intubation between February 2021 and June 2025 in two EDs. The primary outcome was intubation with first-pass success (FPS) without hypoxaemia (SpO2 < 90%). Secondary outcomes included FPS, adverse events (hypoxia, hypotension, aspiration) and oxygenation trajectories (SpO2 and FiO2) pre- and post-intubation. RESULTS: Of the 116 patients who received VAPOX, 78% (90/116; 95% CI 69%-84%) had FPS without hypoxaemia. Overall FPS occurred in 91% (105/116; 95% CI 84%-95%). Hypoxaemia (SpO2 < 90%) occurred in 17% (20/116; 95% CI 11%-25%), including 11% (13/116; 95% CI 7%-18%) with severe hypoxaemia (SpO2< 85%) and 6% (7/116; 95% CI 3%-12%) with critical hypoxaemia (SpO2< 80%). Half of all patients experienced at least one complication (58/116; 50%, 95% CI 41%-59%). Post-intubation hypotension (systolic blood pressure [SBP] < 90 mmHg) occurred in 36% of patients. No reported incidences of aspiration. Respiratory failure was the most common indication for intubation (60%) and was independently associated with a lower likelihood of success (OR 0.14; 95% CI 0.04-0.52). CONCLUSIONS: We describe a cohort of patients who received VAPOX assisted ED intubation with a FPS without hypoxaemia of 78%. This was a critically ill cohort, with 46% of patients having oxygen saturations < 90% in the hour prior to intubation. These findings provide a benchmark for ED intubation using VAPOX and a comparison for future research.
Emergency medicine Australasia : EMADaniel Stewart, Patrick Caldwell
OBJECTIVES: To evaluate the impact of an embedded Ultra-Low Acuity Pathway (ULAP) on emergency department performance indicators for low-acuity patients in a rural referral hospital. METHODS: This pragmatic, single-centre, quasi-experimental study included Australian Triage Scale Categories 4 and 5 patients presenting to Dubbo Health Service between 10:00 and 20:00 from 29 May to 1 October 2023 (n = 4798). Workforce-dependent ULAP availability created a comparison between ULAP (n = 2178) and standard care periods (n = 2620). Primary outcomes were Did Not Wait (DNW), Seen Within Benchmark (SWB), Emergency Treatment Performance (ETP) and length of stay (LOS). Multivariable analyses adjusted for patient characteristics, temporal factors and resource state. RESULTS: ULAP was associated with improvements across all outcomes. DNW decreased from 14.2% to 6.9% (adjusted OR 0.43, 95% CI 0.35-0.53), SWB increased from 72.6% to 82.0% (adjusted OR 1.90, 95% CI 1.64-2.20) and ETP increased from 73.1% to 83.3% (adjusted OR 1.96, 95% CI 1.69-2.28). Mean LOS was 51.7 min shorter after adjustment (95% CI -65.1 to -38.4). All associations remained statistically significant (p < 0.001). CONCLUSIONS: An embedded ULAP was associated with substantial improvements in emergency department performance that were independent of patient characteristics, temporal factors and resource state. Embedding urgent care within existing emergency departments may provide a practical alternative to stand-alone urgent care services for rural communities where separate services are not feasible.
Academic emergency medicine : official journal of the Society for Academic Emergency MedicineNatsumi Hata, Masaaki Nagae, Hiroyuki Umegaki
OBJECTIVES: Triage reflects acute urgency, whereas frailty may also influence disposition in older emergency department (ED) patients. This study aimed to estimate the association between Clinical Frailty Scale (CFS)-defined frailty and hospitalization after ED evaluation within Japan Triage and Acuity Scale (JTAS) categories and assess whether the strength varied across triage categories. METHODS: We conducted a single-center retrospective cohort study in an urban tertiary hospital in Japan. We identified consecutive triaged ED visits by patients aged ≥ 65 years from November 2025 to March 2026. Visits with CFS scores and covariates constituted the complete-case cohort. CFS ≥ 5 was defined as frailty. The primary outcome was admission to the study hospital or acute-care interhospital transfer. We used a mixed-effects logistic regression model with a CFS-by-JTAS interaction term, adjusting for age, sex, mode of arrival, injury- or poisoning-related visit, living arrangement, and long-term care needs certification, with patient-level random intercept. The global interaction was assessed using a likelihood-ratio test. RESULTS: Among 3127 ED visits, 1526 resulted in hospitalization. In JTAS 1, the adjusted odds ratio (OR) for CFS ≥ 5 was not estimated because of quasi-complete separation. In the model excluding JTAS 1, the adjusted OR was 1.00 (95% confidence interval [CI], 0.65-1.55) in JTAS 2, 1.54 (95% CI: 1.19-1.99) in JTAS 3, and 2.01 (95% CI: 1.13-3.58) in JTAS 4/5. The global CFS-by-JTAS interaction was not statistically significant (P for interaction = 0.091). CONCLUSIONS: Category-specific estimates suggested little association in JTAS 2 but were numerically larger in JTAS 3 and JTAS 4/5. However, the global interaction was nonsignificant, providing insufficient evidence that the association differed across categories. Prospective studies should examine the clinical, geriatric, social, decision-related, and healthcare-system factors that may underlie this association among older patients with comparable triage-assessed urgency.
International journal of mental health nursingErin Farmer, Marianne Wyder, Nahid Choudhury, Sarah Cox, Nicola Geffen, Jeremy Anson, Nomthandazo Masuku, Emma Lakin, Manaan Kar Ray
Post-discharge suicide risk remains highest among psychiatric inpatients, yet structured safety planning is rarely embedded into inpatient care. As part of a quality improvement project, in 2022, a major metropolitan hospital in Australia rolled out the 7 SAFE STEPS Programs to address this gap. The training included safety conversations and safety plans, which were introduced to become part of the discharge process. This mixed-methods study evaluated whether the structured safety planning was embedded into inpatient routine practice and explored staff and consumer experiences to identify barriers and enablers to meaningful implementation. A numerical count of the safety plans was undertaken. The quality of safety plans produced was assessed through an audit and benchmarking these to the essential components (recognising early warning signs, identifying adaptive internal coping mechanisms, engaging external supports, accessing professional services, addressing means restriction, and reaffirming reasons for living). Safety plans were given a numerical value based on if these were present or absent. Qualitative data about their experiences with the safety plans was also gathered through interviews and focus groups with nursing staff, peer workers, and recently discharged consumers. The qualitative component of the study was designed and reported according to the EQUATOR Network guidelines for qualitative research (COREQ). While there was an increase in the number of safety plans completed on the ward, the overall quality of these was low (average score of 7.67 out of 22). Themes from the qualitative data identified barriers to the introduction, which included time pressures, training gaps, and procedural drift. Nursing staff and consumers discussed the value of these plans and made suggestions for changes.
Emergency medicine Australasia : EMARupert Phillips, Adrianna Klejnotowska, Harry Claxton, Matthew Cadd
This systematic review and meta-analysis compares the use of high-flow nasal oxygen (HFNO) with conventional oxygen therapy (COT) and non-invasive ventilation (NIV) in the management of acute respiratory failure (ARF) in the emergency department (ED). A comprehensive search of relevant sources was undertaken. Randomised controlled trials (RCTs) assessing adult patients (≥ 18 years) treated in the ED for ARF and comparing HFNO to COT/NIV were included. The primary outcome was the need for endotracheal intubation and mechanical ventilation (IMV). Secondary outcomes included physiological and biochemical parameters, ICU admission, hospital length of stay, dyspnoea scores and mortality. A total of 17 RCTs (1955 patients) were included. There was a significant reduction in IMV favouring the HFNO group compared to COT and NIV (RR 0.64, 95% CI 0.47-0.88). HFNO showed significant improvements in RR, SpO2, PaO2 and Modified Borg Dyspnoea Scale. Subgroup analysis showed reduced rates of IMV with HFNO compared to COT (RR 0.61, 95% CI 0.41-0.91), but not compared to NIV (RR 0.69, 95% CI 0.42-1.14). HFNO additionally showed a reduction of IMV compared to NIV and COT in undifferentiated patients (RR 0.61, 95% CI 0.41-0.93), but not in exacerbations of COPD or acute heart failure. Ten of the 17 studies had at least some concern for risk of bias, with several analyses having notable heterogeneity. HFNO showed a significant reduction in rates of IMV, improvement in peripheral oxygen saturations, PaO2, respiratory rate and patient dyspnoea scores compared to COT and NIV.
Health expectations : an international journal of public participation in health care and health policyVanda Nissen, Renata F I Meuter, Michelle Riedlinger
INTRODUCTION: In this study, we explored how uncertainty was expressed through epistemic adverbs in health consultations where patients and health practitioners (HPs) spoke the same language (language-concordant) versus when they did not (language-discordant). Further, we applied Communication Accommodation Theory (CAT) to identify, in these settings, how HPs used communication strategies and their patients' communicative responses. METHOD: Fifty-three health consultations between bilingual and monolingual patients and their HPs in a metropolitan emergency department were recorded and transcribed, 39 of which contained epistemic adverbs (e.g., probably, maybe). Epistemic adverbs were identified and classified, and the surrounding interactional sequences were analysed using CAT. RESULTS: Analyses revealed overall greater use of uncertainty adverbs versus certainty adverbs. CAT-informed analysis identified approximation, discourse management, interpersonal control, emotional expression and interpretability when HPs or patients expressed uncertainty. HPs responded through clarification, reformulation, backchannelling and reassurance. However, in some cases, the interaction did not establish whether the expressed uncertainty had been fully resolved or understood. DISCUSSION: In the analysed consultations, epistemic adverbs functioned as linguistic markers of uncertainty related to clinical information such as symptoms, timing and possible course of action. Although use of accommodative strategies was evident in all analysed excerpts, in some cases the available data could not confirm whether the bilingual patients had fully understood the information. CONCLUSION: Attending to patients' uncertainty as expressed through epistemic adverbs may help HPs accommodate more effectively to their patients' communicative needs. PATIENT OR PUBLIC CONTRIBUTION: Patients and members of the public were not directly involved in the design, conduct, analysis or reporting of this study. The research was based on the analysis of recordings of real-life clinical consultations. Because the study focused on evaluating communication patterns within existing consultation recordings rather than developing or testing interventions affecting patient care, additional patient or public involvement was not considered methodologically appropriate.
Emergency medicine Australasia : EMAJasmine Poonian, Katie O'Halloran, Thomas Kilner, David Krieser
OBJECTIVE: To evaluate the acceptability and feasibility of implementing a structured 'hot debrief' tool, and its impact on team effectiveness, staff well-being and identification of system-level issues following critical events in two EDs. METHODS: We conducted a multi-site quality improvement study across two metropolitan Australian EDs from 2023 to 2025. A standardised hot debrief process was implemented following predefined critical events, with senior staff trained as facilitators. Staff perceptions were assessed using anonymous pre-, post- and final-implementation surveys, with quantitative data analysed descriptively. Completed debrief proformas from two 6-month trial periods were analysed using reflexive thematic analysis to identify recurring themes related to team function, well-being and system issues. RESULTS: A total of 46 hot debriefs were conducted. In the final survey, 60 of 121 respondents (50%) had attended at least one debrief in the preceding 6 months. Amongst attendees, 98% reported that debriefs created a psychologically safe space, and 59 of 60 found them useful overall. Likert-scale responses indicated high perceived value, with most rating debriefs four or five out of five for team building, learning, issue identification and emotional processing. Thematic analysis identified five key system-level issues: interdepartmental communication, medication dosing in rare events, staffing and handover pressures, staff safety during behavioural emergencies and environmental and crowd-control challenges. CONCLUSIONS: A structured hot debrief tool was feasible and well accepted. It supported team reflection, staff well-being and identification of recurrent system issues. Further research is needed to assess sustainability and downstream impacts on staff well-being and patient safety.
Emergency medicine Australasia : EMADaniel McLennan, Cliff Reid, Rhodri Martin, Susannah Olive, Guy Eslick
OBJECTIVE: Indirect Intensive Care Unit (ICU) admissions, where patients admitted via the Emergency Department (ED) to a non-critical care ward subsequently require ICU admission, may reflect missed recognition or underestimation of deterioration. This study aimed to: (1) Compare the frequency of indirect ICU admissions in an Australian hospital with international literature. (2) Describe this cohort according to ED care factors, reason for ICU admission, and hospital mortality. METHODS: Observational cohort study of indirect ICU admissions occurring within 24 h of ED arrival between 1 June 2019 and 31 May 2022. Postoperative ICU admissions were excluded. Data were extracted from electronic medical records by two independent reviewers using a validated Data Collection Template (DCT). RESULTS: Of 701 indirect ICU admissions, 148 met inclusion criteria. Indirect admissions accounted for 11.3% of all ED-to-ICU admissions. The most common reason for ICU admission was circulatory insufficiency, representing 43% of cases. Approximately half of patients were discussed with or reviewed by a Fellow of the Australasian College for Emergency Medicine (FACEM). 53% had normal observations (44% without supplemental oxygen); 20% were outside normal limits and a further 22% had altered calling criteria. Hospital mortality was 12.8%, higher than that of a reference Australian ICU population. Presentations between midnight and 08:00 were overrepresented. CONCLUSIONS: Unplanned indirect ICU admissions occurred less frequently than reported internationally but were associated with high in-hospital mortality. Given their association with adverse outcomes, quality improvement should focus on patients with abnormal vital signs, particularly circulatory insufficiency, and those presenting overnight.
Emergency medicine Australasia : EMAEmma Whyte, Theophilus I Emeto, Frances Snowden, Vinay Gangathimmaiah
OBJECTIVES: To describe the use, effectiveness and safety of intranasal dexmedetomidine (IN DEX) for ED paediatric procedural sedation. METHOD: A retrospective cohort study was conducted over 7 months following implementation of an IN DEX guideline at Townsville University Hospital ED. Children aged 1-16 years were eligible if they received IN DEX. Outcomes of interest were sedation depth, ED length of stay (EDLOS), adverse events, procedural success and clinician/carer satisfaction. RESULTS: A total of 114 patients were recruited. Median age was 3 years (IQR 2-5), 55.3% were male and 31.6% were Aboriginal and/or Torres Strait Islander children. Median IN DEX dose was 3.11 mcg/kg (IQR 2.81-3.93). Common indications included peripheral intravenous cannulation (35.1%), laceration repair (21.1%), burns care (13.2%), foreign body removal (11.4%) and medical imaging (8.8%). Median EDLOS was 395 min (IQR 255-579). Sedation depth was moderate (mean University Michigan Sedation Scale score 2.1 (SD 0.9), a 0-4 scale on which higher scores indicate deeper sedation; documented for 90 of 114 sedations). IN DEX was successful as a sole sedative agent in 78.1% (95% CI 69.6%-84.7%) patients, ranging from 90.0% (9/10) for medical imaging to 53.8% (7/13) for foreign body removal. Adverse events occurred in 13.2% of patients (95% CI 8.1%-20.6%), predominantly mild bradycardia. Younger age was associated with higher success rates (aOR 0.86 per year, 95% CI 0.74-0.998). No dose-response relationship was identified. Clinicians (mean 4.3/5) and parents (mean 4.5/5) reported high satisfaction, although satisfaction was documented for fewer than half of sedations and significantly more often when sedation succeeded. CONCLUSION: In our single-centre study IN DEX is a well-tolerated, moderately effective and safe agent for ED paediatric procedural sedation with higher success rates in younger patients. Large, prospective, multisite studies are necessary to establish IN DEX's safety, effectiveness and predictors of success.
Australian health review : a publication of the Australian Hospital AssociationChampika Pattullo, William Dace, Anita Pelecanos, Gerben Keijzers, Peter Donovan
OBJECTIVE: Chronic opioid use can develop in previously opioid-naïve patients following an emergency department (ED) or hospital admission; however, most evidence is from North America. This study aims to assess the prevalence of persistent opioid use after an ED presentation in an Australian setting. METHODS: This was a population-based, retrospective cohort study using state-based linked data. Persistent opioid use was defined as continued use after 12 months, among previously opioid-naïve patients who filled an opioid prescription following discharge from any Queensland public hospital ED between 1 January 2011 and 31 December 2017. Descriptive statistics were used to summarise demographic characteristics of the study population and to outline primary outcome measures. RESULTS: There were 3,082,681 ED presentations during the study period, and 11,281,039 opioid prescriptions within 12 months of the ED presentations included in the study. A total of 186,545 opioid-naïve patients had an opioid prescription associated with their ED presentation, with more prescriptions in 2017 (34,273) compared with 2011 (14,896), driven predominantly by oxycodone prescription increases. However, of the total cohort, only 3539 (1.9%) were classified as persistent opioid users, with similar annual proportions seen throughout the study period. CONCLUSION: The proportion of patients progressing to persistent opioid use after ED presentation was low and remained relatively stable, despite a substantial increase in the number of patients receiving at least one opioid prescription after an ED presentation. These results highlight the need for continued focus on appropriate prescribing and patient safety.
Emergency medicine Australasia : EMAAndrew Follows, Ben Rose, Andrew Ross, Abby McCaughey
OBJECTIVES: Local anaesthetic systemic toxicity (LAST) is a rare but potentially fatal complication of local anaesthetic (LA) use. This study assessed knowledge of LA dosing, LAST recognition and management among emergency clinicians in Australia. METHODS: A multicentre cross-sectional survey was conducted at three emergency departments in Queensland, Australia. The survey assessed recall knowledge of recommended maximum local anaesthetic doses, recognition and management of LAST, and self-reported clinician confidence. RESULTS: Of 114 participating clinicians, fewer than half correctly identified the recommended maximum dose for any of the four evaluated LA agents, including for their preferred agent for regional anaesthetic techniques. Correct responses ranged from 18.4% for bupivacaine to 48.2% for lidocaine. Cardiovascular manifestations of LAST were the most frequently recognised features; 21.9% of respondents could not recall any features of LAST. 57.9% of respondents identified lipid emulsion therapy as a management strategy; however, only 10.5% correctly stated a dosing regimen and 6.1% knew its location within their department. Knowledge of doses, LAST recognition and management all significantly improved with clinician seniority. Self-reported confidence was positively associated with knowledge of LAST recognition and management. CONCLUSIONS: Emergency clinicians in this survey demonstrated substantial knowledge gaps in safe LA dosing, LAST recognition and aspects of management. These findings support a need for targeted education and system-level interventions to improve preparedness for this potentially life-threatening emergency.
Milk is a vital nutrient source, playing an essential role in maintaining normal physiological functions and safeguarding human health. However, milk consumption may expose individuals to residual contaminants such as antibiotics and environmental pollutants, which pose serious threats to human health. Currently, traditional milk pretreatment technologies hinder the rapid detection of milk residues due to their cumbersome procedures, operational complexity, prolonged processing time, and high dependence on specialized personnel. Microfluidic devices have emerged as a promising tool for food safety monitoring in resource-limited settings due to their simplicity, portability, and rapid processing capabilities. Nevertheless, the lack of systematic summaries on microfluidic device development for milk pretreatment limits their widespread application. To overcome these drawbacks, this review first presents the types and preparation methods of microfluidic devices employed in milk pretreatment. Subsequently, it summarizes the emerging applications of these devices in this field. Finally, the current challenges and prospects are discussed.
International journal of mental health nursingNaushi Manzoor, Phil Maude, Alistair Ross
This scoping review examined and synthesised existing literature on models of care involving Mental Health Nurse Practitioners (MHNPs) practising or consulting within Emergency Department (ED)-based Emergency Mental Health (EMH) services. EDs are a key access point for mental health care and often provide first contact or after-hours support for people experiencing crisis, reinforcing their central role within the mental health system. The review highlights the need for timely, safe and specialised mental health care within EDs to strengthen the quality, safety and responsiveness of EMH services. Given the limited ED-specific MHNP literature, studies involving related advanced mental health nursing roles were also included where functions overlapped with MHNP practice, although these roles were not considered equivalent. Using Arksey and O'Malley's framework, 13 ED-specific studies were included: two quantitative, two qualitative, five mixed-methods, three realist or realist-informed evaluations and one descriptive or pilot service evaluation. Three themes were identified: consumer outcomes and timely access to care; MHNP roles within ED service models; and stakeholder perspectives and systemic challenges. Across studies, MHNPs and related advanced mental health nursing roles were associated with improved access to specialist assessment, enhanced care coordination, reduced psychological distress and high consumer and staff satisfaction. However, evidence was largely derived from early-stage, single-site evaluations. Barriers relating to role visibility and organisational support also limited sustainability. Overall, MHNP roles remain under-researched, highlighting the need to identify system-level enablers supporting effective integration and impact.
OBJECTIVE: To develop a national expert consensus on procedural sedation and analgesia practices in paediatric emergency departments in Spain and identify priority areas for standardisation, safety and implementation. METHODS: We conducted a modified two-round Delphi study with a panel of 28 clinicians with expertise in paediatric emergency care and procedural sedation from 23 centres in different regions of Spain. Participants rated key domains related to patient selection, fasting, monitoring, staffing, pharmacological strategies, training and safety standards. We used a predefined threshold of ≥ 70% agreement to establish consensus in both rounds. RESULTS: The panel reached strong consensus across core domains of paediatric procedural sedation practice, including minimum safety requirements, monitoring standards, staff competencies and organisational priorities. Strong agreement supported the standardisation of procedural sedation processes. Areas of residual disagreement highlighted persistent variation in implementation and resource availability across departments. Pharmacological preferences differed according to the clinical scenario; ketamine was preferred for more painful procedures, but drug preferences for less invasive procedures or imaging procedures varied. CONCLUSION: This national Delphi consensus provides a pragmatic framework to support safer and more consistent procedural sedation practice in paediatric emergency departments. Although the study included only centres in Spain, it addressed operational and clinical challenges common worldwide, and its findings are likely relevant for all emergency departments seeking to improve paediatric sedation.
JAMA network openLindsey K Jennings, Kelly Barth, Suzanne Lane, Alyssa Rafferty, Carrie Papa, Louise Haynes, Susan Sonne, Heather McCowin, Phillip Moschella, Alain H Litwin, Ja…
IMPORTANCE: Buprenorphine reduces mortality in opioid use disorder (OUD), and emergency department-initiated buprenorphine (EDIB) doubles 30-day treatment retention, yet many patients decline EDIB when offered. Patient-driven factors limiting uptake are not well characterized. OBJECTIVE: To identify factors associated with patients accepting or declining EDIB. DESIGN, SETTING, AND PARTICIPANTS: Convergent parallel mixed-methods qualitative study conducted from May 1 to December 31, 2023, with data analyses performed from March 2025 to April 2026, at 4 emergency departments within the National Drug Abuse Treatment Clinical Trials Network (CTN) in South Carolina, Michigan, and Ohio. Adult patients (aged ≥18 years) with OUD who were offered buprenorphine by clinical staff were eligible; prisoners and patients concurrently enrolled in other CTN trials of OUD treatment or overdose prevention were excluded. MAIN OUTCOMES AND MEASURES: The main outcomes were acceptance or declination of EDIB; validated measures of treatment readiness (Stages of Change Readiness and Treatment Engagement Scale [SOCRATES]), cultural mistrust, perceived discrimination, and social needs; and qualitative interview themes regarding reasons for accepting or declining buprenorphine. RESULTS: Eighty-two participants completed the study (median [IQR] age, 38 [31-53.5] years; 52 male [64%]). Overall, 19 participants (23%) declined buprenorphine. Among 54 participants who described reasons for accepting EDIB, motivators for accepting EDIB included assistance with opioid withdrawal (37 [69%]), desire to be substance free (21 [39%]), wanting to return to a "normal life" (15 [28%]), fear of overdose or death (13 [24%]), and caring for children (7 [13%]). Among 22 participants who described reasons for declining EDIB, barriers included concern about precipitated withdrawal or adverse effects (11 [50%]), not wanting to be physically dependent on buprenorphine (7 [32%]), and housing and logistical barriers (5 [23%]). SOCRATES treatment readiness (1-5 scale) was similar in patients who accepted (mean [SD] score, 4.11 [0.55]) and declined (mean [SD] score, 4.05 [0.50]) EDIB. CONCLUSIONS AND RELEVANCE: In this mixed-methods qualitative study of adult ED patients with OUD who were offered buprenorphine, declination was driven less by low treatment readiness than by specific, addressable concerns: precipitated withdrawal, physical dependence, and housing and logistical barriers. Targeted interventions addressing these concerns may increase uptake of this life-saving treatment.
Journal of the American College of Clinical Pharmacy : JACCPMontserrat Viñas-Bastart, Maria-Estela Moreno-Martínez, Sònia Ruiz-Boy, Jan T De Pourcq, Cristina Martínez Roca, Maria Josep Carreras-Soler, Miguel Ángel Amor …
BACKGROUND: Board of Pharmacy Specialties certification has emerged internationally as a mechanism to support advanced pharmacy practice and professional differentiation. However, little is known about how BPS-certified pharmacists perceive its value within health care systems with specialist training pathways, such as in Spain. This study aimed to explore the perceived value, professional impact, and implementation barriers of BPS certification among hospital pharmacists in Spain. METHODS: A qualitative descriptive study used semi-structured interviews with BPS-certified hospital pharmacists practicing in Spain. Participants were purposively recruited to ensure diversity in certification specialty, geographical region, and profile. Interviews were conducted between April and June 2026, audio-recorded, transcribed, and analyzed using qualitative content analysis. Reporting followed Consolidated Criteria for Reporting Qualitative Research. RESULTS: Eleven hospital pharmacists representing multiple BPS specialties participated. Participants perceived BPS certification as strengthening clinical competence, improving confidence in pharmacotherapeutic decision-making, and supporting advanced clinical practice. Certification was perceived to enhance professional credibility within interprofessional clinical teams and among pharmacist colleagues. However, participants described limited institutional recognition, with little impact on salary, career progression, employment systems, or protected professional development time. Major barriers included time investment, economic costs, recertification requirements, and partial mismatch between the United States-oriented examination framework and the Spanish health care context. Participants viewed BPS certification as a complementary credential to the national hospital pharmacy residency system rather than a substitute for specialist training. Most anticipated demand for credentialing would continue to increase as hospital pharmacy practice becomes specialized and clinically complex. CONCLUSIONS: BPS certification is perceived as a valuable mechanism supporting advanced clinical competence, professional differentiation, and integration into interprofessional practice. Nevertheless, broader implementation remains limited by insufficient institutional recognition and structural support. Greater alignment between international credentialing systems and national professional development frameworks may facilitate integration of pharmacy practice credentials within the Spanish health care system.
Emergency medicine Australasia : EMAThenul Munasinghe, Kaylie Shaw, Claire Charteris, Joe Anthony Rotella
OBJECTIVE: This study sought to characterise the demographics, arrest characteristics, clinical outcomes and ED access variables for out-of-hospital cardiac arrest (OHCA) presentations to the Victorian Heart Hospital (VHH), Australia's first dedicated cardiac hospital. METHODS: A retrospective audit of OHCA presentations to the VHH Cardiac Emergency Department from June 2024 to June 2025 was undertaken. Survival to hospital discharge was the primary outcome. Categorical variables associated with survival were assessed using Fisher's exact test with odds ratios; continuous variables associated with survival were assessed by Mann-Whitney U test. RESULTS: One hundred and twenty-one patients were included; 70.2% male, median age 66 years (IQR 59-75). Shockable rhythms accounted for 61.2% of presentations and prehospital ROSC was documented in 92.6%. The primary outcome of survival to hospital discharge was 50.4% and 30-day survival was 40.0%. Shockable rhythm (OR 3.46, 95% CI 1.55-7.73), cardiac aetiology (OR 3.40, 95% CI 1.32-8.74) and prehospital ROSC (OR 9.23, 95% CI 1.12-76.3) were significant categorical variables associated with survival. Interhospital transfer was required in 24.0% of patients primarily due to a noncardiac aetiology of arrest requiring continuity of care at an affiliated centre. CONCLUSIONS: In this selected postresuscitation OHCA cohort, survival to hospital discharge was 50.4%, with high rates of prehospital ROSC, shockable rhythm and witnessed arrest. These findings should not be interpreted as evidence of superiority over population-based OHCA cohorts. ED access variables, including a 24.0% interhospital transfer rate, represent novel system-level findings warranting prospective investigation.
PloS oneYounggoun Jo, Yunchul Park, Euisung Jeong, Hyunseok Jang, Hyo-Sin Kim
Trauma patients requiring massive transfusion have mortality exceeding 40%, yet early risk-stratification tools for this population remain limited. We evaluated readily available predictors of mortality in massively transfused trauma patients, excluding those with severe traumatic brain injury (TBI) to focus on a hemorrhage-predominant cohort. This single-center retrospective cohort study included trauma patients who received massive transfusion at Chonnam National University Hospital between January 2018 and December 2023. Patients with severe TBI (Head Abbreviated Injury Scale [AIS] ≥ 4) were excluded. Three sequential multivariate logistic regression models were constructed: a primary model using variables available at emergency department (ED) arrival, a secondary model adding laboratory values, and an exploratory model incorporating early transfusion course variables. Of 172 massively transfused trauma patients, 124 met inclusion criteria (Head AIS < 4). Overall mortality was 41.1% (51/124), with 24-hour mortality of 23.7% (28/118). The Glasgow Coma Scale (GCS) was the strongest independent predictor across all models (OR = 0.77-0.79 per point, p < 0.001). In the primary ED arrival model (AUC = 0.770), GCS was the sole significant predictor; GCS alone achieved a comparable AUC of 0.771. The exploratory model incorporating transfusion variables achieved the highest discrimination (AUC = 0.828). All models showed adequate calibration (Hosmer-Lemeshow p > 0.05). Mortality decreased with longer time-to-first-transfusion (54.5% for ≤15 min vs. 23.7% for >60 min, trend p = 0.007), reflecting confounding by indication. In massively transfused trauma patients without severe TBI, GCS assessed at ED arrival is the single most informative predictor of mortality, enabling risk stratification before laboratory results become available. Metabolic acidosis markers and coagulopathy were strongly associated with mortality on univariate analysis but added no independent predictive value beyond GCS. Time-to-first-transfusion appeared to reflect hemorrhage acuity rather than a modifiable prognostic factor.
Liver international : official journal of the International Association for the Study of the LiverChieh-Ching Yen, Shih-Hua Lin, Cheng-Yu Ma, Chung-Hsien Chaou, Yi-Tsung Lin
BACKGROUND: Infection is a major cause of mortality in patients with cirrhosis. However, chronic organ dysfunction may confound the interpretation of organ dysfunction scores, and the prognostic value of the updated Sequential Organ Failure Assessment-2 (SOFA-2) score in cirrhotic patients with suspected infection remains unclear. METHODS: We conducted a retrospective multi-institutional cohort study across four hospitals in Taiwan from January 2010 to December 2021. Adult patients admitted from the emergency department (ED) with suspected infection were included and stratified by cirrhosis status. The primary outcome was 28-day mortality. SOFA-2 score distributions, domain-specific patterns and mortality associations were compared between patients with and without cirrhosis. Cox proportional hazards models with site-clustered robust standard errors were used. RESULTS: Among 150 511 patients with suspected infection, 4288 (2.9%) had cirrhosis. Patients with cirrhosis had higher SOFA-2 scores than those without cirrhosis (median, 4 [interquartile range (IQR), 2-6] vs. 2 [IQR, 0-4]; p < 0.001) and higher non-hepatic SOFA-2 scores (median, 3 [IQR, 1-5] vs. 1 [IQR, 0-3]; p < 0.001). The 28-day mortality rate was 14.9% in patients with cirrhosis and 8.9% in those without cirrhosis. After adjustment for age, sex, non-hepatic Charlson Comorbidity Index and non-hepatic SOFA-2 score, cirrhosis remained associated with higher 28-day mortality (adjusted hazard ratio, 1.31; 95% confidence interval, 1.17-1.46; p < 0.001). CONCLUSIONS: Among ED patients with suspected infection, cirrhosis was associated with an increased risk of SOFA-2-defined organ dysfunction and increased mortality. SOFA-2 may support early risk stratification but should be interpreted in the context of cirrhosis-related baseline physiology.