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We suggest that low-cost innovations, termed as frugal, when diffused from low-income and middle-income countries to high-income countries, offer an opportunity to diversify sources of ideas and solutions in emergency medicine. We outline examples from a preliminary search of the literature, consider the barriers faced by such innovations and suggest what needs to be done to improve their chances of being considered for use in emergency medicine.
The management of patients suspected, but not confirmed, as being poisoned is challenging. The Royal College of Emergency Medicine and National Poisons Information Service have produced this guidance to provide a generalised clinical approach to any poisoned patient in the emergency department. This guideline provides a clinical approach to support the initial assessment of a patient, identification of potential toxic agents and emergency management. A toxidromic approach is used, with emphasis on consideration of the toxicokinetics of potential poisons and how the patient's clinical condition may change. It does not replace poison-specific guidance available from TOXBASE and the NPIS or a locally appropriate poisons centre.
Emergency medicine (EM) is often mischaracterised as symptom-based care, yet, in practice, it is the discipline of making time-critical decisions with incomplete information, under conditions where delay can cause irreversible harm. The emergency physician's central cognitive task is therefore less the pursuit of perfect diagnostic labels and more the management of risk: identifying immediate threats, stabilising physiology, excluding dangerous alternatives and formulating a safe disposition plan. This concepts paper introduces a simple cognitive scaffold-Stabilise, Exclude, Decide (S-E-D)-to make EM reasoning explicit, teachable and transferable across settings. We describe how S-E-D maps onto the realities of undifferentiated presentations, crowding and diagnostic uncertainty, and how neglecting this mindset contributes to predictable errors such as premature closure, anchoring and underestimation of disposition risk. We then outline practical strategies for teaching S-E-D at the bedside using structured questions, deliberate reassessment and probability-based interpretation of tests. By reframing EM as the cognitive craft of safe decision-making under uncertainty, this framework aims to clarify the specialty's contribution for clinicians and residents and to support safer practice and more purposeful education internationally.
The original research priorities for paediatric emergency medicine (PEM) in the UK and Ireland were published in 2015. This list, generated through a modified Delphi process involving healthcare professionals only, has driven the research agenda for over ten years. With many now successfully addressed and a significantly altered healthcare landscape, there was a pressing need to refresh PEM research priorities with the input of patients and carers. James Lind Alliance (JLA) methodology was employed. The scope included unscheduled emergency care provided to children and young people irrespective of setting. An independent JLA facilitator chaired monthly steering group meetings with equal input from parents and healthcare professionals. Two online surveys were employed to generate a list of evidence uncertainties and then to prioritise research questions from key stakeholder groups (patients, carers and healthcare professionals). An online workshop subsequently used an adapted nominal group technique to reach a consensus on the top list of research priorities. 655 questions were submitted in Survey 1 by 338 respondents (35% patients and carers and 65% healthcare professionals). After merging questions by topic and removing out-of-scope questions, 70 summary questions proceeded to evidence reviews; three were found to have been sufficiently answered. Further merging of summary questions resulted in 46 indicative research questions for Survey 2, which received 542 complete responses (26.6% patients and carers, 73.4% healthcare professionals). The 18 highest-ranking questions were brought to the consensus workshop, in which 12 patients/carers and 15 healthcare professionals reached consensus on the 10 highest priority research questions. This refreshed PEM prioritisation study has identified the top 10 research priorities reflecting the views of patients, carers and a range of health professionals across the UK and Ireland. These priorities will be used to drive the PEM research agenda for the next decade.
This study aimed to evaluate the diagnostic accuracy and time-to-diagnosis of compression ultrasonography performed by emergency physicians compared with radiologist-performed Doppler ultrasonography in patients with suspected deep vein thrombosis (DVT). In this prospective blinded study, 309 patients with suspected lower-extremity DVT presenting to a tertiary emergency department between November 2022 and October 2024 were evaluated. All patients underwent compression ultrasonography performed by trained emergency physicians followed by radiologist-performed Doppler ultrasonography as the reference standard. Diagnostic performance was assessed using sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) with 95% CIs. Interobserver agreement was evaluated using Cohen's kappa coefficient. DVT was confirmed in 33/309 patients (10.6%). Emergency physician-performed compression ultrasonography demonstrated a sensitivity of 97.0% (95% CI 84.2 to 99.9) and specificity of 99.3% (95% CI 97.4 to 99.9). The PPV was 94.1% (95% CI 80.3 to 99.3) and the NPV was 99.6% (95% CI 98.0 to 100). Interobserver agreement between emergency physicians and radiologists was excellent across evaluated venous segments, with Cohen's kappa values of 0.926 (95% CI 0.880 to 0.971) for the femoral vein, 0.907 (95% CI 0.855 to 0.958) for the saphenofemoral junction and 0.973 (95% CI 0.947 to 0.999) for the popliteal vein. The median workflow-based time-to-diagnosis was 1 hour (IQR 0.75-1.5) for emergency physician-performed ultrasound and 4 hours (IQR 3-6) for radiologist-performed ultrasound. Compression ultrasonography performed by trained emergency physicians demonstrated high diagnostic accuracy and excellent agreement with radiologist-performed Doppler ultrasonography in patients with suspected DVT. Bedside ultrasound was also associated with shorter workflow-based time-to-diagnosis. These findings support further evaluation of whether earlier bedside diagnosis may translate into clinically meaningful outcomes such as reduced emergency department length of stay and improved patient flow.
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This study seeks to explore the experiences of emergency nurses in providing care to patients nearing the end of life and to identify the needs of emergency nurses in the palliative care (PC) process. A qualitative meta-synthesis approach (following Enhancing Transparency in Reporting the Synthesis of Qualitative Research guidelines) was implemented to systematically review relevant qualitative studies. A comprehensive search was conducted across multiple databases, encompassing PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature; (CINAHL), PsycINFO, Web of Science, CNKI (China National Knowledge Infrastructure), Wanfang database and Scopus. The search duration was from database inception to March 2025. In total, 22 studies complied with the inclusion criteria and were included in the meta-synthesis. Three main themes were identified: (i) needs for emergency palliative care (EPC) and current practice in emergency departments (EDs); (ii) emotional, ethical and communication experiences of nurses in providing PC in EDs; (iii) nurses' perceived needs for training, support and system coordination. Across studies, EPC in the ED was described as occurring alongside acute life-saving care. Nurses' experiences and attitudes towards EPC varied significantly, ranging from positive engagement to perceived incompatibility with their roles in emergency care. This meta-synthesis highlights the complexity of providing PC in EDs and the urgency of implementing systematic interventions. To enhance the effectiveness and quality of EPC, it is necessary to provide systematic support and targeted strategies, thereby helping emergency nurses better meet the needs of patients at the end of life. CRD420251008755.
Communication in a family's primary language can support safe care. Vital steps within the care delivery process are contingent on successful communication, including reporting symptoms, clinical decision-making, informed consent, discharge communication and follow-up coordination. The importance of effective information exchange is particularly pronounced in paediatric emergency care, and complex interactions may arise as parents or carers advocate on behalf of children. This scoping review aimed to identify and map existing research indicating where along the care journey communication-related risks for safety lie during paediatric emergency care and what strategies exist to mitigate them. We searched MEDLINE, Embase, CINAHL, Scopus, Web of Science and Cochrane Library for studies which examined the influence of language barriers on patient safety in paediatric emergency care as well as studies that evaluated interventions. Bibliographic database searches were executed on 18 December 2024; retrieved records were independently screened by two authors at title and abstract level followed by full text level. Data on study objectives, population characteristics, study design and their key findings were extracted. 1578 articles were identified, of which 33 were included and mapped according to (i) studies reporting safety risks linked to language barriers in paediatric emergency care (n=24) and (ii) existing interventions designed to mitigate these risks (n=9). Studies highlighted that language barriers can influence safety at multiple stages of the emergency care pathway, with discharge most frequently reported as a point of risk for paediatric patient safety. Interventions focused primarily on usage, uptake and documentation of professional interpreter services. Addressing misunderstandings around follow-up and home-care advice during medical safety netting are priority areas for intervention. Future research should involve carer and clinical perspectives in exploring whether technology-enabled tools, including artificial intelligence, can safely mitigate language barriers in these situations.
Distal radius fractures commonly require manipulation in the emergency department. Procedural sedation is frequently used but is resource-intensive and associated with potential adverse events. Haematoma block may offer a practical alternative, particularly in busy emergency departments, but its comparative efficacy and safety are uncertain. To evaluate whether haematoma block provides a comparable procedural success rate to procedural sedation, and whether there is a difference in the likelihood of adverse events, in adult patients undergoing manipulation of distal radius fractures in the emergency department. A structured search of MEDLINE and Embase databases was conducted using the Ovid interface. Studies comparing haematoma block with procedural sedation for manipulation of distal radius fractures in adults were included. Outcomes assessed included procedural success rate and adverse events. Seven studies met inclusion criteria, comprising four randomised controlled trials and three observational studies. Two studies were derived from the same dataset and were combined in the Best Evidence Topic (BET) table as one. Across the included studies, there was no consistent evidence of a difference in procedural success between haematoma block and procedural sedation. The highest-quality evidence from two randomised controlled trials found no difference in radiographic outcome. Regarding the likelihood of adverse events when comparing haematoma block versus sedation, one study found less pain in the haematoma block group. None of the other studies detected a statistically significant difference. In adult patients presenting to the emergency department with distal radius fractures requiring manipulation, the use of haematoma blocks appears to be associated with comparable procedural success rate to procedural sedation, without strong evidence of a difference in likelihood of adverse events.
Cerebral CT (CCT) is used in emergency departments (EDs) to assess suspected central nervous system disorders, particularly neurovascular issues. However, the increasing use of CCT raises concerns regarding cost, radiation exposure and efficiency, prompting the development of clinical scoring systems to guide informed decisions and reduce unnecessary imaging. The Emergency CT Head Score (ECHS) is a recent tool designed to streamline CCT prescriptions using four criteria: neurological deficit, acute headache, seizures with altered consciousness and transient neurological disorders. This study aimed to validate the ECHS in a different population and healthcare system in France while also providing a detailed cost analysis. This multicentre retrospective study, conducted in two EDs in Normandy, included adults (≥18 years) presenting with non-rotatory vertigo, acute headache, altered consciousness, seizures, confusion, dizziness, syncope or presyncope without recent trauma who underwent CCT. Exclusion criteria were suspected stroke/transient ischemic attack (TIA) according to French guidelines, head trauma, brain cancer, hydrocephalus, recent stroke or minors. No follow-up was performed. The ECHS was calculated retrospectively and compared with CT findings. Of the 600 included patients, the mean age was 62.4±18.7 years and 86 (14.3%) showed abnormalities on CT. The ECHS score demonstrated strong performance, with an area under the curve of 0.894 (95% CI 0.849 to 0.940). Using a threshold of ECHS≥1, we observed no false negatives, resulting in a sensitivity of 100% (95% CI 95.8% to 100%) and negative predictive value of 100% (95 % CI 98.2% to 100%). At this threshold, 48% of CCT scans could have been avoided without adverse outcomes. The ECHS demonstrated high sensitivity for detecting CT abnormalities in this cohort, suggesting potential to reduce unnecessary scans in patients with a score of 0. However, prospective implementation studies are needed.
Many practising clinicians have voiced concerns about limitations and imperfections associated with evidence-based medicine. Some of those concerns are aimed at the methodology and objectives of present-day medical research; others are a reflection of diverse environments and populations in which medical care is delivered. We argue in this paper that absence of evidence for any particular approach does not equate with evidence of absence of benefit of a considered intervention. Sufficient rather than perfect solutions may reflect patient preference or contextual constraints rather than ignorance on the part of the clinical practitioner. Relying on evidence without applying clinical judgement may sometimes be inappropriate. Medicine that acknowledges gaps in evidence needs to be pragmatic, seeking a solution for the patient in front of us.
Globally, patients with low back pain (LBP) account for 4.4% of all emergency department (ED) attendances, in the UK, 50 000 visits have been reported each month. LBP is reportedly challenging to manage in this setting. Consequently, hospital admission is common despite low numbers of serious pathology. This quality improvement (QI) project aimed to reduce avoidable hospital admissions by implementing and embedding a same day emergency care (SDEC) pathway for LBP over a 2-year period.A 12-bedded area was repurposed as an SDEC unit, staffed by specialist spinal nurses and a senior decision maker (advanced practice physiotherapist or spinal surgical fellow). The service was co-designed with key stakeholders, including spinal leadership, ED representatives, radiology and patients to form an ED-spinal interface group. The pathway was developed and refined over four plan-do-study-act (PDSA) cycles (2018-2021), supported by regular interface meetings and iterative feedback. Prospective data collection included referral activity, clinical timings, MRI utilisation and patient satisfaction. The project was registered as a QI initiative and did not require formal ethical approval.Between November 2018 and December 2021, the spinal SDEC recorded 3921 referrals. PDSA cycle 1 (pilot) recorded 267 referrals with 82 (31%) admitted and 19 (7%) requiring same day MRI. PDSA cycle 2 (referral expansion) recorded 569 referrals with 177 (31%) admitted and 39 (7%) requiring same day MRI. PDSA cycle 3 (system engagement) recorded 1043 referrals with 119 (11%) admitted and 154 (15%) requiring same day MRI. PDSA cycle 4 (embedding SDEC) recorded 2042 patient referrals with only 8% (n=172) admitted and 224 (11%) requiring same day MRI. Across four improvement cycles, the spinal SDEC demonstrated progressive and sustained reductions in hospital admission without an apparent increase in demand for same day MRI.
Chest pain is the second leading emergency department (ED) presentation, with its associated diagnostics requiring ED resource utilisation. Radiography is used in 70% of cases but identifies clinically significant findings in only 1.5%-2.1%. The predominance of non-actionable imaging results, combined with paucity of decision rules, prompted this systematic review to inform the development of a new clinical decision rule (CDR). Four bibliographical databases were searched, including: PubMed, MEDLINE, EMBASE and COCHRANE. Study selection, extraction and quality assessment were conducted independently by two reviewers via Covidence. Studies using a shared clinical decision tool were pooled to calculate sensitivity, specificity, likelihood ratios and false-positive rates using Meta-DiSc V.2.0. Univariate and, where possible, bivariate analyses generated forest plots and summary receiver operating characteristics curves. Heterogeneity was quantified by I², and methodological bias assessed via the Prediction model study Risk of Bias Assessment Tool (PROBAST). From 626 records, 7 studies (6654 ED patients, Canada, Australia, USA) met inclusion. Of these, further analysis was undertaken of four validation studies. Two studies examined the Hess CDR reporting 98.3% sensitivity (95% CI 17% to 100%) and 47.6% specificity (95% CI 43.8% to 51.3%). Two studies examined the Rothrock CDR and reported 88.6% sensitivity (95% CI 80.1% to 93.7%) and 73% specificity (95% CI 17.7% to 97.2%). Hess had a negative likelihood ratio of 0.04 (95% CI 0 to 9.17) compared with Rothrock (0.156, 95% CI 0.06 to 0.38) and Rothrock had a positive likelihood ratio of 3.3 (95% CI 0.52 to 20.95) compared with Hess (1.9, 95% CI 1.67 to 2.11). Meta-analysis showed high heterogeneity with low bias as per PROBAST criteria. A systematic review and meta-analysis of two chest X-ray decision rules for non-traumatic chest pain found the Hess et al rule more sensitive but unlikely to reduce imaging. Evidence is limited by few studies, high heterogeneity and retrospective cohorts. Neither rule is recommendable, highlighting the need for prospective derivation using established methodological standards.
Sex and gender influence how chest pain presents, how it is assessed and its outcomes, yet accelerated diagnostic protocols (ADPs) used in emergency departments (EDs) largely ignore these differences. This systematic review assesses the extent to which sex-based and gender-based factors are addressed in studies implementing ADPs in EDs for adult patients presenting with chest pain. Six electronic databases were searched from inception through 31 May 2024, for ED-based studies on ADP implementation in adults with suspected cardiac chest pain. Eligible study designs included randomised controlled trials, controlled clinical trials, cohort studies, before/after studies and observational studies. Two reviewers independently screened articles for relevance and inclusion, with disagreements resolved by third-party adjudication. The primary outcome was the proportion of studies providing sex-disaggregated or gender-disaggregated analyses for key ED outcomes; secondary outcomes included the accuracy of sex and gender reporting per Canadian Institutes of Health Research definitions. From 19 455 records, 211 studies were included, predominantly prospective cohort designs (39%), with most data collected in ED settings (87%). While 95% reported participant sex, 76% did so appropriately; fewer than 20% considered sex or gender explicitly in their analyses or ADP applications. Gender was reported less frequently (37%) and reporting was largely inaccurate (92%). No studies presented sex-disaggregated or gender-disaggregated analyses for key ED outcomes (eg, length of stay, consultations, admissions, major adverse cardiac events). Regression analyses failed to identify significant increases in sex/gender reporting following major international sex-based and gender-based policy initiatives. Our findings highlight a critical need for improved and consistent integration of sex and gender in ED cardiac research. While most studies recognise the importance of sex differences, few explicitly addressed them, and even fewer considered the complexity of gender identities meaningfully. Future research should examine sex-specific and gender-specific troponin cut points, investigate at-risk groups and report disaggregated analyses of ED-relevant outcomes. CRD42022380813.
It is believed that low health literacy (HL) is associated with inappropriate use of emergency departments (ED). The volume of ED visits in Turkey continues to increase. This study aimed to evaluate the effects of adults' HL level, reasons for attending the ED, frequency of visits and trust in health news on social media on HL level and ED visits. This prospective cross-sectional study was conducted at a university hospital ED in Istanbul from December 2021 to January 2023. Participants were adults (>18 years) admitted to the green or yellow triage areas, representing non-urgent or moderately urgent conditions. Data were collected through a Personal Information Form and the Turkish Health Literacy Scale-32 (THLS-32), administered either face to face or online. A total of 466 participants (mean age 30.3±12.9 years, 71.7% female) were included. Most participants were university graduates. The mean THLS-32 score was 30.35±10.11 (range 0-50), with only 13.9% (42-50 points) classified as having 'excellent' HL. Participants who reported relying on social media for health news and those who visited the ED due to 'long waits for a hospital outpatient clinic' had lower THLS-32 scores. There was no statistically significant association between HL and frequent ED attendance, age, gender or educational level. Lower HL is associated with greater reliance on unverified information in social media for health news and ED attendance due to long outpatient waits. Our findings highlight the need for targeted HL and digital HL initiatives to reduce avoidable ED visits and strengthen healthcare navigation skills.
The Urgent and Emergency Care system generates a wealth of clinical information, but our ability to harness this for public health planning and to address health inequalities is constrained by systemic data quality issues. Modern natural language processing (NLP), driven by the context-aware capabilities of transformer-based architectures and large language models, offers a transformative opportunity to bridge this gap. By training machines to interpret and structure context-rich clinical notes at scale, we can translate complex patient stories into data ready for research and systems intelligence that reflects the realities of real-world care.This technology offers a potential route to addressing health inequities in vulnerable populations, such as those presenting with crises related to mental ill-health, alcohol and drug use. Current reliance on structured but oversimplistic data often fails to capture the complex intersectionalities of clinical and social contexts. This is due to factors like diagnostic overshadowing and unrecorded multimorbidity, leaving these patients statistically obscured within routine datasets, which fail to accurately represent volume or complexity. This data invisibility perpetuates a cycle of inaccurate disease burden estimates, under-resourced services and flawed policy. By unlocking the detailed narrative data within unstructured notes, NLP could allow us to identify the acute social stressors and psychiatric contexts that are currently invisible, making these inequities visible and actionable.
Blood cultures are frequently performed in febrile emergency department (ED) patients despite low yield and risks of contamination. Existing prediction tools are not usable at triage. The objective was to derive and internally validate a score for predicting bloodstream infection using variables assessable immediately after ED triage. This observational retrospective cohort study was conducted in the two EDs of a University Hospital between 1 January and 31 December 2021. Adult patients for whom a blood culture was collected during ED visit were included. The primary endpoint was bloodstream infection. A multivariate analysis using backward stepwise logistic regression was performed to identify risk factors for bloodstream infection and derive the aGe, cOmplaint, Temperature and Hemodynamic for bloodstream Infection Classification (GOTHIC) score. Diagnostic accuracy of the score was evaluated in the derivation and validation cohorts. 6740 visits were analysed, including 4493 patients in the derivation cohort and 2247 patients in the validation cohort. The prevalence of bloodstream infection was 11% (n=512) and 10% (n=234) in each cohort, respectively. The GOTHIC score included seven factors associated with bloodstream infection: age ≥75 years (OR=2.90; +1 point), tachycardia >90 beats per minute (OR=1.51; +1 point), systolic blood pressure <100 mm Hg (OR=1.90; +1 point), diastolic blood pressure <60 mmvHg (OR=1.41; +1 point), fever >38°C (OR=2.14; +1 point), isolated fever as chief complaint at triage (OR=1.62; +1 point) and protective chief complaint (dyspnoea, COVID-19 symptoms or vaso-occlusive crisis) (OR=0.47; -1 point). We propose a simple risk score for bloodstream infection that can be easily calculated using seven variables assessable at triage.
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