This study analyzed the relationship between violence tendency and history of violence in emergency department patients. The study included 384 patients presenting to the Emergency Medicine Unit at Afyonkarahisar Health Sciences University. A questionnaire containing demographic information and the Buss-Perry Aggression Scale was administered to the patients. The demographic information form included questions regarding gender, age, marital status, occupation, reason for emergency room visit, chronic disease, regular medication use, emergency room history, and nominal variables that may be associated with aggression. Physical aggression, anger and hostility score were significantly higher for participants who subjected to verbal violence, use physical and verbal violence and has criminal record (p < 0.05). Verbal aggression was significantly higher for participants who use physical and verbal violence and has criminal record (p < 0.05). Physical aggression was significantly correlated with subjected to verbal violence (r = 0.139; p < 0.01), use of physical violence (r = 0.170; p < 0.01), use of verbal violence (r = 0.270; p < 0.01) and criminal record (r = 0.277; p < 0.01). Anger score was significantly correlated with subjected to verbal violence (r = 0.138; p < 0.01), use of physical violence (r = 0.169; p < 0.01), use of verbal violence (r = 0.221; p < 0.01) and criminal record (r = 0.273; p < 0.01). Hostility was significantly correlated with subjected to verbal violence (r = 0.152; p < 0.01), use of physical violence (r = 0.168; p < 0.01), use of verbal violence (r = 0.213; p < 0.01) and criminal record (r = 0.224; p < 0.01). Verbal aggression was significantly correlated with use of physical violence (r = 0.146; p < 0.01), use of verbal violence (r = 0.190; p < 0.01) and criminal record (r = 0.251; p < 0.01). Our research results revealed that previous verbal abuse, verbal and physical abuse, and a criminal record significantly associated the tendency of violence in emergency departments. However, these results are related to the scale's level of tendency, and further research is needed to determine predictive results. Emergency medicine history, however, did not significantly affect or differentiate violence.
Early risk stratification in geriatric patients presenting to the emergency department remains challenging. Sarcopenia has emerged as a potential marker of reduced physiological reserve and adverse clinical outcomes. This study aimed to evaluate the prognostic value of quadriceps muscle thickness and the paraspinal muscle index for predicting short-term mortality in geriatric emergency department patients and to examine their association with established frailty scales. In this single-center prospective observational study, consecutive patients aged ≥ 65 years presenting to the emergency department were enrolled. Rectus femoris and vastus intermedius muscle thicknesses were measured using bedside ultrasonography. The paraspinal muscle index was calculated from thoracic computed tomography images obtained for clinical indications. Frailty was assessed using the Clinical Frailty Scale (CFS), Elderly Risk Assessment (ERA), and Identification of Seniors at Risk (ISAR). The primary outcome was 30-day mortality. Receiver operating characteristic (ROC) analysis was performed to evaluate discriminatory performance. A total of 139 patients were included, of whom 28 (20.1%) died within 30 days. All sarcopenia indices were significantly lower among non-survivors (p < 0.05). In ROC analysis, the paraspinal muscle index demonstrated the highest discriminatory ability for predicting 30-day mortality (AUC 0.689, 95% CI 0.584-0.795), followed by the vastus intermedius (AUC 0.633) and rectus femoris indices (AUC 0.628). In subgroup analysis, quadriceps indices were associated with mortality only in non-inflammatory patients, whereas the paraspinal muscle index remained predictive across both groups. Among frailty tools, only CFS was significantly associated with mortality. Muscle-based sarcopenia markers, particularly the paraspinal muscle index, are associated with short-term mortality in geriatric emergency department patients. Integration of muscle measurements with frailty assessment may enhance early risk stratification in emergency care settings.
Patients with non-ST-segment elevation myocardial infarction (NSTEMI) are commonly evaluated first in the emergency department, where early estimation of coronary disease burden may support clinical risk assessment before invasive coronary angiography. This study investigated whether routinely available emergency department parameters, with particular emphasis on ejection fraction (EF) and absolute delta troponin, were associated with high angiographic coronary disease burden assessed by the Gensini score. This retrospective observational study included adult NSTEMI patients admitted to the emergency department of a tertiary care hospital between January 1, 2024, and May 1, 2025, who subsequently underwent coronary angiography. Patients were divided into low and high Gensini groups using a predefined threshold of 40. Demographic characteristics, comorbidities, laboratory variables, echocardiographic findings, and absolute changes in serial troponin measurements were compared between groups. Independent associations with the high Gensini category were evaluated using multivariable binary logistic regression. Receiver operating characteristic curve analysis was used to assess the discriminatory performance of EF and absolute delta troponin/100. A total of 394 patients were included in the final analysis; 209 were classified into the low Gensini group and 185 into the high Gensini group. In the adjusted model, lower EF was independently associated with the high Gensini category (OR: 0.888; 95% CI: 0.859-0.918; p < 0.001), while higher absolute delta troponin/100 showed a positive independent association (OR: 1.161; 95% CI: 1.074-1.254; p < 0.001). Diabetes mellitus was also independently associated with the high Gensini category (OR: 1.851; 95% CI: 1.096-3.127; p = 0.021). EF and absolute delta troponin/100 both showed statistically significant discrimination for the high Gensini category, with AUC values of 0.783 and 0.758, respectively. In NSTEMI patients evaluated in the emergency department, lower EF and higher absolute delta troponin were independently associated with high angiographic coronary disease burden. EF showed slightly higher discriminatory performance than absolute delta troponin/100. These findings suggest that EF and absolute troponin change may provide complementary information during early emergency department assessment before coronary angiography, although they should not be interpreted as validated predictors of clinical outcomes.
End-of-life (EOL) care is a frequent and complex aspect of internal medicine, yet data on physicians' training, clinical practices, and perceived challenges are limited. This study aimed to explore current practices, knowledge gaps, and unmet needs in EOL care among Italian internal medicine physicians and residents. A cross-sectional survey was conducted under the auspices of the Piedmont-Liguria-Aosta Valley Section of the Italian Society of Internal Medicine (SIMI). The survey included 25 closed-ended questions addressing five domains: epidemiological, pharmacological, practical, psychological, and educational aspects of EOL care. Physicians actively involved in clinical care from multiple internal medicine wards participated voluntarily. Responses were collected anonymously via paper and online formats. Descriptive statistics were used to summarize data. Differences between groups (specialists vs. residents, oncology/hematology vs. non-oncology wards, low vs. medium vs. high clinical intensity wards) were assessed using the Mann-Whitney U and Kruskal-Wallis tests. Associations between ordinal variables were evaluated using Spearman's rank correlation coefficient. P-values were adjusted using the Benjamini-Hochberg procedure. Of approximately 7,400 invited physicians, 619 completed the survey (response rate ≈ 8.4%; median age 38 years; 60.5% female; 70.8% board-certified internists). More than 88% reported facing terminal patients at least weekly, yet only 2.5% were aware of Advance Directives for > 25% of inpatients. Use of sedatives and analgesics during terminal sedation varied, while discontinuation of active therapies, total parenteral nutrition (TPN), and transfusions was widely accepted. Internal protocols and dedicated multidisciplinary discussions were infrequently used. Most respondents reported difficulties communicating with patients and families at EOL. Formal training in EOL care was perceived as largely inadequate during undergraduate, residency, and postgraduate education. Compared with residents, board-certified internists more frequently reported postgraduate/Master training, whereas residents more frequently reported undergraduate and residency training in EOL. Exploratory correlation analyses generated hypotheses linking communication difficulties with patients to those with family members and training experiences across educational stages. The study highlights substantial gaps in training, communication, and organizational support, independent of clinical setting. Structured education and integration of psychological support are urgently needed. These findings can inform curriculum development, hospital policies, and future research to improve physician preparedness and patient-centered EOL care.
The emergency consultation process is a high-stakes interface between emergency and specialist physicians, yet systematic differences in how each party perceives this process remain poorly characterized. This study aimed to quantify the perception gap between emergency physicians (EPs) and consultants (CNs) across multiple consultation domains and to identify distinct perception profiles and dyadic conflict risk patterns. A cross-sectional survey was administered to 186 physicians (81 EPs, 105 CNs) in Türkiye between January 2024 and January 2026, using parallel EP- and CN-specific questionnaires. Group comparisons were performed using the Mann-Whitney U test with rank-biserial effect sizes. Perception gap analysis, latent class analysis (LCA), and Monte Carlo dyadic conflict risk simulation (n = 10,000 dyads per combination) were conducted. Statistically significant between-group differences were identified in six of eight domains. The largest perception gaps were observed for frequency of unnecessary consultation requests (r = 0.723), clarity of expectations stated in requests (r = 0.658), and timeliness of responses (r = 0.624). LCA identified two latent classes: "Dissatisfied Requesters" (88.1% EPs) and "Overwhelmed Responders" (94.0% CNs; χ² = 110.49, p < 0.001). Dyadic simulation revealed the highest conflict risk in conflictual × conflictual pairings (mean risk score 3.46; 24.8% high-risk dyads), with no asymmetry between mixed-profile combinations (Δ = 0.02). Emergency physicians and consultants exhibit systematically divergent perceptions of the consultation process, converging only in their shared perception of workflow burden. The absence of asymmetric conflict risk in mixed profiles in this exploratory simulation may be consistent with interprofessional conflict being a bidirectional phenomenon, suggesting that system-level rather than individual-level approaches may warrant consideration. Structured consultation training and shared expectation frameworks are proposed as directions for future investigation. Not applicable.
Emergency surgery for complicated diverticulitis carries substantial morbidity and mortality. Whether minimally invasive approaches offer advantages over open surgery in this urgent setting remains uncertain. We synthesized contemporary evidence comparing emergency minimally invasive versus open left-sided colonic resection for complicated diverticulitis. Following PRISMA 2020 guidelines and a prospectively registered protocol, we searched PubMed, Scopus, Cochrane Library, and ClinicalTrials.gov through July 2025. We included comparative studies of emergency minimally invasive versus open colectomy for complicated diverticulitis (Hinchey II-IV). Random-effects meta-analysis with Hartung-Knapp-Sidik-Jonkman adjustment was performed. Risk of bias was assessed using ROBINS-I at the outcome level, and certainty of evidence was evaluated using GRADE. Six studies encompassing 9,637 patients (1,821 minimally invasive, 7,816 open) met inclusion criteria. Minimally invasive surgery was associated with lower 30-day mortality (4.5% vs. 8.7%; RR 0.48, 95% CI 0.40-0.59; P = 0.0002; I²=0%; low certainty); this estimate derived 86.9% of its weight from one database study and was no longer statistically significant when that study was excluded (RR 0.61, 95% CI 0.35-1.06). Major complications did not differ significantly (15.2% vs. 17.7%; RR 0.63, 95% CI 0.36-1.08; P = 0.10; very low certainty). Length of stay was shorter (MD - 2.55 days, 95% CI - 4.37 to - 0.74; P = 0.02) and incisional surgical site infection rates were lower (RR 0.30, 95% CI 0.12-0.75; P = 0.02), though operative time was longer (MD + 18.27 min, 95% CI 0.89-35.64; P = 0.04). Reoperation rates were similar (RR 0.98, 95% CI 0.78-1.22). Emergency minimally invasive resection was associated with lower 30-day mortality and shorter hospital stay, without conclusive evidence of fewer major complications. The mortality estimate derived most of its statistical weight from one large database study; after excluding that study, the point estimate remained favorable but imprecise. Overall certainty was low to very low, so these findings are hypothesis-generating rather than practice-changing. Minimally invasive resection may be considered in hemodynamically stable, selected patients operated on by surgeons with advanced laparoscopic colorectal expertise, pending prospective validation. PROSPERO CRD420251142546.
Pain is common in emergency medical services, and abdominal pain is among the most frequent complaints. This study examined whether documented pain assessment, analgesic treatment, reassessment, and documented end-of-encounter pain status in patients with acute abdominal pain differed by clinician competence (Prehospital Emergency Nurse [PEN] vs. non-PEN), patient sex, age, and prehospital interval. This retrospective observational study was a secondary analysis of adult patients with acute abdominal pain in a previously described cohort. Electronic patient records were reviewed in full, including Numerical Rating Scale (NRS) scores and free-text pain descriptions. Primary outcomes were documented pain assessment, analgesia administration, and any documented reassessment. Secondary outcomes were documented NRS use, analgesia among patients with moderate-severe pain, reassessment after analgesia, and mild pain at the last documented assessment. Age and prehospital interval were dichotomized at the median. Mann-Whitney U and Fisher's exact tests were used, with p < 0.01 considered statistically significant. Of 840 sampled records, 816 were included. Median age was 64 years (IQR 41-79), and median prehospital interval was 38 minutes (IQR 27-60). Compared with non-PEN encounters, PEN encounters had higher rates of pain assessment (67% vs. 53%, p = 0.003), analgesia administration (50% vs. 37%, p = 0.005), and reassessment (31% vs. 17%, p < 0.001). Among patients with moderate-severe pain, analgesia was more frequent in PEN encounters (81% vs. 58%, p < 0.001). Mild pain at the last documented assessment was also more common in PEN encounters (23% vs. 8%, p < 0.001). Younger patients and cases with longer prehospital intervals had higher rates of pain assessment, NRS use, analgesia administration, and reassessment, but not mild pain at last assessment. The PEN encounters showed higher rates of documented pain assessment, analgesia administration, and reassessment, with a higher proportion of patients having mild pain at the last documented assessment. Differences related to age and prehospital interval were mainly limited to process measures. Further research is needed to clarify whether clinician competence and care processes translate into improved pain relief.
Individuals with diabetes have an increased risk of cardiovascular disease, infection, hospitalization, and premature mortality. However, less is known about how diabetes shapes the broader pattern of emergency department (ED) presentations, acute care use, clinical complexity, and short-term mortality in an unselected ED population. We aimed to describe ED presentation patterns and outcomes among individuals with and without diabetes in a large regional cohort. We conducted a population-based cohort study including all adult ED visits to nine hospitals in Region Skåne, Sweden, between 2017 and 2018. ED visits for patients with a registered diabetes diagnosis (n = 60,654) were compared with those without diabetes (n = 502,800). We analysed ED visit frequency, recurrent ED use, arrival by ambulance, triage priority, length of stay, comorbidity burden, presenting complaints, and mortality after ED presentation. The most common presenting complaints were broadly similar in both groups, with dyspnoea, chest pain, and abdominal pain among the leading causes of ED presentation. However, diabetes visits were characterized by greater acute care complexity. Compared with visits by individuals without diabetes, visits by individuals with diabetes more often involved a previous ED visit within 90 days, higher triage priority, ambulance arrival, longer ED stay, and substantially higher comorbidity burden. Early mortality after ED presentation was also higher among individuals with diabetes and occurred at younger ages, particularly among men. Mortality diagnoses differed between groups, with cardiovascular causes more prominent among individuals with diabetes. In this large population-based ED cohort, individuals with diabetes presented with broadly similar symptom categories as those without diabetes, but with markedly greater clinical complexity, higher acuity, recurrent acute care use, and earlier mortality. Diabetes in emergency care may therefore identify a patient group with substantial multimorbidity, reduced physiological reserve, and increased vulnerability during acute illness.
Artificial intelligence (AI) can support and enhance radiologists in musculoskeletal imaging, but evidence of clinical benefit is still lacking. This prospective study aimed to estimate the range of expected effect size on patient recall rates whether after implementation of an AI system for fracture detection affects in a paediatric emergency setting during out-of-hourse care. Children and adolescents (2-18 years) undergoing appendicular skeletal radiography between April and September 2025 during on-call hours at a tertiary referral hospital were eligible. On every second day, automated fracture detection by a commercial AI system (TechCare Kids, Milvue, Paris, France) was available for the treating physician. Endpoints were the rate of diagnostic revisions leading to patient recall the next day, therapeutic changes, length of stay at the emergency department, need for senior consultation, subjective diagnostic confidence, and AI accuracy. Among 1515 screened patients, 667 were enrolled (median age 11.0 years, 61% male). Fractures were present in 296 cases (44.3%). AI accuracy was 95.1%. Diagnostic revisions occurred in 8.6% without AI, in 5.7% with AI support (risk ratio 0.66; 95% CI 0.37-1.19). Resulting therapeutic changes were rare in both groups (2.0% vs. 0.4%; p = 0.10). No significant differences were observed for secondary endpoints, including need for senior consultation (14.3% vs. 12.5%), subjective diagnostic confidence, or length of stay (2.3 h vs. 2.4 h). Given the small effect size for patient recall rates in an academic medical setting, it is questionable whether the efforts conducting a confirmatory study with adequate statistical power would be justified by the expected incremental benefit for the investigated outcomes.
The use of laparoscopy for strangulated inguinal hernia remains controversial, especially when bowel ischemia is suspected. This study evaluated the feasibility and outcomes of emergency laparoscopic TAPP repair in patients with strangulated inguinal hernia and examined preoperative factors associated with bowel resection. We reviewed all patients who were first treated laparoscopically for a strangulated inguinal hernia from April 2024 to December 2025. If laparoscopic reduction failed and conversion was needed, those cases were described separately. The same TAPP technique was used for all, with either a 12 × 15 cm or 15 × 15 cm polypropylene mesh fixed with nonabsorbable tacks. We used univariable analysis to look at factors linked to bowel resection, and described recurrence during follow-up. Of the 62 patients initially approached laparoscopically, 11 (17.7%) required conversion to open repair because reduction was not possible. Two of these 11 needed bowel resection due to bowel ischemia. The main group for analysis included 51 patients who had a completed TAPP repair. Bowel resection was needed in 5 of these patients (9.8%; 95% CI 3.3-21.4%). Longer symptom duration and higher CRP levels were strongly linked to needing bowel resection. During a median follow-up of 16 months (IQR, 10.5-20 months), 6 patients (11.8%; 95% CI 4.4-23.9%) had recurrence. There were no deaths. Emergency laparoscopic TAPP repair appears feasible and safe in well-chosen patients with strangulated inguinal hernia, as long as laparoscopic reduction is possible. Longer symptoms and higher CRP levels were linked to a greater need for bowel resection, but these findings should be viewed with caution because of the small number of cases. These findings support a laparoscopic-first approach in appropriately selected patients, but more research from larger, multicenter studies is needed to confirm these findings and improve patient selection.
To describe the distribution and outcomes of cultures obtained in the emergency department (ED), examine contamination and microbiological yield across specimen types, and compare results between adult and pediatric settings. We conducted a retrospective study including all cultures obtained over a 12-month period in the adult and pediatric EDs of a tertiary hospital. Demographic characteristics, culture type, microbiological results, and patient disposition were extracted from electronic records. Culture results were categorized as no growth, contamination/commensal-flora, bacterial growth with or without extended-spectrum β-lactamase (ESBL) production, yeast growth, or sample rejection. A total of 2,674 cultures were analyzed. Nearly half of the cultures showed no growth (48.8%), and 24.3% were classified as contamination/commensal-flora based on laboratory report wording, representing low-interpretability flora reports rather than a formal blood culture contamination rate. Bacterial growth without ESBL production occurred in 16.6%, while ESBL-producing organisms were detected in 2.3%; yeast growth occurred in 1.0%, and 7.0% of samples were rejected. Urine cultures constituted the largest proportion and demonstrated higher rates of both growth and contamination/commensal-flora compared with blood and sterile body fluid cultures. Contamination/commensal-flora was more frequent in pediatric ED cultures, whereas hospitalized-particularly intensive care-patients had higher microbiological positivity and a greater prevalence of ESBL-producing organisms. A substantial share of ED cultures yielded no growth or laboratory-wording-based contamination/commensal-flora reports, suggesting limited diagnostic interpretability in many cases. Variation by specimen type and patient disposition highlights the importance of selective culture ordering, improved collection practices, and integration of antimicrobial stewardship principles into ED workflows. Prospective multicenter studies incorporating clinical outcomes are needed to clarify the impact of ED culture practices on patient care.
Pulmonary thromboembolism (PTE) is a life‑threatening condition that requires prompt and accurate evaluation in the emergency department (ED). Standardized clinical scoring systems, including the Wells and revised Geneva scores, form the cornerstone of initial risk stratification but have limited specificity, leading to unnecessary D‑dimer testing and frequent overuse of CT pulmonary angiography (CTPA). This study aimed to develop explainable machine‑learning (XML) models as a complementary decision‑support layer following initial clinical assessment, with the dual goals of improving PTE prediction and providing an early, non‑imaging‑based indication of clot location. Clinical and paraclinical data from 472 ED patients with suspected PTE were collected across three centers of Mashhad University of Medical Sciences (2022-2024) using structured forms aligned with Wells/Geneva criteria. CTPA served as the reference standard for diagnosis and anatomical classification. We developed classical ML models, ensemble algorithms such as Extra Trees, and hybrid stacking pipelines. Explainable AI (XAI) using SHAP values quantified global and patientlevel feature contributions. The XML models were designed to operate after Wells/Geneva-based triage: supporting D-dimer decisions in low-risk patients and refining post-triage risk estimation in intermediate - and high-risk patients to help reduce avoidable CTPA utilization. In this intermediate‑ to high‑probability cohort, all patients were classified as PTE‑suspect by Wells/Geneva scoring, whereas only 24% were confirmed positive on CTPA. ML models demonstrated improved discrimination, with Extra Trees achieving the best performance (accuracy 0.82, sensitivity 0.69, specificity 0.86, AUC 0.83). Among PTE‑positive cases, the model achieved an AUC of 0.77 for central emboli and 0.67 for peripheral emboli, with an overall anatomical classification accuracy of 63%. The proposed XML models offer a transparent, clinically aligned framework that augments existing scoring systems, enhancing diagnostic efficiency and reducing unnecessary imaging.
Left ventricular free wall rupture (LVFWR) is a rare, and mechanical complication of acute myocardial infarction (MI) that may rapidly lead to cardiac tamponade and death. Optimal management requires urgent surgical repair; however, patients may deteriorate before definitive treatment can be initiated. A 62-year-old man presented with delayed anterior ST-segment elevation MI and underwent successful primary percutaneous coronary intervention. Persistent hypotension prompted urgent echocardiography, which revealed LVFWR with expanding hemopericardium and cardiac tamponade. Despite intensive supportive therapy, the patient developed profound hemodynamic instability with impending circulatory collapse. Since immediate surgical intervention was not available, fluoroscopy-guided pericardiocentesis was performed as a rescue measure. Drainage of 100 mL of hemorrhagic pericardial fluid resulted in prompt restoration of blood pressure and clinical stabilization, allowing transfer for emergency surgical repair. Intraoperative findings confirmed a 6-mm ventricular free wall tear. Surgical patch repair was successfully performed, and the patient was discharged without major complications. At one-month follow-up, he remained clinically stable. In a patient with LVFWR complicated by cardiac tamponade and rapidly deteriorating hemodynamics, limited pericardial drainage may provide temporary stabilization and serve as a bridge to definitive surgical repair when immediate surgery is not feasible.
Adrenal crisis (AC) is a rare but life-threatening pediatric emergency requiring rapid recognition and immediate administration of stress-dose glucocorticoids. Because AC is infrequently encountered during clinical training, pediatric and medicine pediatric residents may lack confidence and knowledge regarding timely diagnosis of adrenal insufficiency (AI), sick-day management, appropriate hydrocortisone dosing, and appropriate acute AC management. Simulation-based education provides a controlled environment to address these critical gaps. The objective of this pilot study was to assess the immediate educational impact of a high-fidelity simulation and structured debriefing on resident knowledge of AC recognition and management. Pediatric and medicine-pediatric residents participated in a 45-minute simulation session consisting of a novel, investigator-developed pediatric emergency department scenario involving AC, followed by a structured debrief focused on clinical decision-making, stress-dose steroid administration, dosing, and outpatient sick-day management. Residents completed a four-question knowledge assessment immediately before and after the intervention, with each question addressing a distinct domain of AC management. Responses were coded as correct or incorrect. Paired pre- and post-intervention responses were analyzed using McNemar's test for individual questions and paired tests for composite knowledge scores. Thirty-five residents completed paired pre- and post-simulation assessments. Baseline knowledge varied across domains, with particularly low accuracy in outpatient sick-day management (2.9%) and stress-dose hydrocortisone dosing (42.9%). Following the simulation and debriefing, correct response rates improved across all domains, with the greatest gains observed in sick-day management (85.3% post-intervention, p < 0.001) and stress-dose dosing (93.9%, p < 0.001). Recognition of first-line treatment for AC improved from 80.0% to 100% (p = 0.031). Mean composite knowledge scores increased significantly from 2.11 to 3.66 out of 4 (p < 0.001). A single simulation-based educational intervention with structured debriefing was associated with improved immediate knowledge of AC recognition and management among pediatric and medicine pediatric residents. Further studies are needed to evaluate long-term retention and translation to clinical performance.
Unplanned rehospitalisation is an undesirable outcome for patients and resource-constrained health systems. Community health services (CHS) support safe transitions home and recovery following hospital discharge, but evidence on their effectiveness in reducing rehospitalisation is limited. This study examined the impact of timely contact with CHS teams following hospital discharge on the odds of subsequent emergency hospital care. We used individual-level data from the Community Services Dataset on 63,019 individuals referred to 11 NHS Community Trust providers in England following hospital discharge between 1st April and 31st December 2019. Timeliness of CHS contact was defined as care being received within one day or between two and seven days post-discharge, compared to no contact within 30 days of discharge. Outcomes were emergency hospital readmission and emergency department (ED) attendance within 30 days of discharge. We used logistic regressions to estimate the association between timely CHS contact and hospital use, controlling for patient demographics, diagnosis and co-morbidities. Individuals in our sample were 72.5 years of age on average with 2.3 comorbidities, and 52% were female. 52% received care within one day of discharge, 20% within two to seven days, and 28% had no contact within 30 days. Having a CHS contact within one day of hospital discharge was associated with 33% lower odds of ED attendance (OR: 0.674, 95% CI: 0.640 to 0.709) and 38% lower odds of readmission within 30 days of discharge (OR: 0.615, 95% CI: 0.583 to 0.649), compared to individuals with no contact in the follow up period. Receiving a CHS contact between two to seven days of discharge was associated with 20% lower odds of ED attendance (OR: 0.804, 95% CI: 0.756 to 0.855) and 22% lower odds of readmission (OR: 0.775, 95% CI: 0.728 to 0.825) within 30 days of discharge. Timely contact with CHS teams following discharge was associated with substantially lower odds of subsequent emergency hospital use. Whilst contact within two to seven days was beneficial for many patients, contact within one day of discharge was consistently associated with the largest reductions in hospital use across all patient groups.
Among hospitals in the central Saitama Prefecture, only the Saitama Red Cross Hospital (SRCH) provides physician-staffed rapid response car (RRC) services during off-hours (weekday night-time, weekends, and public holidays). During off-hours, concentrated dispatch requests increase the operational and financial burden, particularly when cancellations occur. Furthermore, research on RRC cancellation in the Japanese urban emergency medical system remains limited. By examining the epidemiological characteristics of RRC cancellation, this study aimed to optimise RRC operations and enhance emergency medical response efficiency. This retrospective study analysed RRC dispatches from SRCH between January 1, 2021, and December 31, 2023, focusing on cases classified as 'cancelled' or 'treated'. Variables including age, disease type, distance from the hospital, request source, and time of request were compared using chi-square test, t-test, and Mann-Whitney U test. Logistic regression was performed to identify independent predictors of cancellation. Of 4,005 dispatches, 1,091 were cancelled, and 2,417 were treated; 497 cases were excluded because of incomplete data. Cancellations were significantly associated with patients aged ≥ 65 years, requests initiated by the Command Centre, and greater distance from the hospital. Respiratory failure and anaphylactic shock had the highest cancellation rates. Improving dispatch strategies can enhance pre-hospital emergency care, ensuring timely medical attention for critical patients, while reducing operational and financial strain on medical institutions.
The modern-day population with more chronic, complex medical and social comorbidities is increasing ambulance utilisation and conveyance to emergency departments (ED). This contributes to ambulance ramping, ED overcrowding and increased hospital bed utilisation. This scoping review aims to identify alternative care paths for patients calling for ambulance services. A total of 4902 articles were identified through four databases and the gray literature. The terms 'paramedic', 'ambulance' and 'non-conveyance', 'alternative' and 'community care' were combined to yield the search terms. The population studied includes individuals calling the national emergency number while the intervention focuses on prehospital services designed to avoid ED conveyance. Independent researchers screened the titles, abstracts and full texts, yielding 59 relevant articles which were then meta-synthesised. Five themes of care were identified - hear and treat, hear and refer, see and treat, see and refer and see and convey to a non-ED facility. Low-acuity patients, older patients, palliative and psychiatric patients, as well as those facing exacerbation of chronic conditions, alcoholic and frequent attenders appear to benefit from these alternative care service pathways (ACSPs). Allied health professionals such as nurses, social workers, occupational therapists, and physiotherapists collaborate with paramedics to frontload the care of these patients in the prehospital setting. Alternative conveyance destinations include general practices, geriatric wards, toxicology units, sobering centres and community hospitals. Implementing ACSPs and integrating healthcare approaches to enhance service efficiency and patient outcomes can alleviate pressure on emergency services by providing timely care and directing patients to appropriate services.
In the emergency department, chest pain is a common presentation, and the primary clinical challenge is the early identification of patients at risk of major adverse cardiac events (MACE). This study aimed to evaluate the diagnostic performance of the SVEAT (Symptoms, Vascular Disease History, ECG, Age, and Troponin) score in predicting 90-day MACE in patients presenting with acute chest pain. This study included 348 patients presenting with acute chest pain. Serial high-sensitivity troponin I (HsTn-I) measurements were obtained at admission and 2 h later. Electrocardiographic and clinical data were recorded, and the SVEAT, HEART, and TIMI scores were calculated. Patients were followed for 90 days for MACE occurrence. MACE occurred in 7.2% of patients during the 90-day follow-up. The second high-sensitivity troponin I (HsTn-I) measurement was significantly associated with MACE (p = 0.007). The SVEAT score demonstrated the highest discriminative performance (AUC = 0.806), compared with the HEART score (AUC = 0.756) and TIMI score (AUC = 0.753). At the optimal cut-off value of 4, the SVEAT score showed a sensitivity of 0.56 and a specificity of 0.86. In comparison, both the HEART and TIMI scores (cut-off = 3) showed higher sensitivity (0.72), with specificity values of 0.72 and 0.63, respectively. Not applicable. The SVEAT score may have potential as a rule-in tool for predicting 90-day MACE in emergency department patients presenting with acute chest pain, due to its higher specificity; however, this is accompanied by relatively low sensitivity, which limits its utility as a standalone screening tool.
Endoscopic variceal ligation (EVL) - induced ulcer bleeding is a rare but potentially life-threatening complication. While the incidence following elective and emergency EVL has been reported, semi-elective procedures performed during hospitalization for acute decompensation of cirrhosis have not been separately examined. Additionally, real-world data on endoscopic treatment strategies, hemostasis rates and outcomes are scarce. We conducted a retrospective cohort study analyzing all ligation procedures performed in adults with portal hypertension and esophageal varices at Charité University Hospital, Campus Virchow and Campus Mitte, from 01/01/2016 until 06/30/2023. We assessed incidence and risk factors by ligation indication, described endoscopic treatment strategies and analyzed predictors of 5-day rebleeding and 6-week mortality. Among 1,864 EVLs, 61 (3.3%) resulted in EVL-induced ulcer bleeding; 60 were analyzed. Incidence varied significantly by indication: 0.44% after elective, 8.5% after emergency and 15.9% after semi-elective EVL. Repeat ligation was the most common endoscopic treatment (32.4%), followed by fibrin glue (14.7%) and balloon tamponade (11.7%); the overall primary hemostasis rate was 82.8%. Ten patients (16.7%) underwent TIPS. The 5-day rebleeding rate was 25% and the 6-week mortality rate 41.7%. Multivariate logistic regression analysis revealed that 5-day rebleeding (OR: 8.05; 1.66-39.2; p = 0.01) and post-bleeding sepsis (OR 7.27; 1.15-45.73; p = 0.035) were strongly associated with 6-week mortality. Semi-elective EVL carries 45-fold higher odds for EVL-induced ulcer bleeding. Endoscopic hemostasis is achievable, but early rebleeding and post-bleeding sepsis drive mortality, suggesting that considering early TIPS in high-risk patients and preventing sepsis deserve more attention.
Disaster simulation is central to emergency preparedness; however, many simulation designs insufficiently represent disasters as prolonged, system-disruptive, and ethically complex events. Exercises frequently emphasize mass-casualty throughput, rely on simplified assumptions, and evaluate success primarily in terms of task completion rather than system performance and organizational learning. This study examines how disaster simulation design shapes preparedness outcomes and explores how simulation may be reframed as a translational systems intervention. A qualitative design-based research approach was used to conduct an inductive comparative framework analysis of two established disaster simulation paradigms: Medical Response to Major Incident (MRMI) and the Emergo Train System (ETS). Documentary sources included curricula, instructional materials, scenario templates, published evaluations, disaster evidence literature, and World Health Organization Emergency Medical Team standards. Simulation design features were extracted and compared using constant comparative analysis, and the findings were subsequently interpreted through socio-technical systems and resilience engineering perspectives. Four recurrent design-level tensions were identified using harmonized terminology: (1) divergent disaster conceptualization (governable surge versus unstable system disruption); (2) fidelity emphasis imbalance (cognitive versus behavioral realism); (3) incident-centric temporal framing; and (4) inconsistent translation into organizational learning. Published evaluation reports suggest that MRMI may support governance alignment and coordinated surge reasoning, whereas ETS may provide greater operational realism and more opportunities to expose teamwork under stress. Neither paradigm alone appears to fully address all design requirements relevant to sustained disaster-level system resilience. MRMI and ETS appear complementary but individually incomplete. A staged hybrid architecture integrating governance modeling, operational stress testing, longitudinal degradation modeling, and structured reflective translation is proposed as a design-oriented framework. This framework may help position disaster simulation as a translational systems intervention that connects exercise performance to potentially measurable organizational preparedness and system resilience, while still requiring empirical validation in practical settings.