American College of Emergency Physicians

Background Opioid use disorder (OUD) remains a major public health challenge, with substantial morbidity, mortality, and healthcare costs. Emergency departments (EDs) represent critical intervention points for initiating evidence-based treatment. While ED-initiated buprenorphine improves treatment engagement, its economic value relative to referral-based care requires further evaluation. Methods We developed a decision-analytic Markov cohort model to assess the cost-effectiveness of ED-initiated buprenorphine with rapid primary care follow-up (ED-BUP) compared with referral alone in adults with OUD. The model used monthly cycles over a 5-year time horizon from a healthcare sector perspective. Clinical inputs were derived from randomized and observational studies. Outcomes included total costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness. Uncertainty was assessed using one-way deterministic and probabilistic sensitivity analyses with 1,000 Monte Carlo simulations. Results ED-BUP was associated with lower costs (−$225 per patient) and greater effectiveness (+ 0.012 QALYs) compared with referral alone, indicating that the intervention is dominant. Probabilistic sensitivity analysis showed that ED-BUP was cost-effective in 97% of simulations at a willingness-to-pay threshold of $100,000 per QALY and 99% at $200,000 per QALY. Sensitivity analyses confirmed robustness of results across key model parameters. Conclusions ED-initiated buprenorphine with rapid follow-up is a cost-effective strategy for managing OUD, improving health outcomes while reducing healthcare costs. These findings support broader implementation of ED-based treatment as part of public health and health system strategies to address the opioid crisis.

ABSTRACT Background The current numerical standards for procedural competency in Emergency Medicine (EM) lack strong evidentiary support. In the absence of more validated competency standards, self‐reported confidence has been used as a learner‐centered measure of perceived procedural readiness. Characterizing procedural confidence, patterns across procedures, and factors associated with confidence may help inform improvements in residency curricula and assessment. Objective To characterize self‐reported confidence in key emergency medicine procedures, identify patterns across procedures, and examine associated residency program factors among graduating EM residents. Methods A cross‐sectional survey of graduating EM residents was conducted in June 2025, from 20 programs recruited to be intentionally diverse. The survey underwent content and response‐process validity assessment and pilot testing before distribution. Residents rated their confidence in 17 essential EM procedures using a 5‐point Likert‐based scale; program contacts provided program‐level characteristics through a separate questionnaire. Survey data was analyzed to determine procedure‐specific confidence levels and examine associations between overall procedural confidence and select program characteristics. Additionally, hierarchical clustering was used to identify patterns of confidence across procedures. Results A total of 103 residents (41%) from 20 programs completed the survey. Confidence was highest for intubation (100%) and central line placement (98.1%), and lowest for pericardiocentesis (33.0%). Program‐level variables, including program length and emergency department volume, were not significantly associated with confidence. Hierarchical clustering identified three broad domains of procedural confidence: critical invasive procedures, core procedural skills, and resuscitation procedures. Conclusion Graduating residents reported near universal confidence in performance of select skills, but meaningful confidence gaps remained for rare procedures and some core procedures. Procedural confidence clustered into clinically recognizable domains, while examined program characteristics were not consistently associated with confidence. These findings identify potential targets for curricular and assessment efforts while reinforcing that self‐reported confidence should complement, rather than replace, objective measures of procedural competence.

Objectives: Emergency Departments (EDs) across the US vary widely in resources and availability of specialty consultation. Access to neurology expertise during acute stroke care may influence treatment decisions that impact patient outcomes. We investigated whether hospital-level differences in Neurology access during ED stroke codes were associated with hospital performance on 30-day stroke mortality rates. Methods: We used data from EDs participating in the Emergency Quality Network (E-QUAL) Stroke Collaborative between 2022 and 2024, linked to CMS data for 30-day stroke mortality reported as of June 30, 2023. The primary independent variable was Neurology access during ED stroke code activation, categorized as: in-person, telestroke, or phone/no Neurology. We performed descriptive analysis and linear regression to examine the relationship between Neurology access and 30-day stroke mortality, adjusting for ED annual stroke volume, rurality, participation in a stroke registry, and disposition practices for thrombolysis-treated patients. Results: Among the 52 EDs, Neurology was available during a stroke code in person for 48.1% of EDs, by telestroke for 38.4%, and by phone or not at all for 13.5%. Mean 30-day stroke mortality was 13.1% (standard deviation [SD] 1.7%) for EDs with in-person Neurology, 14.0% (SD 1.8%) for telestroke, and 15.2% (SD 1.2%) for phone/no Neurology (Figure). In both unadjusted and adjusted analyses, EDs with phone/no Neurology had higher 30-day stroke mortality compared to in-person access (adjusted: +1.7%, p = 0.02), while 30-day mortality for EDs with telestroke was not significantly different from in-person Neurology (Table). Independent of neurology access, rural EDs had higher stroke mortality compared to non-rural EDs (adjusted: +2.8%, p = 0.006). Stroke volume, participation in a stroke registry, and disposition of thrombolysis-treated patients were not significantly associated with mortality. Conclusion: Limited access to Neurology expertise during ED stroke codes was associated with higher 30-day stroke mortality for community hospitals. However, consistent with prior research, EDs with telestroke demonstrated comparable outcomes to EDs with in-person Neurology. These findings underscore the importance of addressing gaps in access to Neurology expertise in community EDs for ensuring optimal stroke outcomes for all patients and highlight the value of telestroke as a tool to do so.

Physician well-being is vital to delivering high-quality emergency care.A supported and healthy emergency medicine workforce leads to better patient outcomes,fewer medical errors,and greater job satisfaction and staff retention.[1,2]Emergency physicians(EPs)face unique pressures,including shift work,high patient volumes and acuities,overcrowding,and systemic inefficiencies that escalate their risk of burnout.As a result,EPs have reported the highest rates of burnout among physician specialties.[1,3]Over the past decade,multiple attempts have been made to promote EP well-being.However,early initiatives were oriented around individual"wellness",such as exercise,diet,sleep,yoga,and finding"work-life balance".Recently,there has been evolving recognition of the effects of a number of aspects of burnout that are outside the control of individual EPs,including administrative duties superseding clinical duties,diminishing resources and support,overcrowding and boarding,adverse working conditions,and medico-legal challenges.