OBJECTIVE:The Tetanus, Diphtheria, Pertussis (Tdap, "tetanus") vaccine is recommended for adults every 10 years. In a national sample of adult emergency department (ED) patients, we sought to determine (1) knowledge and up-to-date status of the tetanus vaccine; (2) reasons for nonreceipt of the vaccine; (3) vaccine acceptability if offered in the ED; and (4) reasons for nonacceptance in the ED if offered. METHODS:This was a cross-sectional survey study among non-critically ill adults at 10 US EDs, asking questions about knowledge, receipt, and acceptability of the tetanus vaccine. Vaccine receipt was determined by self-report. Aggregate responses are reported as descriptive statistics. Logistic regression modeling was performed, and data are presented as adjusted odds ratios (aOR) with 95% confidence intervals (CIs). RESULTS:Of 4326 patients approached, 3285 (75.9%) agreed to participate, and 5 were excluded because of incomplete responses. Among 3280 participants, 13.4% had not heard of the vaccine; and 58.0% were not up-to-date. Factors associated with not being up-to-date included age 34-48 (aOR 0.65; 95% CI 0.53-0.81), African American race (aOR 1.46; 95% CI 1.19-1.79), no primary care doctor (aOR 1.29; 95% CI 1.04-1.61) and no insurance (aOR 1.86; 95% CI 1.36-2.56). Among participants not up-to-date, 21.6% would accept it during their ED visit. Primary reasons for nonacceptance were needing more information, concerns about side effects, and preference to get it from their doctor. CONCLUSIONS:Over half of adult ED patients are not up-to-date on the tetanus vaccine but only one-fifth would accept it if offered during an ED visit. ED-centered efforts to increase uptake should provide messaging to address vaccine hesitancy.
Emergency departments (EDs) are increasingly sites of interaction between clinicians and federal immigration authorities. Recent shifts in federal enforcement policy have intensified these encounters. Patients now more frequently arrive in custody, accompanied by immigration enforcement officers who may assert control over communication, decision-making, or access to patients. These circumstances introduce challenges for maintaining standard clinical practice. Clinicians may encounter situations in which patient confidentiality, informed consent, and independent medical judgment are difficult to operationalize in the presence of immigration enforcement officers. In addition to impacts on patient care, these encounters may contribute to clinician moral injury and distress, particularly when emergency medicine (EM) clinicians feel pressured to compromise patient privacy, deviate from standard practices, or navigate conflicts between enforcement priorities and patient care priorities. Uncertainty regarding institutional policy and the appropriate limits of immigration enforcement authority may exacerbate tensions related to liability and compliance. For patients, disruptions in care and delays in treatment may increase the risk of adverse outcomes. In response to these urgent concerns, the National Immigration Law Center (NILC), a leading advocacy organization in U.S. immigration, has developed Advocating On Behalf of Patients in ICE Custody: A Resource for Health Care Providers and Medical Staff, a national resource guide outlining practical considerations for clinicians and healthcare institutions caring for patients in immigration custody. In this commentary, we build on this resource to provide practical, bedside-oriented guidance for EM clinicians when interacting with immigration enforcement officers or caring for patients in immigration custody. We examine the implications of immigration enforcement within healthcare settings while articulating a path forward that protects patient rights, clinical integrity, and the ethical foundations of medical practice. The following highlights clinical questions that EM clinicians may have when caring for patients in immigration custody or interacting with immigration enforcement officials in hospital settings.
BACKGROUND:Low back pain (LBP) is a common reason for presentation to an emergency department (ED) but LBP-care in this setting is frequently low-value, costly and often fails to meet system and patient needs. Other service options are urgently required. This study evaluated a novel care pathway that diverted people with suspected non-serious LBP seeking ED-care to a community-based, hospital avoidance service in a large South Australian health network. METHODS:A retrospective quantitative analysis was conducted on data extracted from electronic medical records (demographics, service activity, subsequent presentations/admissions) for patients seen March-December 2024, and analyzed using descriptive statistics. Repeated measures analysis of selected EQ-5D-5L items (pain/discomfort, usual activities, anxiety/depression) was conducted using the Wilcoxon signed-rank test. Semi-structured interviews undertaken May-Nov 2024 with consecutive eligible patients explored experiences of care via qualitative thematic analysis. RESULTS:There were 143 patients (mean age = 52.1 years, SD = 19.0) managed via this pathway. All received multidisciplinary care and 101 (78%) registered for digitally supported follow-up. Patients reported significant improvements in pain/discomfort and usual activities (p < 0.05) 2-weeks following initial evaluation, but not anxiety/depression. Most patients (90%) did not present to a public hospital ED within 90 days of intervention. Interviews (n = 20) identified four key themes: faster access and reducing ED pressure, care that meets expectations, digitally supported care assists recovery, and recommendations for improvements in LBP-care. CONCLUSION:This digitally supported hospital avoidance pathway provided an acceptable alternative to ED-care for patients with LBP with potential to offer significant benefits to the health system.
OBJECTIVES:Syncope and presyncope are common emergency department (ED) presentations that may indicate dangerous underlying conditions. For patients without serious ED diagnoses, hospitalization for monitoring and further workup is common, yet the benefits remain unclear. We sought to determine the diagnostic yield of hospitalization among adults with unexplained syncope or presyncope. METHODS:We conducted a secondary analysis of data from a prospective, multicenter, observational study enrolling ED patients aged ≥ 40 years with syncope or presyncope and no serious ED diagnosis. We collected 30-day serious adverse outcomes (SAOs), both cardiac and non-cardiac, including only in-hospital SAOs for admitted patients and all SAOs for discharged patients. Logistic and Cox regression analyses compared admitted and discharged participants using propensity score adjustment and matching. RESULTS:Among 1263 patients (mean age 64.8 ± 13.1 years), 74 (5.9%) experienced any SAO, including 62 (4.9%) with serious cardiac outcomes. After propensity-score adjustment, Bayesian logistic regression showed a significant difference in diagnostic yield (OR 3.70 [95% CrI 1.85-6.82]) in the hospitalized cohort. In a propensity-score-matched Cox regression analysis, hospitalization was associated with a shorter time to SAO diagnosis, with an HR of 12.43 (95% CI 2.94-52.48). CONCLUSION:Hospitalization increased the diagnostic yield for SAOs and accelerated time to diagnosis. It is reasonable to hospitalize select, higher-risk adult patients over 40 years old with presyncope or syncope, even if no dangerous diagnosis is found in the ED. TRIAL REGISTRATION:ClinicalTrials.gov identifier: NCT04533425.
BACKGROUND:Malnutrition is common among older adults and is associated with adverse outcomes, yet its impact and relationship with geriatric vulnerability in emergency department (ED) patients remain underrecognized. OBJECTIVES:To determine the prevalence, associated factors, and prognostic impact of malnutrition in noncritically ill older adults in the ED. METHODS:We conducted an observational study of patients aged ≥ 65 years presenting to the ED. Nutritional status was assessed using the Mini Nutritional Assessment-Short Form (MNA-SF) and categorized as normal, at risk of malnutrition, or malnourished. Comprehensive geriatric assessment included functional status (activities of daily living (ADL)), frailty, cognitive function, and handgrip strength. Multivariable logistic regression identified factors associated with malnutrition. Kaplan-Meier survival analysis and multivariable Cox proportional hazards regression were performed to evaluate the association between nutritional status and 30- and 90-day all-cause mortality. RESULTS:Among 1487 patients, 23.3% were malnourished and 46.4% were at risk, with 59.7% overall having impaired nutritional status. Malnourished patients had significantly worse functional status, cognition, and physical performance. Independent factors associated with malnutrition included lower ADL, frailty, and decreased handgrip strength. Malnutrition was associated with significantly lower 30- and 90-day survival (both log-rank p < 0.001) and remained independently associated with both 30-day mortality (adjusted HR, 5.32; 95% CI, 1.36-20.73) and 90-day mortality (adjusted HR, 6.92; 95% CI, 2.16-22.13) after multivariable adjustment. CONCLUSIONS:Malnutrition is highly prevalent among older ED patients and is independently associated with increased short-term mortality. Functional decline, frailty, and reduced muscle strength are closely linked to both malnutrition and nutritional risk. Integrating nutritional screening with functional and physical assessment in the ED may improve early identification of high-risk patients and support timely interventions.
BACKGROUND:Approximately one-quarter to one-third of patients with non-ST-elevation myocardial infarction have a completely occluded culprit coronary artery but are not routinely referred for emergent reperfusion. A growing literature describes electrocardiographic patterns purported to identify acute coronary occlusion (ACO) in non-STEMI populations, but guideline adoption has been limited and inconsistent. We conducted a scoping review to map the extent, characteristics, and methodologies of primary studies examining non-ST-elevation ECG patterns against reference standards for ACO. METHODS:Electronic databases were searched and supplemented by backward and forward citation tracking. Primary studies were included evaluating non-ST-elevation ECG patterns against an angiographic or composite reference standard for ACO. Studies using stenosis severity or anatomical disease burden as the reference standard were excluded. RESULTS:Forty-two studies were included, yielding 78 pattern-level data sources spanning 20 ECG patterns. Only 23/78 data sources evaluated undifferentiated ACS patients. Measurable index test definitions were present in 33/78 data sources. Reference standards were highly heterogeneous. Although 70/78 data sources defined a reference standard for ACO, only 29/78 reported diagnostic test accuracy values, most of which were in the LBBB/VPR category. CONCLUSIONS:The literature is heterogeneous, methodologically uneven, and concentrated in a small number of pattern categories. Outside the LBBB/VPR criteria, diagnostic test accuracy data in NSTE-ACS populations are sparse, and methodological features that critically affect their interpretation are inconsistently reported. These findings identify substantial gaps in the primary literature and inform the scope of future pattern-specific diagnostic test accuracy systematic reviews.
OBJECTIVE:Geriatric trauma patients are at increased risk of death or disability, and some have proposed trauma team activations based on advanced age alone. We sought to determine if there is a specific age at which a different approach to the trauma patient should be taken, based on their age-related risk for death, disability, or for needing acute resuscitative care. METHODS:We conducted a retrospective review of one year of data (2022) abstracted from the National Trauma Data Bank, including 984,335 adult trauma patients. The primary outcome was in-hospital mortality. Secondary outcomes were non-functional status at discharge, and a composite outcome created to capture the need for acute trauma interventions that included death in the ED, admission to the ICU, or need for emergent surgery, intubation, angioembolization, blood transfusions or procedures. RESULTS:Analyses adjusted for covariates showed the risk of receiving any acute intervention, including transfusions, surgeries, intubations and bedside procedures, all fell steadily with advancing age, as did risk of immediate death in the emergency department. Risk of death later during hospitalization, or of discharge to a non-functional status, rose steadily with advancing age. CONCLUSION:Trauma patients have rising mortality with advancing age, and a rise in likelihood of being sent to the ICU for care, but a falling rate of immediate, up-front death in the trauma bay, and a falling rate of receiving the acute, life-saving interventions associated with a trauma team activation. Further investigation is needed to determine the extent to which these findings illustrate differences in injury mechanism and severity, or age-related bias and differences in care.
OBJECTIVES:A 0/2-h algorithm for the i-STAT point-of-care (POC) high sensitivity troponin I (hs-cTnI) assay was recently derived in Australia. The objective of this study was to validate and optimize the performance of the 0/2-h algorithm in a multisite U.S. Emergency Department (ED) cohort. METHODS:A prospective cohort study was conducted at three U.S. EDs (February-September 2025). Adults without STEMI and at least one hs-cTnI ordered were accrued. Blood samples were collected simultaneously for POC hs-cTnI measurement on an i-STAT 1 analyzer (Abbott Laboratories) and central laboratory hs-cTnI measurement (Beckman Coulter). The primary outcome was index myocardial infarction (MI), adjudicated by experts using clinical hs-cTnI measures. Diagnostic performance of the Australian 0/2-h algorithm was assessed by calculating negative and positive predictive values (NPV, PPV) with associated 95% confidence intervals. Efficacy, defined as the proportion of patients classified into the rule-out zone, was calculated. Algorithm optimization tested modified cut points to increase efficacy while maintaining NPV ≥ 99% and achieving PPV ≥ 65%. RESULTS:During the study period, 578 patients with complete 0/2-h algorithm assessments were accrued. These patients were 48% (279/578) female, 40% (233/578) non-White, with a median age of 60 years (IQR: 50-70). Index MI occurred in 7.4% (43/578). Algorithm efficacy was 54.8% (317/578) and 8.8% (51/578) were classified to the rule-in zone. Among patients ruled-out, the NPV was 99.4% (95% CI: 97.7%-99.9%). The rule-in zone was associated with a PPV of 62.7% (95% CI: 48.1%-75.9%). Among 36.3% (210/578) patients classified to the observation zone, 4.3% (9/210) had an adjudicated index MI. An optimized 0/2-h algorithm increased efficacy to 60.0% (347/578) while achieving an NPV of 99.4% (95% CI: 97.9%-99.9%) and PPV of 74.4% (95% CI: 58.8, 86.5%) for index MI. CONCLUSIONS:The original Australian and optimized 0/2-h algorithms for i-STAT POC hs-cTnI measurement had high NPV and efficacy in a multisite U.S. COHORT: TRIAL REGISTRATION:Trial Registration: NCT06899776.
BACKGROUND:Early Warning Scores (EWS) are widely used to standardize the identification of clinical deterioration, yet their comparative performance against clinical judgment in Emergency Department (ED) triage remains uncertain. We aimed to evaluate whether commonly used EWS match or outperform clinical judgment in predicting early adverse outcomes. METHODS:We conducted a retrospective observational study including 361,927 adult ED presentations at a tertiary-care academic center from 2015 to 2024. Clinical judgment was operationalized as the triage category assigned at the initial evaluation. Five EWS (NEWS, NEWS2, MEWS, REMS, and ViEWS) were computed using vital signs recorded at ED presentation. The primary outcome was a composite of 24-h mortality or intensive care unit (ICU) admission. Discrimination, calibration, decision curve analysis, and reclassification metrics were used to compare models. RESULTS:The primary outcome occurred in 1.17% of patients. Discriminatory performance was highest for ViEWS (AUC 0.875) and clinical judgment (AUC 0.872), with no significant difference between them. Other EWS demonstrated significantly lower AUCs. In precision-recall and threshold-based analyses, clinical judgment maintained higher specificity at higher-risk thresholds while preserving adequate sensitivity. Decision curve analysis showed comparable or greater net benefit for clinical judgment than for all tested EWS across clinically relevant thresholds. Reclassification metrics showed no improvement with EWS over clinical judgment. CONCLUSION:Commonly used EWS did not clearly outperform triage clinical judgment in predicting early ICU admission or death. These findings support further investigation of how structured scores and clinical judgment may provide complementary information, particularly in identifying patients whose risk may be modified by timely escalation of care.
