Introduction: Efforts to increase influenza vaccine acceptance must consider the importance of patient education and familiarity with vaccinations and influenza in the emergency department (ED), particularly for populations without another primary source of healthcare. This is the first study, to our knowledge, to assess in-depth perceptions regarding the influenza vaccine and identify barriers and facilitators to influenza vaccination among COVID-19 unvaccinated adult ED patients. Methods: We conducted a qualitative idiographic interview study from July 12, 2021, to September 24, 2021, at four EDs in urban cities across the United States. We recruited adult ED patients (18 years and older) unvaccinated for COVID-19, without a primary care clinician, who were fluent in either English or Spanish. The primary finding was a detailed understanding of patient perceptions regarding the influenza vaccine, with secondary findings assessing influenza vaccination rates, barriers and facilitators to being vaccinated, sources of information, and future vaccination intentions. We used a content analysis approach to identify themes around patient experiences, concerns, barriers, information sources, and future intentions regarding influenza vaccination. Results: Of 65 participants interviewed, 48 discussed the influenza vaccine and were included in this analysis. Among these participants, the median age was 34 years, 21 (43.8%) were women, and 14 (29.2%) were Hispanic. We found three core themes influencing influenza vaccine hesitancy: 1) previous experiences with influenza illness and/or the vaccine; 2) knowledge about the influenza vaccine; and 3) confidence in vaccine safety and effectiveness. In our cohort, 10 (20.8%) participants demonstrated knowledge of the purpose and mechanism of the influenza vaccine. In addition, 14 (29.2%) patients suggested they would accept the vaccine if offered, while 18 (37.5%) patients stated they did not plan to receive the influenza vaccine and/or expressed strong hesitancy due to concerns about lack of vaccine effectiveness, fear of side effects, and lack of concern regarding influenza illness. Conclusion: Our findings identify an important barrier that could be overcome by ED-based vaccine education, particularly for underserved patient populations. Interventions to increase influenza vaccine uptake could focus on overcoming hesitancy related to prior experiences and understanding of vaccine safety and effectiveness.
Introduction: Racial disparities in healthcare persist, with evidence suggesting that bias contributes to inequities in care and outcomes for Black patients. Racial concordance between patients and clinicians has been proposed as one strategy to improve patient satisfaction and health outcomes, but its impact in acute care settings such as the emergency department (ED) remains underexplored. The objective of this study was to assess how racial concordance between patient and clinician, together with patient perceptions of how race affected their care, influence patient satisfaction with care in the ED. Methods: This secondary analysis used data from a previously published text message–based survey of patients discharged from two EDs between August and September 2021. Patients were categorized as not completely discordant if at least one clinician (physician, advanced practice clinician, or nurse) shared their self-identified race. The primary outcome was patient ratings of experience with ED care (scored 0 = poor to 5 = excellent). Multivariable ordinal logistic regression was used to assess associations between racial concordance, perceived impact of race on care, and experience ratings. Results: Of 516 respondents, 195 (37.8%) were classified as not completely discordant with at least one emergency clinician. Not completely discordant patients reported significantly lower experience ratings (scored 0 to 5) compared to racially discordant patients (median, 4 [3-5] vs 5 [3-5]; P = .01). In multivariable ordinal logistic regression, racial concordance was not independently significant in patient experience. Conclusion: Contrary to expectations, in our population, racial concordance was not significantly associated with satisfaction in ED care. In the adjusted analysis, perceived negative impact on care due to race was the strongest independent predictor of lower overall satisfaction. These findings suggest that how patients perceived the role of race in their care may be more influential than simply patient-clinician concordance in the acute care setting. Further research is needed to investigate these factors in more diverse patient-clinician population and other ED settings to help inform policies focused on advancing health equity.
Introduction: Emergency departments (EDs) face escalating pressures from rising patient volumes, workforce shortages, and documentation burdens. Digital health technologies have shown promise individually, but most are implemented in isolation, limiting their collective impact. This narrative review synthesizes evidence for six digital health technologies applicable to the ED and proposes a three-pillar framework for their coordinated implementation, positioning the ED as a convergence point for health system digital transformation. Methods: We searched PubMed and Google Scholar for peer-reviewed literature published from 2018 through July 2026 on ambient artificial intelligence (AI) documentation, telehospitalist programs, virtual nursing, remote patient monitoring, virtual specialty consultation, and postdischarge transitional care, prioritizing systematic reviews and meta-analyses. Fifty-one sources met inclusion criteria and were synthesized. We organized the technologies into three functional pillars: streamlining clinical workflows; expanding workforce capacity; and extending continuity of care. Outcomes included clinical, operational, and implementation measures. Experience from Houston Methodist, a nine-hospital health system, is presented as an illustrative example separate from the literature synthesis. Results: Of the 51 sources, 23 (45.1%) addressed streamlining clinical workflows, 16 (31.4%) expanding workforce capacity, and 12 (23.5%) extending continuity of care. Overall, 22 (43.1%) were ED-specific: 10, five, and seven within the respective pillars. Ambient AI documentation included 13 sources (seven ED-specific); telestroke included one ED-specific source. Evidence maturity varied by technology and setting. In non-ED settings, meta-analyses reported shorter documentation time with ambient AI documentation (standardized mean difference, -0.72; 95% CI, -0.99 to -0.45), lower hospital mortality with tele-intensive care (risk ratio, 0.74; 95% CI, 0.58-0.96), and lower odds of 30-day readmission with low-complexity post-discharge interventions (odds ratio [OR], 0.78; 95% CI, 0.66-0.92). Emergency department-specific evidence remained largely observational; one meta-analysis showed no mortality difference with telestroke (OR, 1.16; 95% CI, 0.94-1.43), while one systematic review found no demonstrable benefits from telephone follow-up post-ED discharge. Conclusion: Current evidence supports individual digital health technologies in and around the ED. Based on implementation science principles and institutional experience, we propose that coordinated implementation across the three pillars may offer advantages over isolated deployments, a hypothesis warranting prospective comparative evaluation.
Introduction: Whether the use of computed tomography (CT) in pediatric minor head trauma varies by documented language preference (English vs non-English), independent of race, is not well understood. Our objective was to identify factors associated with head CT use among children with minor head trauma in an institutional Pediatric Emergency Care Applied Research Network (PECARN)-based pathway. Methods: This single-center retrospective cohort study included patients 2 to 14 years of age presenting with minor head trauma, January 2019 to June 2022, who were classified as low, intermediate, or high risk using PECARN criteria. Our primary outcome measure was a three-level clinical pathway: no CT and no traumatic brain injury (TBI); clinical TBI without CT; or CT performed. Secondary outcomes were CT positivity and short-term clinical outcomes. Multinomial logistic regression assessed associations between pathway and language preference, age, headache, weighted observed symptom score (OSS), and race (White vs non-White). Results: Among 1,167 patients, 319 (27.3%) underwent CT, 132 (11.3%) had clinical TBI diagnosis without CT, and 716 (61.4%) had neither; 430 (36.8%) were classified intermediate risk—the subgroup in which the imaging decision is most discretionary. Non-English language preference was associated with lower adjusted odds of CT in the intermediate-risk subgroup (adjusted odds ratio [aOR], 0.48; 95% CI, 0.24-0.92; P = .03) but not in the full cohort (aOR, 0.78; 95% CI, 0.50-1.22; P = .27). Within the intermediate-risk subgroup, OSS was strongly associated with CT use (aOR, 3.65; 95% CI, 2.67-5.00; P < .001) and headache with clinical TBI without CT (aOR, 4.94; 95% CI, 1.64-14.90; P = .005), whereas race was not independently associated with CT use (aOR, 1.36; 95% CI, 0.82-2.25; P = .48). Language preference was not associated with CT positivity among scanned patients (aOR, 1.10; 95% CI, 0.44-2.72; P = .84), and short-term outcomes did not differ by language (all P > .35). Conclusion: Documented non-English language preference was independently associated with lower use of head CT in PECARN intermediate-risk children; race was not after adjustment for clinical severity. Yield and short-term outcomes did not differ by language preference among imaged patients; however, imaging selection precludes conclusions about mechanism.
Introduction: Inhaled nitrous oxide (iNO) offers rapid onset analgesia with a favorable safety profile yet remains underused for shoulder dislocation reductions in the emergency department (ED). The objective of this study was to evaluate the use and outcomes of iNO for shoulder reduction in the ED, including whether intravenous (IV) access was required, whether successful reduction could be accomplished without additional analgesic or sedative medications under procedural sedation, and the rate of adverse effects from iNO. Methods: We conducted a retrospective chart review of shoulder dislocation reductions using iNO at two high-volume EDs over three years (2019–2022). Data collected included age, sex, indication, procedural success, IV placement, medications administered, and adverse events and was stored in a password-protected database. The primary endpoint was successful reduction with iNO as the primary procedural analgesic; secondary endpoint was occurrence of any adverse events. Results: Of 138 patients, 125 (90.6%; 95% CI, 0.84-0.95) achieved successful reduction with iNO alone without escalation to procedural sedation; 102 patients (74%) did not require IV access. Adverse events were rare (2/138 or 1.4% [95% CI, 0.02-0.05]): one patient experienced transient agitation (a known side effect of N-methyl-D-aspartate antagonism), and one had vomiting. Both were self-limited without hemodynamic changes. Conclusion: This retrospective case series, the largest of its kind to date examining iNO for shoulder dislocation reduction, demonstrated a 90.6% success rate with minimal adverse events and reduced resource utilization compared to procedural sedation. These findings support further prospective investigation of iNO for shoulder dislocation as well as other orthopedic reductions and painful ED procedures.
