Importance:The age-adjusted D-dimer cutoff (age × 10 µg/L in patients 50 years or older), safely increases the diagnostic yield of D-dimer in patients with suspected pulmonary embolism but has not been validated in patients with suspected leg deep vein thrombosis (DVT). Objective:To prospectively validate whether using an age-adjusted D-dimer cutoff allows clinicians to safely rule out DVT. Design, Setting, and Patients:Multicenter, multinational prospective management outcome study conducted in 27 centers in Belgium, Canada, France, and Switzerland between January 2015 and October 2022 (last follow-up visit, January 30, 2023) and including outpatients presenting to the emergency department with suspected DVT. Interventions:Patients were assessed by a sequential diagnostic strategy based on the assessment of clinical pretest probability by the Wells score, a highly sensitive D-dimer test, and leg compression ultrasonography. Patients in whom DVT was ruled out were followed up for a 3-month period. Main Outcome and Measure:The primary outcome was the rate of adjudicated symptomatic venous thromboembolic events during follow-up in patients in whom DVT was ruled out based on a D-dimer value between the conventional cutoff of 500 µg/L and their age-adjusted cutoff. Results:A total of 3205 patients were included. Median age was 59 years, and 1737 (54%) were female. DVT prevalence was 14%. Among the 2169 patients with a non-high or unlikely clinical probability, 531 (24.5% [95% CI, 22.7%-26.4%]) had a D-dimer level less than 500 µg/L, and 161 additional patients (7.4% [95% CI, 6.4%-8.6%]) had a D-dimer level between 500 µg/L and their age-adjusted cutoff. No failures were identified in patients with a D-dimer level 500 µg/L or greater but below the age-adjusted cutoff (0% [95% CI, 0%-2.3%]). Among patients 75 years or older, using the age-adjusted cutoff instead of the 500-µg/L cutoff increased the proportion of negative D-dimer from 33 of 379 (8.7% [95% CI, 6.3%-12.0%]) to 99 of 379 (26.1% [95% CI, 22.0%-30.8%]), without any false-negative test results. Conclusions and Relevance:The age-adjusted D-dimer cutoff may safely rule out DVT and was associated with a larger number of patients in whom DVT could be effectively ruled out. Trial Registration:ClinicalTrials.gov Identifier: NCT02384135.

Despite advances in the management of upper gastrointestinal bleeding (UGIB), hospital admission rates for patients with Inflammatory Bowel Disease (IBD) may not have declined. We analyzed the frequency and temporal trends in hospitalization rates for UGIB among those with IBD. Population-based, administrative healthcare databases were used to identify all individuals who visited the emergency department for a non-variceal UGIB in Alberta, Canada between fiscal year 2010/11 and 2019/20. Alberta Health Services is the only healthcare provider for an estimated 4.39 million Albertans as of 2020. International Classification of Diseases (ICD) identified patients admitted to hospital with UGIB and IBD ICD-10 codes at any diagnostic field. The frequency of hospitalizations in Alberta were stratified by sex, age group, and Charleston comorbidities (one, two, three or more). Hospitalization frequencies were also stratified by quintiles of the Pampalon index of social and material deprivation. The 1st quintile of the Pampalon index is the most privileged and the 5th quintile is the most socially or materially deprived. Differences in frequencies between covariates were measured using a goodness of fit Chi-square test and differences in proportions were measured using a z-test of proportions. Annual hospitalization rates were calculated using annual population estimates of Alberta. Average Annual Percentage Change (AAPC) in hospitalization rates and associated 95% confidence intervals (CIs) were calculated using Poisson regression, or negative binomial regression if data were overdispersed. From 2010/11 to 2019/20, UGIB hospitalization rates among those with IBD decreased from 4.29 (95% CI: 2.63, 7.00) to 1.83 (95% CI: 0.92, 3.67) hospitalizations per 1,000,000 Albertans (AAPC = −7.52; 95% CI: −12.45, −2.32, p = 0.0049). Of the 159 individuals living with IBD, 120 had Crohn’s disease and 39 had ulcerative colitis. The proportion of UGIB hospitalizations was greater among males (62.26%), those 25-64 years of age (62.89%), and those with zero Charleston comorbidities (52.87%). Individuals who were more privileged materially or socially made up a greater proportion of UGIB hospitalizations especially among the 1st, 2nd, and 3rd quintiles in material deprivation and 1st, 3rd, and 4th quintiles in social deprivation. The mean length of stay for a UGIB among those with IBD was 6.31 days (95% CI: 5.23, 7.38). Hospitalization rates for UGIB among those with IBD are decreasing in Alberta. However, there are differences in the frequency and proportion of hospitalization rates among those materially or socially deprived with more privileged quintiles making up a larger proportion of hospitalizations.

Mental health and substance use-related emergency department visits are increasingly common among youth (ages 12-24 years); however, there are no standards or guidelines for providing quality care and referral to appropriate services. Based on existing evidence and insights from a technical committee of 14 Canadian experts (youth, caregivers, service providers and decision-makers), we outline four key priority areas for improving care in emergency department settings and recommendations for implementation. This includes improving the care environment; appropriate and timely mental health and substance use assessment; treatment based on youths' goals, needs, preferences and circumstances; and referral to appropriate services.

Objectives This study aims to describe emergency department (ED) use by persons with crystal arthropathies, to identify where improvements in ambulatory care accessibility could improve acute care health system efficiency. Methods Linked population-based administrative datasets from a universal healthcare system in Canada were used to retrospectively assess all ED use by persons meeting the case definition for crystal arthropathies over a 10-year period (2007/2008-2017/2018). Frequency of use and characterisation of visits for any reason among people with crystal arthropathies including acuity (Canadian Triage and Acuity Scale [CTAS]), length of stay, most responsible diagnosis, and disposition were calculated and stratified by sex and geographic location of residence. Results Six hundred forty-six thousand nine hundred twenty-six ED visits were made by 88,373 individuals with crystal arthropathies in Alberta. We observed a 69% increase in ED use over the study period by the cohort, with 32.5% and 32.2% of visits triaged as urgent (CTAS 3) and less urgent (CTAS 4) acuity, respectively. A final diagnosis was not determined in 33.1% of visits, and crystal arthropathies flares accounted for 5.7% of ED use in the cohort. Female patients more frequently required hospital admission (20.4% vs males 15.7%), and while urban residents had an increased frequency of visits, they were less likely to be admitted to hospital than rural residents (11.4% vs rural 20.0%). Conclusions Acute care use by persons with crystal arthropathies has significantly increased, predominantly with lower acuity presentations. Enhanced ambulatory care services with collaboration between primary and specialty care are proposed to improve alignment in health service use.

Background:Diabetic ketoacidosis (DKA), a life-threatening complication of type 1 diabetes, requires prompt fluid resuscitation to restore circulatory volume and correct metabolic abnormalities. However, the optimal fluid type, volume, and tonicity remain unclear due to concerns regarding cerebral injury and electrolyte imbalances. Methods:We searched PubMed, CINAHL, Cochrane, Scopus, Clinicaltrials.gov, and WHO International Clinical Trials Registry Platform without date restrictions for randomized controlled trials (RCTs) evaluating fluid regimens in children with DKA. Risk of bias was assessed using the Cochrane RoB-2 tool, and certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. Meta-analysis was conducted using RevMan 5.4. Results:The review included 10 RCTs (n = 2291). Children receiving a 20 mL/kg bolus followed by 0.9% saline exclusively for rehydration may have a higher risk of adverse events (AEs) than those receiving 10 mL/kg (risk ratio [RR] = 1.11, 95% CI = 1.01-1.23, low certainty of evidence). However, in children given 0.9% saline exclusively for rehydration, there was a significantly lower risk of hypoglycemia in the 20 mL/kg bolus group compared to the 10 mL/kg group (RR = 0.78, 95% CI = 0.62-0.99, high certainty). For rehydration fluid, compared to 0.45% saline, 0.9% saline (48-72 hours) was associated with a higher risk of hypoglycemia (RR = 1.35, 95% CI = 1.06-1.72, high certainty) and AEs (RR = 1.18, 95% CI = 1.05-1.31, low certainty). Over 36 hours, 0.9% saline may be associated with more AEs (RR = 1.15, 95% CI = 1.03-1.27, low certainty). Conclusion:Smaller bolus volumes may be safer than larger ones, and prolonged use of 0.9% saline may increase the risk of hypoglycemia and AEs, although the certainty of evidence was low.

Alert fatigue remains a major barrier to the effective deployment of predictive models in emergency care, particularly in the context of rare but critical outcomes such as in-hospital mortality (IHM), which often occurs in less than 5.0% of patients admitted from the emergency department (ED). Severe class imbalance leads to low positive predictive value (PPV), undermining the clinical utility of even high-performance predictive models. To address this issue, we propose AI-TEW (Artificial Intelligence-powered Tiered Early Warning), a novel two-stage early warning framework designed to reduce false alarms and improve clinical interpretability. In Stage 1, a robust machine learning model was developed and validated using data from 174,292 ED visits across three hospitals in China and the United States. The model demonstrated strong discriminative ability for IHM prediction, achieving AUROCs ranging from 0.84 (95% CI, 0.81-0.86) to 0.91 (95% CI, 0.90-0.91) in internal and external validation cohorts. In Stage 2, AI-TEW implements a tiered risk stratification strategy by optimizing decision thresholds to prioritize high-risk patients, thereby increasing PPV from baseline levels of 9.8-18.8% to 32.5-40.5% across sites, while maintaining a high negative predictive value (NPV) of over 98% for low-risk individuals. To further refine alert precision, a knowledge-based filtering layer is introduced, leveraging large language models (LLM) to interpret patient-specific risk factors derived from SHAP (Shapley Additive exPlanations) method. Integrating explainable AI with clinical reasoning enhances contextual understanding and reduces spurious alerts, leading to an 11.53% increase in PPV in external validation (p = 0.0092 for MedGemma). By integrating improved predictive efficiency with interpretable, knowledge-informed filtering, AI-TEW reduces alert burden while supporting timely clinical intervention, demonstrating a promising approach to mitigating the impact of class imbalance in emergency risk prediction.

Background: Despite the favorable risk-benefit profile of factor (F)Xa inhibitors (FXai) vs vitamin K antagonists, major bleeding remains a concern. Objectives: This study sought to describe the incidence and mortality rates of major bleeding in FXai-treated patients using large national registries. Methods: This multinational, retrospective cohort study analyzed electronic health records and administrative claims data across Canada and 4 European countries. Adults initiated on FXai for atrial fibrillation, venous thromboembolism, nonmechanical cardiac valve replacement, and other indications were included. Major bleeding was defined as bleeding at critical sites or leading to hospitalization or fatality. Pooled incidence rates of major bleeding, case fatality rates, and associated all-cause mortality up to ≤3 years after the index bleeding event were calculated across countries. Results: This study included 358,143 new FXai users, of whom 23,418 experienced major bleeding. The pooled incidence rate of major bleeding was 11.0 per 100 person-years (95% CI, 6.1-15.9) at 3 months, 8.2 (95% CI, 4.5-11.8) at 1 year, and 6.7 (95% CI, 3.7-9.7) at 3 years, and the case fatality rate was 9.0%, 8.9%, and 9.0%, respectively. Gastrointestinal bleeds were the most common major bleed observed, but intracranial hemorrhage had the highest case fatality rate. In patients with major bleeding, all-cause mortality incidence was 57.5 per 100 person-years (95% CI, 29.1-85.8) at 3 months and 28.9 (95% CI, 17.6-40.3) at 1 year. Conclusion: Results of this large-scale study indicate that the incidence of major bleeding remains elevated during the first 3 years after initiating FXai treatment and that these bleeding events seemed to be associated with significant mortality.

OBJECTIVES:In Canada, approximately 85% of pediatric emergency visits occur in general emergency departments lacking specialized pediatric resources. Through a national co-developed knowledge mobilization strategy, the Translating Emergency Knowledge for Kids (TREKK) network creates evidence-based resources to bridge this gap. This study evaluated the usability of TREKK resources as perceived by healthcare providers. METHODS:Between February 2023 and February 2024, a concurrent triangulation mixed-methods design was used to evaluate eight pediatric clinical resources across seven topics (diabetic ketoacidosis (DKA), bronchiolitis, aerosol-generating medical procedures, pneumonia, respiratory distress, eating disorders, and anxiety). Four iterative survey rounds each assessed two resources on nine usability dimensions (e.g., usefulness, simplicity, and clinical confidence) using an eleven-point Likert scale (0 = strongly disagree; 10 = strongly agree). Survey respondents were invited to semi-structured interviews on three resources (DKA and bronchiolitis Bottom Line Recommendations and the DKA algorithm); purposive sampling ensured diverse professional roles across urban, rural, and remote settings. Interviews were analyzed using reflexive thematic analysis. RESULTS:The survey sample comprised 432 respondents across four rounds. Mean usability scores across nine dimensions ranged from 7.81 to 9.61 (out of 10). The DKA algorithm was rated most positively on clinical usefulness (mean = 9.61), while the aerosol-generating medical procedures Fact Sheet was rated least positively on intention-to-use (mean = 7.2) and provider confidence (mean = 7.0). Thematic analysis of 21 interviews generated four themes: trusted resources, diverse utilization patterns, effective design, and organizational awareness gaps. Triangulation indicated that, although providers rated the resources as highly usable, limited organizational awareness was the primary barrier to uptake in practice. CONCLUSIONS:TREKK resources are valued for evidence-based credibility and bedside usability, yet limited organizational awareness impedes their uptake in practice. Ongoing, active strategies to increase uptake, such as knowledge brokering and curricular integration, are essential to bridge the knowledge-to-practice gap.

Emergency Medicine (EM) is facing a global crisis. System demands and utilization are increasing, while resources are constrained, putting society’s healthcare safety net at risk. In order to approach this crisis, many areas of reform have been suggested (Heymann et al. in Intern Emerg Med, 2024). The first step is the recognition of EM as a specialty of its own. This will give Emergency Physicians (EPs) the potential to take control of their profession. Similar to other examples of bottom-up and horizontalization approaches ( Laloux, F., Wilber, K. (2014). Reinventing organizations: A guide to creating organizations inspired by the next stage of human consciousness.), empowering EPs to provide solutions to wellbeing and resilience issues can only occur if EPs are allowed to organize and control their training, activity, research, and field of action. Traditional models have seen EM as a subspecialty or a secondary degree completed after initial training in an already established profession (e.g., internal medicine). These models ultimately result in longer training pathways and risk trainee and trainer fatigue. Furthermore, in these models, the profession is directed by specialties who do not face the daily challenges of modern EM. The following paper discusses the advantages of recognizing EM as a specialty and how this benefits wellbeing and resilience. The result is that EM recognition protects a cornerstone of the healthcare system.

BACKGROUND:The objective of this systematic review was to examine the effectiveness of pharmacological and physical interventions that target the injection site area on reducing distress during vaccinations in vaccine recipients across the lifespan. METHODS:GRADE and Cochrane methodology were used. Searches were conducted in MEDLINE, EMBASE, APA PsycINFO, CINAHL, and ProQuest Dissertations to identify relevant randomized and quasi-randomized controlled trials. Included interventions and critical outcomes were determined using a voting process. Studies were reviewed and data extracted by at least 2 reviewers. Meta-analyses were conducted separately for infants (0 to 12 mo) and older vaccine recipients (>12 mo), with individual interventions included as subgroups. Point estimates were calculated using standardized mean difference (SMD) with 95% confidence intervals (CIs) using a random effects model. Results were summarized according to certainty of evidence (4 levels: high to very low) and effect size (4 levels: trivial to large). RESULTS:A total of 71 studies were included with a certainty of evidence ranging from high to very low. The magnitude of effect exceeded the minimum threshold (SMD ≥ 0.2) in all but 1 analysis. For infants, topical anesthesia and manual tapping are preferred interventions for reducing distress (critical outcome), followed by manual or device-facilitated pressure, cold/ice, or vibration with an external device with cold. Use of a vapocoolant is next, followed by vibration with an external device without cold. Manual rubbing has insufficient evidence of benefit. For older vaccine recipients, topical anesthesia is preferred, followed by manual tapping. Vibration with an external device with or without cold, follows thereafter. Manual or device-facilitated pressure, cold/ice, or vapocoolant are less preferred, and the evidence is very uncertain for manual rubbing. CONCLUSIONS:Across all ages, topical anesthetics and manual skin tapping emerge as preferred interventions. Implementation should consider the strength of the evidence base and vaccine recipient preferences.

BACKGROUND:Undifferentiated agitation in older adults is common in the prehospital setting, and in transitions from emergency medical services (EMS) to emergency department care. Restraints are commonly used in the management of agitation, although there is little evidence to inform the development of best practices. OBJECTIVES:To explore paramedic experiences and determine perceptions on issues when managing older adults with agitation and using restraints in EMS. METHODS:We conducted a descriptive cross-sectional survey of paramedics in Alberta, Canada, with a mix of multiple choice and open-ended questions that were interpreted using descriptive statistics and a qualitative thematic analysis, respectively. RESULTS:Paramedics (n = 162) reported that older adults were commonly restrained due to risk of harm to self (81.5%) or others (76.5%), combative behavior (73.5%), or resistance to care (58.0%). Most paramedics believed that restraints were effective in facilitating care (76.9%) and had not resulted in adverse events (72.8%). Only 44.5% believed they had the necessary training to provide restraint alternatives, however, 93.6% agreed they have de-escalated situations without restraints, and 80.0% felt capable of using non-restraint-based agitation management strategies. Nearly half endorsed having suffered physical injury from patient agitation (48.1%). The mean total moral injury score was 20.9 ± 6.8 (range 9-35), indicating a relatively high level of moral injury. CONCLUSION:Restraints are frequently used by EMS for the management of agitation among older adults, especially when there was a perceived risk of harm. Physical and moral injury is high among paramedics, as well as insufficient training regarding restraint alternatives.

Approximately 25% of older adult residents who experience an acute change in health status are transferred from Long-Term Care (LTC) to Emergency Departments (ED). We explored the use of an intervention (i.e., LTC to ED) care and referral pathway, INTERACT® Change in Condition cards, and STOP AND WATCH tool, in informing decision making regarding resident transfers. We conducted 22 semi-structured interviews with Health care Providers (HCPs) involved in the LTC to ED care pathway in Western Canada. Thematic analysis of the qualitative interviews was used to evaluate the use of the pathway and tools. We identified six themes influencing decision making around resident transfers including interprofessional practice and conflict, ambiguous and clear medical cases, ageism, health care providers' goals, family involvement in resident care, and intervention tools. The intervention may be useful in streamlining, documenting, and increasing transparency in complicated LTC resident care and transfer decisions.

CLINICAL IMPACT RATINGS:Emergency Med: [Formula: see text] GIM/FP/GP: [Formula: see text] Critical Care: [Formula: see text] Pulmonology: [Formula: see text].

Objectives The significant increase in gout prevalence in the population is anticipated to have effects on health system use, including acute care visits by patients with gout. Our objective was to analyze trends in ED visits for any reason among patients with gout in Alberta. Methods We used linked population-based administrative datasets to retrospectively assess ED use for any reason by persons meeting the case definition for incident gout over a 10-year period (2007/2008-2017/2018). We estimated the annual frequency of ED use and assigned the most responsible diagnosis code to broader diagnostic groupings. We analyzed visit characteristics, acuity at presentation using the Canadian Triage Acuity Scale (CTAS), and disposition using descriptive statistics. All results were additionally stratified by biological sex (male/female) and geographic location of residence (urban/rural). Results 646,926 ED visits were made by 88,373 individuals with gout in Alberta. We observed a 69% increase in ED use over the study period by the cohort although the mean number of visits per person per year decreased over the 10-year period, from 1.06 (95% CI 1.03, 1.09) in fiscal year 2008 to 0.79 (95% CI 0.77, 0.80) in fiscal year 2017. The majority of visits for any diagnosis were assessed at CTAS 3 “Urgent” (32.5%) and CTAS 4 “Less urgent” (32.2%). The proportion of visits triaged as ‘Urgent’ increased over the 10-year period, from 25.9% of all visits in 2008, to 37.9% in 2017. Visits specifically for gout accounted for 5.7% of all visits, primarily triaged as CTAS 3 (23.2%) and CTAS 4 (56%). Injuries and infection each accounted for ~11% of all visits. Almost 1 in 5 (17%) visits resulted in admission, although just 1.3% of admissions were for gout flares specifically. About one-fifth (19.6%) of individuals discharged from an initial ED visit had a minimum of 1 ED return visit within 72 hours. Where the first visit was coded as inflammatory arthritis, 42.2% of return visits were for the same diagnosis. Female patients more frequently required hospital admission (20.4% vs males 15.7%), and while urban residents had an increased frequency of ED visits (25.6% vs 9.2%), they were less likely to be admitted to hospital than rural residents (11.4% vs rural 20.0%). Conclusion Acute care utilization by persons with gout has increased significantly over time, with lower-acuity presentations dominating out-related ED visits suggesting unmet ambulatory care needs.

BACKGROUND:This systematic review was undertaken as part of a 10-year update to our 2015 clinical practice guideline about reducing distress during vaccination. Altogether, 4 clinical questions were included evaluating the effectiveness of process (ie, education and implementation) interventions targeting: (1) clinicians, (2) support persons, (3) vaccine recipients, and (4) multiple user groups (ie, multicomponent/complex interventions). METHODS:The protocol was registered. Randomized and quasi-randomized controlled trials were identified from a search strategy that included 5 databases: MEDLINE, EMBASE, APA PsycINFO, CINAHL, and ProQuest Dissertations. Critical outcomes included distress (self-reported and observer-reported), along with participants' knowledge and use of distress-mitigating interventions. Data were extracted and pooled using a random effects model. Quantitative data were summarized using standardized mean differences (SMDs) and 95% CI. Summary statements were developed based on the certainty of evidence and magnitude of effect. RESULTS:Seventeen unique studies were included. Across the evidence base, the certainty of evidence ranged from high to low and the magnitude of effect exceeded the minimum threshold (SMD=0.2) across available critical outcomes. The results indicate that educating clinicians may increase the use of distress-reducing interventions (SMD=0.66, low certainty). Support person education likely reduces distress in vaccine recipients slightly (SMD=-0.30; moderate certainty), may increase the use of distress-reducing interventions (SMD=0.67; low certainty), and likely increases support person knowledge about distress-reducing interventions slightly (SMD=0.25; moderate certainty). Educating vaccine recipients may result in a large reduction in distress (SMD=-0.80; low certainty). Multicomponent interventions reduce distress slightly (SMD=-0.21; high certainty) and likely increase the use of distress-reducing interventions (SMD=0.60; moderate certainty). CONCLUSIONS:Educating and implementing interventions across relevant user groups involved in vaccinations, including clinicians, support persons, vaccine recipients, and multicomponent interventions, is recommended to reduce distress during vaccine injections.