Abstract Background Critical care delivery in the emergency department (ED) may improve selected patient- and system-relevant outcomes. However, it remains unclear which organisational models to deliver critical care in the ED (CC-ED) have been implemented and what their outcome effects are. Methods We conducted a systematic review and meta-analysis including studies describing organisational approaches to deliver CC-ED. Delivery models were categorised and described qualitatively. For studies reporting comparable outcomes, random-effects meta-analysis was performed to estimate pooled effects and 95% confidence intervals. Outcomes included mortality, intensive care unit (ICU) admission rates, ICU length of stay (LOS), hospital LOS, and cost of care. Results Of 4,967 records, 67 were included into the qualitative assessment and 11 studies into the quantitative analysis, respectively. We identified five models to deliver CC-ED. These consisted of dedicated critical care areas in the ED ( n = 49/67, 73.1%), placement of critical care staff in the ED ( n = 5/67, 7.5%), deployment of critical care teams to the ED ( n = 5/67, 7.5%), telemedical support of ED staff by critical care teams ( n = 5/67, 7.5%), and implementation of protocols to accelerate ICU admission ( n = 3/67, 4.5%). Mortality was not different versus usual care in any of the CC-ED models. CC-ED models had variable effects on the ICU admission rate, hospital and ICU LOS. Dedicated critical care areas in the ED were associated with lower ICU admission rates [OR 0.83 (0.76–0.91), p < 0.001], and shorter hospital LOS [mean difference − 0.31 (-0.59 to -0.03) days, p = 0.03], but longer ICU LOS [mean difference 0.45 (0.31–0.6) days, p < 0.001]. Reported cost of care did not differ between CC-ED and usual care. Conclusions We identified five different organisational model categories to deliver CC-ED. Dedicated critical care areas such as ED-ICUs was the model category most frequently published. Our quantitative meta-analysis suggests that compared with other CC-ED delivery models, dedicated critical care areas in the ED may reduce both ICU admission rates and hospital LOS of critically ill ED patients.

BACKGROUND AND IMPORTANCE:In the cohort of patients presenting to the emergency department (ED) with acute chest pain differentiating between those at high risk of major adverse cardiac event (MACE), and those who can safely be discharged, remains a challenge. The history, ECG, age, risk factors, troponin (HEART) score, as well as several abridged versions [history, ECG, age, risk factors (HEAR), history, ECG, troponin (HET)]. are commonly used for this purpose. As with many clinical risk scores, they might be useful, but often lack proper validation. We aimed to externally validate the HEART, HEAR, and HET scores in the setting of a high-volume tertiary care ED in a healthcare system without gatekeeping functions and thus a low-risk population. We further aimed to compare the prognostic performance (discrimination and calibration) of the scores to each other. DESIGN:External validation study. SETTINGS AND PARTICIPANTS:On the basis of a-priori sample size calculations, we prospectively included consecutive adult patients presenting to the ED with acute chest pain. OUTCOME MEASURES AND ANALYSIS:We assessed overall model performance, discrimination, and calibration of all scores, analyzed reclassification from the HEART score and performed decision curve analysis. MAIN RESULTS:A total of 3273 patients were included, 383 (12%) suffered MACE within 30 days. Classification differed significantly between scores (HEART: 810; 25% low risk; HET: 55; 2%; HEAR: 195; 6%), as did overall performance (area under the curve: 0.85, 0.80, and 0.79, respectively; P  < 0.001). HEART score misclassified 7/810 patients (0.9%; 95% confidence interval: 0.4-1.8%) with MACE as low risk, HET 2/55 (3.6%, 0.9-13.8%), and HEAR 0/195, whereas 2087 (72%), 2837 (98%), and 2695 (93%) patients without MACE were erroneously not classified as low risk. CONCLUSION:The abridged scores fell short of their results in derivation studies, identifying only very few low-risk patients, and showing inferior model performance compared with the original HEART score. Instead of developing new scores, existing scores should be recalibrated to local population characteristics, as needed.

In 2020, the Austrian Association of Emergency Medicine proposed structural quality criteria for in-hospital emergency care in Austria. However, it has not yet been assessed how these criteria apply to existing emergency departments. All in-hospital emergency departments across Vienna were surveyed using a structured assessment based on published proposed structural quality criteria. A total of 54 criteria were analysed, each rated on a scale of 3 (comprehensive care), 2 (standard care), 1 (basic care), or 0 (not met). Among 16 hospitals, we identified 10 emergency departments. The scores ranged from 87 points (54

Study objective Extracorporeal cardiopulmonary resuscitation (eCPR) is a rescue therapy for selected patients when conventional cardiopulmonary resuscitation (CPR) fails. Current evidence suggests that the success of eCPR depends on well-structured in- and out-of-hospital protocols. This article describes the Vienna eCPR program, and the interventions implemented to improve clinical processes and patient outcomes. Methods In this retrospective study, we report on all patients with inhospital and out-of-hospital cardiac arrest treated with eCPR at our department between 2020 and 2023. During this period, the program was restructured, including the introduction of out-of-hospital and inhospital algorithms and interprofessional training. The primary endpoint was survival with favorable neurologic outcomes at 6 months, defined as a cerebral performance category score of 1 or 2. Results Overall, 192 patients were treated with eCPR. The proportion of patients with favorable neurologic outcomes was 25% (n=48), increasing each year: 15% (5/34) in 2020, 19% (8/42) in 2021, 23% (12/53) in 2022, and 37% (23/63) in 2023. This was particularly true for out-of-hospital cardiac arrest patients: 7% (2/29), 14% (4/29), 17% (7/41), and 32% (16/50), respectively. Simultaneously, rates of witnessed arrest, bystander CPR, and initial shockable rhythm increased, whereas low-flow durations decreased. Conclusion After restructuring the Vienna eCPR program, we were able to improve survival rates with favorable neurologic outcomes after eCPR. This improvement was accompanied with increased case volumes, rates of witnessed arrest, bystander CPR, and initial shockable rhythm, and decreased low-flow durations. The learning curve we observed illustrates that outcomes can improve with experience, a summation effect of training, patient selection, and process standardization.

Breast cancer (BC) is the most common malignant disease in women and subtype is a key prognostic factor. In HER2-positive disease, HER2-directed therapies are the mainstay of treatment, as they have yielded a massive improvement in long-term outcomes. On the downside, these drugs carry the risk of cardiotoxicity. This study aimed to assess the clinical implications of cardiac side effects in patients receiving HER2-directed therapy. Moreover, subtype-specific differences in emergency department (ED) presentation and 3-month mortality (3MM) of BC patients were investigated. This single-centre retrospective study evaluated ED visits of breast cancer patients at an Austrian tertiary care centre. The frequency of ED visits due to cardiologic symptoms (decompensated heart failure, cardiomyopathy, arrhythmias [atrial fibrillation, unspecified tachycardia] and hypertensive derailment) in patients with and without HER2-directed therapy was investigated using a Chi Square test and a multinomial logistic regression controlling for age. Moreover, the overall frequency distribution of the breast cancer subtypes luminal A, luminal B/HER2-negative, luminal B/HER2-positive, HER2-positive (non-luminal) and triple negative were calculated. Subtype-specific 3MM rates were calculated for palliative and curative patients separately with a Chi-Square test. There was a total of 463 ED visits among 322 patients (curative setting: 94, palliative setting: 228) between 1st August 2016 and 31st December 2019. Median age was 62 years with a range of 25-95 years. A total of 68 patients had received HER2-directed therapy before ED visits. Active HER2-directed therapy was significantly associated with a higher rate of cardiologic ED visits (OR = 4.67, 95%CI [1.72; 10.02]). 56 % of these visits resulted in hospitalisation. Overall subtype distribution was as follows: 39 % (n = 126) luminal B/HER2-negative, 23 % (n = 74) triple negative, 19 % (n = 60) luminal B/HER2-positive, 10 % (n = 32) luminal A and 9 % (n = 30) HER2-positive (non-luminal). Breast cancer subtype was significantly associated with 3MM after ED visits in palliative patients (p = 0.006), with the highest mortality rate observed in triple negative disease (56%). HER2-directed therapy significantly increased the risk of cardiologic emergency visits in this cohort of real-world cancer patients. These findings indicate the need for tailored cardio-oncology care strategies, including risk assessment, monitoring and cardioprotective interventions, to optimize tolerability, improve patients’ quality of life, and reduce healthcare burdens.

This study aims to retrospectively compare two resuscitation methods (extracorporeal cardiopulmonary resuscitation (ECPR) vs. emergency preservation and resuscitation (EPR)) by pathohistologically assessing pig brains in a ventricular fibrillation cardiac arrest (VFCA) model. In prospective studies from 2004 to 2006, swine underwent VFCA for 13 (n = 6), 15 (n = 14) or 17 (n = 6) minutes with ECPR (ECPR13, ECPR15 and ECPR17). Another 15 min VFCA group (n = 8) was resuscitated with EPR and chest compressions (EPR15 + CC). Brains of animals surviving for nine days (ECPR13 n = 4, ECPR15 n = 2, ECPR17 n = 1, EPR15 + CC n = 7) were harvested. Eight different brain regions were analyzed with the image analysis software QuPath using HE-staining, GFAP- and Iba1-immunohistochemistry. Only ECPR13 and EPR15 + CC animals were included in statistical analysis, due to low survival rates in the other groups. All VFCA samples showed significantly fewer viable neurons compared to shams, but no significant differences between ECPR13 and EPR15 + CC animals were observed. ECPR13 animals showed significantly more glial activation in all cerebral cortex regions compared to shams and in occipital, temporal and parietal cortex compared to EPR15 + CC. In conclusion, EPR + CC resulted in a significantly reduced inflammatory reaction in cerebral cortex compared to ECPR but did not influence the extent of neuronal death after VFCA.

e24095 Background: Breast cancer is the most common malignant disease in women and subtype is a key prognostic factor. In HER2-positive disease, HER2-directed therapies are the mainstay of treatment, as they have yielded a massive improvement in long-term outcomes. On the downside, these drugs carry the risk of cardiotoxicity. This study aimed to assess reasons for ED presentations in breast cancer patients, highlighting subtype-specific differences in ED presentation and 3-month mortality (3MM) and the occurrence of cardiologic side effects in patients receiving HER2-directed therapy. Methods: This single-centre retrospective study evaluated ED visits of breast cancer patients at an Austrian tertiary care centre. The frequency distribution of the breast cancer subtypes luminal A, luminal B/HER2-negative, luminal B/HER2-positive, HER2-positive (non-luminal) and triple negative were calculated. Subtype-specific 3MM rates were calculated for palliative and curative patients separately with a Chi-Square test. An association between HER2-directed therapies and ED visits due to cardiologic symptoms (decompensated heart failure, cardiomyopathy, arrhythmias [atrial fibrillation, unspecified tachycardia] and hypertensive derailment) was investigated using a Chi Square test and a multinomial logistic regression controlling for age. Results: There was a total of 463 ED visits among 322 patients (curative setting: 94, palliative setting: 228) between 1 st August 2016 and 31 st December 2019. Median age was 62 years with a range of 25-95 years. Subtype distribution was as follows: 39 % (n = 126) luminal B/HER2-negative, 23 % (n = 74) triple negative, 19 % (n = 60) luminal B/HER2-positive, 10 % (n = 32) luminal A and 9 % (n = 30) HER2-positive (non-luminal). Breast cancer subtype was significantly associated with 3MM after ED visits in palliative patients (p = 0.006), with the highest mortality rate observed in triple negative disease (56 %). A total of 68 patients had received HER2-directed therapy before ED visits. Active HER2-directed therapy was significantly associated with a higher rate of cardiologic ED visits (OR = 4.67, 95%CI [1.72; 10.02]). 56 % of these visits resulted in hospitalisation. Conclusions: Breast cancer subtype apparently influenced both the frequency of ED visits and subsequent survival outcomes. HER2-directed therapy significantly increased the risk of cardiologic emergency visits in this cohort of real-world cancer patients. These findings indicate the need for tailored cardio-oncology care strategies to optimize tolerability, improve patients’ quality of life, and reduce healthcare burdens.

Background Acute aortic syndromes (AAS) are deadly conditions causing unspecific symptoms, such as chest/abdominal/back pain, syncope and neurological deficit. They are diagnosed with computed tomography angiography (CTA), but the patient selection is challenging. To support physicians and standardize management, protocols combining a clinical score with D-dimer (DD) have been developed. However, direct comparison of their diagnostic performance and cost-effectiveness is lacking. Methods We used individual patient data from 3 prospective diagnostic studies of patients with suspected AAS, enrolled in 12 centers from 5 countries. Diagnostic accuracy, failure rate and costs were calculated for 5 protocols, applying 3 scores (aortic dissection detection [ADD], AORTAs and Canadian) and 2 DD thresholds (500 ng/mL [DD500], age-adjusted [DDage]). Costs were estimated using Italian and German reimbursements. Results Among 4907 patients, 506 (10.3 %) had an AAS. The sensitivity of the diagnostic protocols ranged from 97.6 % for Canadian/DD500 to 99.4 % for AORTAs/DD500 or DDage (P = 0.022). The specificity was lowest for AORTAs/DD500 (46.8 %; P < 0.001 vs AORTAs/DD500) and highest for ADD/DDage (61.5 %; P < 0.001). The number of potential AAS misses was 4-fold higher with Canadian/DD500 vs AORTAs/DD500 or DDage. The net clinical benefit was highest for ADD/DDage. All protocols reduced CTA exams and costs over a CTA-to-all strategy. Numbers of predicted CTA exams and costs per 100 patients were lowest for ADD/DDage (447 CTAs, 34,366 EUR) and highest (579 CTAs, 43,628 EUR) for AORTAs/DD500. Conclusions Guideline-compliant clinical score/DD based protocols are highly sensitive. Differences in specificity and efficiency are present. Data may guide decision-making based on policies and resources.

INTRODUCTION:Extracorporeal cardiopulmonary resuscitation (eCPR) is a rescue therapy for refractory cardiac arrest, with evidence suggesting improved outcomes when performed at experienced centres. Unlike conventional CPR (cCPR), eCPR patients often exhibit delayed recovery. Current guidelines recommend outcome assessment at 1 month or hospital discharge, potentially missing late neurological improvements. This study investigates longitudinal changes in neurological outcomes among eCPR and cCPR patients. METHODS:We conducted a single-centre, retrospective cohort study at the Cardiac Arrest Centre Vienna, including adult patients treated with eCPR or cCPR between January 2020 and May 2024. Patients who survived at least 1 month were analysed. The primary endpoint was the difference in the temporal change in favourable neurological outcome (Cerebral performance category, CPC 1-2) between 1 and 6 months in eCPR versus cCPR patients. Secondary endpoints included CPC distribution, survival rates, and patterns of delayed recovery. RESULTS:Of 912 included patients (209 eCPR, 703 cCPR), 435 were alive at 1 month. In eCPR patients (n = 63), favourable neurological outcome increased from 59 % at 1 month to 87 % at 6 months (p < 0.001), while in cCPR patients (n = 372), it increased from 81 % to 84 % (p = ns). This corresponded to a 29 % versus 3 % increase in patients with a favourable neurological outcome (p < 0.001). There was no change in neurological outcome between 6 and 12 months in either group. Overall, recovery in eCPR patients was prolonged compared to patients after successful resuscitation with cCPR. CONCLUSION:Neurological outcomes in eCPR patients frequently continue to improve after 1 month after cardiac arrest. Future eCPR trials should therefore use outcome assessments beyond 1 month to fully capture recovery potential and patient-centred outcomes.

Background:Living in a neighbourhood with a general lower socioeconomic status (SES) may be linked to unfavourable health consequences. Although Germany has a universal health care system, emergency medicine is increasingly the first point of contact for individuals with limited access to regular healthcare facilities. The aim of this study was to examine the relationship between the socioeconomic status of patients and the rates of emergency medical service (EMS) utilization, the initial diagnoses made by the EMS physician in the field, and the severity of the illness of patients. Materials and methods This retrospective cohort study was based on the physicians' routine data documentation of the Jena EMS between January and December 2019. The risk factor SES was based on the neighbourhood level of SES. Patients living in neighbourhoods with a special developmental need (based on the risk of poverty, the population of immigrants, and housing security, defined by the City Council of Jena) were attributed a less favourable SES. The primary outcome of interest was the mission (dispatch) rates of EMS physicians, the diagnoses by the EMS physician in the field, and the severity of illness or injury. The results of all outcomes were adjusted for age and gender. Results:The mission rate of the EMS was 33% significantly higher in areas with a less favourable neighbourhood SES (adjusted odds ratio [OR] 1.33; 95% confidence interval [CI] 1.25-1.42). Psychiatric disorders were 63% more likely (OR 1.63; 95% CI 1.26-2.10) and pulmonary disorders were 37% more likely (OR 1.37; 95% CI 1.06-1.80) for patients with a less favourable neighbourhood SES than for patients with a higher neighbourhood SES. There was no significant association between the severity of the emergencies and SES. Conclusions:A lower neighbourhood SES is significantly associated with an increased demand for EMS. A higher frequency of psychiatric and pulmonary emergencies may contribute to this observation. Our results may be explained by a heightened healthcare burden and diminished access to medical services in communities characterized by less favourable socioeconomic status. Further studies should confirm and elucidate these results and also explore strategies to mitigate socioeconomic inequalities in health, ultimately alleviating the burden on EMS and emergency departments

Background: In patients complaining common symptoms such as chest/abdominal/back pain or syncope, acute aortic syndromes (AAS) are rare underlying causes. AAS diagnosis requires urgent advanced aortic imaging (AAI), mostly computed tomography angiography. However, patient selection for AAI poses conflicting risks of misdiagnosis and overtesting. Objectives: We assessed the safety and efficiency of a diagnostic protocol integrating clinical data with point-of- care ultrasound (POCUS) and D-dimer (single/age-adjusted cutoff), to select patients for AAI. Methods: This prospective study involved 12 Emergency Departments from 5 countries. POCUS findings were integrated with a guideline-compliant clinical score, to define the integrated pre-test probability (iPTP) of AAS. If iPTP was high, urgent AAI was requested. If iPTP was low and D-dimer was negative, AAS was ruled out. Patients were followed for 30 days, to adjudicate outcomes. Results: Within 1979 enrolled patients, 176 (9 %) had an AAS. POCUS led to net reclassification improvement of 20 % (24 %/-4 % for events/non-events, P < 0.001) over clinical score alone. Median time to AAS diagnosis was 60 min if POCUS was positive vs 118 if negative (P = 0.042). Within 941 patients satisfying rule-out criteria, the 30-day incidence of AAS was 0% (95% CI, 0-0.41 %); without POCUS, 2 AAS were potentially missed. Protocol rule-out efficiency was 48 % (95 % CI, 46-50 %) and AAI was averted in 41 % of patients. Using age-adjusted D- dimer, rule-out efficiency was 54 % (difference 6 %, 95 % CI, 4-9 %, vs standard cutoff). Conclusions: The integrated algorithm allowed rapid triage of high-probability patients, while providing safe and efficient rule-out of AAS. Age-adjusted D-dimer maximized efficiency. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, NCT04430400

Falls are common adverse events, often leading to hospitalization with adverse effects on the physiological and psychological health of patients. Although risk factors for falls are well examined, it is difficult to identify fallers through their electronical health records (EHR). This study investigates whether EHR contain characteristics that indicate a fall before hospitalization. We evaluated 500 EHR of patients hospitalized through the Department of Emergency Medicine of Jena University Hospital. We considered electronically available characteristics including free texts and ICD-10-GM codes. Inpatients with and without a fall event previous to their hospitalization were compared for significant differences in EHR characteristics. Therefore, we applied the Mann–Whitney U test and the exact Fisher test, respectively, with a two-sided significance level of 0.05 and without correction for multiple testing. It was possible to identify significant differences between fallers and non-fallers by gender (66.3