Western Journal of Emergency Medicine最新文献

{"title":"Low-Energy Chest Trauma in Older Adults: Prospective Study of Indications for Chest Computed Tomography.","authors":"Cansu Kurt, Sinan Genç, Emre Öner, Yaşar Çatal, Ayça Koca, Müge Günalp","doi":"10.5811/westjem.53963","DOIUrl":"https://doi.org/10.5811/westjem.53963","url":null,"abstract":"<p><strong>Introduction: </strong>Older adults frequently present to the emergency department (ED) with low-energy blunt chest trauma, and clinically important intrathoracic injuries may be under-detected during the initial evaluation. We aimed to evaluate whether bedside findings-particularly focal chest tenderness patterns (including anterior chest wall tenderness [ACWT] and lateral compression tenderness)-were associated with computed tomography (CT)-confirmed intrathoracic injury in older adults with low-energy blunt chest trauma, while also examining chest pain and early warning scores (EWS) as adjunct clinical variables.</p><p><strong>Methods: </strong>A single-center prospective study included 136 patients 65 years or older presenting within 24 hours of low-energy blunt trauma that did not meet prespecified high-energy criteria. The primary outcome was any intrathoracic pathology on chest CT during the index ED visit. Secondary analyses examined associations between CT-confirmed injury and bedside findings (including chest pain, ACWT, lateral compression tenderness, thoracic spine tenderness, visible chest skin trauma, and auscultatory abnormalities), routine clinical variables, and laboratory measures; rib fracture and disposition were treated as prespecified exploratory analyses. The National Early Warning Score and Modified Early Warning Score were evaluated as exploratory physiologic comparators. Routine laboratory testing at presentation included arterial blood gas analysis. Chest CT performed during the index ED visit served as the imaging reference standard, with intravenous contrast use determined by clinical indication. The National Emergency X-Radiography Utilization Study (NEXUS) chest criteria informed routine imaging selection. Logistic regression identified independent associations, and diagnostic performance metrics were calculated for key bedside tenderness findings.</p><p><strong>Results: </strong>For 136 studied patients, mean age was 78.9 (9.2) years, and 60.3% of patients were female. Ground-level falls accounted for 72.8% of injuries. Chest pain was reported in 19.9% of patients. Lateral compression tenderness (21.3%) and ACWT (25.0%) were the most common examination findings. On univariable analysis, chest pain and lateral compression tenderness were associated with intrathoracic pathology; in multivariable analysis, ACWT was the only independent bedside predictor of the primary outcome (adjusted odds ratio [OR] 4.18, 95% CI, 1.85-9.44; P < .001). For rib fracture, ACWT, chest pain, and lateral compression tenderness remained independently associated. For intrathoracic injury, ACWT had a sensitivity of 47.6% (95% CI, 32.0-63.6), specificity of 85.1% (95% CI, 76.3-91.6), positive predictive value of 58.8% (95% CI, 44.5-71.8), negative predictive value of 78.4% (95% CI, 72.9-83.1), a positive likelihood ratio of 3.2 (95% CI, 1.79-5.70), and a negative likelihood ratio of 0.62 (95% CI, 0.46-0.83), supporting its role as ","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 5","pages":"1263-1270"},"PeriodicalIF":2.3,"publicationDate":"2026-09-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149228871","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Resident Exposure to Acutely Ill Patients Over the Course of Residency.","authors":"Daniel J Hekman, Joe-Ann Moser, Benjamin H Schnapp","doi":"10.5811/westjem.63704","DOIUrl":"https://doi.org/10.5811/westjem.63704","url":null,"abstract":"<p><strong>Introduction: </strong>Emergency medicine literature has long debated the \"black cloud\" and \"white cloud\" phenomena, which suggest individual variability in exposure to acutely ill patients. If true, this variation may have significant implications for resident training. This study investigates whether emergency medicine (EM) residents consistently encounter differing volumes of high-acuity clinical encounters throughout their training.</p><p><strong>Methods: </strong>This retrospective cohort study analyzed 11 years of electronic health record (HER) data from a Midwestern academic emergency department to quantify the number of acutely ill adult patients seen by EM residents across three years of training, using a consensus-based set of clinical criteria. Our primary outcome was the concordance of the ranking of each resident within their cohort by number of acutely ill patients seen during postgraduate year one (PGY 1) compared to PGY 3. Statistical analyses to assess this outcome included weighted kappa and linear regression.</p><p><strong>Results: </strong>A total of 93 EM residents met the criteria for inclusion and saw a total of 359,736 patients during their residency (average 3,493 per resident). Residents saw an average of 167.5 (19.8) acutely ill patients during their residency training. This volume increased sharply by year, with PGY-1 residents seeing an average of 23.8 (7.3) acutely ill patients, and PGY-3 residents seeing an average of 100.3 (19.4). Both weighted kappa (κ = -.274) and linear regression analysis (β = -0.84; 95% CI, -1.4 to -0.31; P = .002) indicated that a resident who saw more acutely ill patients than average in PGY 1 was more likely to see fewer acutely ill patients than average during PGY 3. Results were unaffected by the COVID-19 years or subsequent critical care fellowship pursuit.</p><p><strong>Conclusion: </strong>\"Cloud type\" (as measured by EHR-documented care for acutely ill patients) does not appear to be a stable trait over time. Our findings are consistent with previous studies that found no association between residents' \"cloudiness\" and objective measures of workload. Using EHR data to track resident clinical exposures helps educators identify training gaps and target remediation through in situ or simulated experiences.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 5","pages":"1235-1242"},"PeriodicalIF":2.3,"publicationDate":"2026-09-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149228779","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Standardized Exam of the Abdomen Protocol Through Telemedicine in the Emergency Department.","authors":"Sarah S Abdul-Nabi, Souraya Arabi, Hind Anan, Rasha D Sawaya, Ahmad Zaghal, Hani Tamim, Jean-Marie Al Semaani, Zahi Hamdan, Maha Makki, Moustafa Al-Hariri, Afif Jean Mufarrij","doi":"10.5811/westjem.62235","DOIUrl":"https://doi.org/10.5811/westjem.62235","url":null,"abstract":"<p><strong>Introduction: </strong>Abdominal pain is a common emergency department (ED) presentation, and virtual assessment of such complaints remains a challenge due to the limitations of remote physical examination. The standardized exam of the abdomen protocol (SEAP) was developed to guide patients in performing a self-abdominal examination during telemedicine consultations. We aimed to evaluate agreement between patient-performed abdominal self-examinations using the SEAP and physician-performed abdominal examinations.</p><p><strong>Methods: </strong>We conducted a prospective, single-center study at the American University of Beirut Medical Center ED in Lebanon from August 2023-August 2024. Adult patients who presented with abdominal pain and met the inclusion criteria were enrolled. Each patient performed a video-guided abdominal self-examination by following a brief instructional video (SEAP). The SEAP was developed by an emergency medicine faculty at our institution using pre-established abdominal examination principles and clinical practice frameworks. The protocol was translated into a structured, two-minute instructional video. Blinded abdominal examinations were then performed by an emergency medicine resident and an attending physician. The primary outcome was agreement in abdominal tenderness across seven predefined regions, assessed using the Cohen kappa coefficient. Patient experience and feasibility measures were also collected.</p><p><strong>Results: </strong>We included a total of 103 patients. Agreement between patient-performed and physician-performed examinations was slight to fair across six of the seven abdominal regions (κ range, .13-.41). The highest agreement was observed in the right lower quadrant, with fair agreement between patients and residents (κ = .47; 95% CI, 0.30-0.64) and patients and attending physicians (κ = .36; 95% CI, 0.18-0.53). Agreement in the remaining regions, including the upper quadrants and flanks, remained low; right upper quadrant (κ = .13), left upper quadrant (κ = .28), and flanks (κ range, -0.04 to .41). Most patients (97.9%; n = 94/96) rated the instructional video as clear and easy to follow.</p><p><strong>Conclusion: </strong>Patient-performed abdominal self-examination using the SEAP demonstrated limited agreement with physician examinations across most abdominal regions. Agreement in the right lower quadrant was also fair. These findings indicate that patient-performed abdominal self-examination does not reliably reproduce physician assessment. However, they provide a foundation for further studies aimed at refining and better defining the role of patient-guided abdominal examinations in telemedicine settings.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 5","pages":"1490-1498"},"PeriodicalIF":2.3,"publicationDate":"2026-09-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149228862","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Point-of-Care Ultrasound After Medical Screening Exam Reduces Time to Ruptured Ectopic Pregnancy Diagnosis and Surgery.","authors":"Victoria L Morris, Michael Vu, Yongsu Lee, Evelyn Park, Ravi Soni, Ryan Walsh, Rachel Bower, John C Waller-Delarosa, Kunal Sharma, Benjamin L Karfunkle, Richard Gordon","doi":"10.5811/westjem.53932","DOIUrl":"https://doi.org/10.5811/westjem.53932","url":null,"abstract":"<p><strong>Introduction: </strong>Ectopic pregnancy remains the leading cause of first-trimester maternal mortality. Delays in diagnosis and operative management increase morbidity and may be exacerbated by emergency department (ED) crowding. We evaluated whether integration of point-of-care ultrasound (POCUS) into the medical screening exam of pregnant patients-the obstetric medical screening exam-was associated with improved timeliness of care for patients with surgically managed ectopic pregnancy.</p><p><strong>Methods: </strong>We conducted a single-center retrospective cohort study of adult patients undergoing operative management for ruptured ectopic pregnancy between January 1, 2019, and December 31, 2023, at a county safety-net hospital. The obstetric screening exam was implemented July 12, 2021, and incorporated focused transabdominal pelvic and right upper quadrant ultrasound into the initial ED evaluation, often prior to bed assignment. The primary outcome was time from ED arrival to operating room (OR). Secondary outcomes included time to obstetric consultation, time to hospital admission, ED length of stay (LOS), and POCUS use. Nonparametric testing was used for skewed time data. Logistic regression evaluated the odds of reaching the OR within four hours. Patient-level interrupted time series analysis assessed temporal trends.</p><p><strong>Results: </strong>A total of 150 patients were included (87 pre- and 63 post-implementation). Median arrival-to-OR time decreased from 516 minutes (interquartile range [IQR] 324-709.5) to 391 minutes (IQR 220-619), a 125-minute reduction (P = .020; bootstrap 95% CI, 8-233). The proportion of patients reaching the OR within four hours increased from 16.1% to 31.8% (odds ratio 2.42; 95% CI, 1.11-5.29; P = .02). Time to obstetric consultation (210 vs 146 minutes; P = .003), time to hospital admission (345 vs 250 minutes; P = .005), and ED LOS (451 vs 367 minutes; P = .03) were all reduced. Point-of-care ultrasound use increased from 41.4% to 66.7% (P < .001), while the remainder underwent radiology ultrasound. Interrupted time series analysis demonstrated no significant immediate change after implementation (P = .790), but a significant postintervention trend toward reduced arrival-to-OR time (-0.45 minutes/day, P = .01).</p><p><strong>Conclusion: </strong>Embedding POCUS into the medical screening examination in triage was associated with sustained improvement in operative timeliness for ruptured ectopic pregnancy. Early diagnostic integration within ED workflow may mitigate system-level delays in time-sensitive obstetric emergencies.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 5","pages":"1478-1484"},"PeriodicalIF":2.3,"publicationDate":"2026-09-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149228840","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of Increasing Ambient Temperatures on Emergency Department Trauma Presentations at a Level I Trauma Center.","authors":"Grace E Mosley, Monique Arnold, Bharti Sharma, Jennifer Whittington, Geoff Jara-Almonte","doi":"10.5811/westjem.52977","DOIUrl":"https://doi.org/10.5811/westjem.52977","url":null,"abstract":"<p><strong>Introduction: </strong>Global temperatures are increasing because of climate change, affecting human health. Elevated ambient temperature has been shown to increase rates of trauma presentations in emergency departments and to increase antisocial behavior, such as violent crime. To better understand how to reduce the burden on trauma hospitals, we must better understand the relationship between ambient temperature, trauma patients, and intentional injury. We sought to examine the relationship between trauma rates and minimum and maximum daily temperatures and assess whether the assault trauma mechanism had the strongest association between weather and trauma rates.</p><p><strong>Methods: </strong>We conducted a retrospective cohort study of full and partial trauma team activations that presented to a Level I trauma center in New York from 2012 to 2019, inclusive. Daily maximum and minimum temperatures were divided into quintile ranges. Traumas were classified by injury type and mechanism as either unintentional, assault, or intentional self-harm. We used generalized linear models with a Poisson distribution to examine the relationship between maximum and minimum temperature ranges and trauma rates, controlling for precipitation.</p><p><strong>Results: </strong>Increasing daily minimum and maximum temperatures positively correlated with increasing trauma activations. While all trauma types increased with increasing temperature, assault traumas showed the highest rate of increase (P < .001). Compared to the lowest temperature quintile (< 46 °F), the two highest maximum temperature quintiles (> 73 °F and 83 °F) showed an increase in assault rates of 83% and 65% (incident rate ratio 1.83 [95% CI, 1.46-2.29] and 1.65 [95% CI, 1.32-2.07], respectively).</p><p><strong>Conclusion: </strong>Trauma rates have a positive association with increasing ambient temperature rates. This temperature effect is largest among the assault group, suggesting that as temperatures continue to increase, so too will traumas that are the result of interpersonal violence.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 5","pages":"1149-1159"},"PeriodicalIF":2.3,"publicationDate":"2026-09-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149228876","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Respiratory Viral Positivity Is Associated with Decreased Risk of Serious Bacterial Infections in Febrile Infants.","authors":"Diormi A Rosario, Anum Mitha, Jessica Zerzan, Sharmila Babu, Saxony Busta, Michael Silver, Antonios Likourezos, Christina Bravi, Hector Vazquez","doi":"10.5811/westjem.53209","DOIUrl":"https://doi.org/10.5811/westjem.53209","url":null,"abstract":"<p><strong>Introduction: </strong>Febrile infants ≤ 60 days of age are at increased risk for serious bacterial infections (SBIs), often necessitating extensive diagnostic evaluation and hospitalization. Although respiratory viral infections are common in this population and may influence the likelihood of concurrent bacterial infection, the relationship between respiratory viral panel (RVP) results and SBI risk remains an important consideration in clinical decision-making. The objective of this study was to evaluate the association between RVP results and the occurrence of SBIs among febrile infants ≤ 60 days of age.</p><p><strong>Methods: </strong>In this single-center, retrospective study we analyzed data from infants ≤ 60 days of age who presented to the emergency department with fever (temperature > 100.4 °F/38 °C) between September 2020-May 2024. Infants were divided into two subgroups based on RVP results: positive or negative for any viral infections via a multiplex polymerase chain reaction panel. The overall rate of SBI, and the rates of individual SBIs (urinary tract infection [UTI], bacteremia, and bacterial meningitis), were compared between groups. The primary outcome was the rate of SBIs among infants with any positive RVP compared to those with a negative RVP.</p><p><strong>Results: </strong>We analyzed 1,986 charts of febrile infants ≤ 60 days of age, of whom 485 (24.4%) met criteria. Of these, 309 (63.7%) had a positive RVP for at least one pathogen while 176 (36.3%) were all negative. Overall, the rate of serious bacterial infection in the RVP negative group was 35.8% (95% CI, 29%-43.1%) compared to 6.5% (95% CI, 4.1%-9.6%) in the RVP positive group (P < .001). Infants with a positive RVP had a significantly lower prevalence of serious bacterial infection (7.4%) and UTI (5.5%) compared to those with a negative RVP (P < .001). In the RVP positive group, 17 patients (5.5% [95% CI, 3.4%-8.5%]) had a UTI compared to 46 (26.1% [95% CI, 20.1%-33%]) in the RVP negative group. Notably, there were four cases of bacteremia (1.3% [95% CI, 0.4%-3%]) in the positive RVP group compared to 20 (11.4% [95% CI, 7.3%-16.7%]) in the negative RVP group. In the positive RVP group, there were 0 cases of meningitis (0% [95% CI, 0%-0.9%]) compared to 5 (2.8% [95% CI, 3.4%-85%]) in the RVP-negative group. The differences in bacteremia and meningitis rates between the two groups were statistically significant (P < .001).</p><p><strong>Conclusion: </strong>Febrile infants ≤ 60 days of age with a positive RVP are associated with a significantly lower risk for SBI compared to those with a negative RVP, a 64% relative risk reduction. If validated with a prospective study, these findings could help guide clinical decision-making, potentially allowing for a more nuanced approach to the management and disposition of febrile infants, particularly the need for invasive workup and hospitalization.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 5","pages":"1317-1320"},"PeriodicalIF":2.3,"publicationDate":"2026-09-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149228857","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Syphilis Screening in Pregnancy During Emergency Department Gonorrhea and Chlamydia Testing.","authors":"Michael P Phelan, Elizabeth N Dewey, Fredric M Hustey, Stephen W Meldon, McKinsey Muir, Janet Wu, Matthew J Campbell, Oluwatosin Goje, Kamran Kadkhoda, Charles B Foster","doi":"10.5811/westjem.54849","DOIUrl":"https://doi.org/10.5811/westjem.54849","url":null,"abstract":"<p><strong>Introduction: </strong>Congenital syphilis is rising in the United States, especially among infants born to women with limited prenatal care. Emergency departments (ED) offer opportunities for early detection, particularly among patients evaluated for urogenital sexually transmitted infection (STI) concerns. In October 2019, our health system implemented an ED STI order set that promoted HIV co-testing and included a preselected option for syphilis testing. In this study, we evaluated change in syphilis testing during the post-implementation period among ED encounters with both pregnancy and gonorrhea/chlamydia (GC/CT) testing.</p><p><strong>Methods: </strong>We conducted a retrospective, quasi-experimental study across 20 EDs, using health record data from 2018 to 2023 for patients aged 15-44 years who received both pregnancy and GC/CT testing. We measured annual syphilis and HIV testing and positivity, stratified by pregnancy status. The primary study outcome was syphilis testing during the encounter; HIV testing and detection outcomes were secondary.</p><p><strong>Results: </strong>Among 59,171 ED encounters with pregnancy and GC/CT testing, 5,178 (8.8%) involved pregnant patients, and 9,538 (16.1%) received syphilis testing. Syphilis testing among pregnant patients increased from .9% in 2018 to 46.1% in 2023 (+45.1 percentage points [95% CI, 40.4-49.6]). Testing among nonpregnant patients rose from 1.2% to 35.9% (+34.6 percentage points [95% CI, 33.3-35.9]). Overall, only 1,068 of 5,178 pregnant encounters received a syphilis test (20.6%). Among 1,068 syphilis-tested pregnant encounters, 15 (1.4%) were treponemal-positive and 9 (.8%; 843 per 100,000 tested) met the Centers for Disease Control and Prevention surveillance definition for active syphilis (approximately 1 per 119 tests). Using all pregnant encounters with GC/CT testing as the denominator, the encounter-based active syphilis rate was 173.8 per 100,000 (.17%). HIV testing increased similarly (pregnant: .4% in 2018 to 44.5% in 2023), while HIV positivity remained rare (2 pregnant; 13 overall).</p><p><strong>Conclusion: </strong>Syphilis testing and case detection increased during the postimplementation period following introduction of a preselected STI order set in the electronic health record. Many encounters in the analytic cohort still did not include syphilis testing. These findings support the ED as an important setting for identifying syphilis in pregnancy while underscoring the need for further work to understand remaining testing gaps.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 5","pages":"1467-1477"},"PeriodicalIF":2.3,"publicationDate":"2026-09-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149228817","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of Secure Electronic Health Record Chat on Physician Communication in the Emergency Department.","authors":"Michaela Go, Hasan Alshamrani, Obert Xu, Steven McGaughey","doi":"10.5811/westjem.53220","DOIUrl":"https://doi.org/10.5811/westjem.53220","url":null,"abstract":"<p><strong>Introduction: </strong>Effective communication in the emergency department (ED) is essential for safe patient care. Electronic health record (EHR)-integrated secure messaging may improve communication workflows, but limited evidence exists comparing clinician satisfaction across modalities in the ED. This study evaluated physician satisfaction with an EHR-integrated secure messaging tool compared to existing communication methods for non-emergent communication.</p><p><strong>Methods: </strong>We conducted an electronic pre-post survey study at an urban academic ED following implementation of an EHR-integrated secure messaging tool in October 2024. The primary outcome was overall communication satisfaction pre-post implementation. We also compared nursing communication satisfaction and repeat consult order proportions. Survey domains (ease of use, efficiency, timeliness, clarity, overall satisfaction) were graded using a four-point forced-choice Likert scale.</p><p><strong>Results: </strong>Response rates were 35% (33/95) pre-implementation and 36% (34/95) post-implementation. Although face-to-face communication maintained superior clarity ratings, secure chat received significantly higher overall satisfaction than phone communication (median 3 [IQR 3-4] vs 2 [2-3], P < .001) and higher ratings than the existing consult workflow across all domains (all P ≤ .03). Overall nursing communication satisfaction shifted toward higher scores post-implementation (median 3 [3-4] vs 3 [2-3], P = .03). Repeat consult order proportion decreased from 22% to 18% (risk difference, -3.5%; 95% CI, -4.5% to -2.5%; P < .001).</p><p><strong>Conclusion: </strong>Electronic health record-integrated secure messaging demonstrated high user satisfaction among emergency physicians and may reduce repeat consultant communications. Secure chat provides a complementary communication channel in the ED setting.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 5","pages":"1217-1221"},"PeriodicalIF":2.3,"publicationDate":"2026-09-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149228901","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of Physician Patient Load on Imaging Use in the Emergency Department.","authors":"Wayne A Martini, Jessica Monas, Nicole R Hodgson","doi":"10.5811/westjem.63096","DOIUrl":"https://doi.org/10.5811/westjem.63096","url":null,"abstract":"<p><strong>Introduction: </strong>Emergency department (ED) crowding may alter physician decision-making, yet little is known about how real-time physician workload affects diagnostic imaging use. We examined the association between physician patient load and the proportion of patients who received diagnostic imaging, including computed tomography (CT), CT with intravenous (IV) contrast, CT without contrast, plain radiography, magnetic resonance imaging (MRI), and ultrasound (US).</p><p><strong>Methods: </strong>We conducted a retrospective cohort study of all ED visits at an academic tertiary care center (January 2019-December 2024). Physician workload was defined as the sequential patient assignment order per physician per day (range 1-17). Our primary outcome measures were binary indicators of whether each imaging modality was ordered during the ED visit: CT (any); CT with IV contrast; CT without IV contrast; radiograph, MRI; and US. Multivariable logistic regression with physician-clustered robust standard errors estimated adjusted odds ratios (aOR) for each imaging modality, controlling for age, sex, triage acuity, chief complaint, and temporal factors. We also performed mixed-effects logistic regression with physician random intercepts and a within-between (Mundlak) decomposition. Absolute risk differences (ARD) were computed for the 17th versus the first patient.</p><p><strong>Results: </strong>Among 287,925 encounters across approximately 41,132 physician shifts managed by 77 physicians, higher workload was associated with decreased odds of imaging for most modalities. Computed tomography with IV contrast showed the strongest effect (aOR 0.990, 95% CI, 0.986-0.994; within-physician aOR 0.991; ARD -2.2 percentage points [pp], from 21.8% to 19.6%). Results were as follows: any CT, aOR 0.994 (0.991-0.997); ARD -1.9 pp (from 38.7% to 36.8%); radiograph, aOR 0.994 (0.990-0.998, P < .001); ARD -1.6 pp (from 44.2% to 42.6%); US, aOR 0.994 (0.990-0.998, P < .001); ARD -0.7 pp (from 9.9% to 9.2%); and MRI was nonsignificant in the pooled model (aOR 0.993, P = .09) but significant in the mixed-effects model (P < .001). Noncontrast CT was unaffected (aOR 1.000, P = .87). Intraclass correlation coefficients ranged from 0.020-0.047, indicating 2-5% of imaging variance was attributable to physician-level differences.</p><p><strong>Conclusion: </strong>Higher physician workload was associated with modestly reduced imaging use, particularly for resource-intensive modalities. Noncontrast CT was unaffected. Within-physician analyses were consistent with the interpretation that these effects reflect real-time behavioral adaptation rather than physician practice style alone. These findings highlight a trade-off between throughput and diagnostic testing that warrants further study of its impact on clinical outcomes.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 5","pages":"1208-1216"},"PeriodicalIF":2.3,"publicationDate":"2026-09-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149228959","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Reevaluating the Role and Timing of Fever in Acute Cholecystitis.","authors":"Andrea Villarroel Barrios, Pablo Aguilera Fuenzalida, J Austin Lee, Valentín Gaete Díaz, Óscar Navea Carrasco, Bárbara Lara Hernández","doi":"10.5811/westjem.63649","DOIUrl":"https://doi.org/10.5811/westjem.63649","url":null,"abstract":"<p><strong>Introduction: </strong>Acute cholecystitis is diagnosed based on clinical and diagnostic findings. Fever is commonly considered a sign of systemic inflammation in acute cholecystitis, although its diagnostic performance may vary depending on the timing of presentation. This study analyzed the prevalence of fever as a diagnostic parameter for acute cholecystitis, according to the symptom onset at the time of medical consultation (≤ 24 hours versus > 24 hours), and its potential association with both medical and surgical complications.</p><p><strong>Methods: </strong>We conducted a retrospective cohort study in two urban, tertiary care emergency departments (ED) between March 2023 and June 2024. Adult patients (≥ 18 years) with clinically diagnosed acute cholecystitis were included. Presentations were categorized by time since symptom onset: early (≤ 24 hours) or late (> 24 hours). Fever was defined as axillary temperature > 37.5 °C at home or at ED arrival. The primary outcome was the sensitivity of fever for the diagnosis of acute cholecystitis, stratified by early versus late presentation. Secondary outcomes included the sensitivity of other inflammatory markers and the association between fever and medical or surgical complications. The association between fever and complications was evaluated using a penalized logistic regression model (Firth method) to account for the low number of outcome events.</p><p><strong>Results: </strong>A total of 207 cases of acute cholecystitis were included in the analysis: 108 early presenters; and 99 late presenters. Fever was present in 4.6% (95% CI, 1.5-10.4) of early presenters and 20.2% (95% CI, 12.8-29.4) in late presenters, with an overall sensitivity of 12.1% (95% CI, 8.0-17.2). Medical and/or surgical complications were low in this cohort (n = 15, 7.2%), but more frequent in patients with fever, regardless of time onset of symptom (28% versus 4.5%, P < .001), yielding an adjusted odds ratio of 6.64 (95% CI, 1.42-31.21; P = .02) after adjusting for leukocyte count, C-reactive protein levels, and age.</p><p><strong>Conclusion: </strong>Fever is an uncommon sign of acute cholecystitis, especially in early presentations, but may indicate a higher risk for complications when present. These findings underscore the need to reconsider the role of fever in current diagnostic criteria and suggest further validation of its use as a predictor of complications in prospective studies.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 5","pages":"1420-1427"},"PeriodicalIF":2.3,"publicationDate":"2026-09-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149228849","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}