Western Journal of Emergency Medicine最新文献

{"title":"From De-escalation to Restraint: A Qualitative Study of Emergency Clinician Decision-Making in Patient Agitation.","authors":"Michelle Suh, Beatrice Torres, Elise Brickhouse, Datonye Charles, Ynhi Thomas, Anita Chary","doi":"10.5811/westjem.53798","DOIUrl":"https://doi.org/10.5811/westjem.53798","url":null,"abstract":"<p><strong>Introduction: </strong>Managing agitation in the emergency department (ED) is challenging and frequently involves decisions about physical restraints and emergent medications. While institutional protocols and behavioral response teams exist, little is known about how individual clinicians make decisions about restraint use-decisions with significant implications for safety, ethics, and equity. The objective of the study was to explore how emergency physicians, residents, and nurses make decisions about physical restraint and emergent medication use during episodes of patient agitation in the ED.</p><p><strong>Methods: </strong>We conducted a qualitative study using semi-structured interviews with 35 emergency clinicians (18 attending physicians, 7 senior residents, and 10 nurses) at an urban academic ED. Interviews were transcribed and analyzed using inductive thematic analysis.</p><p><strong>Results: </strong>Clinicians described three key factors informing restraint decision-making: (1) commitment to patient-centered care through noncoercive de-escalation; (2) real-time assessment of threats to staff and patient safety; and (3) team-based collaboration in both the restraint decision and implementation process. Participants shared a common mental model that prioritized verbal de-escalation before moving to pharmacologic or physical restraint. Clinicians acknowledged that unconscious bias and identity-based dynamics, including age, gender and race, may influence perceptions of threat and decision-making.</p><p><strong>Conclusion: </strong>Emergency clinicians share a consistent framework for managing patient agitation, suggesting potential for a standardized, team-based algorithm. Future interventions should consider clinician and patient identities, aiming to reduce disparities and enhance safety while minimizing restraint use.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 5","pages":"1384-1392"},"PeriodicalIF":2.3,"publicationDate":"2026-08-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149228811","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":"Changing Risk Factors in Patients Diagnosed with Human Immunodeficiency Virus.","authors":"Sula Frausto, Heather Sperring, Glorimar Ruiz-Mercado, Cassandra Pierre, Kathryn Scrudder, Ijeoma Okafor, Kerrie Nelson, Elissa M Schechter-Perkins","doi":"10.5811/westjem.52947","DOIUrl":"https://doi.org/10.5811/westjem.52947","url":null,"abstract":"<p><strong>Introduction: </strong>Since 2019, transmission risk factors among patients diagnosed with HIV have changed, although the trends and reasons behind them have not been fully elucidated. The objective of this study was to assess changes in HIV transmission risk factors among patients newly diagnosed with HIV to inform future targeted HIV testing programs.</p><p><strong>Methods: </strong>This study site is New England's largest essential hospital and a major reporter of new HIV cases in Massachusetts. We performed a retrospective chart review of patients diagnosed with HIV infection at our medical center between January 2019 and December 2023. Demographic and clinical variables were collected and analyzed using descriptive and comparative statistics to evaluate trends in primary risk factor for HIV. Our primary outcome measure was incident HIV diagnosis with a primary risk factor of injection drug use (IDU), men who have sex with men (MSM), or heterosexual contact. A secondary outcome examined was CD4 count at the time of diagnosis.</p><p><strong>Results: </strong>A total of 246 patients were newly diagnosed with HIV. Of these, 59% (n = 146) reported heterosexual contact as their most likely cause of transmission, 19% (n = 47) MSM, 19% IDU (n = 46), and 3% (n = 7) reported both MSM and IDU. Heterosexual contact increased as the predominant HIV transmission factor from 53% (24/45) in 2019 to 79% (37/47) in 2023 (risk difference, 25%; 95% CI, 6.7%-44.1%), and the percentage of diagnoses made in non-US-born patients increased from 60% (27/45) in 2019 to 83% (39/47) in 2023 (risk difference, 23%; 95% CI, 5.1%-41%). Non-US born patients had significantly lower CD4 counts at diagnosis (mean [SD] CD4 count 299 [241] cells/μL) compared to US-born counterparts (mean [SD] CD4 count 498 [309] cells/μL, P < .001), with a mean difference of -199 cells/μL (95% CI, -272 to -125).</p><p><strong>Conclusion: </strong>The dominant risk factor for HIV transmission has changed from injection drug use/men who have sex with men to heterosexual contact in New England's largest city. Our findings associate increased HIV incidence in non-US-born immigrants at an urban essential hospital, highlighting the importance of considering this group in targeted public health efforts to avoid missing cases of HIV in similar settings.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 5","pages":"1402-1410"},"PeriodicalIF":2.3,"publicationDate":"2026-08-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149228781","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":"Emergency Severity Index Stratified by Post-Triage Lactate: Association with In-Hospital Mortality in Admitted Patients.","authors":"Gregory Mansella, Valentin Klotzbücher, Roland Bingisser, Christian H Nickel","doi":"10.5811/westjem.62115","DOIUrl":"https://doi.org/10.5811/westjem.62115","url":null,"abstract":"<p><strong>Introduction: </strong>The Emergency Severity Index (ESI) is a widely used triage tool in emergency departments (EDs) and is associated with adverse outcomes. Lactate has also been associated with mortality in various ED populations. This study evaluated whether lactate levels measured after triage at the treating physician's discretion are associated with in-hospital mortality across ESI levels in admitted ED patients.</p><p><strong>Methods: </strong>This study is a secondary analysis of prospectively collected data from adult patients presenting to the ED of a Swiss tertiary care center in 2013, 2015, 2017, and 2019. The study included admitted patients who underwent post-triage lactate measurement at the treating physician's discretion. Only the first lactate value measured in the ED was analyzed and categorized as < 2.0, 2.0-3.9, and ≥ 4.0 mmol/L. The primary outcome was in-hospital mortality; secondary outcomes were 30-day mortality and intensive care unit (ICU) admission. Associations were assessed using multivariable logistic regression models adjusted for age and sex. Model discrimination was compared using receiver operating characteristic curve analysis.</p><p><strong>Results: </strong>Among 3,909 patients admitted from the ED who had a lactate drawn (of 17,327 ED presentations during the study period; 22.6%), the median age was 72 years and 2,062 (52.8%) were male. In-hospital mortality occurred in 168 (4.3%), 30-day mortality in 258 (6.6%), and ICU admission in 698 (17.9%). In ESI levels 2 (n = 1,826) and 3 (n = 1,722), crude in-hospital mortality was similar (59 [3.2%] and 44 [2.6%], respectively), but varied after stratification by lactate level. In ESI level 2 patients, in-hospital mortality occurred in 24 (2.0%) among those with lactate < 2.0 mmol/L (n = 1,210) and in 18 (17.8%) among those with lactate ≥ 4.0 mmol/L (n = 101), corresponding to an age- and sex-adjusted absolute risk difference of 16.0% (95% CI, 8.8-23.3). In ESI level 3, in-hospital mortality occurred in 20 (1.6%) at lactate < 2.0 mmol/L (n = 1,254) and in 8 (15.1%) at lactate ≥ 4.0 mmol/L (n = 53), corresponding to a risk difference of 12.5% (95% CI, 3.7-21.3). Discrimination for in-hospital mortality was higher when lactate was considered alongside ESI (area under the curve [AUC] 0.844 versus 0.799; ΔAUC 0.045, 95% CI, 0.021-0.069), with smaller increases for 30-day mortality and ICU admission.</p><p><strong>Conclusion: </strong>In admitted ED patients who had lactate measured after triage at physician discretion, higher lactate levels were associated with increased in-hospital mortality across ESI levels, particularly among patients triaged as ESI levels 2 and 3.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 5","pages":"1364-1373"},"PeriodicalIF":2.3,"publicationDate":"2026-08-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149228806","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":"From Stress to Strength: Fostering a Positive Learning Climate to Promote Learning, Performance, and Well-Being.","authors":"Juhi Varshney, Esther Chen","doi":"10.5811/westjem.63706","DOIUrl":"https://doi.org/10.5811/westjem.63706","url":null,"abstract":"","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 5","pages":"1258-1262"},"PeriodicalIF":2.3,"publicationDate":"2026-08-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149228814","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":"From AUC to Action: AI Sepsis Alerts as Quality Improvement Tools in the Emergency Department.","authors":"Abhishek Hanumanpratap Singh Kshatri","doi":"10.5811/westjem.61768","DOIUrl":"https://doi.org/10.5811/westjem.61768","url":null,"abstract":"","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 5","pages":"1506-1507"},"PeriodicalIF":2.3,"publicationDate":"2026-08-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149228865","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":"Emergency Department Evaluation and Care of Hepatic Encephalopathy: ACEP Expert Panel Recommendations.","authors":"Christopher W Baugh, Arun B Jesudian, Stanley C Thompson, Christi Jen, William Ford, James F Neuenschwander, Edgardo Ordonez, Alpesh N Amin","doi":"10.5811/westjem.63064","DOIUrl":"https://doi.org/10.5811/westjem.63064","url":null,"abstract":"<p><strong>Introduction: </strong>Patients with hepatic encephalopathy frequently visit the emergency department, and these visits are expected to rise in the coming years due to an increased prevalence of liver disease in the United States. Accordingly, we sought to define a comprehensive and efficient approach for emergency physicians to evaluate, treat, and determine the optimal disposition of patients presenting with possible or confirmed hepatic encephalopathy and its complications.</p><p><strong>Methods: </strong>We reached consensus recommendations through a structured literature review and a modified Delphi technique, informing an expert panel of academic and community emergency physicians convened by the American College of Emergency Physicians.</p><p><strong>Results: </strong>We created the assess, look, treat, evaluate risk, reassess, disposition (ALTERD) framework as a digital point-of-care tool to support clinicians in guiding key bedside steps involved in the diagnosis and care of patients across the spectrum of hepatic encephalopathy.</p><p><strong>Conclusion: </strong>A collaborative expert panel process can create an emergency department-focused, easily accessible, and comprehensive digital tool to complement workflows and improve the care of a vulnerable and growing patient population.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 5","pages":"1411-1419"},"PeriodicalIF":2.3,"publicationDate":"2026-08-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149228847","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":"Climate Change and Heat-related Illness in Older Adults: Implications for Emergency Medicine.","authors":"Erin L Simon, Kevin Watkins, Stephen Meldon","doi":"10.5811/westjem.54008","DOIUrl":"https://doi.org/10.5811/westjem.54008","url":null,"abstract":"<p><p>Climate change is increasing the frequency, duration, and intensity of extreme heat events, creating a growing public health threat for older adults. Age-related physiologic decline, comorbid chronic diseases, polypharmacy, and social vulnerability all contribute to reduced heat tolerance and higher rates of heat-related morbidity and mortality. Emergency departments (ED) are increasingly encountering older adults presenting with minor heat illness, heat stroke, and exacerbations of chronic illnesses triggered by heat exposure. This review synthesizes current evidence describing why older adults are disproportionately affected by extreme heat, highlights key social and environmental determinants of vulnerability, and outlines clinical and public health strategies that emergency clinicians and EDs can assist with to reduce risk. As global temperatures rise, proactive prevention, early recognition, and coordinated community interventions are essential to protect this high-risk population.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 5","pages":"1126-1130"},"PeriodicalIF":2.3,"publicationDate":"2026-08-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149228846","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":"Evaluating the Impact of a Sustainability Education Intervention on Emergency Medicine Residents.","authors":"Atieh D Ashkezari, Christina Bogdani, Xueqing Huang, Michael Gindi","doi":"10.5811/westjem.56998","DOIUrl":"https://doi.org/10.5811/westjem.56998","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Introduction: &lt;/strong&gt;Healthcare is a significant contributor to global greenhouse gas emissions, with emergency departments being among the most resource-intensive settings. Despite increasing awareness of climate change and its health implications, structured sustainability education remains lacking in emergency medicine graduate medical education training. We evaluated the impact of a brief, educational intervention on emergency medicine (EM) residents' knowledge, attitudes, and self-reported behaviors related to sustainability.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;We conducted a prospective pre/post interventional study at two community-based EM residency programs. Emergency medicine residents completed a baseline survey assessing sustainability-related knowledge, attitudes, and self-reported behaviors, followed by a video on sustainable clinical practice and a peer-reviewed paper on the environmental impact of inhalers. Immediate postcourse and one-month follow-up surveys were administered to evaluate short- and intermediate-term changes. Our primary outcome measure was change in sustainability-related knowledge scores. Secondary outcomes included changes in attitudes toward sustainability and self-reported sustainability-related clinical behaviors. Survey responses were analyzed using descriptive statistics, paired t tests and repeated-measures analysis of variance, as appropriate.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;Of 41 eligible EM residents across two residency programs, 34 completed the baseline survey (82.9%), 28 completed the immediate post-intervention survey (68.3%), and 30 completed the one-month follow-up survey (73.2%). Knowledge scores at baseline were 55.0% and increased to 68.0% immediately after the intervention (P &lt; .001). At one month, knowledge scores remained higher than baseline (65.0%) (P = .003). Attitudes improved significantly immediately post-intervention (P = .001), despite already neutral-to-positive baseline levels. Two self-reported behavior items improved at one month: preferential prescribing of dry-powder inhalers, which were described in the educational materials as having less of an environmental impact than aerosolized inhalers (12.0% to 37.0%, P &lt; .050) and self-reported efforts to reduce unnecessary waste (56.0% to 87.0%, P &lt; .050), with overall self-reported behavior change (P = .001). Nebulizer-related prescribing did not significantly change. The open-ended item showed similar thematic patterns at both baseline and after one month, with most residents describing simple waste-reduction actions (eg, minimizing disposables), and no significant shift in qualitative categories.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Discussion and conclusion: &lt;/strong&gt;A brief, structured sustainability module delivered via a video format was feasible and well-received by EM residents. Preliminary data suggest improvements in knowledge, attitude, and self-reported behaviors, highlighting the potential for scalable sustainability education withi","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 5","pages":"1118-1125"},"PeriodicalIF":2.3,"publicationDate":"2026-08-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149228791","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":"Implementation Science to Advance Equity in Climate-Driven Disaster Response.","authors":"William Mundo, Jessica Ryder, Madeline Ross, Corey B Bills, Lee S Newman, Jay Lemery","doi":"10.5811/westjem.53809","DOIUrl":"https://doi.org/10.5811/westjem.53809","url":null,"abstract":"<p><p>Climate hazards are causing increasingly frequent and severe disasters. The populations most impacted by the health and social costs of disasters include language minorities, displaced individuals, and low-income communities. This commentary explores three key issues. First, climate hazards lead to displacement and increase vulnerability by disrupting housing, livelihoods, and access to care. Second, current emergency and disaster frameworks often overlook equity in communication, access to care, and recovery. Third, practical solutions can prioritize equity across mitigation, preparedness, response, and recovery. We review evidence on climate displacement, legal protections, and the roles of the health system. We highlight recurring operational opportunities, such as language access, navigation barriers, and fragmented recovery efforts. We also propose feasible strategies aligned with implementation science, including multilingual warning systems, interpreter-ready triage, mobile clinics, community health worker networks, simplified recovery navigation, and policy changes to reduce documentation barriers. This commentary aims to help emergency leaders, public health agencies, and community partners turn intentions into measurable, sustainable equity improvements. Prioritizing language access and legal realities in disaster planning can reduce preventable health issues and accelerate recovery for groups most affected by climate change.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 5","pages":"1131-1140"},"PeriodicalIF":2.3,"publicationDate":"2026-08-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149228894","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 a Rapid Assessment Zone on Patient Throughput in an Urban Pediatric Emergency Department.","authors":"Amanda Schoonover, Alyssa M Gill, Emily E Hill, Zina Alhaddad, Jessica Parker, Jackson Lanphear, Bhawana Arora","doi":"10.5811/westjem.62068","DOIUrl":"https://doi.org/10.5811/westjem.62068","url":null,"abstract":"<p><strong>Introduction: </strong>The rapid assessment zone is a newer model for optimizing emergency department (ED) throughput. Similar models implemented in adult ED settings have shown improvements in throughput parameters. However, few studies have taken place in the pediatric ED setting. Our study objective was to assess the impact of implementing a rapid assessment zone on throughput in an urban pediatric ED. We hypothesized that length of stay (LOS), time to bed placement, and time to see a clinician would decrease after the intervention and remain sustainable over long-term follow-up.</p><p><strong>Methods: </strong>This retrospective study assessed the effect of rapid implementation from May 2012-April 2018 on LOS for ED visits for three two-year time periods: pre- and post-rapid assessment zone and post-follow-up. Our primary outcome measures were LOS, time from registration to bed, and time from registration to first clinician evaluation. Secondary outcome measures were how LOS differed between high- and low-acuity visits. We analyzed data using Kruskal-Wallis for comparison of medians and Wilcoxon rank-sum tests with Bonferroni correction for pairwise comparisons.</p><p><strong>Results: </strong>There were 304,318 unique ED visits from May 1, 2012-April 30, 2018, with an increase in volume over time (92,551 visits pre-rapid assessment zone and 106,530 visits post-follow-up). Overall median LOS decreased from pre- rapid assessment zone, post- rapid assessment zone, and post-follow-up, respectively (110 minutes versus 101 minutes vs 94 minutes; P < .001). When stratified by acuity level, low-acuity visit LOS decreased from pre- rapid assessment zone to post- rapid assessment zone to post-follow-up (85 min vs 77 min vs 70 min; P < .001), whereas LOS for higher-acuity levels was, on average, unchanged (144 min vs 149 min vs 143 min for pre-RAZ, post- rapid assessment zone, and post-follow-up, respectively; P < .001). The overall registration to clinician time decreased from 15 minutes to 13 minutes (P < .001) between pre-rapid assessment zone and postfollow-up, which is statistically but not clinically significant.</p><p><strong>Conclusion: </strong>Implementation of a rapid assessment zone significantly decreased overall length of stay in our pediatric ED despite increased patient volume, especially for lower acuity patients. The rapid assessment zone model can be effective in preventing crowding in a pediatric ED with a large proportion of low-acuity visits.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 5","pages":"1298-1304"},"PeriodicalIF":2.3,"publicationDate":"2026-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149228913","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}