Western Journal of Emergency Medicine最新文献

{"title":"Reducing Repeat Emergency Department Visits for Low-Acuity Patients Using a Healthcare Connection Program.","authors":"Mitchell Hoyer, Kimberly A Stanford, Ernestina Perez, Rachel Nordgren, Laura Markin, Melanie Francia, Zain Abid, Marika Kachman, Brenda Battle, Thomas Spiegel","doi":"10.5811/westjem.25357","DOIUrl":"10.5811/westjem.25357","url":null,"abstract":"<p><strong>Background: </strong>Emergency department (ED) utilization for non-emergent issues has been a longstanding issue in the United States, especially in service areas with high Medicaid enrollment. The Medical Home and Specialty Care Connection Program (MHSCC) at University of Chicago Medicine (UCM) supports patients recently seen in the ED with follow-up care by assisting patients with follow-up appointments, establishing a medical \"home\" and providing education on primary care utilization via working with a patient advocate. These types of programs have inconsistent results throughout the literature and a dearth of study periods. We conducted a program evaluation to assess the association of the MHSCC in reducing low-acuity ED utilization for program patients.</p><p><strong>Methods: </strong>This program evaluation used retrospective data from the MHSCC program dataset from 2012-2020 and matched with electronic health records of low-acuity ED visits at UCM ED from 2010-2022 for each patient. Pre- and post-low-acuity ED visit rates were calculated based on the patients first program enrollment and compared using the Wilcoxon signed-rank test.</p><p><strong>Results: </strong>In total 5,482 ED patients enrolled in the program were included in the sample, 537 of whom were enrolled more than once. These patients had 41,530 low-acuity ED visits. The rate of low-acuity ED visits after the program enrollment was significantly lower than before with a mean of 2.5 visits per year before program intervention to 1.38 after, a 45% decrease (P<.0001). This resulted in an estimated 9,487 fewer low acuity ED visits over nine years. Patients with multiple enrollments (up to four) further resulted in a slightly lower ED visit rates. Patients who benefitted the most in both proportion and mean analyses were of low acuity.</p><p><strong>Conclusion: </strong>We found a significant reduction in program patient's ED visit rates for low-acuity needs. Further evaluation on the outcomes of the program, mechanisms of physician referrals and attributes of the patient population are recommended to understand what drives these findings.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"26 4","pages":"853-862"},"PeriodicalIF":2.0,"publicationDate":"2025-06-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12342400/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144837993","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Low Frequency, High Complexity: Assessing Skill Decay in Transesophageal Echocardiography Post-Simulation Training.","authors":"Enyo Ablordeppey, Emily Terian, Collyn T Murray, Laura Wallace, Wendy Huang, Erica Blustein, Alexander Croft, Ernesto Romo, Mansi Agarwal, Daniel Theodoro","doi":"10.5811/westjem.35857","DOIUrl":"10.5811/westjem.35857","url":null,"abstract":"<p><strong>Introduction: </strong>Resuscitative transesophageal echo (rTEE) is a promising adjunct to cardiac arrest resuscitation. However, it is a high-acuity diagnostic tool that is rarely used in this setting and its safety establishment is limited because of low occurrence. High-acuity, low occurrence skills such as rTEE during cardiac arrest inevitably decay. In this study we examined the content and percentage of rTEE skill decay following simulation-based education (SBE).</p><p><strong>Methods: </strong>Resuscitative TEE-naïve emergency physicians (EP) were trained using a combination of clinical exposure, web-based didactics, and monthly hands-on sessions with a high-fidelity rTEE simulator for four months. The COVID-19 pandemic created a natural wash-out phase where EPs did not perform any actual or SBE for six months after initial training. Unadvertised assessment of rTEE skill occurred at month 6 after rTEE training to test skill decay and at month 7 to determine the effect of spaced repetition. One year later, the EPs completed a questionnaire assessing rTEE comfort. Statistical measures were used to measure skill decay.</p><p><strong>Results: </strong>Seven EPs were individually evaluated in four domains: name recall; probe manipulation (rotation); probe manipulation (omniplane); and image acquisition adequacy. At the end of training, all participants reached a full proficiency score of 32. At month 6, the mean score was 19 of 32 (SD ±7), reflecting a 41% decay (95% confidence interval (CI) -54%, -27%; P < .001) for eight standard rTEE views. Following spaced repetition at month 7, the median score improved to 26 (IQR 23-30), representing a 19% decay (95% CI -35%, -4%; P < .02). For the three guideline-recommended views, the overall decay percentage was 26% (95% CI -36%, -16%; P < .001), although image acquisition skills did not show significant decay. Spaced repetition resulted in a 23% increase in mean scores (95% CI 9-37%), and the average time to obtain all eight rTEE views decreased from 7.3 minutes at month 6 to 5.7 minutes at month 7.</p><p><strong>Conclusion: </strong>After focused, proficiency-based SBE in rTEE, hands-on image acquisition skills showed the least decay compared to name recall and probe manipulation. Spaced repetition mitigated decay over one month, although not back to baseline.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"26 4","pages":"1070-1077"},"PeriodicalIF":2.0,"publicationDate":"2025-06-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12342464/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144837982","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Additional Commentary on \"The Proposed 48-Month Emergency Medicine Residency Requirement Demands Immediate Scrutiny\".","authors":"Stephen Hayden","doi":"10.5811/westjem.48652","DOIUrl":"10.5811/westjem.48652","url":null,"abstract":"<p><p>This paper provides commentary on the accompanying publication, \"The Proposed 48-Month Emergency Medicine Residency Requirement Demands Immediate Scrutiny.\" The ACGME Residency Review Committee for Emergency Medicine recently proposed a change to the required length of training to 48 months. Currently, there is a lack of objective data to support the optimal duration of emergency medicine residency training. One of the primary concerns regarding a mandated fourth year is the significant financial burden it would place on training programs. If sponsoring institutions are unable or unwilling to provide the necessary resources to support a prolonged curriculum, programs could be compelled to reduce resident class sizes. A reduction in class size would negatively impact the educational environment, including emergency department coverage and participation in external rotations. To better prepare physicians for independent practice, it may be time to consider a base training length of 36 months, followed by alternative pathways such as fellowships, focused practice designations, or targeted curricula-all of which may be more effective than extending the duration of residency training.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"26 4","pages":"767-768"},"PeriodicalIF":2.0,"publicationDate":"2025-06-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12342515/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144837955","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Proposed 48-Month Emergency Medicine Residency Requirement Demands Immediate Scrutiny.","authors":"Shahram Lotfipour, Ian Olliffe, Stephen Hayden, Soheil Saadat, Mark I Langdorf","doi":"10.5811/westjem.48551","DOIUrl":"10.5811/westjem.48551","url":null,"abstract":"<p><p>The Accreditation Council for Graduate Medical Education's (ACGME) proposal to mandate 48-month training for all emergency medicine residency programs represents a significant departure from the current system where both 36- and 48-month formats successfully coexist.The ACGME's justification relies on a methodologically flawed survey that never directly asked program directors about optimal training duration. Instead, it calculated totals by summing individual rotation estimates without considering integrated curricula or practical constraints. Even if these results were to be accepted, directors of three-year programs reported a mean desired duration of only 41.6 months-hardly justifying a universal 48-month mandate.Current evidence contradicts the ACGME's rationale. Three-year graduates achieve higher board pass rates (93.1% vs 90.8%) and demonstrate equivalent clinical performance to four-year graduates. The mandate would impose substantial financial burdens on trainees-an opportunity cost exceeding $200,000-$250,000-while potentially deterring qualified applicants and discouraging fellowship training.We urge the ACGME to pause implementation and provide compelling evidence that a 48-month mandate is necessary and demonstrably superior to the current model.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"26 4","pages":"763-766"},"PeriodicalIF":2.0,"publicationDate":"2025-06-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12342431/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144838013","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Changes in Veterans Health Administration Emergency Department Visits During Two Years of COVID-19.","authors":"Justine Seidenfeld, Aaron Dalton, Anita A Vashi","doi":"10.5811/westjem.18714","DOIUrl":"10.5811/westjem.18714","url":null,"abstract":"<p><strong>Introduction: </strong>To better understand the impact of the COVID-19 pandemic on emergency department (ED) utilization, we examined two years of Veterans Health Administration (VHA) ED visits. Emergent and non-emergent ED visits were examined separately to understand the impact of systems-level changes in healthcare delivery.</p><p><strong>Methods: </strong>In this retrospective, observational cohort study we examined ED visits in 111 EDs within the VHA from March 2018-February 2022. Primary outcome was the count of emergent and non-emergent ED visits, using incident rate ratios (IRR) with 95% confidence intervals (CI) to examine ED visits during the first two years of the COVID-19 pandemic in eight separate quarters, compared to two years of seasonally equivalent quarters before COVID-19.</p><p><strong>Results: </strong>Over the four-year period, US veterans made 8,057,011 ED visits, with 54.7% in the eight pre-COVID-19 quarters, and 45.3% in the first eight quarters during the COVID-19 pandemic. Both emergent and non-emergent visit counts decreased in each of the first eight quarters during COVID-19 when compared to their respective pre-COVID-19 baseline. The change in emergent visits ranged between -26.9% (March-May 2020; IRR 0.73, 95% CI 0.72-0.74) and -7.0% (June-August 2021; IRR 0.93, 95% CI 0.92-0.94). The change in non-emergent visits ranged between -33.0% (March-May 2020; IRR 0.67, 95% CI 0.67-0.67) and -5.7% (June-August 2021; IRR 0.94, 95% CI 0.94-0.95). After the first six months of the pandemic, emergent ED visits had a sustained greater decrease compared to non-emergent visits.</p><p><strong>Conclusion: </strong>As of 2022, ED visits had not returned to pre-pandemic baselines, and our results suggest that emergent visits have sustained a greater decrease even in the second year of the pandemic compared to their respective, seasonally equivalent pre-pandemic quarters from March 2018-February 2020. The finding that emergent visits decreased more than non-emergent is notable given that system-level changes in care delivery, particularly a shift toward use of telehealth, would be expected to have a greater impact on non-emergent care. More work is needed to understand whether acute care is being forgone altogether, as well as the subsequent impact.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"26 4","pages":"869-875"},"PeriodicalIF":2.0,"publicationDate":"2025-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12342404/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144837914","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Developing Machine-Learning Models to Predict Bacteremia in Febrile Adults Presenting to the Emergency Department: A Retrospective Cohort Study from a Large Center.","authors":"Chia-Ming Fu, Ike Ngo, Pak Sheung Lau, Yaroslav Ivanchuk, Fan-Ya Chou, Chih-Hung Wang, Chien-Yu Lin, Chu-Lin Tsai, Shey-Ying Chen, Tsung-Chien Lu, Hung-Yu Wei","doi":"10.5811/westjem.35866","DOIUrl":"10.5811/westjem.35866","url":null,"abstract":"<p><strong>Introduction: </strong>Bacteremia, a common disease but difficult to diagnose early, may result in significant morbidity and mortality without prompt treatment. We aimed to develop machine-learning (ML) algorithms to predict patients with bacteremia from febrile patients presenting to the emergency department (ED) using data that is readily available at the triage.</p><p><strong>Methods: </strong>We included all adult patients (≥18 years of age) who presented to the emergency department (ED) of National Taiwan University Hospital (NTUH), a tertiary teaching hospital in Taiwan, with the chief complaint of fever or measured body temperature more than 38°C, and who received at least one blood culture during the ED encounter. We extracted data from the Integrated Medical Database of NTUH from 2009-2018.The dataset included patient demographics, triage details, symptoms, and medical history. The positive blood culture result of at least one potential pathogen was defined as bacteremia and used as the binary classification label. We split the dataset into training/validation and testing sets (60-to-40 ratio) and trained five supervised ML models using K-fold cross-validation. The model performance was evaluated using the area under the receiver operating characteristic curve (AUC) in the testing set.</p><p><strong>Results: </strong>We included 80,201 cases in this study. Of them, 48120 cases were assigned to the training/validation set and 32,081 to the testing set. Bacteremia was identified in 5,831 (12.1%) and 3,824 (11.9%) cases of the training/validation set and test set, respectively. All ML models performed well, with CatBoost achieving the highest AUC (.844, 95% confidence interval [CI] .837-.850), followed by extreme gradient boosting (.843, 95% CI .836-.849), gradient boosting (.842, 95% CI .836-.849), light gradient boosting machine (.841, 95% CI .834-.847), and random forest (.828, 95% CI .821-.834).</p><p><strong>Conclusion: </strong>Our machine-learning model has shown excellent discriminatory performance to predict bacteremia based only on clinical features at ED triage. It has the potential to improve care quality and save more lives if successfully implemented in the ED.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"26 3","pages":"617-626"},"PeriodicalIF":1.8,"publicationDate":"2025-05-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12208070/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144498163","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Beyond Efficiency: Considering the Benefits of Residents in the Emergency Department.","authors":"Rachel Elizabeth Armstrong","doi":"10.5811/westjem.38598","DOIUrl":"10.5811/westjem.38598","url":null,"abstract":"","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"26 3","pages":"761"},"PeriodicalIF":1.8,"publicationDate":"2025-05-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12208026/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144498154","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Beyond Efficiency: Considering the Benefits of Residents in the Emergency Department.","authors":"Jake Valentine, Johnathan Poulson","doi":"10.5811/westjem.41505","DOIUrl":"10.5811/westjem.41505","url":null,"abstract":"","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"26 3","pages":"762"},"PeriodicalIF":1.8,"publicationDate":"2025-05-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12208021/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144498155","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Comparing Prehospital Time Among Pediatric Poisoning Patients in Rural and Urban Settings.","authors":"Aaron T Phillips, Michael Denning, Em Long-Mills, Dmitry Tumin, Jennifer Parker-Cote, Kathleen Bryant","doi":"10.5811/westjem.33507","DOIUrl":"10.5811/westjem.33507","url":null,"abstract":"<p><strong>Objectives: </strong>Barriers to healthcare in rural areas can delay treatment in pediatric patients who have experienced poisoning. We compared emergency medical services (EMS) response times and EMS-reported delays in responding to pediatric poisoning incidents between rural and urban settings using the 2021 National Emergency Medical Services Information System (NEMSIS).</p><p><strong>Methods: </strong>The NEMESIS defines rural areas as locations with a population of <50,000, not part of metropolitan areas, while all other locations are classified as urban (metropolitan) areas. In this study we included 11,911 patients (12% rural) <18 years of age who were transported by EMS with a first-responder primary impression of poisoning. We compared study variables using rank-sum tests and chi-square tests. Multivariable analysis of outcomes included quantile regression and logistic regression for continuous data and categorical data, respectively.</p><p><strong>Results: </strong>The median total prehospital time by EMS was 40 minutes (interquartile range 29-57), and the most common type of delay was scene delay (6%). On multivariable quantile regression, patients transported by rural EMS agencies experienced 6.6 minutes (95% confidence interval 5-8, P<0.001) longer prehospital time than those transported by urban agencies. There were no differences between rural and urban EMS agencies in the occurrence of dispatch, response, scene, and transportation delays.</p><p><strong>Conclusion: </strong>These results elucidate the need for equitable allocation of resources and training to enhance rural EMS responders. The additional nearly seven minutes translates into greater risk for the human body to remain physiologically unstable and not be optimally treated. Therefore, by integrating targeted interventions to rural pediatric populations, better care can be achieved across all geographic regions. Further research must be conducted to ascertain the specific factors, aside from delays, that result in the disparity between rural and urban prehospital response time.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"26 3","pages":"650-656"},"PeriodicalIF":1.8,"publicationDate":"2025-05-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12208025/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144498159","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Non-invasive Monitor of Effective Chest Compressions with Carotid and Femoral Artery Ultrasound in the Emergency Department.","authors":"Feihong Yang, Hao Zou, Jiaohong Gan, Xia Zhao, Xiaopeng Tu, Cheng Jiang, Jian Xia","doi":"10.5811/westjem.36710","DOIUrl":"10.5811/westjem.36710","url":null,"abstract":"<p><strong>Background: </strong>End-tidal carbon dioxide (EtCO₂) has been regarded as the gold standard for assessing the effectiveness of cardiopulmonary resuscitation (CPR). However, the clinically observed limitations of EtCO₂ influenced by ventilation during CPR suggest the need to implement a new, non-invasive hemodynamic monitoring method to evaluate and optimize CPR effectiveness in real time.</p><p><strong>Methods: </strong>For this prospective study we enrolled 31 cardiac arrest (CA) patients who presented to the emergency department (ED) and 13 healthy volunteers as point-of-care ultrasound (POCUS) controls. Two physicians not involved in the resuscitation team performed POCUS of the bilateral carotid and femoral arteries during chest compression within the first 10 minutes of CPR. The clinical data and presumed CA cause were recorded. We observed the arterial pulse and measured the peak systolic velocity (PSV). The EtCO₂ values during POCUS were also recorded. We explored the correlation between arterial PSV and EtCO₂.</p><p><strong>Results: </strong>The mean age of the patients was 69 ± 2 years, and 22 were male. Of 25 patients who experienced out-of-hospital cardiac arrest, 18 had an average no/low-flow time >30 minutes before ED arrival. Five patients achieved return of spontaneous circulation (ROSC). We found no significant difference in arterial PSV between ROSC and non-ROSC patients. The PSV of the left femoral artery was most consistently and positively correlated with EtCO₂ in CA patients (R² 0.35, P=0.003).</p><p><strong>Conclusion: </strong>Detection of arterial peak systolic velocity by point-of-care ultrasound, especially of the left femoral artery, might be a feasible method for non-invasive, real-time monitoring of chest compression effectiveness during CPR.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"26 3","pages":"491-499"},"PeriodicalIF":1.8,"publicationDate":"2025-05-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12208035/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144498141","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}