Western Journal of Emergency Medicine最新文献

{"title":"Temporal Trends in Mortality from Gunshot Wounds for Emergency Medical Services Compared to Private Vehicle Transport.","authors":"Gregory Muller, Kate Miller, Loretta Matheson, Xinhang Wang, Laleh Gharahbaghian, Peter D'Souza, Marc Gautreau, Maame Yaa A B Yiadom","doi":"10.5811/westjem.53151","DOIUrl":"10.5811/westjem.53151","url":null,"abstract":"<p><strong>Introduction: </strong>Despite expectations that emergency medical services (EMS) transport following a gunshot wound (GSW) would improve 30-day mortality compared to transport by private vehicle, the opposite has been found in several studies. In response, EMS has adopted interventions over the past decade to reduce patient mortality. We compared mortality of GSW patients transported by EMS versus private vehicle as these field practice advancements became widespread.</p><p><strong>Methods: </strong>We conducted a retrospective cohort study using data from the National Trauma Data Bank (NTDB) from 2007-2021. We included adults (≥ 16 years of age) with GSW injuries transported solely by ground EMS (≤ 2 hours) or by personal vehicle to a Level I or Level II trauma center. The primary outcome was 30-day in-hospital mortality. We also aimed to describe demographic changes over time in these patient populations. A multivariable logistic regression model was developed to estimate the adjusted odds ratio (aOR) of mortality, with demographic and clinical controls. To describe change over time, we performed the multivariable logistic regression model separately within three-year periods. To determine whether the change was significant, we performed the multivariable logistic regression model with the same controls and the addition of an interaction term for transport mode with year group.</p><p><strong>Results: </strong>Of 355,913 patients, 83.7% were transported by EMS and 16.3% by private vehicle. Unadjusted mortality was consistently higher for EMS patients, ranging from 18.8% (vs 3.7% private vehicle) in 2007-2009 to 19.3% (vs 4.3% private vehicle) in 2019-2021. The aOR for mortality in the EMS cohort decreased from 2.2 (95% CI, 1.7-2.8) in 2007-2009 to 1.6 (95% CI, 1.3-1.8) in 2019-2021. However, this temporal trend was not statistically significant (P = .17).</p><p><strong>Conclusion: </strong>Our analysis suggests EMS transport remains associated with higher odds of mortality compared to private vehicle transport for patients with gunshot wounds. This may suggest that improvements in EMS clinical and transport practices have not yet proved sufficient to reduce relative mortality, or that there may be differences in injury severity or type of injury that are not adequately accountable from the NTDB data.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 4","pages":"938-946"},"PeriodicalIF":2.3,"publicationDate":"2026-06-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13436646/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148674285","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":"Emergency Department Closures and Patient Outcomes: Scoping Review of Impacts on Care, Equity, and System Performance.","authors":"Zahra Ridha, Adam Steiner, Helena Son, Suneel Upadyhe, Stephenson Strobel","doi":"10.5811/westjem.53973","DOIUrl":"10.5811/westjem.53973","url":null,"abstract":"<p><strong>Introduction: </strong>Emergency department (ED) closures have become increasingly common across health systems worldwide, reflecting mounting pressures from staffing shortages, resource constraints, and rising patient demand. Closures, whether temporary or permanent, pose potential risks to timely access to emergency care and may significantly impact patient outcomes and healthcare system performance. Despite growing attention from policymakers and the public, academic evidence on real-world impacts of ED closures remains fragmented. In this scoping review we compiled and summarized the current literature directly addressing the impacts of ED closures.</p><p><strong>Methods: </strong>Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews criteria, we conducted a search of PubMed.gov, the Cumulative Index to Nursing and Allied Health Literature, and Web of Science databases for papers published in English after the year 2000 that directly addressed ED closures. We screened these papers by title and abstract. This search yielded 15 studies for which we then conducted a forward and backward citation search, ultimately producing 22 unique papers. Data from these papers were initially extracted into a spreadsheet and then organized into thematic tables based on the impacts they discussed.</p><p><strong>Results: </strong>Our search yielded 1,725 papers, and we ultimately included 22 of these (1.3%). Most studies were observational or quasi-experimental, covering 147 unique ED closures, with some analyzing all United States closures (thousands). We found that we could organize the papers into four themes determined by the impact of ED closures had on the following: 1) patient outcomes (eg, mortality, likelihood of acute myocardial infarction treatment) (n = 14); 2) equity-deserving populations (n = 6); 3) alternate EDs that remain open (n = 10); and 4) on healthcare networks as a whole, including emergency medical services (n = 5). Most of the papers were observational or quasi-experimental in design and drew data from a wide scale of closures, from single-site to national ED closures (> 500 sites). The largest proportion (40%) of studies were based in the U.S.</p><p><strong>Conclusion: </strong>The literature demonstrated mixed and context-dependent impacts of ED closures. The ED closures consistently adversely affected mortality rates of patients with time-sensitive conditions when travel times or distances exceeded certain thresholds. Closures also disproportionately affected equity-deserving populations. However, the negative impacts were often mitigated in the long term, and were less pronounced in well-resourced systems capable of adaptation. There are key gaps in the literature regarding impacts on conditions that are not time sensitive, on marginalized populations, and on broader system-level performance, which should guide future research.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 4","pages":"899-912"},"PeriodicalIF":2.3,"publicationDate":"2026-06-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13436648/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148674043","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":"Oxygen Saturation Thresholds for Opioid-induced Respiratory Depression: A Systematic Review.","authors":"Akash Manes, Joban Sran, Ivjot Samra, Balkaran Dhaliwal, Adam Soliman, Nitasha Puri","doi":"10.5811/westjem.54000","DOIUrl":"10.5811/westjem.54000","url":null,"abstract":"<p><strong>Introduction: </strong>Hypoventilation and hypercapnia are the primary physiological indicators of opioid-induced respiratory depression (OIRD), while hypoxia is typically a later manifestation. However, use of pulse oximetry to measure oxygen saturation (SpO₂) level remains the most widely available and commonly used monitoring modality in both clinical and community settings, whereas capnography is not routinely accessible. Given this reality, it is important to evaluate hypoxia thresholds reported in the literature to inform practical detection and intervention strategies. Oxygen saturation monitoring may serve as a valuable support tool to help determine when individuals experiencing opioid toxicity require intervention; however, there is limited consensus on SpO₂ thresholds that indicate OIRD. Our objective in this study was to evaluate existing evidence on SpO₂ thresholds for OIRD as a physiological marker to incorporate with clinical assessment to potentially prevent opioid-related outcomes such as hypoxemia, hypoxic brain injury, cardiac arrhythmias, and mortality, and to inform monitoring and intervention strategies for future research.</p><p><strong>Methods: </strong>We electronically searched Ovid MEDLINE, Ovid Embase, PubMed, and grey literature databases for qualitative and quantitative studies published from 2014-2024. We included studies published in English where participants with opioid use disorder (OUD) experienced opioid toxicity and continuous SpO₂ monitoring in medical settings. Quality was evaluated using the modified Downs and Black checklist. The primary outcome measure was the SpO₂ level used to quantify opioid-induced respiratory depression.</p><p><strong>Results: </strong>Of the 2,864 articles screened, 37 underwent full-text review, and 16 were included in data extraction and analysis (total patients, N = 12,887). Reported SpO₂ thresholds ranged from 85-95% (median 92, interquartile range 90-95). In three studies where patients experienced opioid-induced respiratory depression, SpO₂ levels dropped to a median value of 80%.</p><p><strong>Conclusion: </strong>Although hypoxia is a late indicator of opioid-induced respiratory depression, SpO₂ monitoring remains a widely deployed tool for detecting clinically significant deterioration. Reported SpO₂ thresholds for defining OIRD ranged from 90-95% across studies of \"excellent\" and \"good\" quality, underscoring the need for standardized, patient-centered thresholds to guide monitoring and intervention in future research.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 4","pages":"886-894"},"PeriodicalIF":2.3,"publicationDate":"2026-06-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13436640/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148674299","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":"Emergency Front-of-neck Access: Comparing Needle and Surgical Cricothyrotomy Using a Human Cadaver Model.","authors":"Eric Boccio, Daniel Levi, James Bonz, Justin Belsky, Jason D'Amore","doi":"10.5811/westjem.52840","DOIUrl":"10.5811/westjem.52840","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Introduction: &lt;/strong&gt;Emergency front-of-neck access may serve as a life-saving intervention when facing patients with difficult airways. Cricothyrotomy consists of needle and surgical techniques and is performed in approximately 0.2-0.5% of all airway management attempts. Our primary aim in this study was to compare procedural completion time and first-pass success of needle and surgical approaches to cricothyrotomy by civilian and military practitioners using a human cadaver model.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;Emergency medicine (EM) attendings and residents and U.S. Air Force Pararescue specialists were randomized to perform either a needle or surgical cricothyrotomy on an unfixed human cadaver a single time following a 30-minute didactic session about both procedure types. We recorded procedural completion time, first-pass success, frequency and type of observed complications, and subject level of training. Our primary outcome measure was procedural completion time. Secondary outcome measures included first-pass success and complication rates. We used a Wilcoxon signed-rank test to compare the difference in median completion times between needle and surgical groups. We performed a Cox regression analysis to evaluate the relationship between technique and procedural completion time while adjusting for subject level of training. Chi-squared or Fisher exact tests were used to compare unadjusted first-pass success and complication frequencies between needle and surgical groups. Multivariable logistic regression analysis modeling the association between technique and first-pass success and complication events while adjusting for subject level of training was performed.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;A total of 99 subjects were enrolled, and 19 (19%), 68 (69%), and 12 (12%) were classified as EM attending, EM resident, and Pararescue specialist, respectively; 51 (52%) and 48 (48%) were randomized into the needle and surgical groups, respectively. The median time to procedural completion was shorter in the needle group than the surgical group (56.5 seconds [sec], 95% confidence interval, 54-66 sec vs 65 sec, 95% CI, 59-73 sec, respectively). The difference in median completion times was 8 sec (95% CI, -1.0 to 17 sec, P = .08). The hazard ratio comparing completion time of surgical to needle cricothyrotomy while adjusting for level of training was 1.41 (95% CI, 0.93-2.13, P = .11). First-pass success and complication rates were similar between the needle and surgical groups (94% vs 94%, P = .32, and 27% vs 33%, P = .52, respectively). The adjusted odds ratios comparing the likelihoods of first-pass success and complication between surgical and needle groups while adjusting for level of training were 1.06 (95% CI, 0.20-5.54, P = .95) and 1.40 (95% CI, 0.55-3.56, P = .48), respectively.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion: &lt;/strong&gt;In this study using unfixed human cadavers, needle and surgical cricothyrotomy demonstrated comparable performance re","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 4","pages":"964-970"},"PeriodicalIF":2.3,"publicationDate":"2026-06-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13436657/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148674005","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":"Neoplastic Incidentalomas in the Emergency Department: Incidence, Imaging Type, Location, and Clinical Relevance.","authors":"Carmine Nasta, Romeo Morelli, Antonia Ida Facciuto, Francesca Palumbo, Martina Finelli, Vincenzo Brunelli, Mario Puoti, Alfredo Palumbo, Antonio Voza, Giuseppe Paolisso, Mauro Giordano","doi":"10.5811/westjem.48928","DOIUrl":"10.5811/westjem.48928","url":null,"abstract":"<p><strong>Background: </strong>Incidentalomas-unexpected neoplastic lesions discovered during imaging for unrelated complaints-represent a growing clinical and ethical challenge in emergency medicine. Their detection has increased due to widespread use of advanced imaging, particularly in patients who may otherwise escape thorough diagnostic evaluation.</p><p><strong>Objective: </strong>We sought to determine the frequency, anatomical distribution, and clinical management gaps of neoplastic incidentalomas observed in patients presenting with non-specific, low-severity complaints at the emergency department (ED). (In this paper, neoplastic incidentalomas include both lesions discovered incidentally during imaging for unrelated conditions and newly diagnosed malignancies plausibly related to the patient's presenting symptoms,) METHODS: Data collection covered the period January 1-December 31, 2023. We conducted a retrospective observational study of all adult patients presenting to the ED of P.O. Anastasia Guerriero University Hospital in Marcianise, Italy. Incidentalomas were identified through discharge summaries and classified by imaging modality, anatomical site, and triage code. We analyzed data using descriptive and inferential statistics.</p><p><strong>Results: </strong>Among 35,081 ED visits, 53 neoplastic incidentalomas were identified (1.52 per 1,000). The majority occurred in females (69%) and elderly (> 65 years) patients (61%), who often presented with minor complaints such as abdominal pain (38%) or anemia (15%). Most incidentalomas were gastrointestinal (31%) or pulmonary (23%) and primarily detected via computed tomography (51%). Notably, 100% of cases were triaged as non-urgent. Based on established guidelines, up to 20% of cases may represent potential overdiagnosis. The next most common modalities of detection were ultrasound (28%) and chest radiograph (22%).</p><p><strong>Conclusion: </strong>Neoplastic incidentalomas are not rare in the ED setting, even among patients who present with low-severity symptoms. Our findings underscore the importance of structured follow-up protocols and integration of guideline-based reporting to avoid diagnostic delays, overdiagnosis, and unnecessary interventions. Emergency physicians should maintain diagnostic vigilance and consider incidental findings in clinical workflows.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 4","pages":"842-847"},"PeriodicalIF":2.3,"publicationDate":"2026-06-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13436637/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148674353","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":"Implementing a Multimodal Palliative Care Curriculum: Impact on Knowledge, Confidence, and Skills.","authors":"Travis Hase, Cindy Ndiaye, Margaret Putman","doi":"10.5811/westjem.53884","DOIUrl":"10.5811/westjem.53884","url":null,"abstract":"<p><strong>Introduction: </strong>Emergency physicians frequently care for patients with serious or terminal illnesses, yet they often lack formal palliative care training. Our primary objective was to develop a structured, multimodal palliative care curriculum for emergency medicine (EM) residents and evaluate whether this curriculum improved residents' knowledge, comfort level, and perceived application of skills to care for patients with chronic or terminal illness in the emergency department (ED). Our secondary objective was to determine whether EM residents found palliative care education important and to identify which educational modalities are most effective for acquiring palliative care knowledge and skills.</p><p><strong>Methods: </strong>We implemented an eight-hour multimodal curriculum for EM residents at a single, large Level I trauma center (four hours of didactics, a three-hour simulated patient communication skills lab, and one hour of high-fidelity simulation). Our primary outcome was pre- and post-intervention surveys (12 questions) that assessed perceived knowledge, comfort, and skill application on five-point Likert scales. We analyzed paired responses using the Wilcoxon signed-rank test, with a P value of < .05 considered statistically significant. Effect size was calculated using Cohen d. Our secondary outcome measure was a post-intervention survey (six questions) that assessed participants' opinions on the effectiveness of the different educational methods.</p><p><strong>Results: </strong>There was a 100% response rate among 41 residents from all postgraduate years 1-3. Significant improvements (P < .001) were observed in residents' self-reported abilities across all domains with large effect sizes. Median scores and interquartile ranges increased for conducting goals-of-care discussions (4 [3-4] vs 4 [4-5]), interpreting advance directives (3 [2-4] vs 4 [4-4]), managing end-of-life symptoms (3 [2-3] vs 4 [3-4]), communicating bad news (3 [2-4] vs 4 [4-4]), and coordinating with palliative or hospice teams (2 [2-3] v. 4 [4-4]). All educational modalities were rated effective, with simulation and small-group sessions preferred over lectures.</p><p><strong>Conclusion: </strong>A structured, multimodal palliative care curriculum significantly enhanced EM residents' perceived preparedness to manage patients with palliative care needs. Embedding didactic and simulation-based palliative training in EM residencies is both feasible and impactful, addressing critical gaps in palliative competencies and aligning with national best-practice guidelines.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 4","pages":"1011-1017"},"PeriodicalIF":2.3,"publicationDate":"2026-06-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13436656/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148674251","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":"Potentially Avoidable Spine Transfers to a Level I Trauma Center: A Five-Year Retrospective Analysis.","authors":"Clifford M Marks, Ryan C Burke, Cody Rasner, Martina Stippler, Carlo L Rosen","doi":"10.5811/westjem.47485","DOIUrl":"10.5811/westjem.47485","url":null,"abstract":"<p><strong>Background: </strong>Emergency physicians frequently transfer patients with spine pathology to tertiary-care centers, although research suggests many are discharged without requiring a procedure or specialized imaging. Such transfers consume resources and remove patients from their families and communities. Better understanding these transfers might help identify which patients can receive care without transfer.</p><p><strong>Methods: </strong>This was a retrospective cohort study of transfers for spine evaluation to an urban, tertiary-care, Level I trauma center from October 1, 2017-October 1, 2022. Transfers were defined as necessary if the patient a) went to the operating room (OR) within 12 hours of arrival, b) had a neurologic magnetic resonance image (MRI), c) was admitted to an intensive care unit from the emergency department (ED), or d) was admitted to either neurology or a surgical service (including neurosurgery and orthopedics, which share spine coverage in the study hospital).</p><p><strong>Results: </strong>The study included 1,918 transfers with a spine evaluation, of which 617 (32.2%) were deemed potentially avoidable. Just 3.3% of all transfers went to the OR within 12 hours of receiving ED arrival, 45.7% had a neurologic MRI at the receiving hospital, and 36.6% were admitted to a neurology or a surgical service. For all transfers, 17.7% were discharged directly from the ED, 16.8% were placed in observation and then discharged, 6.8% were placed in observation and then admitted, and 58.7% were admitted to inpatient from the ED. The average ED length of stay for necessary spine transfers was 15.4 hours vs 16.6 hours for potentially avoidable transfers (P = .07). Compared to the overall rate of necessary transfers (67.8%), patients with the following conditions had a decreased incidence of necessary transfers: cervical spine fractures (62% necessary, P = .008), lumbar spine/sacrum/coccyx fractures (53.5% necessary, P < .001), and disc disorders (51.4% necessary, P = .003). Patients diagnosed with cervical spinal cord lesions (91.7% necessary, P = .01) had an increased incidence of necessary transfers.</p><p><strong>Conclusion: </strong>Nearly one-third of spine evaluation transfers were potentially avoidable. Patients transferred for spine evaluation experienced prolonged ED stays, creating challenges for both receiving hospitals and patients. Further research is needed to prospectively identify patients who do not require tertiary care and to study methods for managing them in community settings.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 4","pages":"930-937"},"PeriodicalIF":2.3,"publicationDate":"2026-06-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13436667/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148674282","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":"A Systems-based Emergency Department Intervention to Conserve Intravenous Fluids During a National Shortage.","authors":"Phillip D Jenkins, Obert Xu, Kenneth DeVane, Melinda Hartenstein, Haley Manella, Beech Burns","doi":"10.5811/westjem.53894","DOIUrl":"10.5811/westjem.53894","url":null,"abstract":"<p><strong>Background: </strong>Intravenous (IV) fluids are commonly used in emergency departments (ED), but their supply can be vulnerable to national shortages. In September 2024, Tropical Storm Helene disrupted production at a major manufacturing facility, triggering a nationwide IV fluid shortage. In response, our ED implemented a multiphase intervention aimed at reducing non-essential fluid utilization. We aimed to reduce total IV fluid use in the ED by at least 25% through a staged, systems-based conservation strategy.</p><p><strong>Methods: </strong>We conducted a single-center, retrospective, pre-post quality improvement initiative in a tertiary academic ED with approximately 57,000 annual visits. Interventions were deployed across three Plan-Do-Study-Act cycles: 1) clinician education on fluid stewardship (7 days); 2) protocol modifications to reduce routine IV placement (11 days); and 3) electronic health record (EHR) clinical decision support tools, including an interruptive alert and oral hydration order set (32 days). We analyzed daily fluid administration volumes, and ED census data from September 2024 (pre-intervention) and November 2024 (post-intervention). The primary outcome was total IV fluid usage per day; a secondary outcome was IV fluid volume per patient encounter. We compared mean daily utilization between periods using two-sample t-tests.</p><p><strong>Results: </strong>Average daily IV fluid use declined from 56.3 to 24.8 liters, a 56.0% relative reduction (P < .001), while ED volume remained stable (155.4 vs 153.1 encounters/day pre- vs post-intervention). Normalized per-encounter IV fluid administration decreased from 0.36 to 0.16 liters per visit (P < .001), representing a 56% relative reduction. Assuming a pharmacy acquisition cost of approximately $2 per liter of crystalloid, the intervention was associated with an estimated reduction of $63 in IV fluid expenditures per day (31.5 liters), or $1,890 over the 30-day post-intervention period.</p><p><strong>Conclusion: </strong>A structured intervention combining education, protocol changes, and EHR decision support significantly reduced IV fluid use in the ED without disrupting operations. This approach may serve as a scalable model for resource stewardship during future supply chain crises. The most substantial reductions occurred during the final intervention phase involving EHR-based decision support.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 4","pages":"855-860"},"PeriodicalIF":2.3,"publicationDate":"2026-06-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13436644/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148673874","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":"No \"Golden Hour\" in Alaska: Characteristics and Implications of Medevac-centered Emergency Care.","authors":"Brian Rice, Chelsea Williams, Cindy Y Chang, Jeremy Wood, Henry Saul, Angelica Pritchard, Gretchen Day, Timothy Thomas, David Hao, Carla Britton, Robert Onders, Tina Hernandez-Boussard","doi":"10.5811/westjem.53174","DOIUrl":"10.5811/westjem.53174","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Introduction: &lt;/strong&gt;Rural areas in the United States have higher mortality rates than urban regions, particularly from emergency care-sensitive conditions. Air medical ambulances (medevacs) are critical to emergency care access in the rural U.S., but limited data hinder the ability to study this critical system. In Alaska, medevac services often represent the sole method for connecting Alaska Native patients in remote clinics to physician emergency medical care. This study characterizes medevac use and timing between tribally administered village clinics and hospitals in Northwest Alaska. Our objective in this study was to describe the use and timing of medevacs and investigate how medevac decision-making impacts medevac transport times.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;We conducted a retrospective cohort analysis of medevac transfers between 2020-2024 from 11 Alaskan village clinics within the Maniilaq Association, which serves ~8,000 people over 35,862 square miles.We included 1,579 medevacs representing 1,119 unique patients flying from remote clinics to a central critical access hospital hub.. Our primary outcome measure was the association between short medevac decision times (&lt; 60 minutes), and short total medevac times (&lt; 180 minutes). We measured \"flight time,\" \"decision time,\" and \"ground time\" (time spent waiting for an aircraft to become available) as key components of total medevac time.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;A total of 1,579 medevacs were deployed for predominantly Alaska Native (96.8%) patients, of whom 22.2% had traumatic injuries. Between 4.1-7.9% of community members in the region are transported by medevac each year. Median medevac time was 262 minutes (interquartile range [IQR] 196-402 [101-4,142]) from activation call to arrival at the critical access hospital. No medevacs were &lt; 100 minutes. \"Ground time\" was the longest phase of medevac encounters overall (median ground time 105 minutes (IQR 81-187]) vs median decision time 75 minutes (IQR 42-130) or median flight time 44 minutes (IQR 35-77). We found no association between short medevac decision times and short medevac response time (P = .93). Medevac decision-making was the longest phase in only 6% of the shortest total medevacs (&lt; 190 minutes), but it was the longest phase in 40% of the longest total medevacs ( &gt; 400 minutes).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion: &lt;/strong&gt;We found four key themes: 1) no medevacs were &lt; 100 minutes. Independent of human or system factors,atients cannot be transferred from a village clinic to a critical access hospital within the \"golden hour\" of emergency care; 2) short medevac decision times were not significantly associated with short overall medevac times; 3) the longest phase in a medevac transfer was \"ground time\"; and 4) in the subset of the longest total medevacs, medevac decision-making was much more likely to be the longest phase than in the shortest total medevacs. This emergency transfer system is not responsive to p","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 4","pages":"1039-1047"},"PeriodicalIF":2.3,"publicationDate":"2026-06-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13436660/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148674342","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":"Impact of Substance Use Disorder Curriculum and X-Waiver Training on Emergency Medicine Residents.","authors":"Chigozie Chukwunyere, Jessica Heil, Matthew Salzman, Rachel Haroz","doi":"10.5811/westjem.50864","DOIUrl":"10.5811/westjem.50864","url":null,"abstract":"<p><strong>Introduction: </strong>We incorporated an 8-hour standardized substance use disorder (SUD) curriculum and X-waiver training into our emergency medicine (EM) residency. We sought to assess whether the implementation of the standardized SUD curriculum and X-waiver training affected graduated EM residents' comfort with treating SUD and prescribing practices, as well as their view of their future career paths.</p><p><strong>Methods: </strong>Physicians who completed their EM residency at our hospital from 2016-2022 were invited to complete the survey in 2023. The primary outcome measure was the proportion of surveyed graduates who reported comfort and confidence in treating patients with SUD, measured by affirmative responses to survey items. The secondary outcome measure was the proportion of surveyed graduates reporting that participation in the SUD curriculum and X-waiver training during residency influenced their career plans, measured by affirmative responses to career-related survey items. For each outcome measure, we compared percentages of affirmative responses between physicians who completed residency prior to and after the implementation of the SUD curriculum and X-waiver training.</p><p><strong>Results: </strong>Among 81 graduated EM residents invited to complete the survey, 63 (78.8%) responded. We grouped them based on whether they had completed residency prior to the addition of the standardized SUD curriculum (pre-curriculum, 2016-2017) or after (post-curriculum, 2018-2022). Of the 63 participants, 17 were pre- and 46 were post-curriculum residents. Of the pre-curriculum residents, 58.8% prescribed buprenorphine in their practice after residency, compared to 76.1% of the post-curriculum residents (Fisher exact test, P = .22, odds ratio [OR] 0.46, 95% confidence interval, 0.12-1.76). Of the post-curriculum graduates, 93.5% noted that they were better prepared to treat patients with SUDs than their peers compared to 88.2% of the pre-curriculum graduates (Fisher exact test, P = .605, OR .529, 95% CI, 0.055-6.909), and 69.6% believed the training impacted their careers professionally and increased their interest in helping patients with opioid use disorder.</p><p><strong>Conclusion: </strong>Overall, a greater proportion of EM graduates who had been X waiver-trained in a substance use disorder curriculm during residency training at our institution prescribed buprenorphine to their patients than those who had not undergone specific training. Although the X-waiver is no longer a requirement, our SUD curriculum and training remain relevant for buprenorphine prescribing and may offer some opportunities for EM residents to develop their careers.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"27 4","pages":"880-885"},"PeriodicalIF":2.3,"publicationDate":"2026-06-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13436645/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148674232","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}