Musculoskeletal conditions are the most common low acuity ED presentation. In response, over the last 13 years, Advanced Practice Physiotherapist (APP) roles have been established in emergency departments (ED) across Australia. Despite APP roles being well established in many Australian EDs, the current scope of practice for APPs as defined by discharge diagnosis is not accurately defined. To derive a scope of practice based on ED diagnosis for APPs in an Australian tertiary hospital ED. Descriptive classification study of patients who received care from an APP in the study ED between January 2015 and September 2024, with an iterative consensus process to establish the scope of APP practice by ED discharge diagnosis. APPs provided 37,771 individual episodes of care with 388 assigned International Classification of Diseases (10th revision) (ICD-10) discharge diagnoses. 204 ICD-10 diagnoses were rated as representing the local scope of practice for ED APPs. These codes accounted for 37,000 (98.2%) of the episodes of care. The APP team provided care for 33,713 adult patients, 4058 paediatric patients, 1197 patients who arrived by ambulance and 3477 patients referred to the ED by a GP. The consensus process demonstrated that APPs have clarity on their scope of practice and the capability to manage a differential diagnosis process that includes non-musculoskeletal diagnoses in the ED setting. Using 10 years of ED data, a consensus process mapped the local scope of practice of APPs in a single Western Australian Tertiary Hospital ED to 204 ICD-10 diagnoses.

Emergency departments are acentral component of emergency care in Germany. The decision by the Federal Joint Committee (G-BA) to establish central emergency departments and the required qualifications for medical personnel are changing emergency care throughout Germany; however, so far not much is known about the various patient groups treated in emergency departments. For the present analysis aretrospective evaluation of treatment data for adult patients for the years 2019-2022 from 25emergency departments in the AKTIN emergency department register was carried out. The reasons for presentation were classified in accordance with the Canadian Emergency Department Information System Presenting Complaint List3.0 (CEDIS-PCL) and the emergency department diagnoses and inpatient treatment diagnoses based on the 10th edition of the International Statistical Classification of Diseases and Related Health Problems, German modification (ICD-10-GM) codes. Of the total of 2,102,029 treatment cases 795,904 (38%) patients can were assigned to the disciplines of orthopedics and trauma surgery. The majority of patients from the field of orthopedics and trauma surgery attended independently (51.5%) and remained outpatients (68.8%). Even though many patients remained outpatients, expertise in the field of orthopedics and trauma surgery is needed to recognize potentially dangerous developments and indications for inpatient admission ("red flags"). At the same time there is the high potential to treat patients who remain outpatients at other levels of care.

Severe maternal morbidity has been linked to maternal mortality and several perinatal complications, but the evidence on associations with children's neurodevelopmental disorders is still unclear. To assess associations between severe maternal morbidity and cerebral palsy in children, overall and by major severe maternal morbidity subtypes. Longitudinal cohort study of all live births in the province of Ontario, Canada, between 2003 and 2019 followed up through 2020 (n=2,136,816), under a single-payer healthcare system. Severe maternal morbidity (n=41,396) was identified from inpatient or emergency department diagnoses during the index pregnancy or postpartum (20 weeks gestation to 42 days postpartum) based on validated algorithms according to diagnostic and procedure codes. Severe maternal morbidity was categorized into severe hypertensive disorders of pregnancy (severe preeclampsia, Hemolysis, Elevated Liver enzymes, and Low Platelets syndrome, and eclampsia combined), severe hemorrhage (eg, antepartum or postpartum hemorrhage with coagulation defect, red cell transfusion, procedures to the uterus, or hysterectomy), sepsis (puerperal sepsis or septicemia during labor), and other severe maternal morbidities (eg, admission to intensive care, shock). Cerebral palsy in offspring was defined as a single inpatient or 2 or more outpatient diagnoses at least 2 weeks apart between birth and the end of follow-up (age, 1-17 years). Associations were estimated using Poisson regression models. Of 2,136,816 children included in this study (mean [standard deviation] gestational age, 38.9 [1.8] weeks; 1,074,548 males [51.3%]), 41,396 (2.0%) were exposed to severe maternal morbidity. In a median follow-up of 9.5 years (interquartile range, 5.2-13.7), 5352 children were diagnosed with cerebral palsy (0.3%), of which 272 cerebral palsy cases (0.7%) were exposed to severe maternal morbidity. The average annual cerebral palsy incidence rate was 7.5 per 10,000 child-years in those exposed to severe maternal morbidity and 2.5 per 10,000 in those unexposed. Children of mothers with severe maternal morbidity had an increased risk of cerebral palsy (rate ratio, 2.71; 95% confidence interval, 2.39-3.06) after adjusting for maternal sociodemographic and clinical characteristics. All severe maternal morbidity subtypes considered were associated with increased risks of cerebral palsy, with the strongest associations observed for severe hypertension disorders (adjusted rate ratio, 3.29 [2.44-4.33]). Other severe maternal morbidity subtypes also showed similarly increased risks (adjusted rate ratio for sepsis, 2.45 [1.86, 3.15]), severe hemorrhage 2.44 (1.89, 3.09), and other severe maternal morbidity subtypes (2.81 [2.30-3.39]). In this population-based study of more than 2 million births, severe maternal morbidity was associated with an increased risk of cerebral palsy. This risk was observed across major severe morbidity subtypes, including hypertensive disorders, hemorrhage, and sepsis. These findings highlight the potential benefits of optimizing maternal health and illustrate potential long-term adverse consequences of severe maternal morbidity in offspring. Children of mothers who experience severe or life-threatening events during the perinatal period may benefit from enhanced surveillance for early cerebral palsy symptoms.

Syncope is a frequent presentation in the emergency department (ED) and carries a heterogeneous risk of adverse outcomes, making early stratification challenging. The Canadian Syncope Risk Score (CSRS) is among the most validated prognostic tools; however, its inclusion of the "ED diagnosis" variable may hinder real-time applicability. We aimed to evaluate a modified version of the CSRS, excluding this variable (CSRS-ED), in predicting 30-day serious outcomes. We conducted a retrospective, single-center study including 935 consecutive patients presenting with syncope to the ED of Santa Croce e Carle Hospital (Cuneo, Italy) between January 2021 and December 2024. The primary endpoint was a composite of arrhythmic and non-arrhythmic serious conditions and all-cause mortality within 30days, in accordance with prior CSRS derivation and validation studies. CSRS-ED performance was assessed through discrimination, calibration, and diagnostic accuracy at predefined score thresholds to determine sensitivity, specificity, and predictive values. Comparisons were made with SFSR, EGSYS and OESIL scores. Overall, 127 patients (13.6%) experienced adverse outcomes, with 1.3% 30-day mortality. The CSRS-ED showed excellent discrimination (AUROC 0.87, 95% CI 0.84-0.90). At a threshold of ≥ 0, sensitivity was 0.97 with a negative predictive value of 0.99 and a negative likelihood ratio of 0.06. Calibration analysis revealed no significant miscalibration. In conclusion, the CSRS-ED maintains strong prognostic accuracy without requiring an adjudicated ED diagnosis, supporting its potential as a practical tool for early risk stratification and safe discharge decisions in ED patients presenting with syncope.

Acute coronary occlusion is a time-sensitive cardiac emergency that requires early, accurate diagnosis and prompt treatment to restore coronary perfusion, usually by percutaneous coronary intervention. Successful management of these patients demands a highly coordinated effort among emergency medical services, the emergency department, and cardiology. This issue highlights the importance of recognizing distinct electrocardiographic patterns that represent acute coronary occlusion, even in the absence of traditional STEMI criteria, and reviews evidence-based management recommendations.

Social Vulnerability and Out-of-Hospital Identification of Neurologic Emergencies.

Emergency room visits by older patients living with HIV: an approach based on the EDEN registry.

11 The Route of the Problem for Lung Cancer: Emergency Department Diagnosis of Lung Cancer is Still Associated with Worse Outcomes

Characterizing Emergency Department Visits to Pediatric Hospitals After Local Disaster Declarations.

Abstract Background Inappropriate diagnosis of community-acquired pneumonia is common, especially in older patients and those with altered mentation, leading to inappropriate antibiotic use and adverse effects. The aim of this study is to compare the differences in antibiotic, steroid, and diuretic use from patients initially misdiagnosed with CAP in the emergency department (ED) to patients that were initially misdiagnosed but corrected by the time of discharge. Secondary aims are to describe the length of stay difference between the two groups. Methods This was a single-center retrospective study of adults from July 1, 2023 to July 31, 2024 at a 660-bed teaching hospital in Central Texas. Patients were divided into two groups. The control group included patients who retained an inappropriate CAP diagnosis throughout their hospital stay (concordant group), and the comparator group included patients with an initial ED diagnosis of CAP not listed as a discharge diagnosis (discordant group). Inappropriate diagnosis was defined as patients with fewer than two signs or symptoms of CAP or negative chest imaging. Patients with sepsis, ICU admission, or another infectious disease requiring antibiotics were excluded. Chi-square and linear ANOVA tests were used to detect differences between the two groups. All statistical analysis was performed in R (R version 4.4.2). Results Eighty-nine patients met inclusion criteria. There were 73 patients in the concordant group and 16 patients in the discordant group. Baseline characteristics were similar between groups. The average age was 70 years and 57.3% were male. Median duration of antibiotic (7 vs 8 days, p=0.8), diuretic (0 vs 1.5 days, p=0.4), and steroid (0 vs 0 days, p=0.4) therapy in the concordant vs discordant groups did not differ. Length of stay between the two groups (6.5 vs 7.3 days, p = 0.48) did not differ. Conclusion Our study suggests that antibiotic use is prolonged in patients inappropriately diagnosed with CAP, whether that diagnosis persists until discharge or not. Overall, only a small percentage of patients (17.9%) initially inappropriately diagnosed had their diagnosis changed at discharge. Antibiotic stewardship opportunities remain alongside diagnostic stewardship in community-acquired pneumonia. Disclosures All Authors: No reported disclosures

300 Background: Roughly half of new cases of gastric cancer are diagnosed in the Emergency Department (ED-dx). Patients with ED-dx have poorer clinical outcomes than those who are not ED-dx. However, the reasons for this difference are unclear. We aim to explore whether ED-dx is associated with receipt of Guideline-Concordant Therapy (GCT) for patients with gastric cancer in a large New Jersey-based health system. Methods: Gastric cancer patients, identified via single institution cancer registry, were included in a retrospective chart review from 2016-2022. Univariable and multivariable analyses were performed to evaluate the association between sociodemographic factors and utilization of GCT as defined by the NCCN by cancer stage. Logistic regression was used to estimate covariate adjusted odds ratios for the association of ED-dx with GCT. Results: A total of 331 patients were included, of which 154 (46.5%) were ED-dx and 69 (20.8%) did not receive GCT. Among patients who did not receive GCT, 60.9% were ED-dx, compared to 42.8% of those who got GCT (p=0.007). Despite adjusting for demographic factors and comorbidities, ED-dx patients had a higher probability of not receiving treatment (OR 2.13 [1.19-3.83]). However, this association was no longer significant when socioeconomic conditions (OR 1.69, [0.91-3.15]) and clinicopathologic variables (OR 1.27, [0.65-2.50]) were also accounted for. Factors most strongly associated with not receiving GCT were age >75 years (OR 7.40 [2.46-22.26]), Charlson comorbidity index > 3 (4.22 [1.61-11.04]), having Medicaid or no health insurance (3.49 [1.36-8.98]), living in areas with moderate compared to low area deprivation index (3.32 [1.37-8.04]), having stage IV disease (2.33 [1.06-5.15]) and having gastric cancer histology other than adenocarcinoma (OR 2.63 [1.11-6.23]). Conclusions: Lower rates of oncologic treatment compared to those diagnosed in other settings are largely attributable to differences in socioeconomic and clinicopathologic variables, not whether patients were ED-dx. Further investigation is warranted to understand the poor outcomes observed among ED-dx gastric cancer patients with a particular focus on modifiable or early identifiable factors to improve outcomes. Multivariable logistic regression for the association of being diagnosed in the emergency department and receiving GCT. Model 1 Model 2 Model 3 OR (95%CI) OR (95%CI) OR (95%CI) Diagnosis at Emergency Department 2.13 (1.19-3.83) 1.69 (0.91-3.15) 1.27 (0.65-2.50) Model 1: Adjusted for age, sex, and ethnicity, Charlson comorbidity index. Model 2: Adjusted for age, sex, ethnicity, Charlson comorbidity index, area deprivation index, and insurance. Model 3: Adjusted for age, sex, ethnicity, Charlson comorbidity index, area deprivation index, insurance, symptoms, stage, and gastric cancer histology type.

To evaluate the diagnostic accuracy of presepsin and procalcitonin (PCT) for sepsis and septic shock (Sepsis-3) in the emergency department (ED) based on the Sepsis-3 definition, where early diagnosis remains challenging due to the lack of rapid and reliable diagnostic methods. This multicentre prospective cohort study recruited adults from eight EDs in Thailand between October 2020 and June 2022. Patients with suspected infection or those who met the quick Sequential Organ Failure Assessment criteria were enrolled. Admission blood samples were analysed for presepsin, PCT, lactate and blood culture, with follow-up presepsin and PCT measurements performed on days 3 and 7, and follow-up for 30-day mortality. Sepsis diagnosis was adjudicated with reference to the Sepsis-3 criteria and blood culture result. Diagnostic accuracy metrics, including the area under the receiver operating characteristics curve (AUROCs), sensitivity, specificity and predictive values of presepsin and PCT were evaluated. Of 668 included participants, 438 (65.6%) were diagnosed with sepsis and 58 (8.7%) with septic shock. Presepsin levels were significantly higher in patients with Sepsis-3 than in patients without sepsis at ED admission and decreased over time. Presepsin exhibited a slightly higher AUROC for predicting sepsis (AUROC 0.63 (95% CI 0.59 to 0.67)) and septic shock (AUROC 0.73 (95% CI 0.66 to 0.80)) compared with PCT (AUROC for sepsis 0.62, 95% CI 0.58 to 0.66 and septic shock 0.72, 95% CI 0.65 to 0.78). Elevated presepsin and PCT levels were associated with increased mortality within 30 days (OR 2.61, 95% CI 1.73 to 3.92 and OR of 1.62, 95% CI 1.09 to 2.42 consequently). Presepsin showed slightly higher diagnostic accuracy than PCT, but overall diagnostic accuracy was modest. When interpreted together with clinical assessment and routine tests, presepsin may assist early risk stratification and support, rather than replace, clinical judgement in decisions such as resuscitation or antibiotic initiation.

To examine the distribution and frequency of International Classification of Diseases, 10th Revision (ICD-10), codes in emergency departments (EDs) across Malaysia, providing insights into the most common diagnoses. The aim is to support the development of a principal diagnosis short list for implementing ED-specific diagnosis-related groups (DRGs) to enhance resource allocation and healthcare efficiency. A cross-sectional study conducted as part of a functional exercise by the Ministry of Health Malaysia, with systematic retrospective data collection over a 6-week period in 2022. 13 public emergency hospitals across Malaysia, representing state, major specialist, minor specialist and non-specialist hospitals, including facilities from Sabah and Sarawak for geographical diversity. 10 247 ED visit records were collected through systematic random sampling, of which 9942 complete and valid records were retained for analysis after the exclusion of incomplete or erroneous entries. The study included 9942 ED patient records from 13 public hospitals across Malaysia over a 6-week period. Of these, 54.4% were male, and 45.5% were female. Malaysian citizens comprised 96.1% of the study population. The most frequently reported diagnoses were respiratory diseases (21.2%), followed by injuries and poisoning (13.2%) and digestive system disorders (8.4%). A total of 946 unique ICD-10 codes were identified, with 73.7% used fewer than five times. The top 20 diagnoses accounted for 42.9% of all records. Acute upper respiratory infection (J06.9) was the most commonly reported diagnosis (961 cases), followed by COVID-19 (U07.1, 608 cases) and gastroenteritis of unspecified origin (A09.9, 313 cases). The data demonstrated variation in the distribution of ICD-10 diagnoses across participating hospitals, highlighting key diagnostic categories relevant for future DRG development. This study highlights the diversity of diagnoses in Malaysian EDs and underscores the need for tailored DRGs to optimise healthcare resource allocation. The findings suggest that a principal diagnosis short list may support future efforts to improve classification consistency and inform resource planning, although its effect warrants empirical evaluation. Given the concentration of diagnoses within a limited number of ICD-10 codes, implementing DRGs in emergency care is both feasible and necessary. Future research should expand data collection to capture seasonal trends and refine the principal diagnosis list to further support DRG categorisation and ensure its applicability across varying healthcare demands.

Syphilis is a sexually transmitted infection known as the "great imitator" due to its large variety of presentations, depending on the stage of the disease. Because of its prevalence and the possibility of severe outcomes, emergency clinicians must remain vigilant when evaluating patients, especially those in high-risk groups. Clinicians should be familiar with the treatment recommendations for the various stages of syphilis, including alternative regimens, when national drug shortages limit the availability of first-line treatments. This review discusses the various presentations, diagnostic options, and potential complications for syphilis, as well as current and emerging treatment recommendations.

Head CT is an essential element of emergency department (ED) diagnosis and treatment of numerous neurologic emergencies. However, it is costly in aggregate, exposes patients to ionizing radiation, and can contribute to increased ED delays and length of stay. The objective of this study was to characterize head CT use in a nationwide sample of EDs between 2007 and 2022. This is a retrospective cohort analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS) database from 2007 to 2022. We used multivariable logistic regression to determine the odds of an ED encounter receiving a CT scan of the head, applying NHAMCS survey weights. Study exposures included year, patient demographics, and hospital characteristics. To explore differential trends over time, we created interaction terms between year and patient age, sex, and race/ethnicity. In 2007, the weighted number of ED encounters that received a head CT was 7,841,855 (95% CI 6,328,471-9,355,239), and by 2022, it had more than doubled to 15,977,551 (95% CI 12,343,286-19,611,816) (p < 0.001 for difference), representing an increase from 6.7% to 10.3% of ED encounters. We did not find a significant interaction between time (years) and sex, but the interaction between time and age was highly significant (p < 0.001). Patients aged 65 years or older had 6.24 (95% CI 5.66-6.88) times the odds of receiving a head CT compared with patients aged younger than 18 years after controlling for year, month, and chief concern at ED admission. Patients who were Black (OR 0.90, 95% CI 0.85-0.96), on Medicaid (OR 0.82, 95% CI 0.77-0.87), or from a rural hospital (OR 0.76, 95% CI 0.70-0.83) were less likely to receive a head CT. The overall number of head CT scans during an ED encounter increased more than twofold from 7.8 to 16 million during 2007-2022. Racial, insurance, and geographic variations continue to exist in head CT usage. Given increasing rates of head CT scans in the ED, additional evaluation of their yield in comparison with the relative risks and costs is needed.

Early recognition of stroke in young adults is crucial for effective treatment and mitigation of long-term impact on quality of life. This issue of Emergency Medicine Practice: Stroke EXTRA! offers a comprehensive, evidence-based review of stroke in young adults, including its distinct etiologies, diagnostic complexities, and tailored management approaches. Select case presentations highlight key considerations in evaluating and managing stroke in young adults, emphasizing the importance of timely recognition, rapid intervention, and longterm management.

Background and Purpose: Telestroke improves access to acute ischemic stroke (AIS) expertise, aids in decision-making, and reduces interhospital transfers. Few studies have examined subacute inpatient telestroke services, which focus on inpatient stroke workup and management. Methods: In this retrospective cohort study of patients with emergency department (ED) diagnosis of AIS from 10/2021-6/2024, we sought to determine the impact of a novel subacute telestroke program on ED transfer rates at participating hospitals. For intervention sites (that implemented the subacute teleconsult program), the period prior to subacute consult "go-live" date was considered the pre-implementation period. Control sites (without the subacute program) were considered preimplementation prior to 5/22/2023 (when approximately half of intervention sites had initiated the subacute program). Logistic regression with generalized estimating equations evaluated the association between implementation time-period and odds of ED transfer in intervention and control sites, adjusting for age, NIHSS, sex, race, and an intervention by time-period interaction term. Results: 1266 patients met eligibility criteria (N = 544 patients from 11 control sites and N = 722 patients from 11 intervention sites). The ED transfer rate was lower within intervention sites post-implementation (pre: 25.7% to post: 22.5%) and higher in control sites (pre: 25.9% to post: 27.1%). These comparisons were statistically nonsignificant in the multivariable analysis. Conclusions: There was a reduction in interhospital transfers after implementation of a subacute telestroke consultation service, but results were nonsignificant in adjusted models. Future analyses should evaluate whether receipt of a subacute telestroke encounter at the patient-level is associated with reduced interhospital transfer for stroke.

Community-acquired pneumonia (CAP) due to Mycoplasma pneumoniae is a frequent and challenging diagnosis in Emergency Departments (EDs), often leading to unnecessarily broad-spectrum or ineffective antibiotic therapy. We hypothesize that rapid diagnostic tools, such as point-of-care (POC) devices, could improve initial antibiotic therapy appropriateness and reduce unnecessary additional diagnostic tests. We conducted a retrospective, single-centre, study involving 81 patients visiting our ED with Mycoplasma pneumoniae CAP diagnosed between January 2023 and June 2024. Patients were divided into two groups depending on whether their nasopharyngeal swab, taken to detect viruses or selected bacteria such as Mycoplasma pneumoniae, was handled at the ED with a POC device (POC group) or at the main laboratory (Lab group). Primary outcome was the appropriateness of initial antibiotic therapy, defined as the use of macrolide (or tetracycline or fluoroquinolone in allergic patients) alone or, in case of severe disease, in combination with third-generation cephalosporin. Initial antibiotic therapy was more frequently appropriated in patients of the POC group than in patients of the Lab group (28 of 43 [65%] vs. 6 of 38 [16%], adjusted OR: 9.9, 95% confidence interval: 3.4 to 29.1; p < .001). Point-of-care testing was associated with fewer additional biological and radiological tests performed in the ED. POC improved the management of Mycoplasma pneumoniae CAP by increasing the appropriateness of initial antimicrobial therapy and reducing unnecessary additional diagnostic procedures. Larger multicentre studies are needed to confirm these findings, assess the impact on overall healthcare costs, and investigate the integration of POC devices into routine clinical workflows.

Risk Factors for Pediatric Deep Neck Infection Revisit After Emergency Department Discharge for Pharyngitis or Localized Neck Symptoms.

Who has incomplete emergency department care among mental health patients in Australia? Does it impact short and longer-term representations?