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

Firearm injury in the United States disproportionately affects marginalized and disadvantaged communities and results in high rates of functional limitations, mobility impairments, and chronic pain. Despite the high rates of firearm injury and impact on function, few studies have examined access to rehabilitation care after firearm injury. This study analyzed the use of physical therapy after firearm injuries compared to other traumatic injuries. A retrospective cohort study was performed using medical claims data from a statewide All Payer Claims Database linked with an institutional trauma registry (2013-2022). The setting was a Level I trauma center. Patients were identified from our institution's trauma registry to obtain initial injury information, and trauma registry data were linked to the Washington State All Payer Claims Database to identify physical therapy service use. The exposure was mechanism of injury (firearm vs other trauma). The main outcome was the use of physical therapy services in any setting in the year after hospital or emergency department discharge, and the secondary outcome was the total number of physical therapist visits. Covariates included sociodemographic factors (race, ethnicity, insurance, age, and gender) and clinical characteristics indicating the need for physical therapy (injury region, injury severity, and hospital length of stay). Multivariable Poisson regression with robust SEs was used to evaluate the effect of firearm mechanism on outcomes. Among 25,404 patients, the overall rate of physical therapist service use was 37.2%. Firearm injury survivors were less likely to use physical therapy services than survivors of other trauma (21.3% vs 38.4%; adjusted relative risk = 0.79; 95% CI = 0.71-0.88). Firearm injury survivors had fewer total physical therapy visits (8.0 [SD = 11.4] vs 11.9 [SD = 13.8]; adjusted relative risk = 0.79; 95% CI = 0.76-0.82). Despite a high incidence of serious and disabling physical conditions after firearm injury, there was less use of physical therapy services after firearm injury than after other mechanisms of injury in this single-institution sample. Insufficient use of physical therapy services after firearm injury may affect recovery and long-term outcomes among firearm injury survivors, and interventions are needed to support improved access to rehabilitation in this population.

This study aimed to evaluate whether a single dose of intravenous dexamethasone, when added to standard abortive therapy, reduces relapse of migraine after emergency department (ED) discharge in children and adolescents. Migraine is a leading cause of headache presentations to the ED for children and adolescents. Although corticosteroids have been suggested to reduce relapse in adults with acute migraine, their efficacy in children remains unknown. We conducted a randomized, double blind, placebo-controlled trial at the tertiary pediatric ED of the CHU Sainte-Justine in Montréal, Canada. Patients 8-17 years old with acute migraine attack requiring intravenous rescue therapy (metoclopramide with diphenhydramine) were randomized to receive dexamethasone (0.6 mg/kg iv, max 15 mg) or placebo before discharge. All participants were discharged on oral naproxen for 48 h. The primary outcome was relapse within 48 h, defined as recurrence or worsening of headache after initial improvement. Secondary outcomes included pain scores, return to school and activities, health care revisits, and adverse events. Analyses were performed using a modified intention-to-treat approach including all children who provided data for the primary outcome. Between July 2013 and February 2025, 116 patients were enrolled, and 87 patients (75%) provided outcome data at 48 h. Median age was 14 years, and 85 patients (73%) were female. Relapse occurred in 39% (16 of 41) of the dexamethasone group versus 44% (20 of 46) of the placebo group (risk difference: -4%; 95% confidence interval, -32% to 24%). Pain scores, return to school, functional recovery, and health care consultations did not differ significantly between groups. Adverse events were infrequent and mild in both arms. In this small clinical trial of children and adolescents with acute migraine attack treated in the ED, adjunctive dexamethasone did not reduce relapse rates nor improve functional outcomes compared with placebo. Although limited by low statistical power, these findings raise questions about the routine use of dexamethasone in migraine management of children and adolescents.

The time following emergency department (ED) discharge is a high-risk period for suicidal behavior. This study examined correlates of suicidal behavior patterns over one-year follow-up among adults presenting to the ED with active suicidal thoughts and behaviors. Participants were n = 863 adults presenting to the ED with active suicidal thoughts and behaviors followed for one year post-discharge. Participants were categorized into four suicidal behavior groups: none (no suicidal behavior at baseline or follow-up), worsening (no suicidal behavior at baseline but at follow-up), improving (suicidal behavior at baseline but not follow-up), or persistent (suicidal behavior at both timepoints). We used binary logistic regression models to compare persistent versus improving and worsening versus none groups to examine factors that distinguished groups with the same baseline but different follow-up suicidal behavior. The most common suicidal behavior patterns were none (52.7%, n = 455) or improving (24.7%, n = 213). Risky alcohol use and previous psychiatric inpatient hospitalization distinguished participants in the worsening group from the none group. None of the factors distinguished the improving from the persistent group. Individuals with active suicidal ideation, alcohol use, and past psychiatric inpatient hospitalization may require additional support following ED discharge to prevent future suicide attempts.

Diagnosis-specific patterns for direct ED discharge after physician-staffed HEMS transport in Japan: A nationwide registry study.

Cumulative Incidence of Stroke Disability and Mortality Following Emergency Department Discharge for Dizziness: A Cohort Study.

Medications for alcohol use disorder, or "anti-craving medications", are effective yet underutilized treatments for alcohol use disorder. This study examined whether a pre-printed prescription embedded in a printable order set could "nudge" clinicians to increase prescribing for medications for alcohol use disorder. We conducted a prescription database review comparing prescribing rates at baseline to those at monthly intervals up to 12months following implementation of a new provincial pre-printed order set for alcohol withdrawal syndrome in Saskatchewan. Patients were included if they had an alcohol-related emergency department (ED) visit, were discharged home, had a prescription for a medication for alcohol use disorder filled within 3days of ED discharge, and did not have a previous prescription for a medication for alcohol use disorder filled within a washout window prior to the ED visit. The review captured all provincial prescriptions of naltrexone and acamprosate-the two medications available on the pre-printed prescription-for patients who fit the inclusion criteria. A total of 5740 pre-implementation and 6021 post-implementation patients met inclusion criteria. Baseline demographics and comorbidities were similar across groups. The rate of ED visits with a filled prescription increased from 1.8% pre-implementation to 3.4% post-implementation. Naltrexone prescribing rose from 1.6 to 2.7%, and acamprosate from 0.2 to 0.7%. Interrupted time-series and logistic regression analyses confirmed a statistically significant increase in prescribing post-implementation (adjusted OR 1.9; 95% CI 1.5-2.5). Introducing an order set incorporating pre-printed prescriptions for medications for alcohol use disorder effectively increased prescribing rates for physicians treating patients with alcohol-related ED visits, validating use of a "nudge" to effect behavioural change. While promising, sustaining these gains may require reinforcement. In resource-constrained EDs, nudges offer a feasible strategy to improve alignment with evidence-based treatment for alcohol use disorder.

Hemoptysis is a potentially life-threatening symptom that often prompts emergency department (ED) evaluation and hospitalization. Reliable prognostic tools to guide clinical decision-making and optimize resource use are currently lacking. To prospectively validate the Florence Hemoptysis Assessment Score (FLHASc) in patients presenting with hemoptysis to the ED, and to eventually derive and validate an improved version of the score (FLHASc2). We analyzed data from the POPEIHE study (NCT06067997), a multicenter prospective cohort of 546 consecutive adult patients presenting with hemoptysis to 9 Italian EDs. The primary outcome was a composite of in-hospital death, need for ventilatory support, intensive care unit (ICU) admission, blood transfusion, or invasive hemostatic procedures. We evaluated the prognostic performance of the original FLHASc, then derived a new model (FLHASc2) using multivariate logistic regression in a randomly selected derivation cohort (n=321) and validated it in the remaining cohort (n=225). A simplified version of the score was also tested. The original FLHASc demonstrated moderate discriminatory ability (AUC 0.71; 95% CI: 0.65-0.76) and suboptimal calibration. The FLHASc2 showed improved performance (AUC 0.79, 95% CI: 0.73-0.87 in derivation and 0.81, 95% CI: 0.73-0.88, in validation cohorts; Brier score<0.10 in both). The simplified FLHASc2 (sFLHASc2), assigning one point per variable, maintained comparable accuracy (AUC 0.80, 95% CI: 0.72-0.87) and identified 47.8% of patients as low risk (2.7% event rate). When combined with a negative chest X-ray, the observed event rate in this subgroup dropped to 0.87%, with a negative predictive value of 99.1% (CI 95%, 96.5-100%). The FLHASc2 and its simplified version are accurate prognostic tools for identifying hemoptysis patients at low risk of short-term adverse outcomes. Use of the sFLHASc2 combined with chest X-ray may allow safe ED discharge in nearly half of cases. A prospective management trial is warranted to confirm its clinical impact. NCT06067997.

Teaching hospitals are vital for training future physicians, yet there is concern that the presence of learners may increase unscheduled emergency department (ED) return visits. Previous studies of this phenomenon are limited to a sample of EDs in a region. Our study aimed to address this gap using a comprehensive regional dataset and multiple academic years of routinely collected electronic medical record data. Our objective was to determine whether ED patients seen by supervised learners had higher rates of unscheduled return visits within 72hours compared to those seen by attending physicians alone. Secondary outcomes were return visits resulting in hospital admission and the impact of learner training level. We conducted a cohort study of over 1 million ED discharges across nine linked hospitals in a large Canadian health region between July 1, 2015, and June 30, 2018. The primary outcome was the rate of unscheduled return visits within 72hours. Secondary outcomes included return visits with hospital admission and critical care admission. Logistic regression models were adjusted for patient demographics, acuity, and site characteristics. Among 1,033,026 patient visits, 7.4% returned within 72hours. There was no statistically significant difference in unscheduled return visits between supervised learners and attending physicians alone (adjusted RR 0.98, 95% CI 0.96-1.00, p = 0.054). Return visit admissions were slightly higher among patients seen by learners (adjusted RR 1.06, 95% CI 1.01-1.13), primarily those seen by medical students and off-service residents. Emergency medicine residents in mid-training had lower return visit rates than attendings. Patients seen by supervised learners in a regional ED network did not have increased rates of unscheduled return visits. Further research is warranted to explore factors underlying return visit admissions in learner-involved care.

Background/Objectives: Traumatic brain injury (TBI) affects more than 50 million people annually worldwide. Challenges in managing moderate-to-severe TBI include high rates of hospital-acquired infections and substantial variability in discharge disposition, and these combined challenges contribute significantly to the cost and trajectory of health recovery. Although current strategies such as antibiotic-impregnated external ventricular drains (EVDs) offer some benefit in controlling infections, they remain limited by high cost and inconsistent implementation. A clearer understanding of clinical and demographic factors associated with infection risk and discharge disposition are essential for improving care pathways. This study aims to identify and quantify key determinants of infection and discharge outcomes in patients with TBI. Methods: The National Trauma Database (NTDB) was queried using structured query language (SQL) based on predefined inclusion criteria (adult patients with ICD-coded TBI), input variables (basic demographics, injury location and severity, and vital signs), and specified outcome variables (emergency department discharge disposition, infection, and sepsis) to identify and filter the eligible patient cohort. A set of machine learning models were trained for each outcome (e.g., Emergency Department (ED) discharge, types of infections, and sepsis). Results: Data from 310,494 patients were extracted. The prediction model we developed, the Predictive TBI-Disposition Model (PTDM), was able to predict the outcome of a patient’s discharge with 96% accuracy. The accuracy of the models for infection and sepsis was 93% and 94%, respectively. Conclusions: Demographic and clinical factors significantly influence the discharge disposition and infection risk among TBI patients. Machine learning models demonstrated strong predictive performance, suggesting their utility in early risk stratification and targeted clinical decision-making.

Evaluating the Performance of Large Language Models for Generating Emergency Department Discharge Instructions.

Suicide rates have increased among Black youth. Caring contacts can decrease adult suicide reattempts and rehospitalizations and may be both acceptable and scalable among adolescents. We assessed the experiences of Black adolescents visiting an emergency department (ED) for suicidal thoughts and/or behaviors and their perceptions about a caring contacts intervention. We used a qualitative thematic analytic approach to generate key findings from 10 in-depth interviews with patients and/or their parents after ED discharge. Black adolescents experienced lacking ED-based therapeutic interventions, family-inclusive services, and orientation to future steps. Participants perceived caring contacts as an acceptable, developmentally and culturally appropriate postdischarge intervention.

Automated auditing of emergency department documentation using large language models.

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.

This study develops and evaluates an artificial intelligence (AI)-driven model to predict the 28-day mortality in patients with pneumonia by integrating AI-interpreted chest radiographs (CXR) and clinical data available at the time of emergency department (ED) disposition. This multicenter retrospective study included patients who visited the ED with pneumonia at a tertiary academic hospital in South Korea, as well as recorded in the Medical Information Mart for Intensive Care (MIMIC-IV, v3.1) database during study periods. To compare AI-driven models with a traditional clinical scoring system, three survival prediction models were developed using a baseline CURB-65 score. Five variable sets were constructed by combining the CURB-65 score, AI-interpreted CXR findings, and additional clinical information. A total of 2,874 ED visits were analyzed. The random survival forest (RSF) model using the all-feature set (CURB-65, CXR interpretation, and clinical information) achieved a concordance index (C-index) of 0.872 (95% confidence interval [CI]: 0.861–0.886) in the test set, significantly outperforming the RSF model excluding the CXR interpretation information, which had a C-index of 0.865 (95% CI: 0.854–0.879). This study highlights the potential utility of a multimodal AI-driven prediction model to support prognosis estimation and clinical decision-making for patients with pneumonia in ED.

Understanding the economic cost of self-harm is essential for evaluating intervention cost-effectiveness and guiding funding allocation and service planning. To estimate the cost associated with self-harm presentations to hospital emergency departments and investigate key predictors of cost. Data on presentations to hospital for self-harm in all Irish emergency departments were analysed for 2018 and 2019. Costs of hospital treatment following self-harm were identified (in 2019 euros) using top-down and bottom-up approaches. The perspective taken was that of the health service. Factors associated with costs were investigated using generalised linear models. There were 25 053 self-harm presentations from 2018 to 2019. The average annual cost of self-harm was approximately €26.5 million; almost half of the total cost was due to repeat self-harm presentations (47.3%). The mean cost per presentation was €2117 (s.d. €1845), which incorporates acute hospital costs (mean €2067, s.d. €2127) and those of initial aftercare (mean €50, s.d. €69). Psychiatric and medical admissions were associated with highest costs, three times that of presentations resulting in emergency department discharge (incidence rate ratio (IRR) 3.01, 95% CI 2.72-3.36 and IRR 2.88, 95% CI 2.72-3.36, respectively). Other factors associated with higher costs included older age, emergency department medical assessment unit admission, receiving a psychosocial assessment and self-harm involving a firearm. Demographic and clinical predictors of cost varied according to care pathway. Significant costs associated with repeat attendances and hospital admission provide evidence for investment in emergency department services providing comprehensive care for those presenting with self-harm, as well as in community-based mental health services.

Diagnostic uncertainty is an important, yet understudied, driver of patient safety within pediatric emergency medicine. Understanding how uncertainty is experienced and communicated may reveal opportunities to optimize patient safety. This study aims to determine the frequency of physician-reported uncertainty at emergency department (ED) discharge for pediatric acute respiratory illness and to describe strategies and challenges in communicating uncertainty to caregivers. This was a cross-sectional study of children (<18y) discharged with acute respiratory illness from a tertiary care pediatric ED (April to May 2025). For each patient, the discharging attending physician completed a survey assessing diagnostic uncertainty (6-point Likert scale, dichotomized for analysis), and whether and how this was communicated to caregivers. Physicians indicated their general overall comfort communicating uncertainty. Wilson CIs were calculated around the prevalence of visits with uncertainty. Among 220 patients with acute respiratory illness, 68 (31%, 95% 25 to 37%) were discharged with diagnostic uncertainty. Uncertainty was communicated to 61 caregivers (90%) in the following ways: using terms such as "maybe," "probably," or "likely" (74%), provision of return precautions (59%), discussion of the differential diagnosis (56%), and discussion of diagnoses excluded (27%). Many (45% of 60 physicians surveyed) reported communication challenges, citing perceived caregiver expectations, anxiety, and risk communication concerns. Diagnostic uncertainty occurred in nearly one-third of ED discharges for pediatric acute respiratory illness. Communication approaches varied, and several challenges were noted. Future research engaging clinicians and families is needed to address these challenges and develop optimal methods of family-centered communication of uncertainty.

Emergency department (ED) fall-risk screening often relies on measures that incompletely capture body movement signals relevant to future falls. Test whether inertial measurement unit (IMU) features from a brief, modified, instrumented Timed Up and Go (miTUG) provide incremental prognostic value for 6-month falls after ED discharge beyond a clinical screening tool. We conducted a prospective cohort study of community-dwelling adults ≥ 60 years discharged from an urban academic ED (September 2023-May 2024). Before discharge, participants completed a miTUG; four IMU features (sit-to-stand dominant frequency and duration; turn-to-sit spectral power and dominant frequency) were added to nine clinical predictors. The primary outcome was any fall within 180 days (6 months). Model performance was assessed using discrimination (AUC/C-index) and operating characteristics at ED-relevant thresholds. Secondary analyses examined models predicting time to first fall. Exploratory analyses examined patient sub-groups that may benefit from additional testing. Among 360 participants, 94 (26.1%) fell within 180 days. The combined clinical+IMU model demonstrated modestly improved discrimination compared with the clinical-only model (AUC 0.72 vs. 0.67; Wilcoxon p = 0.19). At a prespecified 30% fall risk threshold, addition of IMU features improved sensitivity (0.57 vs. 0.45), specificity (0.80 vs. 0.76) and positive predictive value (0.50 vs. 0.39). In time-to-event analyses, the combined clinical+IMU model showed higher concordance (C-index 0.73 vs. 0.69) and better fit (likelihood-ratio p = 0.0006). Incremental gains were largest among adults ≥ 70 years, those with a recent prior fall, and those classified as lower risk by the clinical screen. In older adults discharged from the ED, IMU features from a brief, mobility assessment added modest improvements in fall risk stratification beyond a clinical screen. These findings are hypothesis-generating and support the need for external validation and implementation studies before clinical adoption.

A Digital Referral Tool to Link Adolescent Females from the Emergency Department to Sexual and Reproductive Healthcare: A Cohort Study.

Opioid use disorder (OUD) remains a critical public health crisis in the U.S., affecting over six million people and contributing to more than 50,000 deaths annually. Medicaid enrollees are disproportionately impacted, comprising about 40% of those with OUD. Despite the proven effectiveness of medications for opioid use disorder (MOUD), only 25% receive them. The emergency department (ED) is a key touchpoint for initiating MOUD, especially in South Carolina (SC), where fentanyl-related overdoses have surged. However, little is known about MOUD initiation and retention following ED visits among SC Medicaid enrollees. This study addresses that gap by examining initiation within 30days and retention at 90days. This study examined MOUD initiation and retention for Medicaid enrollees in South Carolina post-OUD related ED discharge utilizing claims data from January 1, 2020, through June 30, 2024. Estimates for MOUD initiation within 30days of ED discharge and MOUD retention for 90days post-initiation were calculated using logistic regression. There was a total sample size of 2605 Medicaid enrollees with an opioid-related ED visit. Of the total 2603 that had a follow-up period of at least 30days, 7.6% initiated any MOUD post-discharge. Furthermore, among the 183 enrollees who initiated MOUD and had at least 90-days of continuous-enrollment post-initiation, only 32.2% retained MOUD for 90days. Black enrollees had significantly lower odds of initiating MOUD compared to White enrollees (AOR: 0.29, CI=0.17-0.50), while enrollees aged 45-54 had higher odds of initiating MOUD compared to enrollees aged 18-24 (AOR: 1.75, CI=1.11-2.75). Similarly, enrollees aged 35-44 higher odds of retaining MOUD compared to enrollees aged 18-24 (AOR: 5.57, CI=1.53-20.27). Despite the ED being a key touchpoint for MOUD, initiation and retention rates among South Carolina Medicaid enrollees remain low, especially among Black enrollees and younger adults. These disparities highlight urgent needs for targeted, equitable strategies to improve MOUD access and engagement amid rising fentanyl-related overdose deaths.