BMC Emergency Medicine最新文献

Background: Emergency departments (EDs) around the globe are experiencing increasing patient attendance and staffing challenges, making it difficult for management to balance supply and demand. Time series forecasting (TSF) is a statistical technique that uses historical data and external variables to predict phenomena over time. Given the growing interest in TSF applications in emergency care, the aim of this study was to explore how these technologies could be aligned with everyday clinical demands to close the translational science gap.

Methods: This was a prospective qualitative interview study. Through interviews with European emergency department directors, we collected and analysed perspectives on the practical applicability of time series forecasting in everyday emergency care. The study is reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ).

Results: We interviewed 26 ED directors in 19 countries. Over half had prior knowledge of time series forecasting technology. Only three countries had TSF implemented in daily practice. Most ED directors reported that their management decisions are informed by data and indicated openness to the adoption of additional decision-support tools, such as TSF. Novel, previously undescribed external variables were identified, including local primary care availability, fruit harvesting, and neighbouring hospital conditions (e.g. ED closures).

Conclusions: We recommend that future TSF modelling studies in ED implement, at a minimum, both short- and long-term forecast horizons; conduct in-depth interviews with local senior staff to align models with operational needs; and validate models using real-world data from deployment sites. Through semi-structured interviews, we identified key directions for further TSF model development to enhance usability and support translation from academia into clinical practice.

Study registration: This study was preregistered via Open Science Framework site ( https://doi.org/10.17605/OSF.IO/SGZH7 ).

Background: Emergency department triage is commonly conceptualised as a standardised classification of patient urgency based on vital signs and presenting symptoms. However, research shows that triage is deeply shaped by the clinical context such as organizational structure, clinical uncertainty and subjective decision-making. This contextual complexity presents a challenge for the implementation of artificial intelligence decision-support in emergency care. While Artificial Intelligence-supported triage has demonstrated promising accuracy in controlled settings, these evaluations capture only a limited part of triage work and rarely account for the underlying mechanisms through which triage is sustained in everyday clinical practice. To address this gap, this study aimed to examine how triage unfolds in real-world emergency care and to understand the underlying generative mechanisms shaping triage practice.

Methods: An ethnographic study was conducted across three Danish emergency departments with different organisational triage configurations. Data consisted of participant observations of triage practice and semi-structured interviews with nurses and physicians. Data were analysed using inductive qualitative content analysis. Findings were interpreted, informed by a critical realistic lens, to understand underlying generative mechanisms shaping triage practice.

Results: Triage was not a standardized classification event but a dynamic, negotiated practice across the acute admission pathway. Two core generative mechanisms were identified: 1) Coherence work sustained continuity, safety, and flow through transitional coordination, gap compensation, situated judgement, and pragmatic prioritisation. 2) Interpretive reasoning enabled healthcare professionals to navigate clinical complexity through situated interpretive filtering and experience-driven judgement. Both mechanisms were activated by managing competing demands between safety, continuity, and flow within fragmented, resource-constrained organisational setups. Both mechanisms drew on tacit and embodied knowledge not routinely documented or available to artificial intelligence systems.

Conclusions: These findings demonstrate that safe and effective triage depends not only on accurate classification but on largely invisible adaptive work embedded in everyday practice under conditions of clinical uncertainty and organisational fragmentation. For artificial intelligence-supported triage to achieve clinical impact, system design must recognise and support the coherence- and interpretive reasoning work through which continuity, safety, and flow are maintained in real-world emergency care.

Background: Adolescent suicide is a major public health concern and self-harm-related emergency department (ED) visits are key predictors. Although social distancing during and after the pandemic likely affected the incidence of self-harm, few studies have explored these changes. We examined the variations in the incidence of adolescent self-harm-related ED visits before, during, and after social distancing.

Methods: We conducted a retrospective analysis of data from the ED‑Based Injury In‑Depth Surveillance registry in the Republic of Korea from January 2017 to December 2023. Injured patients aged 10 - 17 years were included in this study. The incidence rate of self-harm was recorded quarterly. Data on demographic, pre-hospital, and clinical characteristics were compared across three periods: pre-pandemic; pandemic; and post-pandemic, using data from Quarter 1 of 2020 (when social distancing was implemented) and Quarter 2 of 2022 (when it was fully lifted) as reference points. Multinomial logistic regression analyses were performed for each group to evaluate the association with changes in the incidence of self-harm.

Results: We included 109,929 adolescent patients with injuries, 6,316 (5.75%) of whom presented with self-harm. The incidence of self-harm increased significantly during the pandemic (from 3.6% to 8.8%), although this immediate increase was attenuated to borderline significance in a sensitivity analysis incorporating seasonal variation, and decreased modestly after social distancing was lifted (to 7.8%). Self-harm occurring at home, among individuals with medical-aid insurance, and in those with psychiatric problems was significantly associated with these overall changes.

Conclusions: Adolescent self-harm increased with the onset of the pandemic and social distancing, followed by a modest relative decline in incidence after the restrictions were lifted; however, the absolute number of self-harm presentations did not return to pre-pandemic levels. This suggests that social distancing measures may have had a greater impact on adolescents, whose daily lives largely revolve around home and school environments.

Background: Acute ischemic stroke (AIS) requires rapid diagnosis and treatment. While neuroimaging remains the gold standard, it is often unavailable in early emergency or prehospital settings. Clinical stroke scales may bridge this gap. Thus, this study aimed to compare the diagnostic accuracy of the ROSIER scale with the Cincinnati Prehospital Stroke Scale (CPSS), Field Assessment Stroke Triage for Emergency Destination (FAST-ED), and National Institutes of Health Stroke Scale (NIHSS) for the detection of AIS in patients with suspected stroke, using MRI as the imaging reference standard.

Methods: This prospective cross-sectional study was performed on adult patients admitted to the emergency department (ED) between June 2021 and 2023, with acute neurological symptoms and underwent brain MRI for a suspected stroke. After data gathering, receiver operating characteristic (ROC) curve analysis was performed, and sensitivity, specificity, positive predictive value, and negative predictive value of ROSIER for detecting of AIS were calculated and compared with CPSS, FAST-ED, and NIHSS. MRI was considered the gold standard for the diagnosis of AIS.

Results: A total of 655 patients were included, and 477 (72.8%) were diagnosed with AIS. The mean age was 68.43 ± 13.01 years, and 57.3% were male. The AUROC values for ROSIER, CPSS, FAST-ED, and NIHSS were 0.813, 0.860, 0.811, and 0.822, respectively. No significant differences were found between the tools. Sensitivities for ROSIER ≥ 2, CPSS ≥ 2, FAST-ED ≥ 3, and NIHSS ≥ 8 were 86.8%, 90.7%, 74.7%, and 73.5%, respectively. Their specificities were 58.1%, 67.7%, 77.4%, and 81.5%, respectively.

Conclusion: All four tools showed good diagnostic accuracy. CPSS was the most sensitive and suitable for prehospital detection, whereas NIHSS offered the best specificity for in-hospital confirmation. Selection of the tool should be context-dependent, based on resources, time, and examiner expertise.

Background: Healthcare professionals working in regional, rural, and remote emergency departments are at increased risk of psychological distress, burnout, and emotional exhaustion due to demanding work environments and ongoing workforce pressures. Poor psychological wellbeing contributes to reduced workforce retention and may compromise the delivery of safe, equitable emergency care. However, evidence regarding their psychological wellbeing in these settings remains fragmented and lacks comprehensive synthesis.

Methods: An integrative review of global evidence on the psychological wellbeing of healthcare professionals working in regional, rural, and remote emergency departments was undertaken, focusing on challenges, contributing factors, supports, and reported outcomes. Five electronic databases (MEDLINE, CINAHL, PsycINFO, Embase, and Scopus) were systematically searched from inception to June 2025.

Results: Seventeen primary studies from ten countries met inclusion criteria and were appraised using the Mixed Methods Appraisal Tool. Findings revealed multifactorial stressors, including workplace violence, excessive workloads, professional isolation, inadequate leadership, moral distress, and limited access to training, with nurses and female staff most affected. Supports were clustered into four domains: education and professional development, peer and social support, organizational support, and individual coping strategies. Most supports were descriptively reported, with outcomes identified as both positive and negative. In only two studies, structured interventions were formally evaluated, including a self-care program and the implementation of a Serenity Room.

Conclusion: The review highlights that psychological distress among healthcare professionals working in regional, rural, and remote emergency departments is influenced by context-specific, systemic, and individual factors, yet evidence-based interventions addressing these issues remain scarce. Multi-level, co-designed strategies integrating organisational safety, training, and wellbeing supports are recommended as potential approaches to support healthcare staff psychological wellbeing, workforce sustainability, and equitable, high-quality emergency care in regional, rural, and remote settings.

Prospero registration number: CRD420251079431.

Background: Prehospital care is central to outcomes in ST-elevation myocardial infarction (STEMI), yet how systems of care evolve over time remains incompletely described. This study aimed to evaluate the statewide temporal trends in prehospital ST-elevation myocardial infarction (STEMI) care in Victoria, Australia, examining changes in epidemiology, clinical management, time metrics, and adverse events.

Methods: We conducted a retrospective analysis using data from the Victorian Ambulance STEMI Quality Initiative (VASQI). Adults with suspected STEMI treated by paramedics between January 2018 and December 2023 were included. Patient demographics, clinical presentation, and compliance with a prehospital bundle of care (aspirin administration, First Medical Contact [FMC] to ECG ≤ 10 min, hospital notification, and transport to percutaneous coronary intervention [PCI] facility) were analysed and further stratified into patients who received prehospital thrombolysis (PHT) or primary PCI (pPCI) reperfusion pathways. Descriptive statistics and nonparametric tests for trends were used.

Results: A total of 18,075 patients were included (median age 67 years, IQR 56-78; 69.7% men). The incidence of suspected STEMI was 58.2 cases per 100,000 person-years (≥ 18 years), increasing from 49.0 in 2018 to 59.5 in 2023 (p = 0.102). Bundle of care compliance was achieved in 69.1% of patients, increasing from 59.5% to 78.2% (+ 18.7% mean difference [MD], 95% CI 16.3-21.1; p for trend < 0.001). Improvements were observed in both PHT (MD, + 22.7%; 95% CI 13.9-31.4; p for trend < 0.001) and non-PHT reperfusion pathways (MD, + 18.4%; 95% CI 15.8-20.9; p for trend < 0.001). All bundle elements showed improvement: aspirin administration by 0.9% (95% CI 0.3-1.4; p for trend = 0.002), FMC to ECG ≤ 10 min by 8.7% (95% CI 6.6-10.8; p for trend < 0.001), hospital notification by 12.6% (95% CI 10.8-14.4; p for trend < 0.001), and direct transport to PCI by 0.9% (95% CI 0.0-1.9; p for trend = 0.046).

Conclusions: Paramedic compliance with the STEMI processes of care improved significantly over the study period. Although key clinical interventions for patients with STEMI have been delivered at high rates, opportunities remain to further optimise care, highlighting the importance of ongoing monitoring of clinical quality performance.

Background: Early recognition of non-invasive ventilation failure in patients with acute respiratory failure in the emergency department is essential to prevent delayed intubation and its associated adverse outcomes. The HACOR score is a pragmatic bedside tool developed to predict non-invasive ventilation failure, most prior investigations have been conducted in intensive care settings and have predominantly relied on single time-point measurements or simple change analyses. In this study, we aimed to evaluate predictive value of early change in the HACOR score for non-invasive ventilation failure in emergency department patients with acute respiratory failure and to examine the temporal nature of this association using Generalized Estimating Equations models.

Methods: This prospective observational cohort study included 106 adult patients. HACOR, National Early Warning Score, National Early Warning Score 2, and Modified Early Warning Score were calculated immediately before and at 1 h after non-invasive ventilation initiation. ΔHACOR was defined as the difference between 1-hour and baseline HACOR scores. The primary outcome was non-invasive ventilation failure. Discriminative performance was assessed using ROC analysis. Logistic regression was used to evaluate the independent association between ΔHACOR and non-invasive ventilation failure. Generalized estimating equations models were constructed to analyze the time-dependent relationship between HACOR and non-invasive ventilation failure.

Results: Non-invasive ventilation failure occurred in 50.9% of patients. Baseline clinical variables and scores did not significantly discriminate between success and failure groups. In contrast, 1-hour HACOR (AUC = 0.760, 95% CI 0.667-0.854) and ΔHACOR (AUC = 0.798, 95% CI 0.711-0.885) demonstrated significant predictive performance. Patients with ΔHACOR ≥ 0 exhibited a substantially higher failure rate (74.4%) compared to those with ΔHACOR < 0 (34.9%). Each one-point increase in ΔHACOR was independently associated with failure (OR 1.63, 95% CI 1.31-2.03; p < 0.001). In Generalized Estimating Equations analysis, the HACOR × time interaction remained statistically significant across adjusted models, supporting the prognostic value of serial HACOR assessment.

Conclusions: In emergency department patients receiving non-invasive ventilation, early dynamic changes in HACOR provide superior prognostic information compared with baseline measurements alone. Serial HACOR assessment demonstrated through Generalized Estimating Equations modeling supports potential value of response-guided risk stratification and highlights importance of early reassessment in emergency non-invasive ventilation management.

Background: Pediatric emergencies are rather rare in pre-hospital care. The aim of this study was to analyze the frequency and urgency of pediatric emergency medical service (EMS) missions and to identify age-specific characteristics in EMS utilization in the rural district of Vorpommern-Greifswald in northeastern Germany.

Methods: In this retrospective observational study, all emergency protocols from ambulance vehicles and emergency physician vehicles from January 1, 2022, to December 31, 2023, in the study region were analyzed using descriptive statistical methods. Patients were categorized into age groups: infants (< 1 year), toddlers (1-5 years), schoolchildren (6-13 years), adolescents (14-17 years), adults (18-64 years), and seniors (≥ 65 years).

Results: Over the study period, 71,446 patients had an EMS contact, thereof 255 infants (0.4%), 976 toddlers (1.4%), 1,437 schoolchildren (2.0%), 1,395 adolescents (2.0%), 25,220 adults (35.3%), and 42,163 seniors (59.0%). The annual emergency rate among adults ≥ 18 years was nearly three times higher than among minors < 18 years (169 vs. 58 patients per 1,000 inhabitants within the respective age groups). Pediatric cases accounted for 5.7% of all missions. Vehicle dispatches for minors followed a bimodal temporal distribution with peaks between 12:00 and 1:00 p.m. and between 6:00 and 7:00 p.m. Seasonal variation was observed, with the highest dispatch volume in June (10.5% of all pediatric dispatches) and the lowest in February (5.3%). Trauma was more common in minors compared to adults (41.8% vs. 23.1%), with the highest proportion among schoolchildren (52.2%). The proportion of critically ill or injured patients (NACA IV-VII) was lower in minors than in adults (10.2% vs. 20.8%). Physician involvement was more frequent in pediatric missions than in adult missions (39.4% vs. 32.9%). Infants showed the highest physician involvement (53.5%).

Conclusions: In pediatric missions, the involvement of physicians is high, however, critically ill children are rare. Low exposure to pediatric cases may contribute to insecurity among paramedics and emergency physicians in pediatric emergencies. Therefore, hands-on training in pediatric emergency care is essential. Given the rising demand for EMS, telemedicine could be a valuable addition in rural settings to reduce the burden on physician resources and ensure comprehensive pediatric care.

Clinical trial number: Not applicable.

Background: Whole body computed tomography (WBCT) is widely used in the initial assessment of pediatric trauma patients to rapidly identify injuries; however, its routine use exposes children to substantial ionizing radiation. Clear guidance on which pediatric trauma patients truly benefit from WBCT is lacking, leading to practice variability and potential overuse in emergency departments. The proposed score is intended to complement existing pediatric imaging decision frameworks that emphasize selective and risk-based use of computed tomography.

Methods: This retrospective, single-center observational study included trauma patients under 18 years of age who underwent WBCT in a tertiary pediatric trauma center between June 2021 and June 2022. The primary outcome was the presence of traumatic injuries involving ≥ 2 anatomical regions on WBCT not necessarily the clinical need for WBCT. Candidate predictors were identified from the literature and clinical practice and evaluated using multivariable logistic regression. Continuous variables were dichotomized based on receiver operating characteristics (ROC) analysis. Independent predictors were used to develop a clinical decision support tool, the WHOLE score. Model performance was assessed using ROC analysis and diagnostic accuracy metrics.

Results: A total of 407 pediatric trauma patients who underwent WBCT were included; 37.6% (n = 153), had injuries involving two or more anatomical regions. Independent predictors of multi-region injury were age ≥ 133 months, tachycardia, hypoxia, positive physical examination findings in the head, thoracic, pelvic, or lower extremity regions, and aspartate aminotransferase (AST) ≥ 50 U/L. These variables were incorporated into the WHOLE score (range 0-8). The WHOLE score demonstrated good discrimination (AUC 0.84; 95% CI 0.80-0.88). Using a cut-off of ≥ 2 points, sensitivity was 96.7% (CI 92.5-98.9) and NPV was 94.8% for detecting multi-region injuries.

Conclusions: The WHOLE score is a simple clinical decision support tool designed to identify pediatric trauma patients at low risk for multi-region injuries, thereby supporting emergency physicians in safely withholding WBCT in appropriately selected cases. The score functions as a rule-out tool: a low score (0-1) may support a decision to forego WBCT, whereas a high score does not independently mandate it. By reducing unnecessary WBCT in low-risk patients, the score has the potential to decrease radiation exposure while maintaining diagnostic safety. This is a preliminary single-center derivation study, and external prospective validation is required before routine clinical implementation.

Trial registration: The study protocol was registered retrospectively at clinicaltrials.gov (Clinical Trials Identifier: NCT07411235, Date:11/02/2026).