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OBJECTIVE: This study sought to externally validate and compare proposed methods for stratifying sepsis risk at emergency department (ED) triage. METHODS: This nested case/control study enrolled ED patients from four hospitals in Utah and evaluated the performance of previously-published sepsis risk scores amenable to use at ED triage based on their area under the precision-recall curve (AUPRC, which balances positive predictive value and sensitivity) and area under the receiver operator characteristic curve (AUROC, which balances sensitivity and specificity). Score performance for predicting whether patients met Sepsis-3 criteria in the ED was compared to patients' assigned ED triage score (Canadian Triage Acuity Score [CTAS]) with adjustment for multiple comparisons. RESULTS: Among 2000 case/control patients, 981 met Sepsis-3 criteria on final adjudication. The best performing sepsis risk scores were the Predict Sepsis version #3 (AUPRC 0.183, 95 % CI 0.148-0.256; AUROC 0.859, 95 % CI 0.843-0.875) and Borelli scores (AUPRC 0.127, 95 % CI 0.107-0.160, AUROC 0.845, 95 % CI 0.829-0.862), which significantly outperformed CTAS (AUPRC 0.038, 95 % CI 0.035-0.042, AUROC 0.650, 95 % CI 0.628-0.671, p < 0.001 for all AUPRC and AUROC comparisons). The Predict Sepsis and Borelli scores exhibited sensitivity of 0.670 and 0.678 and specificity of 0.902 and 0.834, respectively, at their recommended cutoff values and outperformed Systemic Inflammatory Response Syndrome (SIRS) criteria (AUPRC 0.083, 95 % CI 0.070-0.102, p = 0.052 and p = 0.078, respectively; AUROC 0.775, 95 % CI 0.756-0.795, p < 0.001 for both scores). CONCLUSIONS: The Predict Sepsis and Borelli scores exhibited improved performance including increased specificity and positive predictive values for sepsis identification at ED triage compared to CTAS and SIRS criteria.

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Background: The "surprise question" (SQ) ("Would you be surprised if this patient died in the next 12 months?") is the most frequently used screening tool in emergency departments (EDs) to identify patients with poor prognosis and potential unmet palliative needs. Objective: To test and compare the accuracy of the SQ between emergency nurses (ENs) and emergency physicians (EPs) in predicting long-term mortality among older patients (OP) in the ED. Design and Setting/Subjects: A prospective cohort study of OPs (≥75 years) conducted in two Belgian EDs. EPs and ENs answered the SQ for the patients they cared for. Positive SQ (SQ+) was defined as a "no" answer. One-year mortality was assessed by phone call. Results: EPs and ENs both answered the SQ for 291 OPs (mean age 83.2 ± 5.4, males 42.6%). The SQ was positive in 43% and 40.6%, respectively. Predictive values were similar in both groups: sensitivity, specificity, c-statistics, negative predictive value, and positive predictive value were 0.79 (0.66-0.88), 0.68 (0.62-0.76), 0.69 (0.63-0.75), 0.92 (0.86-0.96), and 0.4 (0.31-0.50), respectively, for EPs and 0.71 (0.57-0.82), 0.69 (0.62-0.75), 0.69 (0.63-0.75), 0.89 (0.83-0.93), and 0.41 (0.31-0.51), respectively, for ENs. SQ + was associated with a higher mortality risk in both group (EPs hazard ratio: 3.2 [1.6-6.7], p = 0.002; ENs hazard ratio: 2.5 [1.3-4.8], p = 0.006). The survival probability was lower when both EPs and ENs agreed on the SQ+ (p < 0.001). Conclusion: The SQ is a simple tool to identify older ED patients at high mortality risk. Concordant responses from EPs and ENs are more predictive than either alone.

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Functional decline following hospitalization remains an important problem in health care, especially for frail older adults. Modifiable factors related to reduction in harms of hospitalization are not well described. One particularly pervasive factor is emergency department (ED) boarding time; time waiting from decision to admit, until transfer to an in-patient medical unit. We sought to investigate how the functional status of frail older adults correlated with the length of time spent boarded in the ED. We found that patients who waited for 24 hours or more exhibited functional decline in both the Barthel Index and Hierarchical Assessment of Balance and Mobility and an increase in the Clinical Frailty Scale from discharge to 6 months post discharge. In conclusion, there is a need for additional investigation into ED focused interventions to reduce ED boarding time for this population or to improve access to specialized geriatric services within the ED.

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Over 10 million ED visits occur each year across Australia and Aotearoa New Zealand. Outside basic administrative data focused on time-based targets, there is minimal information about clinical performance, quality of care, patient outcomes, or equity in emergency care. The lack of a timely, accurate or clinically useful data collection represents a missed opportunity to improve the care we deliver each day. The present paper outlines a proposal for a National Acute Care Secure Health Data Environment, including design, possible applications, and the steps taken to date by the Australasian College for Emergency Medicine ED Epidemiology Network in collaboration with the College of Emergency Nursing Australasia. Optimal use of the existing information collected routinely during clinical care of emergency patients has the potential to enable data-driven quality improvement and research, leading to better care and better outcomes for millions of patients and families each year.

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Early identification of patients with a poorer prognosis in the Emergency Department (ED) is crucial for prompt treatment and resource allocation. We investigated the relationship between the Neutrophil to Lymphocyte Ratio (NLR) and 30-day mortality in elderly acute medical patients. Prospective single-center cohort study including consecutive patients admitted to the ED. Inclusion criteria were age > 65 years and medical condition as the cause of ED access. Exclusion criteria were patients admitted for traumatic injuries or non-traumatic surgical diseases. ROC analysis was used to set the best cut-off of the NLR for mortality. 953 patients were included and 142 (14.9%) died during follow-up. ROC analysis showed a good predictive value of the NLR with an AUC 0.70, 95%CI 0.67-0.73 (p < 0.001) and identified a NLR > 8 as the best cut-off. Patients with NLR > 8 had a more serious triage code (72.6% had a triage code ≤ 2) and an increased heart rate and body temperature. They more often presented with dyspnea, abdominal pain, falls and vomiting. They also were characterized by an increase in urea, creatinine, white blood cells, neutrophils, fibrinogen, D-dimer, glycemia, CRP, LDH and transaminases and by a decrease in eGFR, of lymphocytes and monocytes. Multivariable logistic regression analysis demonstrated that the NLR remained associated with mortality after adjustment for confounders (Odds ratio 2.563, 95%CI 1.595-4.118, p < 0.001). Patients with NLR > 8 showed a higher mortality rate. NLR is an easy and inexpensive tool that may be used for risk stratification in the ED. The results of this study need to be validated in larger external cohorts.

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BACKGROUND: Chest pain is a prevalent reason for emergency room referrals and presents diagnostic challenges. The physician must carefully differentiate between cardiac and noncardiac causes, including various vascular and extracardiovascular conditions. However, it is crucial not to overlook serious conditions such as acute coronary syndrome (ACS). Diagnosis of acute myocardial infarction (AMI) and early discharge management become difficult when traditional clinical criteria, ECG, and troponin values are insufficient. Recently, the focus has shifted to a "multi-marker" approach to improve diagnostic accuracy and prognosis in patients with chest pain. METHODS: This observational, prospective, single-center study involved, with informed consent, 360 patients presenting to the emergency department with typical chest pain and included a control group of 120 healthy subjects. In addition to routine examinations, including tests for hsTnI (Siemens TNIH kit), according to the 0-1 h algorithm, biochemical markers sST2 (tumorigenicity suppression-2) and suPAR (soluble urokinase plasminogen activator receptor) were also evaluated for each patient. A 12-month follow-up was conducted to monitor outcomes and adverse events. RESULTS: We identified two groups of patients: a positive one (112 patients) with high levels of hsTnI, sST2 > 24.19 ng/mL, and suPAR > 2.9 ng/mL, diagnosed with ACS; and a negative one (136 patients) with low levels of hsTnI, suPAR < 2.9 ng/mL, and sST2 < 24.19 ng/mL. During the 12-month follow-up, no adverse events were observed in the negative group. In the intermediate group, patients with hsTnI between 6 ng/L and the ischemic limit, sST2 > 29.1 ng/mL and suPAR > 2.9 ng/mL, showed the highest probability of adverse events during follow-up, while those with sST2 < 24.19 ng/mL and suPAR < 2.9 ng/mL had a better outcome with no adverse events at 12 months. CONCLUSION: Our data suggest that sST2 and suPAR, together with hsTnI, may be useful in the prognosis of cardiovascular patients with ACS, providing additional information on endothelial damage. These biomarkers could guide the clinical decision on further diagnostic investigations. In addition, suPAR and sST2 emerge as promising for event prediction in patients with chest pain. Their integration into the standard approach in PS could facilitate more efficient patient management, allowing safe release or timely admission based on individual risk.

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Background: Asthma represents a substantial public health challenge in the United States, affecting over 25 million adults. This study investigates the impact of neighborhood economic deprivation on asthma-associated Emergency Department (ED) visits in Maryland, using the Distressed Communities Index (DCI) for analysis. Methods: A retrospective analysis of Maryland's Emergency Department Databases from January 2018 to December 2020 was conducted, focusing on asthma-associated ED visits. Results: The study involved 185,317 ED visits, majority of which were females (56.3%) and non-Hispanic whites (65.2%). A significant association was found between increased neighborhood socioeconomic deprivation and asthma-related ED visits. The poorest neighborhoods showed the highest rates of such visits. Compared to prosperous areas, neighborhoods classified from Comfortable to Distressed had progressively higher odds for asthma-related ED visits (Comfortable: OR = 1.14, Distressed OR = 1.65). Other significant asthma predictors included obesity, female gender, tobacco smoking, and older age. Conclusion: There is a substantive association between higher asthma-related ED visits and high neighborhood economic deprivation, underscoring the impact of socioeconomic factors on health outcomes. Public health implications: Addressing healthcare disparities and improving access to care in economically distressed neighborhoods is crucial. Targeted interventions, such as community health clinics and asthma education programs, can help mitigate the impact of neighborhood disadvantage.

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Introduction: Poisoning is a major public health issue and a leading cause of admission to the emergency department (ED). There is a paucity of data describing the epidemiology and cost of acute poisoning. Therefore, this study investigated the epidemiology, patterns, and associated costs of acute poisoning in emergency department of the largest tertiary care healthcare centre in Qatar. Method: This study was a retrospective review of the health records of patients admitted to the ED due to poisoning between January 2015 and December 2019. Incidence, clinical characteristics, and costs associated with acute poisoning were assessed. Frequency and percentages were calculated for categorical variables and mean and SD for continuous variables. The relationship between sociodemographic characteristics and poisoning profile was assessed using the chi-square test. A micro-costing approach using the cost of each resource was applied for cost calculations. Result: The incidence of acute poisoning was 178 cases per 100,000 patients. Females (56%) and children below 14 years (44.3%) accounted for the largest proportion. Most of the exposures were accidental involving therapeutic agents (64.2%). The mean length of hospital stay was found to be 1.84 ± 0.81 days, and most patients (76.6%) were discharged within the first 8 h. A statistically significant difference was found between age groups and type of toxin (χ2 = 23.3, p < 0.001), cause and route of exposure (χ2 = 42.2, p < 0.001), and length of hospital stay (χ2 = 113.16, p < 0.001). Admission to intensive care units had the highest cost expenditure (USD 326,008), while general wards accounted for the least (USD 57,709). Conclusion: Unintentional poisoning by pharmacological agents is common in infants and children. This study will assist in the development of educational and preventive programmes to minimise exposure to toxic agents. Further studies are required to explore the impact of medical toxicology services, and post discharge monitoring of poisoning.

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OBJECTIVE: This cross-sectional descriptive study aimed to ascertain the prevalence of non-urgent cases, investigate gender and age preferences, and explore factors influencing individuals' selection of the emergency department (ED) for non-urgent cases in the Al-Qassim region of Saudi Arabia. METHODS: From July 15, 2022, to December 31, 2022, a structured online questionnaire via a Google Docs survey collected data. The study sampled 425 patients from two prominent Al-Qassim healthcare institutions: Buraydah King Fahad Specialized Hospital and Buraydah Central Hospital. Encompassing patients aged 20 to 80 admitted to the ED between 8:00 and 16:00, concurrent with primary healthcare center availability, the study categorized participants by urgency using the Canadian Triage and Acuity Scale (CTAS) criteria. Data analysis employed descriptive statistics, chi-square tests, and probit regression in R version 4.3.3, with a significance level of p < 0.05 for result interpretation. RESULTS: In Al-Qassim in 2022, 82.4% of ED visitors sought care for non-urgent cases, while 17.6% sought care for urgent cases. No statistically significant relationship was found between age and gender and urgent ED visits. Among those with non-urgent conditions, the top reasons for bypassing primary healthcare services were slow treatment (52.7%), lack of knowledge about primary healthcare (PHC) services (33.9%), and appointment unavailability (5.5%). Evaluation of awareness of the ED triage system showed a significant difference only among patients with excellent awareness. CONCLUSION: The investigation found a higher prevalence of non-urgent cases, especially among females. Challenges in appointment booking, accessibility, and the perception of urgency were key factors leading patients to choose the emergency department over PHC centers. The study emphasized the crucial role of ED triage system awareness and the impact of satisfaction with PHC services on healthcare-seeking behavior, with younger individuals less likely to visit the ED and males more inclined at specific satisfaction levels.

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OBJECTIVES: To compare the proportion of nursing home residents dispatched to an emergency department (ED) after a call to the emergency medical communication center (EMCC) according to the availability or nonavailability of telemedicine. DESIGN: This prospective, observational trial was conducted in the EMCC and 74 nursing homes in a French county. SETTING AND PARTICIPANTS: All nursing home residents who needed to contact the EMCC between June 2019 and April 2020 were included in the study. We excluded calls notifying the death of a resident, for completing data from a previous call, and for nursing home staff. METHODS: The primary outcome was the proportion of residents dispatched to an ED after their first call to the EMCC. The secondary outcomes were the proportion of second calls, proportion of residents dispatched to an ED after a second call, and proportion of death within 30 days. RESULTS: We included 3103 calls in the final analysis (355 from equipped nursing homes and 2748 from unequipped nursing homes). The proportion of patients dispatched to an ED after the first call was lower among telemedicine-equipped than among telemedicine-unequipped nursing homes (41% vs 50%; odds ratio, 0.71; 95% CI, 0.56-0.90). The proportion of a second call for the same purpose within 72 hours, proportion of dispatching to an ED at the second call, and proportion of deaths within 30 days were similar between the groups. CONCLUSION AND IMPLICATIONS: The use of telemedicine by nursing home residents requiring a call to the EMCC is associated with a reduction in the number of dispatches to an ED without any increase in the number of 72-hour callbacks or 30-day mortality rates.

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BACKGROUND: Shortages of mechanical ventilation have become a constant problem in Emergency Departments (EDs), thereby affecting the timely deployment of medical interventions that counteract the severe health complications experienced during respiratory disease seasons. It is then necessary to count on agile and robust methodological approaches predicting the expected demand loads to EDs while supporting the timely allocation of ventilators. In this paper, we propose an integration of Artificial Intelligence (AI) and Discrete-event Simulation (DES) to design effective interventions ensuring the high availability of ventilators for patients needing these devices. METHODS: First, we applied Random Forest (RF) to estimate the mechanical ventilation probability of respiratory-affected patients entering the emergency wards. Second, we introduced the RF predictions into a DES model to diagnose the response of EDs in terms of mechanical ventilator availability. Lately, we pretested two different interventions suggested by decision-makers to address the scarcity of this resource. A case study in a European hospital group was used to validate the proposed methodology. RESULTS: The number of patients in the training cohort was 734, while the test group comprised 315. The sensitivity of the AI model was 93.08% (95% confidence interval, [88.46 - 96.26%]), whilst the specificity was 85.45% [77.45 - 91.45%]. On the other hand, the positive and negative predictive values were 91.62% (86.75 - 95.13%) and 87.85% (80.12 - 93.36%). Also, the Receiver Operator Characteristic (ROC) curve plot was 95.00% (89.25 - 100%). Finally, the median waiting time for mechanical ventilation was decreased by 17.48% after implementing a new resource capacity strategy. CONCLUSIONS: Combining AI and DES helps healthcare decision-makers to elucidate interventions shortening the waiting times for mechanical ventilators in EDs during respiratory disease epidemics and pandemics.

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Background: Fecal occult blood tests (FOBT) are inappropriately used in patients with melena, hematochezia, coffee ground emesis, iron deficiency anemia, and diarrhea. The use of FOBT for reasons other than screening for colorectal cancer is considered low-value and unnecessary. Methods: Quality Improvement Project that utilized education, Best Practice Advisory (BPA) and modification of order sets in the electronic health record (EHR). The interventions were done in a sequential order based on the Plan-Do-Study-Act (PDSA) method. An annotated run chart was used to analyze the collected data. Results: Education and Best Practice Advisory within the EHR led to significant reduction in the use of FOBT in the ED. The interventions eventually led to a consensus and removal of FOBT from the order set of the EHR for patients in the ED and hospital units. Conclusions: The use of electronic BPA, education and modification of order sets in the EHR can be effective at de-implementing unnecessary tests and procedures like FOBT in the ED and hospital units.

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Headache is a common complaint of individuals seeking treatment in the emergency department (ED). Because pain is subjective, medical evaluation is susceptible to implicit bias that can lead to disparities in wait times. The aim of this study was to determine whether there are racial and ethnic disparities in ED wait times for headache. Our study used the 2015-2018 National Hospital Ambulatory Care Surveys (NHAMCS), a nationally representative sample of ambulatory care visits to EDs. Our sample consisted of visits made by adults for headaches, which were identified using ICD-10 diagnosis codes and NHAMCS reason for visit codes. There were 12,301,655 ED visits for headache represented by our sample. The mean wait time for headache visits was 38.1 min (95%CI: 31.1, 45.0). The mean wait time for Non-Hispanic White patients, non-Hispanic Black patients, Hispanic patients, and the other race and ethnicity groups were 34.7 min (95%CI: 27.5, 42.0), 46.4 min (95%CI: 26.5, 66.4), 37.9 min (95%CI: 19.4, 56.3), and 21.0 min (95%CI: 6.3, 35.7) respectively. After controlling for patient- and hospital-level covariates, visits by non-Hispanic Black patients had 40% (95%CI: -0.01, 0.81, p = 0.056) longer wait times and visits by Hispanic patients had 39% (95%CI: -0.03, 0.80, p = 0.068) longer wait times than visits by non-Hispanic White patients. While our findings suggest that there may be longer wait times for visits by non-Hispanic Black and Hispanic patients compared to visits by non-Hispanic White patients, further research is needed to confirm these findings and determine causes of wait times disparities in the ED.

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Background: The uncertainties surrounding the COVID-19 pandemic led to a surge in non-urgent emergency department (ED) attendance among people presenting with upper respiratory tract infection (URTI) symptoms. These non-urgent visits, often manageable in primary care, exacerbated ED overcrowding, which could compromise the quality of ED services. Understanding patients' expectations and the reasons for these ED visits is imperative to mitigate the problem of ED overcrowding. Hence, we assessed the factors influencing patients' expectations for diagnostic tests during their ED visits for uncomplicated URTI during different phases of the pandemic. Methods: We conducted a cross-sectional study on adults with URTI symptoms seeking care at four public EDs in Singapore between March 2021 and March 2022. We segmented the study period into three COVID-19 pandemic phases-containment, transition, and mitigation. The outcome variables are whether patients expected (1) a COVID-19-specific diagnostic test, (2) a non-COVID-19-specific diagnostic test, (3) both COVID-19-specific and non-COVID-19-specific diagnostic tests, or (4) no diagnostic test. We built a multinomial regression model with backward stepwise selection and classified the findings according to Andersen's healthcare utilization model. Results: The mean age of participants was 34.5 (12.7) years. Factors (adjusted odds ratio [95% confidence interval]) influencing expectations for a COVID-19-specific diagnostic test in the ED include younger age {21-40 years: (2.98 [1.04-8.55])}, no prior clinical consultation (2.10 [1.13-3.89]), adherence to employer's health policy (3.70 [1.79-7.67]), perceived non-severity of illness (2.50 [1.39-4.55]), being worried about contracting COVID-19 (2.29 [1.11-4.69]), and during the transition phase of the pandemic (2.29 [1.15-4.56]). Being non-employed influenced the expectation for non-COVID-19-specific diagnostic tests (3.83 [1.26-11.66]). Factors influencing expectations for both COVID-19-specific and non-COVID-19-specific tests include younger age {21-40 years: (3.61 [1.26-10.38]); 41-60 years: (4.49 [1.43-14.13])}, adherence to employer's health policy (2.94 [1.41-6.14]), being worried about contracting COVID-19 (2.95 [1.45- 5.99]), and during the transition (2.03 [1.02-4.06]) and mitigation (2.02 [1.03-3.97]) phases of the pandemic. Conclusion: Patients' expectations for diagnostic tests during ED visits for uncomplicated URTI were dynamic across the COVID-19 pandemic phases. Expectations for COVID-19-specific diagnostic tests for ED visits for uncomplicated URTI were higher among younger individuals and those worried about contracting COVID-19 during the COVID-19 pandemic. Future studies are required to enhance public communications on the availability of diagnostic services in primary care and public education on self-management of emerging infectious diseases such as COVID-19.

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BACKGROUND: People who use substances (PWUS) encounter significant barriers to accessing care for their complex health needs. As a result, emergency departments (EDs) often become the first point of healthcare access for many PWUS and are a crucial setting for the study of health inequities. This study aimed to understand the ED healthcare experiences of PWUS with the intent of informing ways of improving the delivery of equitable care. METHODS: This qualitative study was part of a larger cross-sectional, mixed-methods study that examined ED experiences among diverse underserved and equity-deserving groups (EDGs) within Kingston, Ontario, Canada. Participants shared and self-interpreted a story about a memorable ED or UCC visit within the preceding 24 months. Data from participants who self-identified as having substance use experiences was analyzed through inductive thematic analysis. RESULTS: Of the 1973 unique participants who completed the survey, 246 participants self-identified as PWUS and were included in the analysis. Most participants were < 45 years of age (61%), male (53%), and white/European (57%). 45% identified as a person with a disability and 39% frequently struggled to make ends meet. Themes were determined at the patient, provider, and system levels. PATIENT: history of substance use and experience of intersectionality negatively influenced participants' anticipation and perception of care. Provider: negative experiences were linked to assumption making, feelings of stigma and discrimination, and negative perceptions of provider care. Whereas positive experiences were linked to positive perceptions of provider care. System: timeliness of care and the perception of inadequate mental health resources negatively impacted participants' care experience. Overall, these themes shaped participants' trust of ED staff, their desire to seek care, and their perception of the care quality received. CONCLUSIONS: PWUS face significant challenges when seeking care in the ED. Given that EDs are a main site of healthcare utilization, there is an urgent need to better support staff in the ED to improve care experiences among PWUS. Based on the findings, three recommendations are proposed: (1) Integration of an equity-oriented approach into the ED, (2) Widespread training on substance use, and (3) Investment in expert resources and services to support PWUS.

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Background: Rapid treatment is critical in managing acute ischemic stroke (AIS) to improve patient outcomes. Various strategies have been used to optimize this treatment process, including the Acute Stroke Protocol (ASP) activation, and minimizing the duration of key performance metrices, such as door-to-needle time (DNT), CT-to-needle time (CTNT), CT-to-groin puncture time (CTGP), and door-to-groin puncture time (DGPT). However, identifying the delay-causing sub-tasks within the ASP could yield novel insights, facilitating optimization strategies for the AIS treatment process. Methods: This two-phase prospective observational time and motion study aimed to identify sub-tasks and compare their respective durations involved in the treatment process for AIS patients within ASPs. The study compared sub-task durations between "routine working hours" and "evenings and weekends" (after-hours), as well as between stroke neurologists and non-stroke neurologists. Additionally, the established performance metrices of AIS were compared among the aforementioned groups. Results: Phase 1 identified and categorized 34 sub-tasks into five broad categories, while Phase 2 analyzed the ASP for 389 patients. Among the 185 patients included in the study, 57 received revascularization treatment, with 30 receiving intravenous (IV) thrombolysis only, 20 receiving endovascular thrombectomy (EVT) only, and 7 receiving both IV thrombolysis and EVT. Significant delays were observed in sub-tasks including triage, registration, patient history sharing, treatment decisions, preparation of patients, preparation of thrombolytic agents, and angiosuite preparation. The majority of these significant delays (P < 0.05) were observed when were performed by a non-stroke neurologist and during after-hours operations. Furthermore, certain sub-tasks were exclusively performed during after-hours or when the treatment was provided by a non-stroke neurologist. Consequently, DNT, CTNT, and CTGP were significantly prolonged for both non-stroke neurologists and off-hours treatment. DGPT was significantly longer only when the ASP was conducted by non-stroke neurologists. Conclusions: The study identified several sub-tasks that lead to significant delays during the execution of the ASP. These findings provide a premise to design targeted quality improvement interventions to optimize the ASP for these specific delay-causing sub-tasks, particularly for non-stroke neurologists and after-hours. This approach has the potential to significantly enhance the efficiency of the AIS treatment process.

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Purpose: Since the introduction of National Emergency Access Targets (NEATs) in 2012 there has been little research examining patients admitted to the intensive care unit (ICU).We assessed differences in baseline characteristics and outcomes of patients admitted from the Emergency Department (ED) to the ICU within 4 hours compared with patients who were not. Methods: This retrospective observational study included all adults (≥18 years old) admitted to the ICU from the ED of Austin Hospital, Melbourne, Australia, between 1 January 2017 and 31st December 2019 inclusive. Results: 1544 patients were admitted from the ED to the ICU and 65% had an ED length of stay (EDLOS) > 4 hour. Such patients were more likely to be older, female, with less urgent triage category scores and lower illness severity. Sepsis and respiratory admission diagnoses, and winter presentations were significantly more prevalent in this group.After adjustment for confounders, patients with an EDLOS > 4 hours had lower hospital mortality; 8% v 21% (p = 0.029; OR, 1.62), shorter ICU length of stay 2.2 v 2.4 days (p = 0.043), but a longer hospital length of stay 6.2 v 6.8 days (p = < 0.001). Conclusion: Almost two thirds of patients breached the NEAT of 4 hours. These patients were more likely to be older, female, admitted in winter with sepsis and respiratory diagnoses, and have lower illness severity and less urgent triage categories. NEAT breach was associated with reduced hospital mortality but an increased hospital length of stay.

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BACKGROUND: Sepsis, a life-threatening infection-induced inflammatory condition, has significant global health impacts. Timely detection is crucial for improving patient outcomes as sepsis can rapidly progress to severe forms. The application of machine learning (ML) and deep learning (DL) to predict sepsis using electronic health records (EHRs) has gained considerable attention for timely intervention. METHODS: PubMed, IEEE Xplore, Google Scholar, and Scopus were searched for relevant studies. All studies that used ML/DL to detect or early-predict the onset of sepsis in the adult population using EHRs were considered. Data were extracted and analyzed from all studies that met the criteria and were also evaluated for their quality. RESULTS: This systematic review examined 1942 articles, selecting 42 studies while adhering to strict criteria. The chosen studies were predominantly retrospective (n = 38) and spanned diverse geographic settings, with a focus on the United States. Different datasets, sepsis definitions, and prevalence rates were employed, necessitating data augmentation. Heterogeneous parameter utilization, diverse model distribution, and varying quality assessments were observed. Longitudinal data enabled early sepsis prediction, and quality criteria fulfillment varied, with inconsistent funding-article quality correlation. CONCLUSIONS: This systematic review underscores the significance of ML/DL methods for sepsis detection and early prediction through EHR data.

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BACKGROUND: The Emergency Department (ED) is not always the optimal place for people with palliative care needs but is the most common route for treatment when urgent care is sought. The aim of this study,''REasons for PalLIative Care Admissions (REPLICA)' was to explore the perspectives of ED healthcare professionals of hospital admission or discharge via ED for palliative care patients. METHODS: This is a sequential mixed methods study comprising (i) quantitative descriptive analysis of Hospital Episode Statistics (HES) of palliative care patients (code Z51.5) who were admitted through ED in a West Midlands Hospital and for the rest of England; (ii) in-depth semi-structured interviews with 17 ED staff which were analysed using thematic content analysis. RESULTS: Over the four years (2013-2017), 430,116 people admitted through ED were identified with a Z51.5 diagnosis code, 0.6% (n = 2736) of whom were from the West Midlands Hospital. The most common reasons for palliative care patients' admission to hospitals across England were for care of chronic kidney disease, cancers and urinary tract infections. Five themes were elicited from the qualitative analysis: (1) Providing palliative care in ED is challenging, due to factors including lack of training in palliative care and the unsuitable environment. (2) Patients go to ED due to challenges in community management such as inappropriate referrals and no care plan in place. (3) Health system influences admission and discharge decisions, including bed availability and being unable to set up community services out-of-hours. (4) Discussion with patient about treatment and end of life care needs to be outside of ED whilst the patient is still well enough to express their wishes. (5) Improving services for patients with palliative care needs. Recommendations include short training sessions for ED staff and accessing palliative care professionals 24/7. CONCLUSIONS: A large number of palliative care patients visit ED and are admitted to hospital for care; there is an urgent need to prevent patients attending the hospital through the establishment of a coordinated and dedicated service to support palliative care patients in the community.

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Background: Patients seeking emergency care for self-harm and suicidality report varying experiences from being believed and taken seriously to not being believed and taken seriously. Epistemic injustice provides a conceptual framework to explore how peoples' experiences of self-harm and suicidality are believed or not. We use an empirical method -conversation analysis - to analyze epistemics in clinical communication, focusing on how knowledge is claimed, contested and negotiated. In courtroom, police and political interaction, conversation analysis has identified communication practices implying implausibility in a person's story to contest and recharacterize their accounts. Aims: To investigate communication practices in Emergency Department (ED) biopsychosocial assessments that may (1) undermine, imply implausibility and recharacterize or (2) accept peoples' experiences of suicidal ideation and self-harm. Methods: Using conversation analysis, we micro-analyzed verbal and non-verbal communication in five video-recorded biopsychosocial assessments with people presenting to the ED with self-harm or suicidal ideation, and conducted supplementary analysis of participants' medical records and post-visit interviews. We present three cases where experiences were not accepted and undermined/recharacterized and two cases where experiences were accepted and validated. Results: When peoples' experiences of suicidality and self-harm were not accepted or were undermined, questioners: did not acknowledge or accept the person's account; asked questions that implied inconsistency or implausibility ("Didn't you tell your GP that you were coping okay?"); juxtaposed contrasting information to undermine the person's account ("You said you were coping okay before, and now you're saying you feel suicidal"); asked questions asserting that, e.g., asking for help implied they were not intending to end their life ("So when you called 111 what were you expecting them to do"); and resistinged or directly questioned the person's account. Multiple practices across the assessment built on each other to assert that the person was not suicidal, did not look or act like they were suicidal; that the person's decision to attend the ED was not justified; that an overdose was impulsive and not intended to end life; asking why the person didn't take a more harmful medication to overdose; that self-harming behaviors were not that serious and should be in the person's control. Alternative characterizations were used to justify decisions not to provide further support or referrals to specialist services. At times, these practices were also delivered when speaking over the patient. When peoples' experiences were accepted, practitioners acknowledged, accepted, validated suicidality/self-harm and introduced a shared understanding of experiences that patients found helpful. Non-verbal feedback such as nodding and eye contact was central in acceptance of patients' accounts. Conclusion: These findings advance our understanding of how peoples' experiences of suicidality or self-harm are undermined or accepted in mental health encounters in the ED. They have important clinical implications: patients report that when their experiences are not accepted or undermined, this makes them more distressed, less hopeful about the future and discourages future help-seeking when in crisis. Conversely, acknowledging, accepting and validating suicidality/self-harm and introducing a new ways of understanding peoples' experiences may make people less suicidal and more hopeful, generates shared understanding and encourages future help-seeking.