Emergency Medicine Journal

Background and importance Emergency Department (ED) crowding is an increasing public health concern, with evidence of harms to patients, the public and healthcare systems. When the number of patients requiring emergency care exceeds the capacity of EDs, operational decisions must be made regarding the best place of care for patients. It is not known if there is an association between place of escalation area care (for example 'ramping' in an ambulance, or in an ED corridor) and patient outcomes. Objective(s) This study aimed to assess the association between the relative proportion of all escalation area care that a site provided in an ambulance (the Ambulance:Escalation Index) and all-cause 28-day mortality. Design A secondary analysis of a prospective cohort study. Adult patients of 16 years or older, attending EDs in England, Wales and Northern Ireland in March 2025. Intervention or exposure (if any) The Ambulance:Escalation Index, a site-level indicator of the proportion of all time in escalation area care provided in an ambulance. Outcome measures and analysis The profile of site-level ambulance use was presented descriptively. Multivariable survival analysis was used to assess the primary outcome, all-cause 28-day mortality. Main results Of 131 EDs using escalation area, 82 (62.6%) used ambulances as a place of escalation area care. There was a significant association between a site's increasing use of ambulances as escalation areas and mortality; for each 5% increase in the proportion of a site's total escalation area care delivered in ambulances, there was a 2.1% increase in the hazard of death by 28 days (HR 1.021, 95% CI 1.002-1.041, p=0.032). Conclusion Emergency Department crowding is associated with poor outcomes irrespective of where departments are forced to deliver care; however this study suggests that there is excess mortality where escalation area care is more often delivered in ambulances.

Background: Pain management post-rib fractures is often difficult. High pain levels can lead to altered respiratory mechanics and delayed complications such as poor mobility. Whilst as-needed Opioids are the mainstay of treatment, the potential negative side effects have led to research into alternatives such as kinesiotaping, single-shot chest wall regional anaesthesia, and incentive spirometry. Methods: A systematic review was undertaken using Medline (Ovid), Emcare, CINAHL, and the Cochrane Library. Article review and selection were undertaken by two independent reviewers using Covidence. Quality was assessed through the Mixed Methods Appraisal Tool (MMAT). Where appropriate, meta-analysis was undertaken using R studio with a REML random effects model. Forest plots were completed, and Higgins I2 and Chi2 were calculated. Results: Kinesiotaping demonstrates a reduced pain score than medication alone (SMD: -1.87, 95% CI [-2.65, -1.08]), as did single-shot chest wall regional anaesthesia (SMD: -0.79 [-1.15, -0.01]). The regional anaesthesia group had lower opioid consumption (SMD -0.84 [-2.18, 0.50]) and reduced length of hospital stay (SMD: -0.18 [-0.39, 0.03]) but no change in the risk of complications (RR: 0.92 [0.36, 2.36]). The incentive spirometry group had an increased risk of complications (RR: 3.35 [0.68, 16.44]); however, the causative effect could not be inferred due to significant confounding variables. Conclusions: Low-to-moderate certainty evidence suggests that kinesiotaping and single-shot chest wall regional anaesthesia may reduce pain in adult emergency department patients with rib fractures. However, evidence is insufficient to show a clear benefit for opioid reduction, length of stay, or complications. The current evidence does not support routine use of incentive spirometry in this setting, but the evidence is severely confounded by baseline injury severity in the current published studies.

Background Emergency Department (ED) crowding is an international crisis primarily driven by exit block. Point of care (POC) cardiac biomarker testing and reduced sampling intervals have been proposed to mitigate crowding by improving throughput, but whole-ED operational impacts remain poorly understood, and evaluations often rely on vulnerable observational designs. This study aimed to assess whether introducing POC high-sensitivity troponin testing and reduced sampling intervals changed whole-ED flow metrics, and to test the robustness of interrupted time series (ITS) methodology in this setting. Methods A multi-centre controlled interrupted time series (CITS) across two large urban intervention EDs and one untreated control ED in Glasgow, UK. The intervention combined whole-blood POC high-sensitivity troponin testing with a reduction in sampling intervals from 3 to 2 hours. Outcomes included daily ED admissions, mean occupancy, maximum occupancy, and mean length of stay. Analyses used a window of 120 days either side of each implementation date. Effects were evaluated using segmented ITS models, with and without controls, with permutation tests against 147 pre-intervention placebo dates. The minimum detectable effects of a similar study, applied to a national dataset, were simulated. Results Across 483,412 presentations to the intervention sites, the intervention produced no statistically significant change in any whole-ED flow metric against the untreated control at either site. Analysed alone, one intervention site appeared to show reductions in mean occupancy (-6.08, 95% CI -12.04 to -0.12) and maximum occupancy (-7.60, -14.47 to -0.73); the untreated control department produced reductions in the same direction at the same date, and both estimates attenuated to the null once the control was applied. Under a pre-specified 14-day transition specification the reductions in the untreated department reached statistical significance while those at the treated site did not. The study was limited by power due to the study window and limited control pool. Simulation demonstrated that a national dataset has the potential to provide operationally feasible and clinically important findings. Conclusion POC cardiac biomarker testing and reduced sampling intervals did not detectably improve whole-ED flow, though the design was underpowered. More importantly, uncontrolled ITS designs are highly vulnerable to confounding in complex healthcare systems; evaluations of operational interventions must utilise concurrent controls, and routinely report falsification tests.

Objectives Emergency Department (ED) crowding is an international concern, predominantly caused by 'exit block', the lack of availability of inpatient beds for those requiring admission. The implementation of Flow Navigation Centre Plus (FNC+) services in Scotland aimed to reduce self-presentation to EDs and reduce crowding by providing remote clinical assessment for patients contacting urgent care by telephone and professional-to-professional advice on patient pathways, but their effectiveness is unknown. This study aimed to estimate the effect of board-wide implementation of FNC+ on ED attendances and long waits during the first year of FNC+ operation. Methods Controlled interrupted time series using weekly, publicly reported Public Health Scotland data. The intervention was implementation of the FNC+ in NHS Lanarkshire on 1 April 2024. Counts were summed across constituent sites and percentages derived from board totals. Co-primary outcomes were ED attendance volume and the proportions of attendances spending more than 4, 8 and 12 hours in the department. Segmented regression was fitted with contemporaneous control boards, seasonal terms, and accounted for autoregression. Results 118 pre-intervention and 52 post-intervention weeks were analysed across all 3 EDs in the implementing board. Attendances showed no detectable step change (+1.20%; 95%CIs -0.66 to +3.10) relative to the counterfactual. The estimated effect increased across follow-up, however, changing by +3.95% over 52 weeks (95% CI +0.36 to +7.67%). There was no significant step change in the proportion of attendances waiting more than 4 hours following the intervention (+1.74%; 95%CIs -0.71 to 4.20%). Some transition and structural sensitivity analyses demonstrated significant deteriorations in ED performance, and increased attendances, in the year following implementation, and none demonstrated improvements. Conclusions Board-wide implementation of a Flow Navigation Centre Plus was not associated with a step change in ED attendances or in long waits, but there is some evidence that attendances increased and long waits increased in the year following implementation. Their provision of supply-sensitive care is a possible mechanism. Additionally, given their action at the point of input, aiming to divert patients from ED attendance, it is unlikely that such services could relieve a constraint due to exit block, the availability of inpatient care for those requiring admission.

Background: Predictive risk stratification tools are widely used to support proactive care for older adults, yet head-to-head external validation within local English health systems remains limited. Eclipse-PRISM implemented in UK primary care settings, while the Johns Hopkins Adjusted Clinical Groups (ACG) system provides risk scores derived from diagnosis groupings and healthcare utilisation data. Aim: To externally validate and compare PRISM and Johns Hopkins ACG scores for predicting emergency hospital admission among older adults in an English integrated care system. Methods: We conducted a retrospective cohort study in the Norfolk and Waveney Integrated Care System. Individuals aged 75 years and over at the index date with valid PRISM and ACG emergency admission risk scores and linkage to hospital activity data were included. The primary outcome was 1 or more emergency hospital admission within 1 month. Discrimination was assessed using the area under the receiver operating characteristic curve (AUC), with paired AUCs compared using DeLongs test. Calibration was evaluated using calibration plots and quantified using calibration intercept and slope from logistic recalibration models. Overall accuracy was summarised using the Brier score. Clinical utility was assessed using decision curve analysis (DCA). Results: The cohort included 114,407 patients aged 75 years and over; 2,136 (1.87%) had 1 or more emergency admission within 1 month. ePRISM showed higher discrimination than Johns Hopkins ACG (AUC 0.860 [95% CI 0.852 to 0.867] vs 0.739 [95% CI 0.728 to 0.749]; difference-in-AUC 0.121 [95% CI 0.111 to 0.130]; DeLong p<0.0001), with consistent differences across age and sex subgroups. Calibration differed materially: ePRISM showed closer agreement between predicted and observed risks, whereas Johns Hopkins ACG systematically overpredicted risk across much of the range. Brier scores favoured ePRISM (0.017 [95% CI 0.017 to 0.018] vs 0.051 [95% CI 0.050 to 0.051]). In DCA, ePRISM provided higher net benefit across clinically plausible thresholds, while Johns Hopkins ACG showed lower or negative net benefit across much of the threshold range. Conclusions: In this English older population, ePRISM demonstrated higher discrimination and more favourable apparent calibration, overall accuracy and decision-analytic performance for predicting 1-month emergency admission than Johns Hopkins ACG. Model selection for short-term risk stratification should therefore consider calibration and clinical utility alongside discrimination, with local validation and recalibration where appropriate before implementation.

Background: Early defibrillation is a key factor of survival following out of hospital cardiac arrest (OHCA). In the United Kingdom, initial anterior lateral (AL) defibrillator pad placement is standard practice. However, anterior posterior (AP) pad positioning has been proposed as a method of improving current flow through the myocardium particularly in cases of refractory ventricular fibrillation (VF). Concerns remain regarding potential delays to defibrillation associated with alternative pad placement strategies and the practical application of AP positioning. Objective: We conducted two consecutive simulation studies to explore whether there is a difference in the time taken to apply defibrillator pads, and placement accuracy, between AP and AL positions during simulated OHCA. Methods: This research study comprised of two simulation studies. First, we evaluated pad placement accuracy before and after written instruction showing optimal pad placement (RESTART SIM accuracy). Second, we undertook a randomised crossover examining time to pad placement, timing to successful pad application was recorded for each attempt (RESTART SIM speed). Results: RESTART SIM (accuracy) out of 14 participants 50% correctly placed AL pads and 14% correctly placed AP pads initially. Following provision of guidance this increased to 93% for AL but remained at 14% for AP placement. 9 participants completed RESTART SIM (speed). Mean AP pad placement time was 14.2 seconds and standard deviation of 2.64, compared with 10.6 seconds for AL placement and a standard deviation of 4.24. AP first strategy mean placement time was 15.3 seconds and mean AL placement time was 11.5 seconds. In AL first mean AP placement time was 12.8 seconds and mean AL placement time was 9.6 seconds. Conclusion: AP pad placement whilst slower than AL placement the time difference of 4 seconds is unlikely to be clinically significant. However, without guidance, both AL and AP placements were often inaccurate. After a guidance picture AL placement was increased but AP remained poorly placed.

Background: High-quality, longitudinal data from the Emergency Department (ED) are essential for understanding acute illness trajectories and for developing clinically deployable prediction models. However, most existing ED datasets are static, limited in modality or disconnected from long-term outcomes or biomaterials. Methods: We describe a two-year sample of Acutelines, a continuously operating ED-based data-biobank infrastructure at the University Medical Center Groningen. Acutelines is embedded in routine care and captures the full acute care trajectory and uses a stepped consent procedure. It integrates demographics, vital signs, laboratory results, diagnoses, treatments, waveforms, patient-reported outcomes, and prospectively collected biomaterials. Data are linked to in-hospital outcomes and post-discharge mortality. Results: The presented dataset comprises 29,314 ED visits from 18,850 adult patients. Clinical variables are available for nearly all visits, with additional data and questionnaires (n=4,963) and biomaterials (n=2,723) collected in predefined subgroups. Associations between early triage features (National Early Warning Score, vital signs, diagnostic categories) and outcomes, illustrate the clinical depth and longitudinal value of the infrastructure. Conclusion: Acutelines is a living, continuously expanding research infrastructure. Its combination of ED-first inclusion, multimodal data, linkage to long-term outcomes, and availability of biomaterials distinguishes it from existing datasets. Acutelines provides a robust foundation for hypothesis generation, translational research, and the development, validation, and benchmarking of data-driven clinical decision support tools and biomarker tests in acute medicine, while its ongoing expansion enables prospective studies and interventional research. Trial registration: Acutelines is registered at ClinicalTrials.gov under trial registration number NCT04615065.

Background Decision-making in emergency services involving the allocation of scarce resources is a key challenge for large, complex organisations required to prioritise demand against multiple, often competing criteria. Emergency Medical Dispatch is a case in point, where Enhanced and Critical Care Teams (ECCTs) represent a scarce and lifesaving clinical resource. Despite its operational and system-level significance, the allocation of ECCTs remains under-researched. Methods We conducted a methodological development study using the P.A.T.H.S. framework (Participants, Artefacts, Transition Stages, Historicity, Setting). We designed and piloted this in our previous work under the 999 R.E.S.P.O.N.D. project, which examined the decision-making process for ECCT dispatch. We applied P.A.T.H.S. to 17 dispatch cases (comprising 100 decision-making episodes). We analysed five data sources: recordings of emergency calls and internal dispatch-related interactions, sequence-of-events records, policy documents, and ethnographic observations. A four-phase analysis--indexing & data mapping, transcription & coding, charting, and synthesising & outputs--was undertaken taking Interactional Sociolinguistics as the theoretical approach and methodology. Results P.A.T.H.S. enables the mapping of non-linear, multifactorial textual trajectories across human and non-human actors. The case example presented herein illustrates how information on key risk indicators (e.g. mechanism of injury) were often delayed, fragmented, or lost between the caller, call-handler, and written records. P.A.T.H.S. provides a framework and analytical tool capturing the textual trajectory of information flow, and trace how dispatch decision making unfolds. We subsequently developed a template and codebook for other researchers to further study complex decision making in multi-actoral systems using a textual trajectory approach. Conclusion This methodological development work demonstrates the potential of P.A.T.H.S. to capture and clarify complex decision-making processes. P.A.T.H.S. offers a practical and theoretically grounded framework for future research, training, and policy that addresses risk points in communication between oral and written forms among teams of actors, to support optimal deployment of scarce resources.

Low- and middle-income countries bear over 90% of global injury-related mortality yet largely lack formal prehospital emergency systems, leaving laypersons as the primary point of care. In Pakistan, nearly 90% of out-of-hospital cardiac arrests are witnessed, but bystander resuscitation rates remain critically low, attributable to knowledge deficits, absent Good Samaritan protections, and unaddressed psychological barriers. Rigorous multi-domain evaluations of first aid training that simultaneously examine knowledge acquisition, self-efficacy, attitudinal barriers, and medium-term retention remain limited in South Asian contexts. A single-centre, single-arm, pre-post quasi-experimental study evaluated a structured multi-station first aid workshop at a tertiary academic institution in Karachi. A convenience sample of 132 health-adjacent trainees completed six competency-based stations covering cardiopulmonary resuscitation, haemorrhage control, fracture management, foreign body airway obstruction, and burns, delivered through didactic teaching, video demonstration, mannequin-based simulation, and facilitated scenario exercises. Paired data were available for 68 participants on knowledge, 100 on self-efficacy, 65 on perceived barriers, and 15 at three-month follow-up. Knowledge scores increased from a mean of 5.9 to 9.1 out of 13 (Cohen's d = 1.06), a large effect. Statistically significant item-level improvements were observed in 9 of 13 items, with the greatest gains in chest-compression rate, first response to witnessed cardiac arrest, and choking management. Self-efficacy improved significantly across all seven assessed domains, with mean gains of approximately 38 to 55 points on a 100-point scale. Perceived barriers, including fear of legal liability, patient harm, and performance panic, remained unchanged. Exploratory three-month knowledge retention averaged approximately 96% among returners, although this is likely a modest upper bound, as returners scored marginally higher post-training and the comparison was underpowered. The intervention produced substantial short-term gains in knowledge and self-efficacy. The persistence of psychological and legal barriers despite these gains suggests that cognitive instruction alone is insufficient to translate preparedness into bystander action, underscoring the need for integrated legal education and barrier-focused psychological components in future curricula.

Acute lower-limb arterial thrombosis is a vascular emergency that often reaches internists and emergency physicians before a vascular specialist, and data from Central Asia are scarce. We asked which patient-level factors mark limb-threatening severity at first presentation, and whether routine admission laboratory tests add to that judgement. We studied a registry of 288 consecutive patients hospitalised with acute lower-limb arterial thrombosis between 2017 and 2022 at a tertiary centre in Karaganda, Kazakhstan. Severity was graded with the Savelyev classification, with grades IIB-IIIA defined as limb-threatening. Associations were tested by logistic regression with Firth-penalised and bootstrap sensitivity analyses, and predictors of tissue loss were modelled separately. Patients were mostly elderly men (median age 67 years, 72.2% male) with a heavy atherosclerotic burden (hypertension 74.0%, coronary disease 54.9%, diabetes 19.1%, prior revascularisation 35.8%). At presentation 142 (49.3%) had limb-threatening ischaemia and 31 (10.8%) tissue loss. Independent markers of limb-threatening severity were diabetes (adjusted odds ratio 2.15, 95% CI 1.02-4.55), hypertension (2.14, 1.05-4.37), tissue loss (2.55, 1.01-6.45) and lower body-mass index (0.71 per 5 kg/m2, 0.52-0.97). Admission haematology, coagulation and metabolic values did not differ between severity groups (all p>0.10), and the chronic-disease model discriminated modestly (area under the curve 0.68). Low body-mass index (0.49 per 5 kg/m2, p=0.005) and prior amputation (7.08, p=0.04) independently predicted tissue loss. Limb-threatening severity tracked the chronic vascular-metabolic phenotype rather than the admission laboratory profile, which did not discriminate. Low body weight was a consistent danger signal. Bedside assessment, not routine bloods, should anchor early triage.

We present our Stage-1 Registered Report as a full clinical trial article with all methods in past tense and including mock results, table and figures for the primary analysis. To remind the reader that this Stage-1 article is written before data collection, we highlight in color that these mock results are only for illustrative purposes and will be replaced by the actual results in the Stage-2 Registered Report. Background In patients experiencing out-of-hospital cardiac arrest, optimization of oxygen delivery during cardiopulmonary resuscitation is a critical. Although both positive end-expiratory pressure (PEEP) and zero end-expiratory pressure (ZEEP) are employed during CPR, their respective impacts on clinically relevant outcomes is yet to be clearly established. Methods This investigator-initiated, pragmatic, registry-based, multicenter, triple-blind randomized controlled superiority trial evaluates whether applying 8 cm H2O PEEP during cardiopulmonary resuscitation improves outcomes compared with ZEEP in adults with non-traumatic, non-drowning out-of-hospital cardiac arrest. Pre-randomized CPR kits (1:1 PEEP vs. sham) were used by ambulance sites during manual ventilation throughout the resuscitation process. The primary analysis was conducted in the principal stratum of patients who received either a supraglottic airway or endotracheal tube. The primary outcome was neurological status at hospital discharge measured by a utility-weighted score on the modified Rankin Scale. Secondary outcomes included prehospital return of spontaneous circulation, 30-day survival, and 6-month quality of life. The primary safety outcome was clinically significant pneumothorax.

Objectives People with mental health conditions experience increased rates of diagnostic errors and delays in acute treatment. While causes such as diagnostic overshadowing (misattribution of physical symptoms to mental health conditions) are well documented, less attention has been paid to the organisational and structural conditions that shape diagnostic work. This study examines how physical illness is diagnosed in patients with mental health conditions in emergency departments (EDs), with a focus on the structural conditions that enable or constrain safe diagnostic practice. Method We conducted a multi-site ethnography across three purposively selected EDs in England between April 2023 and April 2024, varying in size, population demographics, and local service configuration. Data were collected through 284 hours of non-participant observation and 20 semi-structured interviews with ED staff. Results Our analysis identified four recurring structural gaps that shaped the conditions under which physical health diagnosis took place for patients with mental health conditions: a design gap, whereby targets and physical layouts constrained diagnostic reasoning; a preparedness gap, reflecting the lack of structural support to allow staff to act on their existing knowledge and skills; a coordination gap, reflecting fragmented ownership and the challenges of joint assessment across mental and physical healthcare teams; and an expectation gap, whereby unmet need elsewhere in the system increased demand for ED services that were beyond its formal scope. These gaps made diagnostic errors and delay more likely for patients with mental health conditions seeking physical healthcare in the ED. Conclusions As new dedicated mental health EDs are introduced in England, there is an opportunity to avoid reproducing these structural gaps in new settings. Our study suggests that improving physical healthcare for patients with mental health conditions requires changes to how EDs are designed, resourced and supported, and how they connect with the wider health and care system. Keywords: mental health, diagnostic inequality, emergency departments

Study Objective Little is known about where in hospital care for multiple long-term conditions (MLTC) is delivered. We aimed to describe pathways of care (ward transfers) and outcomes for people admitted to hospital for unscheduled care by MLTC status and other key sociodemographic characteristics. Design and setting Analysis of routinely-collected electronic health records from a large acute UK hospital. Participants Adult unscheduled care admissions from 1st July 2018 to 30th June 2019. The presence of two or more of 59 long-term conditions was ascertained using ICD-10 codes from previous hospital discharges. Main outcome measures Markov state transition probabilities were derived for ward moves and compared for MLTC vs no MLTC, age, sex, ethnicity and neighbourhood deprivation. Outcomes (length of stay, death, readmission, move from definitive ward) and time spent in emergency and assessment departments were compared between subgroups. Results A total of 33,252 adults, mean age 56.0 (SD 21.9) years were analysed; 14,834 (42.4%) had MLTC. People with MLTC were more likely to die in hospital (4.2 vs 1.9%, p<0.001), transfer to internal medicine wards or older peoples medicine wards, were less likely to transfer to surgical wards, had longer median length of stay (1.83 vs 0.69 days, p<0.001), stayed longer in acute medical units (15.5 vs 9.6 hours, p<0.001), and were more likely to move from their definitive ward (18.2 vs 16.4%, p=0.002). Conclusion Unscheduled hospital care pathways are complex and differ for people with MLTC, who have worse outcomes and may be less likely to receive optimal care.

Background: General purpose language models such as ChatGPT are increasingly used by physicians and triage nurses during emergency triage. A recent study reported 51.6% undertriage of emergencies when patients queried ChatGPT directly (Ramaswamy et al., 2026). DR. INFO is an agentic AI based clinical assistant that retrieves over a curated clinical knowledge base, and an MTS specific retrieval configuration is available in which the system also retrieves the Manchester Triage System (MTS) textbook at inference time. The safety of these systems as a triage adjunct against a structured framework has not been characterised. Methods: We adapted the clinical scenarios published by Ramaswamy et al. and mapped them to the Manchester Triage System, yielding 39 emergency cases covering all five MTS priority levels. Each case was evaluated in two variants, one without and one with the objective clinical data block (vital signs, examination findings, and laboratory results), and permuted across two genders, giving 156 prompts per condition. Three systems were tested with and without a misleading GP referral statement prepended as an anchoring statement, giving 312 prompts per system: DR. INFO Baseline, DR. INFO with MTS retrieval, and OpenAI GPT-5.1. The primary outcome was the undertriage rate on the ordered MTS scale, tested with Fisher's exact test. Results: GPT-5.1 undertriaged 44.2% of cases (69/156; 95% CI 36.7 to 52.1), including 75.0% of Red and 73.4% of Orange presentations. Both DR. INFO configurations undertriaged 11.5% of cases (18/156; 95% CI 7.4 to 17.5; Fisher's exact p = 1.0 x 10^-10 versus GPT-5.1). GPT-5.1 produced 6 dangerous misses (3.8%), and both DR. INFO configurations produced none (p = 0.030). When the anchoring statement was prepended, GPT-5.1 undertriaged 8 of 8 Red cases, while both DR. INFO configurations continued to undertriage none. Adding objective clinical data to the input reduced undertriage in DR. INFO with MTS retrieval from 19.2% to 3.8% (p = 0.005). DR. INFO Baseline and GPT-5.1 showed no comparable change. There was no significant effect of gender. Conclusion: On this benchmark, replacing a general purpose language model with an agentic retrieval augmented system over a curated clinical knowledge base substantially reduced the undertriage and dangerous miss rates. Adding retrieval of the Manchester Triage System textbook to the agentic system was further associated with a reduced susceptibility to the anchoring statement and with an appropriate change in the assigned MTS priority when objective clinical data became available. Of the three configurations evaluated here, only DR. INFO with MTS retrieval combined a clinically conservative assignment at first contact with appropriate updating as additional clinical information arrived.

Objectives Emergency department (ED) crowding is recognised as an important public health concern internationally, and is driven principally by exit block, the shortage of inpatient beds for patients requiring admission. This study aimed to evaluate whether a complex intervention targeting hospital occupancy improved ED patient flow, and quantified the change in attendances. Methods A controlled interrupted time series using weekly, publicly reported Public Health Scotland data from 1 January 2022 to 1 February 2026. The multi-component intervention focused on reducing hospital occupancy and included additional adult social care funding; engagement with regional social care providers; accelerated implementation of the Discharge without Delay programme; re-evaluation of whole-hospital escalation thresholds and response; resource and data supporting inpatient department reductions in length of stay; and additional investment in remote clinical assessment. The intervention commenced at a large tertiary ED on 01 February 2025. Primary outcomes were the proportions of attendances spending [&ge;]4, [&ge;]8 and [&ge;]12 hours in the ED. The secondary outcome was attendance volume. Segmented regression was fitted with a contemporaneous control series, seasonal terms and autoregressive moving average errors. Long waits were additionally illustrated as potentially avoided deaths. Results The analysis covered 161 pre-intervention and 52 post-intervention weeks. Relative to pre-intervention levels, the proportion of attendances waiting over 4 hours fell by 10.4% (95% CI 1.6 to 19.2%), by 16.4% (95%CI 1.3 to 31.5%) over 8 hours and by 24.3% (95%CI 2.6 to 46.1%) over 12 hours. Using established associations between long ED waits and excess mortality, by one-year the intervention was potentially associated with 54 fewer excess deaths (95%CI 19 to 93). Attendances rose by 3.8% (95%CI 1.3 to 6.4%) against the counterfactual. Conclusions A complex intervention targeting hospital occupancy was associated with a reduction in long ED waits despite rising attendances. Interventions addressing hospital occupancy can meaningfully improve ED crowding.

Background. A primary constraint on the capacity of EMS programs to meet industry demand is psychomotor instruction and verification, requiring direct observation of each student by a qualified evaluator. Whether AI video analysis can relieve it is untested; none has been applied to EMS skill examination or compared with human examiners. Objective. To quantify human EMS evaluator inter-rater reliability and evaluate an AI video-analysis platform against it. Methods. In a prospective, fully crossed study, five certified EMS evaluators and an AI platform independently scored identical video-recorded EMT performances of cervical collar application (n=15), bag-valve-mask (BVM) ventilation (n=14), and medical assessment (n=15) on dichotomous checklists with critical-failure criteria. Agreement was assessed at item, score, and decision levels using Fleiss' kappa, Krippendorff's alpha, Gwet's AC1, and ICC(2,1)/ICC(2,k). Results. Human item agreement was moderate (kappa 0.409 to 0.467), as was single-rater reliability (ICC(2,1) 0.539 to 0.694), against good panel reliability (ICC(2,k) 0.854 to 0.919). Recorded pass/fail agreement was fair (kappa 0.297 to 0.388) and critical-failure agreement near zero for two skills (kappa 0.028, 0.119). AI alignment tracked rubric observability rather than task complexity: r = 0.857 (collar, exceeding every human), -0.173 (BVM), 0.664 (medical), and it was most lenient on two skills. Conclusions. Human evaluators are an imperfect standard, especially on critical failures. The AI was a legitimate additional rater where checklist items were discrete and visually verifiable, but not where credit required judging continuous quantities such as ventilation rate, volume, or suction duration. Defensible uses are formative and archival, not summative. These results reflect an early, non-specialist configuration: a baseline, not a limit.

Background: Focused cardiac ultrasound (FoCUS) is operator dependent and requires coordinated probe manipulation, image interpretation and iterative visual feedback. Existing assessment approaches often emphasize final image quality or expert rating. We developed Expert in Ultrasound Skills (EXUS) , a platform that synchronizes transducer-mounted inertial measurement unit (IMU) data with ultrasound video, and evaluated its technical feasibility during FoCUS acquisition. Methods: This observational pilot study included 6 operators performing two repetitions of a four-view FoCUS protocol, yielding 12 analytical sessions and 48 planned acquisitions. Feasibility was defined by acquisition completion, video availability, start/stop events, fused IMU-video windows, temporal coverage, complete human label entries and IMU integrity. A 100-image Likert rating task was used to summarize pairwise inter-rater agreement for still-frame image quality assessment. Results: All 48 planned acquisitions were completed with video, start/stop events, fused windows and complete human label entries. Temporal coverage was at least 90% in 47/48 acquisitions. IMU integrity endpoints exceeded the 80% threshold: 43/48 acquisitions had no extreme IMU-derived artifact, 43/48 had no active-segment IMU restart and 44/48 had no complete motion flatline. Mean pairwise exact agreement for the Likert task was 38.9%, with mean quadratic-weighted Cohen's kappa of 0.564. Post hoc profiles varied across duration, visual quality, mechanical load and motor efficiency. Conclusions: EXUS was technically feasible for synchronized IMU-video capture during FoCUS. The pilot supports multimodal acquisition data as a way to describe technical profiles and generate formative feedback hypotheses, but the post hoc indices are not validated competency measures. Keywords: focused cardiac ultrasound; point-of-care ultrasound; inertial measurement unit; medical education; deliberate practice

OBJECTIVES: Population aging is a major contributor to increasing demand for emergency medical services (EMS), yet EMS workforce projections based on population data remain limited. This study projected future EMS incident volume and clinician workforce requirements in Florida from 2026 to 2035 based on historical data on EMS response records to inform workforce planning. METHODS: We conducted a retrospective, population-based secondary analysis and forecasting study using de-identified state-wide emergency EMS response records from Florida's Emergency Medical Services Tracking and Reporting System (EMSTARS) spanning January 1, 2017 through December 31, 2025. Incidents were assigned to seven age cohorts and aggregated into monthly time series. We used Seasonal Autoregressive Integrated Moving Average models with exogenous inputs (SARIMAX) to project age and cohort-specific incident volume for 2026 through 2035. Projected future incident volumes were translated into EMT and paramedic full-time equivalent (FTE) requirements using observed EMSTARS staffing configurations and target operational parameters. RESULTS: Annual EMS incidents increased from 4.10 million in 2017 to 5.22 million in 2025 and are projected to reach 7.76 million by 2035, a 48.8% increase over the 2025 baseline. By 2035, adults aged 60 and older are projected to represent 31.2% of Florida's population while accounting for 61.6% of all EMS incidents. Total estimated EMS workforce requirements are projected to increase from 9,542 FTEs in 2025 to 14,195 FTEs by 2035, requiring approximately 4,654 additional FTEs (a 48.8% increase). CONCLUSIONS: Florida's aging population is projected to drive a nearly 50% increase in EMS incident volume and associated workforce requirements over the next decade, with demand disproportionately concentrated among older adults. With a substantial concentration of adults aged 80 and older and a rapidly expanding oldest-old cohort, Florida is confronting the demographic conditions projected to emerge in other states over the next decade. The findings offer researchers and policymakers a replicable framework and a directly applicable planning reference for jurisdictions across the United States.

Objective We aimed to evaluate the performance of the recently updated Sequential Organ Failure Assessment Score-2 (SOFA-2) on organ dysfunction classification and prognostication compared to SOFA-1 in critically injured trauma patients. Methods Adult trauma patients admitted to critical care at four urban Major Trauma Centres between 2011 and 2024 were included. Daily organ dysfunction scoring was performed using SOFA-1 and SOFA-2 until death or discharge. The primary outcome was MODS, defined as SOFA score [&ge;]6. Results In 2162 severely injured patients (median Injury Severity Score 25 [IQR, 17-34]), SOFA-2 reduced the proportion of patients classified as having MODS compared with SOFA-1 (61.6% vs 68.5%, p<0.001). SOFA-2 scores on the first day after admission were lower than SOFA-1 (median 6 [IQR, 3-8] vs 7 [IQR, 4-10], p<0.001), driven predominantly by lower respiratory and cardiovascular scoring. Critical care mortality in trauma patients was increased in respiratory, cardiovascular and renal components of SOFA-2 at the higher ends of the scores, consistent with the aims of the SOFA-2 reclassification. A group of 159 severely injured patients (7.3%) classified as MODS by SOFA-1 were reclassified to no-MODS by SOFA-2. Despite this reclassification, these patients had substantially higher ICU mortality (7.5% vs 0.7%, p<0.01), greater ventilator and vasopressor requirements, and longer hospital stays than patients classified as no-MODS by both systems. Conclusions SOFA-2 reduces MODS prevalence in severely injured patients and changes organ dysfunction classification, with lower rates of severe respiratory and cardiovascular dysfunction. This represents an important update in trauma MODS measurement and has implications for future trauma trial design. However SOFA-2 reclassification generates a small cohort a small but clinically significant group with occult MODS that warrants further evaluation in severely injured trauma patients.

Background The time trend in long-term survival after a stroke is to some extent unknow due to (relatively) short follow up periods in available data. The objective of this study is to identify and quantify differences in long-term stroke survival in Sweden between men and women and patients with different attained educational levels, comparing two time-periods, 2000-2009 and 2010-2022. Methods This study employs total population Swedish register data pertaining to hospital-based care and mortality due to stroke for the period 2000-2022 in order to estimate survival (all-cause mortality) after ischaemic and haemorrhagic stroke, respectively, and pertaining to attained educational level. Kaplan-Meier survival functions are estimated stratifying for time-period, sex and educational level. Cox regressions are employed to quantify mortality hazard ratios between the strata. Age is taken into account in complementary analyses (supplement). Results Taking only time-period (2000-2009 vs 2010-2022) into account resulted in significantly higher survival in the second period for ischaemic stroke patients (HR: 0.84; 95% CI: 0.83-0.84), while no significant difference could be detected for haemorrhagic stroke. Stratifying for sex showed that men gained more than women in terms of reduced mortality hazard rate between the periods. Further stratifying by educational level and estimating survival separately for men and women showed that, for both men and women, patients with the lowest education were relatively worse off (compared to patients with higher education) in the second period. Further analyses, taking age into account, reversed the relative hazard ratio between men and women, but corroborated the result that low education is associated with poorer outcome than high education. Conclusions The results suggest that there are considerable differences in expected long-term survival after stroke between the sexes, but that this may be due to differences in age between the sexes at the time of stroke. Moreover, lower educational level is significantly associated with lower long-time survival.