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: Foreign body airway obstruction (FBAO) is a life-threatening emergency; however, bystander treatment recommendations rely on retrospective data. We evaluated the feasibility of a population-based prospective cohort study of FBAO interventions. Methods: We conducted a prospective observational pilot study in Alberta, Canada, between November 2025 and April 2026. We identified individuals with out-of-hospital FBAO who called emergency medical services or attended an emergency department using a validated health-record case definition. Participants were stratified into adults and children (aged>2 years) and younger children (aged< 2 years) cohorts. The primary outcome was included cases per month, with several secondary feasibility (proportion of eligible cases included, data completeness) and clinical outcomes (FBAO relief, survival to acute care discharge, favourable neurological outcome, intervention-associated injuries). Results: Among 5,208 screened encounters, 147 FBAO cases were identified. Of these, 91 adults and children (89.2%) and 39 young children (86.7%) were enrolled. Mean recruitment was 15.2 participants/month (SD=1.1) in the adult and child cohort, exceeding the predefined feasibility threshold ([&ge;]13/month), and 6.5 participants/month (SD=1.3) in the young child cohort, meeting the amber-zone criterion (6-8/month). Data completeness exceeded 90% across all participants. In adults and children, bystander intervention relieved the obstruction in 59 cases (66.3%), and 80(87.9%) survived to acute care discharge. In young children, bystander intervention relieved the obstruction in 33 cases (84.6%); all survived with favourable neurological outcomes. Conclusions: Prospectively identifying and recruiting individuals with FBAO is feasible using population-based prehospital and emergency department records. These findings support a larger adequately powered prospective cohort study comparing the effectiveness and safety of FBAO interventions.

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.

Objective: To describe the use of, and outcomes following, Emergency Department (ED) escalation area care among children. Design: Two-stage prospective multicentre observational study. Stage one was a cross-sectional snapshot study reporting the point prevalence of escalation area care; stage two was an observational cohort study of eligible participants present in the EDs during snapshots. Setting: 5 snapshots of 96 type 1 UK EDs. 83/96 (86.5%) of sites were mixed EDs and 13 sites were paediatric-only EDs. Patients: Patient level data was collected on those who experienced escalation area care and/or were admitted. Outcomes: The primary outcome was the proportion of patients cared for in escalation areas in paediatric-only EDs. Secondary outcomes were demographics, length of stay (LOS), 28-day mortality, type of escalation area experienced and time in escalation areas in all ED types; stratified by escalation area experience. Results: 6.6% (n=75/1132) of patients in paediatric-only EDs were receiving escalation area care during the study snapshots, the majority of this occurred in a minority of departments. Across all ED types, 15.4% (n=104/675) of admitted children experienced escalation area care during their ED stay. 124/244 (50.8%) of those cared for in escalation areas were cared for in a non-clinical area such as a corridor. 9.6% (n=8/83) of mixed EDs reported caring for adults in paediatric areas. Three children died within 28 days; all admitted to hospital without experiencing escalation area care. Hospital LOS was 2.00 days (1.00, 3.00) for those in escalation areas and 2.00 days (2.00, 4.00) for those not cared for in escalation areas. Conclusions: Escalation area care is a common and systemic feature of paediatric emergency care in the UK which requires urgent action to ensure children are cared for in appropriate environments.

Background Emergency Department (ED) overcrowding is associated with adverse outcomes including delays to treatment, patients leaving without being seen and increased mortality. Increasingly, evidence suggests that crowding may disproportionately affect those of lower socioeconomic status, worsening health inequalities. This study investigates the relationship between prolonged ED length of stay and vulnerable patient groups choosing not to wait to be seen. Methods A retrospective cohort study analysed monthly ED attendance data from a large district general hospital between January 2020 and July 2025. Patients who did not wait to be seen (DNW) were assessed for vulnerability based on age, presenting complaint and inferred frailty. Associations were explored using generalised estimation equation model with binary outcome. Results During the 66-month study period, 317,978 patients attended the ED, of whom 35,403 (11.1%) did not wait to be seen. Of these, just under one third met vulnerability criteria. As the percentage of patients staying in the ED for more than 8-hours increased, so did the proportion of patients leaving the department without being seen. With each 10% increase in LOS>8h percentage, the odds of any patient choosing not to wait increases by 48% (OR=1.48, 95% CI(1.47 to 1.49), p<0.001). Of the three vulnerability groups assessed, paediatric patients, those presenting with mental health complaints and frailty, frail patients were the most affected when lengths of stay in the ED increased and crowding became a problem (OR=1.73, 95% CI(1.72 to 1.74), p<0.001). Conclusion These findings demonstrate that while all patient groups are more likely to leave without being seen as crowding worsens, elderly and paediatric patient cohorts are significantly more likely to leave without being seen as crowding worsens. This raises genuine concerns about the accessibility of healthcare, in the presence of crowding, in these vulnerable groups.

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.

Abstract Background The Simplified Geneva Score (SGS) incorporates two heart-rate thresholds. Multiple heart-rate measurements are commonly recorded during emergency department (ED) assessment. While the original SGS specifies use of mean heart rate, real-world implementation is unlikely to reflect this, and the effect of alternative heart-rate selection methods on score performance is unknown. Methods SCORES was a retrospective within-subject study of consecutive ED patients at a single urban hospital undergoing computed tomography pulmonary angiography (CTPA) for suspected pulmonary embolism (PE). Four SGS variants were calculated using the first, highest, mean, and lowest recorded pre-CTPA heart rate. Outcomes included score output, risk classification, diagnostic performance, reclassification flow, and downstream imaging utilisation. Precision estimates and comparisons were derived using empirical resampling techniques. Results 590 episodes were reviewed with 581 included for analysis. PE was confirmed in 50 cases (8.6%). Mean SGS differed significantly across all heart-rate implementations (p<0.0001). The proportion classified as high risk varied from 15% using the lowest heart rate to 40% using the highest heart rate. Reclassification across the SGS threshold was common, with 25% of episodes changing risk category unidirectionally between lowest and highest heart rate implementations. SGS(lowest HR) compared with SGS(mean HR) and SGS(highest HR) demonstrated higher specificity (87.6% vs 73.4% vs 62.1%), improved AUROC (0.744 vs 0.704 vs 0.659), and reduced downstream CTPA utilisation (818 vs 876 vs 920 scans per 100 PEs diagnosed), with no additional pulmonary emboli missed within the complete diagnostic pathway. Conclusions Heart-rate selection materially influences SGS output, risk classification, diagnostic performance, and imaging utilisation. In this retrospective cohort, use of the lowest recorded heart rate produced the most favourable overall balance of discrimination and diagnostic efficiency, supporting prospective validation.

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.

Objective: Rural hospitals in the United States have fewer specialists, fewer critical care resources, and longer transport distances than urban hospitals, yet national studies disagree on whether rural patients are more likely to die after emergency care. The goal of this study was to determine whether short-term mortality differs between rural and urban patients receiving emergency or trauma care and to estimate the size of the difference. Methods: We conducted a systematic review and meta-analysis reported in line with PRISMA 2020. PubMed was searched on October 11, 2026, for studies published from 2010 onward, supplemented by web searching. Eligible studies were US observational studies that compared rural with urban patients or hospitals and reported mortality after emergency or trauma care. Odds ratios (ORs) were pooled with a DerSimonian-Laird random-effects model, with Hartung-Knapp confidence intervals (CIs) as a sensitivity analysis. Injury and trauma studies formed the primary analysis. Certainty of evidence was rated with GRADE. Results: Of 161 records identified, 14 studies were included and 12 were pooled. Across seven injury and trauma studies, rural setting was associated with higher odds of death (OR, 1.27; 95% CI, 1.07-1.52), with substantial heterogeneity (I^2 = 84%; 95% prediction interval, 0.74-2.19). Across all 12 studies, the pooled OR was 1.23 (95% CI, 1.09-1.40; I^2 = 96%). With Hartung-Knapp intervals, the overall estimate remained significant (95% CI, 1.05-1.45) and the trauma estimate was borderline (95% CI, 0.99-1.64). Study estimates ranged from 0.65 to 1.97. Three pediatric trauma studies gave a consistent estimate (OR, 1.32; 95% CI, 1.18-1.47; I^2 = 0%). Subgroup analyses by rurality definition, age group, and geographic scope did not explain the heterogeneity. Certainty of evidence was very low. Conclusions: In pooled US observational data, rural patients receiving emergency and trauma care had about 23% higher odds of short-term death than urban patients, most consistently among injured children. The evidence is inconsistent, rests on a single-database search with several reports assessed from abstracts only, and should be treated as preliminary. Why rural patients die more often, and at what point in the pathway from injury to definitive care, remains unanswered.

Background: The practice of hospitalizing emergency department (ED) patients with chest pain after ruling out acute myocardial infarction (AMI) varies widely. The long-term outcome and cost implications of this variation are uncertain. Methods: Analyzing 2007-2021 claims from a national commercial insurer, we identified 223,569 adults (18 years or older) ED visits with a principal diagnosis of chest pain without major secondary cardiopulmonary diagnoses, seen by 19,001 clinicians in 2,273 EDs. Within each ED, clinicians with the highest and lowest terciles of risk-adjusted hospitalization rates were classified as high- versus low-admitting. Primary outcomes were 30- and 180-day subsequent AMI hospitalizations. Secondary outcomes included 7-day cardiac testing, 30-day coronary intervention, and 30-day total and out-of-pocket costs. We estimated adjusted rate ratios (aRRs) and relative cost differences using generalized estimating equations, adjusting for patient and visit characteristics. Results: Patients had a mean age of 48.6 years, and 53.9% were female; measured characteristics were similar between groups. Compared with low-admitting clinicians, visits to high-admitting clinicians had higher 7-day cardiac testing (13.1% vs 10.8%; aRR 1.22, 95% CI 1.17-1.27) and 30-day coronary interventions (4.3% vs 3.8%; aRR 1.16, 95% CI 1.09-1.23). AMI hospitalization did not differ at 30 days (0.60% vs 0.60%; aRR 1.00, 95% CI 0.84-1.15) or 180 days (0.85% vs 0.87%; aRR 0.97, 95% CI 0.85-1.10). Thirty-day total costs were higher after visits to high-admitting clinicians (relative change 11.3%, 95% CI 8.8-13.8), and out-of-pocket costs $1,000 or more were more common (32.0% vs 29.6%; relative change 8.2%, 95% CI 6.1-10.3). Conclusions: Higher clinician hospitalizing tendency for ED chest pain is associated with greater downstream testing, more coronary interventions, and higher costs without lower short- or intermediate-term AMI risk. Reducing marginal admissions among high-admitting clinicians may decrease spending and practice variation with minimal impact on AMI outcomes.

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.

Introduction Aging populations are placing increasing pressure on Emergency Medical Services (EMS) providers to address the potentially suboptimal use of scarce resources. EMS utilization that falls outside the established deployment framework, referred to here as non-indicated use, may constitute an important source of such suboptimal resource use. Frequent users of EMS represent a key target group in efforts to reduce non-indicated utilization. The focus on frequent users is driven by the substantial workload and costs associated with their use of EMS, as well as by the need to address potential underlying quality-of-care issues reflected in high, persistent, or intensive EMS utilization. Addressing possible non-indicated EMS use among frequent users requires the development of monitoring systems that can be applied in both clinical practice and research to identify such use and support appropriate action once it has been detected. This study aims to explore the relationships between the drivers of frequent EMS use, potential remedies for non-indicated use, and subsequent reductions in utilization. Based on these insights, the study seeks to develop, through prototyping, a framework to guide the design of monitoring systems for research and clinical practice. Methods and analysis We will employ a mixed-methods observational study design. A systematic literature review and interviews with stakeholders who play key roles in the EMS referral process will be conducted to identify the drivers of frequent use and non-indicated EMS use and their potential remedies. Pseudonymized routinely collected data covering 2013-2026 from three Dutch EMS providers will be analyzed using machine learning (ML) and artificial Intelligence (AI) techniques to develop a typology of drivers and trustworthy, interpretable models for identifying frequent use and non-indicated use. A prototype monitoring system will be developed to demonstrate the online and the offline functionalities of the proposed framework for use in both clinical practice and research. The prototype usability, trustworthiness, and interpretability will be evaluated in collaboration with relevant stakeholders involved in the EMS referral process. Ethics and dissemination The data is routinely collected for administrative purposes only. Accordingly, the data will be completely pseudonymized, and as such this study falls outside the scope of the Dutch Medical Research Involving Human Subjects Act. After assessment we obtained a full waiver for using pseudonymized data from the EMS services from the Medical Ethics Review Board of the University Medical Center Groningen (reference number METc 2022/053). Patients and/or the public are not involved in the design, conduct, reporting, or dissemination plans of this research. Interviewees and participants in evaluating prototype monitoring systems (e.g. EMS clinicians, medical directors, ambulance nurses, emergency physicians, general practitioners (GPs), policy makers and police officers) will provide informed verbal consent prior to their participation in the study. The study findings will be disseminated through peer-reviewed publications, presentations at conferences, and in social media. Also, summary reports will be made available to participating institutions and relevant stakeholders.

Background Traumatic brain injury (TBI) is a major cause of morbidity and mortality in low- and middle-income countries (LMICs), where the burden of injury is disproportionately high, and healthcare resources are often limited. Clinical Practice Guidelines (CPGs) improve the consistency and quality of TBI care by shifting medical decision-making from individual judgement to evidence-based recommendations. The strong link between improved TBI outcomes and CPG adoption has largely been established in high-income country (HIC) hospital settings; evidence on implementing TBI CPGs in LMIC hospital settings is limited. Objective This study explored healthcare providers experiences to identify barriers and facilitators to implementing a TBI CPG in the Emergency Department (EMD) at Kilimanjaro Christian Medical Center in Northern Tanzania, guided by the Consolidated Framework for Implementation Research 2.0 (CFIR). Methods We conducted semi-structured in-depth interviews (IDIs) with doctors and nurses who regularly managed TBI patients at the EMD. We purposively sampled participants between June and August 2023. The research team analysed data using thematic content analysis guided by CFIR domains, developing codes and memos iteratively. Results 7 nurses and 8 doctors with an average of 5 years of experience caring for patients in the EMD completed in-person, in-depth interviews. Most providers reported frequent exposure to TBI cases and regular use of the CPG in routine clinical practice. However, not all participants reported consistent CPG use, highlighting variation in implementation among providers. Key facilitators included strong interprofessional teamwork, readily accessible guideline materials in clinical areas, availability of diagnostic imaging, and perceived improvements in patient outcomes. Barriers to consistent adherence included ICU bed shortages, limited operating theatre capacity, equipment and medication stock-outs, high patient volumes, staffing pressures, and a lack of structured refresher training or formal audit and feedback mechanisms. Variability in procedural confidence, particularly among less experienced providers, also affected implementation consistency. Conclusion Our findings show that a TBI CPG is well accepted and largely integrated into routine care among experienced providers. However, sustainability depends on strengthening training, mentorship, audit, and feedback systems for CPG use and on addressing system-level resource constraints. Institutional investment in capacity building is essential to ensure consistent and sustained CPG uptake in our setting.

Background: During emergency tracheal intubation, clinicians use waveform capnography or colorimetric carbon dioxide (CO2) detection to confirm exhaled CO2 from the endotracheal tube to determine its location. Both devices reliably yield a negative result when the tube is in the esophagus. However, in most emergency intubations the tube is correctly located in the trachea, and in this circumstance the relative diagnostic accuracy of the two devices is uncertain. If one device more often fails to detect exhaled CO2 despite correct tube placement (a false negative result), this could lead to unnecessary tube removal, repeated intubation attempts, and an increased risk of serious complications. Research Question: Among critically ill adults undergoing emergency tracheal intubation, is waveform capnography or colorimetric CO2 detection more sensitive for identifying an endotracheal tube correctly placed in the trachea? Study Design and Methods: The WAVE study is a pragmatic, prospective, paired diagnostic accuracy study conducted in emergency departments and intensive care units in the United States. The study compares waveform capnography and colorimetric CO2 detection (index tests) against a non-CO2-based reference standard for endotracheal tube location among 2,092 critically ill adults undergoing tracheal intubation. The primary outcome is the sensitivity of each index test for identifying a tube located in the trachea. The secondary outcome is specificity for identifying a tube located outside the trachea. Results: Enrollment began on April 21, 2025 and is ongoing, with completion anticipated in 2026. Interpretation: The WAVE study will provide prospective evidence comparing waveform capnography with colorimetric CO2 detection for determination of endotracheal tube location in critically ill adults. These findings may inform clinical practice and guideline recommendations regarding the optimal test of exhaled CO2 for use in the ED and ICU. Prespecifying the protocol and statistical analysis plan before completion of enrollment enhances the rigor, reproducibility, and transparency of the study.

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.

Occupational injuries remain a cause of preventable morbidity and death, but evidence from emergency departments in Nigeria is limited. This retrospective study described occupational injuries treated at two hydropower plant hospitals between May 2020 and December 2022. Records of 120 patients were reviewed using a standardized abstraction form. Data were summarized using frequencies and percentages, and associations were assessed using chi-square tests. Vehicular crashes were the leading cause of injury (50.0%), lacerations were the most frequent injury type (39.2%), and the head/face was the most commonly affected single site (30.0%). Most patients were discharged (85.0%); 12.5% were transferred and 3.3% died. Serious injuries accounted for 40.8% of cases. Injury type was associated with discharge and injury severity, while injury site was associated with discharge and transfer. These findings support stronger workplace prevention, timely emergency assessment, and clearer referral pathways for injured workers.

Background Interruptions are common in hospital outpatient departments (OPDs) and are linked to error. Many are clinically necessary, so the aim is to regulate them. Most interventions target the individual clinician. Little is known about how doctors manage interruptions in practice or what makes their strategies work. Methods Qualitative study using focus groups and interviews with 42 doctors working in UK National Health Service OPDs (19 sessions, September to November 2025). Participants were purposively sampled by clinical experience and self-reported patient complexity. Data were analysed using Framework Analysis, informed by Cognitive Load Theory and Social Identity Theory. Results We developed four themes. (1) Pre-emptive protection of attention. Doctors withdrew, signalled unavailability and set thresholds for interrupting. These depended on colleagues learning and sharing the norm, which staff rotation eroded. (2) Sharing the burden through team coordination. Designated roles and time-limited rotas moved interruptions to colleagues with capacity set aside for them and made interrupting legitimate. (3) Real-time cognitive repair. Doctors asked interrupters to wait while they secured the task, and rebuilt the consultation on return, sometimes with the patient's help. Asking a colleague to wait depended on seniority or team membership; some trainees described difficulty doing this with senior colleagues. (4) Organisational recognition as the precondition for sustainable regulation. Where supervision was built into job plans, the interruptions it generated were expected and doctors held capacity in reserve for them. Advice, vetting and telephone queries were rarely counted as work. Conclusions Each strategy served a cognitive purpose, and social and organisational conditions decided whether it was perceived to work. Interventions could make norms shared and roles explicit, count interruption work in job plans and keep routes open for junior staff to raise concerns. Evaluations should ask who is able to use them.

Background While overall application volume by ethnic minority doctors into UK postgraduate medical training has expanded significantly, workforce diversity varies substantially across specialties. Previous reports have suggested that doctors from certain ethnic backgrounds and international medical graduates (IMGs) experience lower likelihoods of securing training posts, but granular longitudinal evaluations across all specialty training levels and recruitment stages remained limited. Therefore, this study evaluates longitudinal trends in self-reported ethnicity and country of qualification across postgraduate medical training in England between 2021 and 2025, maps specialty representation, and tests the hypothesis that recruitment success rates differ significantly between ethnic minority and White baseline applicants. Methods We conducted a retrospective national longitudinal analysis of mandatory NHS specialty recruitment data across England from 2021 to 2025, encompassing over 300,000 applications across ST1/CT1 (entry-level) and ST3+ (higher specialty) pathways. Applicants were categorised into census-aligned broad and granular ethnic groups, alongside IMG classifications. Unadjusted odds ratios (ORs) with 95% confidence intervals were calculated using White graduates and internal sub-ethnic baselines as comparators. Specialty-level ecological correlations (Spearman's rho) were performed to evaluate whether international workforce reliance moderated ethnic recruitment disparities. Results Between 2021 and 2025, applicant volume expanded rapidly, with ethnic minority applicants and IMGs comprising numerical majorities. However, Asian and Black applicants experienced substantially lower odds of receiving training offers compared to White baseline applicants across multiple high-volume specialties (e.g., emergency medicine and anaesthetics at ST1, where Black applicants faced multi-fold reductions in success odds: OR 0.03 to 0.05, p<0.001). Granular analyses revealed notable intra-ethnic heterogeneity, including lower success among Pakistani and Bangladeshi applicants compared to Indian applicants. Furthermore, UK graduates maintained higher offer success than IMGs across most specialties. Ecological correlations demonstrated that higher international applicant reliance was moderately and significantly associated with wider recruitment disparities at higher training levels for Black applicants {rho}=-0.43, p=0.019). Conclusions Centralised medical recruitment in England exhibits some persistent ethnic and international qualification disparities despite rising application diversity. The findings highlight the necessity of disaggregating ethnic groups and addressing subjective evaluation vulnerabilities within multi-stage recruitment processes to foster equity. Trial registration: Not applicable