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Creating a master training rotation schedule for emergency medicine residents and challenges in using artificial intelligence

The allocation of resident physicians to clinical rotations presents a complex challenge that requires balancing multiple objectives with the goals of providing optimal patient care, maintaining adequate depar...

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Violence in the emergency department: a quantitative survey study of healthcare providers in India

Workplace violence (WPV) in Emergency Departments (EDs) is an increasingly recognized challenge healthcare providers face in low-resource settings. While studies have highlighted the increased prevalence of WP...

Low-dose tenecteplase during cardiopulmonary resuscitation in massive pulmonary embolism

We report the case of an 18-year-old male who presented to the Emergency Department with sudden onset dyspnea. The patient was intubated on arrival, but suffered a cardiac arrest soon after. Point-of-care echo...

Paracetamol overdose causing acute kidney injury without hepatotoxicity: a case report

Paracetamol is a widely used analgesic and antipyretic. Paracetamol-induced hepatotoxicity is well known, but nephrotoxicity without hepatotoxicity is rarely seen.

The wolf in sheep’s clothing: vasovagal syncope in acute aortic dissection

The presentation of acute aortic dissection can pose a challenge for emergency physicians, as it may occur without pain. Atypical presentations can lead to significant delays in diagnosis and increased mortali...

A rare cause of abdominal pain in pregnancy - mesenteric artery thrombosis and miscarriage in a 34-year-old patient

Mesenteric arterial thrombosis is an extremely rare thrombotic event, especially during pregnancy, that can cause rapid fatal consequences unless the patient receives early definitive treatment.

A potentially lifesaving error: unintentional high-dose adrenaline administration in anaphylaxis-induced cardiac arrest; a case report

Cardiopulmonary resuscitation is a crucial skill for emergency medical services. As high-risk-low-frequency events pose an immense mental load to providers, concepts of crew resource management, non-technical ...

Beyond urinalysis: evaluation of various clinical and laboratory reflex criteria to warrant urine culture collection in the emergency department

Clinical criteria are essential for diagnosing urinary tract infections (UTIs) followed by urine testing, including urinalysis (UA). No study has evaluated the potential related factors that may guide the appr...

Identifying trigger cues for hospital blood transfusions based on ensemble of machine learning methods

Traumatic shock is the leading cause of preventable death with most patients dying within the first six hours from arriving to the hospital. This underscores the importance of prehospital interventions, and gr...

Emergency medicine residents’ learning curve in diagnosing deep vein thrombosis with 3-point venous point-of-care ultrasound

Many cases of deep vein thrombosis (DVT) are diagnosed in the emergency department, and abbreviated lower extremity venous point-of-care ultrasound (POCUS) has already shown an accuracy comparable to that of s...

Mortality predictors in patients with suspected sepsis in the emergency department of a tertiary care hospital: a retrospective cohort study

Sepsis remains a worldwide major cause of hospitalization, mortality, and morbidity. To enhance the identification of patients with suspected sepsis at high risk of mortality and adverse outcomes in the emerge...

Clinical and laboratory parameters as predictors of mortality in patients with chronic liver disease presenting to emergency department- a cross sectional study

The World Health Organization (WHO) reports that Asia and Africa have the highest Chronic Liver Disease (CLD) mortality rate. Cirrhosis, responsible for 22.2 fatalities per 100,000 people, is India’s 10th most...

Prediction of the future number of fall-related emergency medical services calls in older individuals

Falls among older individuals contribute significantly to the rise in ambulance transport use. To recognize the importance of future countermeasures, we estimated the projected number and percentage of fall-re...

Implementing enhanced extracorporeal membrane oxygenation for CPR (ECPR) in the emergency department

Refractory out-of-hospital cardiac arrest (OHCA) has a very poor prognosis, with survival rates at around 10%. Extracorporeal membrane oxygenation (ECMO) for patients in refractory arrest, known as ECPR, aims ...

Evaluation and treatment of gastrointestinal bleeding in patients taking anticoagulants presenting to the emergency department

This manuscript is a consensus document of an expert panel on the Evaluation and Treatment of Gastrointestinal Bleeding in Patients Taking Anticoagulants Presenting to the Emergency Department, sponsored by th...

Palliative care education: a nationwide qualitative study of emergency medicine residency program directors in the United Arab Emirates

Emergency medicine (EM) physicians routinely care for patients with serious life-limiting illnesses. Educating EM residents to have general skills and competencies in palliative medicine is a global priority. ...

Limitations and consequences of public health models centred on hospitals and lacking connections with territorial and home-based social and health services

Delayed discharge from hospital to home or other care institutions is a significant problem and has been investigated in the international scientific literature for many years.

Factors and clinical prediction score for complication development after cellulitis diagnosis in adult patients

Cellulitis is defined as a bacterial infection of the skin and subcutaneous tissue that can cause multiple complications, such as sepsis and necrotizing fasciitis. In extreme cases, it may lead to multiorgan f...

Emergency medicine residents and performance under pressure: learning from elite athletes’ experience

The skills of coping with stress and pressure within emergency medicine are conveyed informally and inconsistently throughout residency training. This study aims to identify key psychological competencies used...

Emergency medical services in Armenia: national call trends and future directions

Emergency medical services (EMS) are paramount to boosting health indices in lower-middle income countries (LMICs); however, lack of uniform data collection and analysis hinders system improvement efforts. In ...

The effect of the COVID-19 pandemic on pediatric emergency department utilization in three regions in Switzerland

The COVID-19 pandemic was associated with a decrease in emergency department (ED) visits. However, contradictory, and sparse data regarding children could not yet answer the question, how pediatric ED utilizat...

Double bad luck: pulmonary embolism and vaginal bleeding - a case report

Pulmonary embolism is a common and potentially fatal condition. Exogenous estrogens in contraceptives are associated with an increased risk of venous thrombo-embolism. However, discontinuation of a combined or...

Mediastinitis and septic shock complicating spontaneous esophageal rupture “Boerhaave’s syndrome”: a case report

Boerhaave’s syndrome, also known as spontaneous esophageal rupture, is a rare but life-threatening condition characterized by a tear in the esophagus. It is most commonly caused by a sudden increase in intraes...

Patients’ pathways to the emergency department: a scoping review

Emergency department (ED) crowding is a common healthcare issue with multiple causes. One important knowledge area is understanding where patients arrived from and what care they received prior to ED admission...

Guanfacine poisoning resulting in transient ST-segment elevation: a case report

Guanfacine is an alpha-2 adrenergic agonist that decreases norepinephrine release and sympathetic outflow. With the increased use of guanfacine for attention-deficit hyperactivity disorder (ADHD), reports of g...

An unexpected case of tetanus in a fully immunized 20-year-old female: a case report

Widespread vaccinations have significantly decreased the number of tetanus cases in developed countries. Today, most cases of tetanus affect the elderly and those with inadequate immunization in developed coun...

Physicians’ experiences with reporting domestic violence against women: a cross-sectional study in Saudi Arabia

Domestic violence, including violence against women, is a global public health concern with significant implications for women’s health and well-being. Despite its prevalence, healthcare providers often face b...

Diagnostic utility of capnography in emergency department triage for screening acidemia: a pilot study

Capnography is a quantitative and reliable method of determining the ventilatory status of patients. We describe the test characteristics of capnography obtained during Emergency Department triage for screenin...

What factors are effective on the CPR duration of patients under extracorporeal cardiopulmonary resuscitation: a single-center retrospective study

Extracorporeal cardiopulmonary resuscitation (ECPR) is an alternative method for patients with reversible causes of cardiac arrest (CA) after conventional cardiopulmonary resuscitation (CCPR). However, cardiop...

From symptom onset to ED departure: understanding the acute care chain for patients with undifferentiated complaints: a prospective observational study

For most acute conditions, the phase prior to emergency department (ED) arrival is largely unexplored. However, this prehospital phase has proven an important part of the acute care chain (ACC) for specific ti...

Correction: Patient-controlled analgesia morphine for the management of acute pain in the emergency department: a systematic review and meta-analysis

The original article was published in International Journal of Emergency Medicine 2024 17 :37

Randomized controlled open-label trial to evaluate prioritization software for the secondary triage of patients in the pediatric emergency department

The continual increase in patient attendance at the emergency department (ED) is a worldwide health issue. The aim of this study was to determine whether the use of a secondary prioritization software reduces ...

Screening for harmful substance use in emergency departments: a systematic review

Substance use-related emergency department (ED) visits have increased substantially in North America. Screening for substance use in EDs is recommended; best approaches are unclear. This systematic review synt...

Emergency department responses to nursing shortages

The COVID-19 pandemic exacerbated the nursing shortage, which is predicted to continue to worsen with significant numbers of nurses planning to retire within the next 5 years. There remains a lack of published...

Bibliometric analysis of ChatGPT in medicine

The emergence of artificial intelligence (AI) chat programs has opened two distinct paths, one enhancing interaction and another potentially replacing personal understanding. Ethical and legal concerns arise d...

Clinical significance of elevated D-dimer in emergency department patients: a retrospective single-center analysis

D-dimer is a marker of coagulation and fibrinolysis widely used in clinical practice for assessing thrombotic activity. While it is commonly ordered in the Emergency Department (ED) for suspected venous thromb...

The state of emergency medicine in Greece: at critical momentum

Greece is a parliamentary republic in southeastern Europe populated by over 10 million permanent residents: 9 million reside on the mainland, with almost 4 million in the greater Athens area. The remaining 1 m...

Single intravenous dose ondansetron induces QT prolongation in adult emergency department patients: a prospective observational study

Ondansetron is one of the most commonly used drugs in the emergency department (ED) for treating nausea and vomiting, particularly in intravenous (IV) form. Nevertheless, it has been shown to prolong QT interv...

Evaluation of elevated serum apelin-13 and D-dimer concentrations in individuals diagnosed with pulmonary embolism

Given the limited specificity of D-dimer, there is a perceived need to discover a more precise marker for diagnosing individuals who are suspected of having pulmonary embolism (PE). In this study, by evaluatin...

An AI-based multiphase framework for improving the mechanical ventilation availability in emergency departments during respiratory disease seasons: a case study

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 complicatio...

A survivor with unexplained chest scars

This case illustrates chest scars after piston-based chest compression device resuscitation and raises the awareness of the potential benefits of following up survivors of critical illness.

Natto (fermented soybeans)-induced anaphylaxis in a surfer with the possibility of sensitization to poly(γ-glutamic acid) from cutaneous exposure to jellyfish sting: a case report

We report a case of anaphylaxis induced by natto (fermented soybeans) allergy that occurred following dermal sensitization from a jellyfish sting.

Utilizing the National Early Warning Score 2 (NEWS2) to confirm the impact of emergency department management in sepsis patients: a cohort study from taiwan 1998–2020

Most sepsis patients could potentially experience advantageous outcomes from targeted medical intervention, such as fluid resuscitation, antibiotic administration, respiratory support, and nursing care, prompt...

Emergency airway management in resource limited setting

Emergency airway management in resource-limited settings presents multifaceted challenges due to shortages in essential medical resources, healthcare professionals, and infrastructure.

From compression to diagnosis: identification of superior vena cava syndrome using point-of-care ultrasound in the emergency department

Superior vena cava (SVC) syndrome is an urgent condition arising from restricted blood flow through the SVC, often linked to factors like malignancy, thrombosis, or infections. Typically, confirmation of the d...

PoCUS identification of distal biceps tendon rupture: a case report

In the Emergency Department (ED), patients may present with various injuries that damage muscles, tendons, ligaments, and bony structures. Fractures, joint dislocations, strains, and sprains are prevalent amon...

Jejunogastric intussusception associated with jejunojejunal intussusception (double telescoping) occurring 20 years after gastrojejunostomy

Jejunogastric intussusception (JGI) is a rare but potentially lethal complication following gastrectomy or gastrojejunostomy surgeries. Diagnosis of this condition can be challenging due to its rarity and non-...

Patient-controlled analgesia morphine for the management of acute pain in the emergency department: a systematic review and meta-analysis

The ideal pain control approach is typically viewed as titration of analgesia for pain reduction and periodic pain evaluation. However, this method takes time and is not always possible in the crowded Emergenc...

The Correction to this article has been published in International Journal of Emergency Medicine 2024 17 :54

Use of bitemporal NACA score documentation in prehospital emergency medical services– a retrospective study

The assessment of illness severity in the prehospital setting is essential for guiding appropriate medical interventions. The National Advisory Committee for Aeronautics (NACA) score is a validated tool common...

Recurrent transitory attacks with cytotoxic edema could benefit from thrombolysis

The original article was published in International Journal of Emergency Medicine 2023 16 :62

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• Published: 03 July 2024

A collaborative pharmacist-led intervention to prevent hospital readmissions among elderly patients discharged from the emergency department: a retrospective cohort study

• Susan Tran-Nguyen 1 , 2 &
• Stephen Edward Asha 2  

Scientific Reports volume  14 , Article number:  15285 ( 2024 ) Cite this article

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Unplanned hospital readmission is a safety and quality healthcare measure, conferring significant costs to the healthcare system. Elderly individuals, particularly, are at high risk of readmissions, often due to issues related to medication management. Pharmacists play a pivotal role in addressing medication-related concerns, which can potentially reduce readmissions. This retrospective single-centre cohort study, conducted from November 2022 to February 2023 in an emergency department, aimed to determine if integrating emergency medicine pharmacists into Emergency Department care models reduces unplanned hospital readmissions within 28 days and to identify the interventions they employ. The inclusion criteria included patients aged ≥ 65, taking ≥ 3 medications, and presenting with falls, cognition changes, or reduced mobility and were planned for discharge to home from the emergency department. Collaborating with the Emergency Department Aged Care Service Emergency Team, a pharmacist provided comprehensive medication management consultations, discharge liaison services, and other pharmacy related interventions to eligible participants whenever the pharmacist was available. Patients who met the eligibility criteria but did not receive pharmacist interventions due to the pharmacist's unavailability served as the control group. This method was chosen to ensure that the control group consisted of comparable patients who only differed in terms of receiving the pharmacist intervention. The study included 210 participants, with 120 receiving pharmacist interventions and 90 acting as controls. The results revealed a significant reduction in unplanned hospital readmissions among participants who received pharmacist interventions (10.0%, n = 12) compared to controls (22.2%, n = 20), with a notable difference of 12.2% (95% confidence interval 2.4–23.4%, p  = 0.01). A total of 107 interventions were documented, emphasising medication selection recommendations (28.0%) and identification of adverse drug reactions/drug-drug interactions (21.5%) as primary areas of focus. These findings suggest that integrating skilled pharmacists into Emergency Department Aged Care Service Emergency Team (ASET) lowered the rate of unplanned hospital readmission within 28 days resulting in improved hospital performance metric outcomes. This highlights the potential role of pharmacists in addressing medication-related issues and enhancing the quality and safety of healthcare delivery, particularly for elderly patients transitioning from the ED to home care settings.

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Introduction.

In Australia, the rates at which patients are readmitted to the same facility within 28 days of discharge are a key performance indicator for safety and quality in healthcare 1 , 2 . Similar approaches for quantifying the performance of public health systems have been adopted in England, Scotland, the US and Canada 3 , 4 . Data from America 5 , France 6 , Belgium 7 , and Taiwan 8 have reported readmission rates at 28 days to 6 weeks ranging from 10.7 to 23.6%. In 2015, the unplanned 28-day readmission rate from state health systems in Australia ranged from 3.2 9 to 10.9% 2 , 3 , 10 . Unplanned readmissions have a substantial financial burden on the healthcare system, 3 , 4 , estimated to cost Australia in the order of $1.5 billion annually 11 . Unplanned readmissions are also associated with overcrowding, hospitalisation-acquired complications and infections, iatrogenic harms, and poor health outcomes 2 , 12 .

Older patients are a high-risk group for hospital readmission 13 . The Australian Institute of Health and Welfare has estimated people aged 65 years and over accounted for 46% of all potentially preventable hospitalisations, and medication management was identified as a risk factor 14 .

Pharmacists are involved in medication history taking, medication reconciliation, and are in an optimal position to identify and address medication-related problems. They can identify and provide advice to manage polypharmacy, drug side-effects, drug interactions, identify deprescribing opportunities, and engage patients in medication education to improve knowledge and compliance, interventions that have been shown to reduce readmissions 15 , 16 .

In 2022, the Deeble Institute for Health Policy Research Queensland published a comprehensive review on strategies to mitigate unplanned hospital readmissions. The review concluded a model of care that employed multidisciplinary teams and multifaceted approaches resulted in improved patient care and were more successful in reducing unplanned readmissions 12 . Moreover, the tangible benefits of this approach have been exemplified in studies involving specific disease states, showcasing the efficacy of a collaborative strategy involving pharmacists in mitigating readmissions 17 , 18 , 19 .

In light of these insights, the concept of integrating emergency medicine pharmacists into allied healthcare teams within the Emergency Department (ED) emerges as a promising solution for reducing unplanned readmissions.

The primary aim of this study was to determine whether integrating an emergency medicine pharmacist into existing ED care teams that manage older patients led to a reduction in unplanned hospital readmissions within 28 days. A secondary aim was to examine the types of interventions carried out by the ED pharmacist.

Study design

This study involved collecting prospective data collected from the quality improvement initiative and then reviewing patients' electronic medical records 28 days later to assess if they had any readmissions. It was conducted at the St George Hospital ED in Sydney, Australia. The quality improvement initiative occurred over a four-month period from November 2022 to February 2023. The project plan was reviewed by the South Eastern Sydney Local Health District Human Research Ethics Committee, and advised that as this was a quality improvement initiative it was exempt from formal ethics committee review. Permission to conduct an interview with participants by the pharmacist was sought as part of the clinical practice interaction. Written informed consent was deemed unnecessary by the ethics committee. This study was carried out in accordance with the standards for quality improvement reporting excellence (SQUIRE 2.0) 20 .

Participants

Patients were eligible for the study if they were referred to the Aged Care Service Emergency Team and/or the quick response program and were taking at least three chronic disease medications. Aged Care Service Emergency Team is an allied health service that supports elderly patients transitioning back to their own homes after discharge from the ED. The Aged Care Services Emergency Team works collaboratively with ED staff, participating in patient assessment and treatment. Quick response program, is an extension of Aged Care Service Emergency Team, focuses on providing short-term services to promote safe and independent living at home, aiming to reduce readmissions. Quick response program ensures that any pharmacy recommendations made during the ED presentation are implemented at home. Referral criteria are aged 65 years or older who are in the ED, are being considered for discharge home, and have one or more of the following: falls within the past 12 months, changes in cognition or behaviour, or concerns regarding safe mobility. Patients admitted to the hospital or discharged to nursing homes were not assessed by Aged Care Service Emergency Team and were excluded from the study.

Study group allocation

Participants were assigned to either the intervention or control groups based on the order of their referral, following a first-referred, first-intervened basis. Allocation decisions were made on each study day, with assignments to the intervention and control groups determined by the pharmacist’s availability. This approach aimed to minimize potential biases by ensuring that external factors, such as changes in the emergency department's patient load or staffing levels, did not influence the assignment process.

Each day, as patients were referred to the study, decisions were promptly made regarding their inclusion in the intervention group. Patients who did not receive the intervention on the same day were placed in the control group. By making these allocation decisions simultaneously, we aimed to balance the groups with respect to time-related variables and external conditions, thus enhancing their comparability.

On average, six patients were referred daily. The pharmacist did not have time to see all patients but included an average of four patients daily based on the time of referral. Patients the pharmacist did not have time to see were included in the control group.

Pharmacy intervention group

Patients who met the above criteria and received the pharmacy intervention based on the pharmacist availability were assigned to the intervention group. The intervention was delivered opportunistically by a single part-time pharmacist when available during business hours to conduct a comprehensive medication management. The pharmacist was available Monday, Tuesday and Wednesday each week. All participants in this group underwent a thorough medication history, sourced from at least two reliable references and medication reconciliation upon admission. Additionally, their attitudes toward medications and health were assessed to ensure sound knowledge of medications and compliance. Moreover, pathology review (renal and hepatic) was conducted for potential dosing adjustments as needed.

Types of pharmacist-led interventions included:

Change medication order/clarify medicine Instances where adjustments were made to the prescribed medication or inquiries were made to ensure clarity regarding a particular medicine.

Medication selection recommendation Recommendations put forth by the pharmacist that are clinically appropriate for the patient.

Discharge liaison service Pharmacy related services provided that facilitates the transition of patients from the hospital back to their homes or alternative care settings.

Therapeutic duplication Identification and rectification of instances where patients were prescribed multiple medications with similar or same therapeutic class.

Overdose Instances where the prescribed dosage exceeded the recommended guidelines.

Subtherapeutic dose or duration Cases where the prescribed dosage or duration of medication was insufficient for optimal therapeutic effect as per recommended guidelines.

Adverse drug reactions or drug–drug interaction Identification and management of adverse reactions.

Administrative issues Addressing administrative challenges related to medication dosage forms and providing appropriate dosage form alternatives.

Medication education Provision of education and information to patients regarding their medications, including dosage, administration, and potential side effects.

Deprescribing Initiatives aimed at reducing or discontinuing medications that are no longer clinically necessary or may pose risks when used long term.

On discharge, the medication reconciliation review included the following (focusing on new therapy):

Accuracy and completeness of the clinical provider completed discharge medication reconciliation by comparing home medications with new orders at discharge.

Review financial barriers of certain medications to ensure compliance after discharge.

Arrange a supply of discharge medication where needed

Identify drug interactions of newly commenced medications with home medications

Counselling patients/caregivers on the purpose and appropriate doses of medications. Provide written treatment plan and written information about the medications.

If there were changes to medications for a patient who had a dose administration aid, the ED pharmacist would follow-up with the patient’s local pharmacy to ensure that change to medication was communicated.

The quick response program team ensured that patients who were discharged had their pharmacy recommendations implemented.

Pharmacist documentation was a part of the intervention. Upon admission, the ED pharmacist would create a comprehensive medication list, which the ED medical officer would then use to reconcile medications. Following the completion of the medication management process, a detailed summary of the patient, including identified issues, recommendations, medication compliance review, and the updated medication list, would be documented in the patient's electronic medical record, and identifiable by the title 'Pharmacy Progress Note'. This documentation was accessible to all hospital clinical providers.

Control group

Control participants were patients referred to Aged Care Service Emergency Team on Mondays, Tuesdays and Wednesdays during the pharmacist’s working hours during the study period. However, they were not seen by the pharmacist as they presented at a time when the pharmacist’s services was not available due to competing demands.

The primary outcome was unplanned readmission to the ED within 28 days. Secondary outcomes included examining the types of interventions carried out by the ED pharmacist.

Data collection

The Aged Care Service Emergency Team maintained a record of all referrals made to the service as part of routine care. Participants were identified from this list. The ED Pharmacist maintained a record of those who received the intervention, as well as the type of interventions conducted. All other data were collected retrospectively from the electronic medical record, including the date of presentation, sex, age, degree of dependency (lives alone or with support), the reason for initial presentation, number of chronic medications on presentation, number of comorbidities, readmission within 28 days, and reason for readmission.

Statistical analysis

Descriptive categorical data are presented as total counts and proportions, while continuous variables are nonparametric and are presented as medians with interquartile ranges (IQRs). The primary outcome was presented as a difference in proportions with a 95% confidence interval and compared using the chi-square test. This analysis was performed using Microsoft Excel.

Ethics approval

The SESLHD Research Ethics Committee has confirmed that no ethical approval is needed.

During the study period, Aged Care Service Emergency Team received 282 referrals, and 218 met the eligibility criteria. Pharmacy interventions were conducted on 128 patients; however, eight were subsequently admitted after review and excluded. This left 120 participants in the intervention group and 90 in the control group, as illustrated in Fig.  1 . Table 1 shows the characteristics of the study participants. Unplanned hospital readmission occurred in 12 participants (10.0%) in the intervention group and 20 participants (22.2%) in the control group, a difference of 12.2% (95% confidence interval 2.4–23.4%, p  = 0.01).

Flow chart.

For those with a primary outcome event, the median time from first presentation to readmission was 14 days (IQR 7–22.5) in the intervention group and 16 days (IQR 8–22) in the control group. Table 2 presents reasons for initial presentation and subsequent readmission.

The study’s primary outcome, the risk ratio, was calculated to be 0.45 with a 95% confidence interval of 0.233–0.871. This indicates that the risk of unplanned hospital readmission within 28 days is approximately 45% lower in the intervention group compared to the control group. Additionally, the number needed to treat (NNT) to prevent one older adult from being readmitted within 28 days was estimated to be 8.17. This means that for every eight patients receiving the intervention, one fewer readmission would be expected within 28 days.

The secondary aim was to examine the types of clinical interventions made by the pharmacist’s participants in the intervention group. A total of 107 interventions were recorded and are shown in Table 3 . Among these, medication selection recommendations were the most common, at 28.0% (n = 30), followed by adverse drug reactions and drug‒drug interaction recognition, at 21.5% (n = 23). Over 93% of the recommendations were proposed and implemented by the ED physician.

In this study, we integrated a pharmacist into current Aged Care Service Emergency Team. The pharmacist’s primary focus was on optimising all aspects of patient medication management. While pharmacist interventions are not novel, what distinguishes our study is the strategic placement of a pharmacist within the Aged Care Service Team model and multifaceted pharmaceutical intervention, including medication review and interview. It's important to note that many studies on readmissions tend to focus on patients admitted to the hospital rather than those seen solely in the emergency department. However, the increasing trend of readmissions to the emergency department within one month, rising from 2.4% in 2010 to 3.1% in 2014, is concerning 21 . Additionally, the elderly cohort represents the highest proportion of these readmission with statistics revealing a 6.2% per annum rise in readmission rates among those over 85 years of age 21 , emphasising the urgent need for improved streaming processes within the hospital system to prevent these patients from being repeatedly assessed in the ED.

Potential solutions may include implementing multidisciplinary assessment areas, or enhancing geriatric outreach services. Our study contributes to this conversation by demonstrating that proactive interventions, such as integrating pharmacists into the Aged Care Service Emergency Team, can effectively reduce unplanned hospital readmissions. This highlights the potential benefits of such strategies in improving patient care and alleviating burdens on the healthcare system.

We found that the intervention was associated with a reduction in unplanned hospital readmissions within 28 days. This suggests that integrating pharmacists into models for managing older patients can optimise medication management and address potential issues that may lead to readmissions.

Several studies have examined the role of pharmacists within other interdisciplinary and multidisciplinary teams and have demonstrated reductions in hospital readmissions which aligns with our study 17 , 18 , 19 , 22 , 23 . These investigations have highlighted a diverse range of interventions orchestrated by pharmacists, who collaboratively engage with medical specialists, consultant nurses, and allied health professionals.

For example, several chronic obstructive pulmonary disease (COPD) specific care bundles that have investigated the inclusion of pharmacists as a strategy to decrease readmissions, with varying degrees of success reported in the literature. In a study by Gentene et al., it was found that pharmacists play a pivotal role in hospital-based transitions of care to lower COPD readmissions 18 . The integration of a multidisciplinary team incorporating pharmacists into the care plan led to a reduction in COPD hospital 30-day readmission rates, from 22.7 to 14.7% 18 .

Similarly, Thurston et al. found that adding a pharmacist to the transitional care team that managing heart failure patients decreased the readmission rate from 33.7 to 21.3% in the intervention group 17 . The intervention group received the pharmacist-led intervention during their hospital stay and post discharge. The study also found an increase in self-reported patient medication adherence 17 .

Our study found that the Number Needed to Treat (NNT) is 8, meaning that for every 8 patients receiving our intervention, one fewer readmission would be expected. This indicates a potential benefit of our intervention in reducing hospital readmissions within 28 days.

According to the National Hospital Cost Data Collection (NHCDC), the average cost per emergency department presentation in 2020–21 is $789 24 . Therefore, if we effectively reduce readmissions within this cohort, the potential cost savings would be substantial.

Contributions from the pharmacist’s interventions may have influenced patients' initial presentation or, if left unidentified, could have potentially exacerbated their conditions, necessitating further medical attention. This demonstrates that the role of pharmacy practice extends beyond merely compiling medication histories and conducting patient interviews. However, as an integral component in preventing readmissions and highlighting the proactive stance in recognising medication-related issues may avert potential harm that could lead to repeat presentations.

Limitations

There are several limitations that need to be considered when interpreting the results of this study. This was a relatively small study, with an intervention carried out in a single institution by a single pharmacist, which limits the generalisability to other institutions and pharmacists. The data collected focused solely on readmissions within the hospital where the study was conducted, disregarding occurrences at other hospitals. Consequently, the data might underestimate the actual rates of readmissions.

This retrospective cohort study involved participants selected for the intervention on an opportunistic basis. It is acknowledged that the allocation method of first-referred, first-intervened is not equivalent to random allocation and may introduce selection bias. Specifically, this opportunistic selection process may have resulted in systematic differences between the intervention and control groups. Participants chosen to receive the intervention might have differed in their characteristics, reasons for hospital admission, and potential for having a medication-related reason for presentation or representation. Consequently, observed differences in outcomes may partly reflect these underlying differences rather than the effect of the intervention itself. To address this limitation, we have described the allocation process in detail in the method section. Despite these efforts, it is possible that selection bias influenced our findings, and this should be considered when interpreting the results.

Future studies should aim to use random allocation methods to more robustly assess the impact of pharmacist interventions. Randomised controlled trials would provide stronger evidence by minimising selection bias and ensuring comparable groups.

In this retrospective cohort study, the inclusion of a pharmacist in the Aged Care Service Emergency Team, responsible for managing older patients being discharged from the ED, was associated with a reduction in unplanned hospital readmissions within 28 days following discharge from the ED. These findings suggest that a collaborative intervention between healthcare professionals may have a positive impact on patient-centred care. To further validate and generalise these findings, a larger randomised multicenter study is necessary.

Data availability

The datasets generated during and/or analysed during the current study are available from the corresponding author upon reasonable request.

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Acknowledgements

The authors also thank the members of the Aged Care Service Emergency Team and Quick Response Program Teams and the Emergency Department at St George for all their support in performing this research.

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

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Susan Tran-Nguyen

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S.T.N. had full access to all aspects of the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. S.T.N. and S.E.A. participated in the research design. S.T.N. and S.E.A. participated in the statistical analysis. S.T.N. and S.E.A. Participated in the writing of the paper. S.T.N supervised the study process and engaged key stakeholders including ASET, QRP and Emergency Department teams.

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Tran-Nguyen, S., Asha, S.E. A collaborative pharmacist-led intervention to prevent hospital readmissions among elderly patients discharged from the emergency department: a retrospective cohort study. Sci Rep 14 , 15285 (2024). https://doi.org/10.1038/s41598-024-64968-8

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A potential game-changer for emergency medicine: Synthetic platelets

by NIH/National Heart, Lung and Blood Institute

Imagine being a paramedic treating a trauma patient who's bleeding severely. You know your patient's life is in danger, but there's not much you can do because the patient needs an infusion of blood containing platelets. Platelets encourage clotting, help stop bleeding, and are critical in emergencies like this. Yet on board your ambulance, none are on hand.

As it turns out, it's not an uncommon problem.

Unlike whole blood (plasma, red and white blood cells , and platelets) that can be stored for up to a month under constant refrigeration, platelets by themselves need a different and even more challenging kind of attention. They require constant agitation to keep them from clumping, and they must be kept at room temperature to maintain their clotting function. The increased risk of bacterial contamination at room temperature means they have a shorter shelf life.

"Platelets only last about five days," said Ashley Brown, Ph.D., an associate professor in the joint biomedical engineering program at North Carolina State University and the University of North Carolina at Chapel Hill. "This makes them one of the weakest—yet most critical—links in the chain when you look at blood products we need to access quickly."

And that's just the beginning of the difficulties. Platelets are frequently in short supply as they're harvested from human donors, they're hard to transport, and they can carry contamination risks.

A miracle solution?

To overcome these obstacles, Brown and her team have come up with something novel that just might check all the boxes: synthetic platelets. The synthetic platelets they have designed have a long shelf life, can be stored under a variety of conditions, and don't carry contamination risks in the animal models they've so far been tested on.

The platelets are created using hydrogel nanoparticles—gels invisible to the naked eye that are formed through a mixture of water and a tiny bit of polymer molecules to give them structure. Brown calls the magical result "Jell-O at the microscale"—except for one enhancement.

"We designed the platelets in a way that makes them extra squishy," Brown said. "It was really important for us to mimic features of natural platelets."

One area where these synthetic platelets really shine is their ability to focus on the site of injury after injecting them intravenously, said Ronald Warren, Ph.D., a program director in the Division of Blood Diseases and Resources at NHLBI. "Other methods to treat internal hemorrhage can run the risk of off-target clot formation, which could lead to stroke, heart attack, or pulmonary embolism," he explained.

Brown's platelets are engineered to incorporate antibody fragments on the surface of the hydrogel that bind to a protein, called fibrin, that is naturally produced when the body is injured. The platelets use the antibody like a homing mechanism to go directly to the injury site. The fibrin's job is to generate a mesh-like substance to enhance clot formation. The researchers found that the synthetic platelets can help stiffen the clot and stabilize it, which then aids the wound-healing process after clotting happens.

"This was a really exciting finding and a total surprise when we first discovered it," Brown said. She explained that if a person is bleeding excessively, the body isn't able to make enough fibrin. But when her platelets are infused, they can actually speed up fibrin formation.

After they reach the site of the injury and become active, the platelets, due to their squishiness, can also change shape—from being rounded to being more star-like, mimicking what natural platelets do in the body. This change encourages a process called clot retraction, or the shrinking of a blood clot to allow the edges of the injured blood vessel wall to be slowly brought together again for repair.

The squishiness of the platelets gives them another advantage at the end of the process. "They can squeeze through pores that are way smaller than their size, allowing them to be excreted by the kidneys," Brown said. "Normally they would accumulate in the liver, which could have harmful effects."

Still testing—and showing promise

Brown and her research team have been testing the synthetic platelets in a variety of animal models, and so far the results have been positive. In mice with liver injuries, the synthetic platelets went directly to the injury site and had the lowest levels of blood loss when compared to mice given normal platelets or a control solution of saline. At seven days after injury, mice given the synthetic platelets also had the smallest wounds, a sign of improved healing. Testing in rats with an injury to the blood vessel instead of the liver, the researchers found similarly promising results.

But Brown said that pigs are the gold standard, for their ability to provide greater insight into how synthetic platelets might work in humans. When given immediately after a liver injury in pigs, the synthetic platelets traveled to the site of injury and reduced blood loss. They also didn't cause any measurable allergic or immune system reactions, and began to be excreted by the kidneys in as little as two hours after injection.

"We think that synthetic platelets could be the best thing since sliced bread, but that's yet to be determined through further testing," Brown said. Her team is still experimenting to find the ideal conditions to store the platelets for the best results. Currently, testing shows they can be stored as a freeze-dried powder, which could be useful in ambulances or similar trauma situations such as on the battlefield, or suspended in a solution that may be better for hospital use.

While they continue testing storage conditions, Brown has launched a company with her colleague Seema Nandi, Ph.D. serving as the CEO. SelSym Biotech is focused on completing all the necessary steps, such as manufacturing, pre-clinical studies, and clinical trials , to get synthetic platelets into clinical use. It will evaluate the long-term stability and safety of the platelets, as well as work out the processes for scaling up production after testing in humans shows they are safe and effective. Brown expects those trials to begin in about two years.

"By developing a new generation of treatment options for emergency medicine, this research may help improve patient outcomes while potentially reducing health care costs," Warren said. "Unlike donated platelets, which can vary in quality, synthetic platelets could potentially be produced in large quantities with uniform quality and performance."

Brown said she is hopeful the platelets will find their way to emergency medical service vehicles, military medic kits, and hospitals soon, so that her "extremely motivating" work to save lives finally pays off.

"So many people die from unnecessary bleeding injuries," she said. "I'm hopeful that this work could have a big impact."

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A Randomized Trial Comparing the Efficacy of Five Oral Analgesics for Treatment of Acute Musculoskeletal Extremity Pain in the Emergency Department This randomized control trial compared the efficacy of 5 oral analgesics for the treatment of acute musculoskeletal extremity pain. All patients were deemed to need an x-ray and be appropriate for oral pain control by the treating physician. In the end, no particular analgesic was more efficacious at 1 or 2 hours. However, there was significantly more nausea and vomiting among patients treated with opioids.

Regimens included:

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• 800 mg ibuprofen and 1,000 mg acetaminophen
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• 5 mg hydrocodone and 300 mg acetaminophen
• 5 mg oxycodone and 325 mg acetaminophen

The Use of Tranexamic Acid to Reduce the Need for Nasal Packing in Epistaxis (NoPAC): Randomized Controlled Trial The largest RCT of TXA in epistaxis (496 participants) demonstrates that TXA does not provide improved benefit compared to traditional nasal packing at reducing the need for anterior nasal packing (43.7% of the experimental group still required anterior nasal packing to achieve tamponade). Limitations of the study include the studied population (primarily older men on anticoagulation), and the dose of TXA used.

Regional anesthesia on the finger: traditional dorsal digital nerve block versus subcutaneous volar nerve block, a randomized controlled trial A prospective, multicenter, RCT of 409 ED patients compared the subcutaneous volar nerve block vs. the traditional dorsal digital nerve block. All patients had a finger injury requiring regional anesthesia for surgical treatment. Results demonstrated that numbing the thumb via a dorsal block is preferred, whereas individual fingers achieve better dorsal analgesia via the dorsal block and better analgesia on the proximal phalanx via a volar block. Overall, the dorsal nerve block gave greater anesthesia but required 2 injections and a greater amount of lidocaine.

Isopropyl alcohol nasal inhalation for nausea in the triage of an adult emergency department A randomized, double-blind, placebo-controlled trial assessed the efficacy of isopropyl alcohol (IPA) to patients who presented to triage in the ED with the chief complaint of isolated nausea and vomiting. Patients scored 3 or higher on the nausea/vomiting numerical rating scale. Among 118 patients, 62 patients who received IPA reported improved nausea and vomiting-related symptoms vs. placebo and required less rescue treatment. This is the third RCT demonstrating the efficacy of inhaled IPA for the acute treatment of uncomplicated nausea and vomiting.

GASTROENTEROLOGY

A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis A non-blinded, pragmatic non-inferiority randomized trial of 1,552 patients with appendicitis compared quality of life at 30 days between patients treated with 10 days of antibiotics vs. appendectomy for appendicitis. The results demonstrated that antibiotics have comparable outcomes to surgery for acute appendicitis etiologies, with the exception of patients with an appendicolith who had higher rates of complications in the antibiotic group.

Prospective Validation of Canadian TIA Score and Comparison with ABCD2 and ABCD2i for subsequent stroke risk after transient ischemic attack: multicenter prospective cohort study This prospective multicenter cohort study was designed to validate the Canadian TIA Score for patients needing risk stratification for future adverse neurologic events. Results demonstrated that among the 7,607 ED patients presenting for TIA, 1.4% had a subsequent stroke within 7 days, and 1.1% required carotid endarterectomy/stenting. The Canadian TIA score outperformed the ABCD2 and ABCD2I in risk stratifying patients with an improved area under the curve. The Canadian TIA risk score was also able to identify a low-risk cohort appropriate for rapid outpatient evaluation. The Canadian TIA score is now validated and can be used in clinical practice.

MAGraine: Magnesium compared to conventional therapy for treatment of migraines The single-center, prospective, double-blinded, randomized, three-armed trial compared magnesium, metoclopramide, and prochlorperazine for the treatment of migraine. This study found that magnesium was not inferior in efficacy to the other two medications, which can be especially useful in patients who simultaneously present with prolonged QT. However, patients who received magnesium for migraine management were more likely to require additional analgesia subsequently. One significant limitation of this study is that it was stopped early due to COVID, causing it to be underpowered, with n = 157.

Effect of a Restrictive vs Liberal Blood Transfusion Strategy on Major Cardiovascular Events Among Patients With Acute Myocardial Infarction and Anemia: The REALITY Randomized Clinical Trial An open-label, noninferiority, randomized trial attempted to identify an optimal transfusion strategy in patients with acute myocardial infarction and anemia. Primary outcome was major 30-day adverse cardiovascular events. The study concluded that among the 668 participants, between the restrictive (transfuse at HgB ≤ 8) and liberal transfusion groups (transfuse at HgB ≤ 10), major adverse cardiac events occurred in 11.0% of patients in the restrictive group vs. 14.0% in the liberal transfusion group. The authors concluded that a restrictive transfusion resulted in a noninferior rate of MACE after 30 days with a relative risk of 0.79 (1-sided 97.5% CI, 0.00-1.19). They also cautioned that the non-inferiority confidence interval was large enough to contain worse outcomes in the restrictive group, warranting a larger study to confirm these results.

  DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction (DIFOCCULT Study) This is a retrospective case-control study evaluating the performance of EKG STEMI criteria or expanded EKG Acute Coronary Occlusion Myocardial Infarction(ACOMI) criteria for the identification of Acute Coronary Occlusion. In this study, 1,152 STEMI and 2,353 non-STEMI patients were evaluated. In the non-STEMI group 28% were found to have an acute coronary occlusion identifiable on EKG with ACOMI criteria. These non-STEMI patients with ACOMI had similar mortality rates to STEMI patients. The author shows that a refined EKG paradigm for the identification of acute coronary occlusion would have improved sensitivity to identify those who need acute reperfusion therapy.

Effects of Fluoroquinolones on Outcomes of Patients With Aortic Dissection or Aneurysm This was a retrospective cohort study that compared patients who were diagnosed with aortic aneurysms or aortic dissections and their mortality risk after fluoroquinolone exposure. Patients were identified after their initial hospitalization and then outpatient data was followed, looking at prescription days of fluoroquinolones (experimental group) or amoxicillin (negative control group) and then monitored for adverse outcomes. The study concluded that exposure to fluoroquinolones was associated with a higher risk of all-cause death (adjusted hazard ratio [aHR]: 1.61; 95% confidence interval [CI]: 1.50 to 1.73) as well as aortic-related death (aHR: 1.80; 95% CI: 1.50 to 2.15). Increasing evidence has shown fluoroquinolones should be avoided in high-risk patients unless no other treatment options are available.

CRITICAL CARE

The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness With Paralysis in Mechanically Ventilated Patients Admitted From the Emergency Department The single-center, prospective cohort study assessed the prevalence of awareness with paralysis in ED patients receiving mechanical ventilation. In this study, 383 patients were surveyed following extubation for awareness during paralysis. The study identified a prevalence of 2.6% (10/383), with rocuronium usage at any point resulting in higher instances of awareness (70%) vs. all other paralytics (31.4) (95% confidence interval 0.94 to 8.8). While there are many possible reasons for this prevalence, it is much higher than the rate observed in general anesthesia (~1%), and care should be taken to start appropriate and timely post-intubation sedation.

Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest This is an open-label randomized control trial of 1,850 adults with an out-of-hospital cardiac arrest who subsequently underwent targeted hypothermia (at 33°C), or targeted normothermia. Primary outcome was mortality at 6 months. Functional outcomes at 6 months were also evaluated. The study concluded 50% of the patients treated with hypothermia died, compared to 48% of the normothermic group (relative risk with hypothermia, 1.04; 95% confidence interval [CI], 0.94 to 1.14; P = 0.37). Similarly, 55% of patients in the hypothermic group suffered from severe disability (modified Rankin scale score ≥4), compared to 55% of normothermic patients (relative risk with hypothermia, 1.00; 95% CI, 0.92 to 1.09), thus concluding that targeted hypothermia does not decrease mortality within 6 months when compared to targeted normothermia. This study should be narrowly interpreted, as it is a highly selected patient population that does not compare well to the general U.S. cardiac arrest population in regard to rates of bystander CPR, rates of presenting with a shockable rhythm, and neurologically intact survival rates.

Lung-Protective Ventilation and Associated Outcomes and Costs Among Patients Receiving Invasive Mechanical Ventilation in the ED A retrospective study assessed how ventilation settings in the ED affected ICU outcomes among 4,174 patients. In this study, 58.4% of patients on ventilation received lung-protective ventilation in the ED (defined as tidal volume ≤ 8mL/kg predicted body weight) and were less likely to suffer from ARDS (aOR, 0.87; 95% CI, 0.81-0.92) or in-hospital death (aOR, 0.91; 95% CI, 0.84-0.96). ED ventilatory care of critically ill patients can have lasting effects on mortality and other adverse outcomes.

Early head-to-pelvis computed tomography in out-of-hospital circulatory arrest without obvious etiology In patients who present following an out-of-hospital cardiac arrest, identifying obvious causes can be challenging and not immediately identifiable. A prospective, observational pilot study assessed the safety and efficacy of early head-to-pelvis CT imaging to identify the cause of cardiac arrest. Among 104 patients a sudden death CT scan (SDCT) protocol (non-contrast CT head, ECG-gated cardiac and thoracic CT angiogram, and nongated venous-phase abdominopelvic CT angiogram) identify the cause of cardiac arrest in nearly 39% of patients. In addition, life-threatening complications of resuscitation were identified in 16% of patients. Though exploratory, these findings suggest that a sudden death CT protocol can expedite the diagnosis of potential causes and identify resuscitation complications in patients with out-of-hospital cardiac arrests.

Noninvasive Ventilation Use in Critically Ill Patients with Acute Asthma Exacerbation A retrospective cohort study assessed the association between noninvasive ventilation and a subsequent need for invasive mechanical ventilation and in-hospital mortality among patients admitted to the ICU with an asthma exacerbation. Noninvasive ventilation was associated with a lower likelihood of receiving invasive mechanical ventilation (adjusted generalized estimating equation odds ratio, 0.36; 95% CI, 0.32-0.40) and decreased in-hospital mortality (odds ratio, 0.48; 95% CI 0.40-0.58) unless patients had concomitant comorbid pneumonia and/or severe sepsis.

Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia: The SAFER Randomized Clinical Trial A multicenter, blinded, non-inferiority RCT compared rates of cure for community-acquired pneumonia with a short course (5 days) vs. standard course (10 days) of amoxicillin. In this study, 281 pediatric ED patients between 6 months and 10 years old with CAP who were being discharged were randomized. The results demonstrated that the short course of antibiotic therapy was comparable to longer course antibiotics. Clinical cure occurred in 88.6% in the short group and 90.8% in the control group (risk difference, -0.016; 97.5% confidence limit, -0.087). In pediatric patients who are otherwise healthy presenting with community-acquired pneumonia, it is reasonable to consider a shorter course (< 10 days) of antibiotics and follow-up with primary care physician to ensure clinical cure. Though these results are consistent with other trials, the results themselves are not as robust, and an additional trial is likely needed with different endpoints to confirm these findings.

Risk Factors and Outcomes After a Brief Resolved Unexplained Event: A Multicenter Study To evaluate whether current American Academy of Pediatrics risk criteria predict BRUE outcomes, a multicenter retrospective cohort study assessed more than 2,000 infants less than 1 year of age who presented with a suspected BRUE without a probable alternative or definite diagnosis. Among these patients, 87% met AAP higher-risk criteria for having at least 1 AAP risk factor; 63% were hospitalized, with the most common explanations being less serious such as GERD (18.5%), choking or gagging (8.2%), viral respiratory infections (4.4%), and breath-holding spells (4.1%). A serious diagnosis was identified in 4.0% of patients, with 45% of these diagnoses being made after discharge from the index visit without an explanation. Having at least 1 AAP risk factor (ie, higher-risk criteria) was associated with a recurrent event in the ED or hospital (odds ratio [OR] 5.9; 95% confidence interval [CI] 2.7–12.6) and a recurrent event that led to an explanation (OR 15.1; 95% CI 2.1–108.6). The results suggest that while the absence of AAP high-risk criteria had a robust NPV (97%) for underlying serious conditions, the presence of criteria did not have a strong PPV (4%).

Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old This paper represents the first official guidelines from the American Academy of Pediatrics for the evaluation of well-appearing febrile(≥ 38°C) infants 8-60 days old. These landmark guidelines are divided into three algorithms for infants 8-21 days of age, 22-28 days of age, and 29-60 days of age. There is an abundance of information in this paper and it is worth becoming familiar with and having handy for when this situation arises. Importantly, there are inclusion and exclusion criteria listed to ensure kids are appropriate for utilization of these guidelines.

PRE-HOSPITAL

Tranexamic Acid During Prehospital Transport in Patients at Risk for Hemorrhage After Injury: A Double-blind, Placebo-Controlled, Randomized Clinical Trial Pragmatic, phase 3, multicenter, double-blind, placebo-controlled, superiority randomized trial which assessed clinical outcomes among 6559 patients at risk for hemorrhage who received prehospital tranexamic acid (single dose). The 30-day all-cause mortality was assessed among patients who received 1g TXA (treatment) or 100 mL saline (placebo) prior to hospitalization. Results showed 30-day mortality among patients receiving TXA was 8.1% vs. placebo 9.9% (95% CI, -5.6% to 1.9%; P = .17). Post-hoc analysis, stratified by time to TXA administration, showed giving TXA within 1 hour of injury in patients with severe shock lowers 30-day mortality compared with placebo (18.5% vs 35.5%; difference, -17%; 95% CI, -25.8% to -8.1%; P < .003).  

Diagnostic Accuracy of Lung Point-Of-Care Ultrasonography for Acute Heart Failure Compared with Chest X-ray Study Among Dyspneic Older Patients in the Emergency Department A retrospective cohort study assessed whether POCUS was comparable to chest x-ray in identifying acute heart failure exacerbation among older patients. An 8-zone lung ultrasound protocol was used to look for signs of pulmonary edema; 148 patients were enrolled. For the diagnosis of acute heart failure, POCUS had a sensitivity of 92.5% and a specificity of 85.7% vs. chest x-ray with a sensitivity of 63.6% and specificity of 92.9%. Overall, POCUS had a significantly higher sensitivity for the diagnosis of acute heart failure, while demonstrating comparable specificity.

Impact of point-of-care ultrasound on treatment time for ectopic pregnancy A retrospective, observational, cohort study assessed whether transabdominal POCUS by itself or in addition to consultative radiology ultrasound (RADUS), reduces ED treatment time for patients with ectopic pregnancy requiring operative care. Among 109 patients admitted with ectopic pregnancies, 36 received POCUS (with 23 of those 36 also receiving RADUS), and 73 received RADUS only. POCUS involved the RUPTURE exam (Right Upper and Pelvis Timley Ultrasound for Ruptured Ectopic) to evaluate for an intrauterine pregnancy and abdominal free fluid. The average ED treatment time in the POCUS group was 157.9 min vs. 206.3 min in the RADUS group (p = 0.0141). The median time to OR for ruptured ectopic pregnancies was 203.0 min (interquartile range [IQR] 159.0) in the POCUS group versus 293.0 min (IQR 139.0) in the RADUS group (p = 0.0002). These results conclude that POCUS was associated with significantly faster time to OR for ectopic pregnancies.

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Explore the latest in critical care medicine, including management of respiratory failure, sepsis, HAI prevention, end-of-life care, and more.

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This systematic review and meta-analysis examines the use of termination of resuscitation rules to estimate patient survival of out-of-hospital cardiac arrest.

• Optimizing the Value of β-Lactam Antibiotics Through Extended Infusion JAMA Network Open Opinion July 2, 2024 Emergency Medicine Infectious Diseases Sepsis Resuscitation Pharmacy and Clinical Pharmacology Full Text | pdf link PDF open access

This cohort study assesses whether extended-infusion β-lactam therapy is associated with survival, adverse events, and/or emergence of resistance in adults with gram-negative bloodstream infections.

This cohort study assesses factors associated with family surrogates in Taiwan and their critically ill loved one’s categorization into 1 of 4 response classes based on the Quality of Dying and Death Questionnaire.

This cross-sectional study of US adults hospitalized with suspected community-onset sepsis examines trends in empirical broad-spectrum antibiotic use from 2017 to 2021.

This cohort study assesses whether various types of antibiotics and the length of exposure are associated with the incidence of bronchopulmonary dysplasia (BPD) among very preterm infants at low risk of early-onset sepsis (EOS) in China.

This cohort study examines data for infants in a sample of NICUs across the US to estimate the incidence rates and attributable mortality of hospital-onset bacteremia as well as determine associated clinical characteristics.

This Medical News article discusses a new Boston Medical Center initiative that helps patients with financial hardship pay their utility bills.

This cohort study evaluates whether intravenous opioids administered during mechanical ventilation are associated with opioid use following hospital discharge among medical (nonsurgical) patients.

This randomized clinical trial assessed whether adding dapagliflozin to standard care for patients with acute organ dysfunction could reduce the composite outcome of hospital mortality, initiation of kidney replacement therapy, and length of stay compared with standard care alone.

• Sodium-Glucose Cotransporter 2 Therapy for Acute Organ Dysfunction in Critically Ill Patients JAMA Opinion June 14, 2024 Full Text | pdf link PDF

This cross-sectional study compares differences in demographics, respiratory support modes, and clinical outcomes for children with respiratory syncytial virus before vs after the COVID-19 pandemic.

This Review discusses whether treatment with low-dose corticosteroids may benefit critically ill patients with respiratory infections who have septic shock, acute respiratory distress syndrome, or both.

This systematic review and bayesian meta-analysis investigated whether administration of β-lactam antibiotics by prolonged infusion reduces 90-day mortality compared with intermittent infusion in adult patients with sepsis or septic shock.

This clinical trial compares the efficacy of continuous vs intermittent infusion of a β-lactam antibiotic (piperacillin-tazobactam or meropenem) in decreasing all-cause mortality at 90 days in critically ill patients with sepsis.

• Resolving the Dilemma on Continuous vs Intermittent β-Lactam Antibiotics in Sepsis JAMA Opinion June 12, 2024 Infectious Diseases Antibiotic Use, Overuse, Resistance, Stewardship Resuscitation Sepsis Full Text | pdf link PDF

This cohort study examines the hospitalization rates associated with respiratory syncytial virus infection during the 2021-2022 and 2022-2023 seasons compared with the pre-COVID-19 2017-2020 seasons in Ontario, Canada.

This prognostic study analyzes the accuracy of the Phoenix Sepsis Score for the classification of attributable mortality risk in children with cancer presenting to the intensive care.

This prognostic study investigates the ability of a large language model to perform risk stratification and predict postoperative outcomes using a description of the procedure and the patient’s preoperative clinical notes.

• The Quest for Evidence on Time to Antibiotics in Children With Sepsis—Finding the Sweet Spot JAMA Network Open Opinion June 5, 2024 Pediatrics Emergency Medicine Infectious Diseases Sepsis Resuscitation Full Text | pdf link PDF open access

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Stanford is leading research efforts to transform health care for  all  through Precision EM. Precision Emergency Medicine utilizes information and technology to effectively, efficiently, and authentically deliver acute care for our patients and our communities.

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Emergency medicine: past, present, and future challenges

Wei, Shujian ∗

a Department of Emergency Medicine and Chest Pain Center, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China

b Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China

c Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China

d Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China

e Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.

∗Corresponding author. Address: Department of Emergency Medicine and Chest Pain Center, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No. 107, Wenhuaxi Road, Jinan, Shandong, 250012, China. E-mail address: [email protected] (S. Wei).

How to cite this article: Wei S. Emergency medicine: past, present, and future challenges. Emerg Crit Care Med. 2021;1:49–52. doi: 10.1097/EC9.0000000000000017

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0

Origin and history of emergency medicine

The term “emergency,” first used in the 1630s, is derived from the Latin word emergere , meaning unforeseen events that require immediate attention. The term “emergency medicine” can be traced to the French Revolution (1789–1799). In 1792, Dominique Jean Larrey, a military medical surgeon, gained a position in the Army of the Rhine and left for Strasbourg, where he witnessed great mobility of the horse artillery and then suggested that General Adam Philippe de Custine have the medical staff use this method to speed up transport of the wounded. The general approved Larrey's proposal. Larrey's “ambulance” was a simple carriage, despite the exposure to enemy fire. In 1797, during the first Italian campaign, Larrey created a complete rescue system with an active medical team in the battlefield. In contrast to previous rescue methods, Larrey transported critically wounded patients to the rescue station and operated on them as soon as possible, instead of delaying the operation after the battle. The timely rescue system created by him enabled every wounded soldier to be treated within 24 hours, which significantly reduced the mortality rate. Therefore, Larrey has often been referred to as “the father of emergency medical services.” [1]

Medicine, as a professional field, dates back to the early 19th century, while emergency medicine can only be traced back to 50 years ago, making it the most recently developed major field in medicine. Before the 1960s, staff in hospital emergency departments usually worked in rotation with family doctors, general surgeons, physicians, and other specialists. In many small emergency departments, nurses conducted the triage of patients, and specialty doctors were called in based on the type of injury or disease. Many pioneers of emergency medicine were family doctors and other specialists, who believed that extra training in first aid was necessary. A group of doctors left their professional positions and devoted themselves to education. In 1952, Maurice Ellis was appointed as the first “first aid consultant” at Leeds General Infirmary in England. In 1967, the Casualty Surgeons Association was founded, with Maurice Ellis as its president. [2,3] In 1961, in the United States, Dr James DeWitt Mills, along with 4 assistant physicians, established 24/7 emergency care at Alexandria Hospital in Alexandria, Virginia; it was later known as the Alexandria Plan. [4] In 1970, the University of Cincinnati launched the first emergency resident physician program in the world. In 1971, the University of Southern California became the first American medical school to establish a department of emergency medicine. [5] History was made in 1979, when the American Board of Medical Specialties voted to make emergency medicine a recognized medical specialty in the United States. [5]

In China, emergency medicine started relatively late. The Ministry of Health issued “Suggestions on Strengthening First Aid Work in the City” and “On the Release of the Construction Plan of Hospital Emergency Departments (Trial)” on October 30, 1980 and June 11, 1984, respectively. These 2 documents stipulated the work direction, scope, and tasks of the emergency department; thereby, laying the foundation for the construction of emergency departments in China. In 1985, Peking Union Medical College Hospital established the first postgraduate program in emergency medicine. [6–8]

Current state of emergency medicine

Emergency medicine mainly involves the rapid assessment, treatment, and triage of critically ill patients, and has transformed from the emergency room to the emergency department or emergency center. Hospitals typically set up a relatively complete emergency medical system of “out-of-hospital emergency medical services, in-hospital emergency medical services, and critical care.” Numerous emergency diagnostic and treatment technologies, such as cardiopulmonary resuscitation, emergency percutaneous coronary intervention, continuous renal replacement therapy, left ventricular assistive devices, and extracorporeal membrane oxygenation, are applied in emergency medicine. Moreover, a growing number of qualified physicians have devoted themselves to emergency medicine, and several academic platforms have been established, which facilitate knowledge exchange.

With the continuous reform of the medical system and the comprehensive implementation and promotion of hierarchical diagnostic and treatment systems from medical reform, the development of emergency medicine is confronted with rare opportunities and more challenges. For example, the construction of emergency systems varies across nations and regions. Practitioners in emergency services have the vital task of establishing a complete emergency diagnosis and treatment system to maintain the daily health of the public and to satisfy the emergency demands of major public health events. It is necessary to move the front of first aid forward, carry out multidisciplinary cooperation, treat all types of critically ill patients, deal with public health emergencies, and boost hierarchical diagnosis and treatment work. Amid the rapid growth of modern medicine, advanced technology and innovative drugs continue to emerge. In many cases of emergency work, it is the timely, orderly, and efficient application of these technologies and drugs to the early treatment of critically ill patients that matters. Therefore, “process optimization and early treatment” is an important direction in emergency medicine research.

With the development of a medical discipline, each medical specialty is more characterized, and even some single diseases tend to form specialties. [9] Following the law of medical development, emergency medicine also gives full play to specialty characteristics and the development of subspecialties. [10] For example, in areas with a high incidence of cardiovascular diseases, emergency centers have subspecialty focus areas for cardiovascular diseases, and in rural areas with a common occurrence of acute poisoning, emergency departments of primary hospitals establish a subspecialty for the treatment of acute poisoning. In developing subspecialties, emergency medicine focuses on the advancement of diagnostic and treatment technologies for life-threatening diseases and integration with other subspecialties. The construction of high-quality subspecialties in emergency medicine is conducive to the development of new diagnostic and treatment equipment and technology.

Future of emergency medicine

The coronavirus disease pandemic has brought huge challenges to medical systems, especially emergency medicine. [11] Elevating the capability of early identification, appropriate treatment, and life support for severe or critical patients will always be the core topics of emergency medicine.

Emergency medicine in the future will be characterized by continuous advances in practices, research, technologies, and so forth. In terms of clinical practices, problems such as inefficiency and crowding may arise and cause tension in emergency departments. The development of emergency medicine is still in its primary stage and is extremely uneven between rural and urban areas. The resolution of such issues and optimization of processes in emergency medicine can be realized by implementing an increasing number of equipment configurations, improving the structure of emergency medical personnel, and establishing a closer linkage between out-of-hospital and in-hospital emergency services. In essence, “process optimization and early treatment” manifests as an influential component in the development of emergency medicine. In the optimization of the emergency process, the stability of emergency medical professionals is a valuable resource. Upgrading clinical emergency care competence, including rapid response, effectiveness, and service attitude, and improving the skills of medical professionals in the emergency department are of great importance.

The demands for technology are certain to direct the course of emergency services, as the need for timely diagnosis and treatment of patients continues to grow. Information technology can be used to tap available resources and collect information on patients and disease management to aid emergency staff in real time via telemedicine. Specifically, in the absence of specialists or general practitioners on site, the vital signs of patients and critical information can be wirelessly transmitted to experts who can provide remote guidance that may be critical to saving lives. [12] In addition, remote monitoring also enables hospitals to grasp the condition of patients at the earliest time, formulate emergency plans in advance, and ensure a seamless connection between out-of-hospital emergency and in-hospital treatment. By virtue of networks, the real-time transmission of medical devices that monitor information, ambulances’ positioning information, and video footage from inside and outside ambulances can facilitate remote consultation and guidance. Moreover, the collection, processing, storage, transmission, and sharing of out-of-hospital emergency information can fully enhance treatment efficiency and service quality, thereby optimizing the process and mode of service.

Big data technology can fully explore medical information to aid in the management and decision-making of emergency care. [13] One of the applications of big data in the medical field is the establishment of a cloud platform for emergency and critical care information management. Such a platform would collect the diagnosis-, examination-, and treatment-related information of patients from databases, such as an emergency logbook, a hospital information system, a picture archiving and communication system, a microbial detection and management system, and a pathology information system. Next, the data were classified, cleaned, extracted, and explored in depth using the platform. Based on this information, a teaching management system can be obtained, including a multidisciplinary triage management system, a critical care score and grading management system, and an early warning system for serious emergencies. The application of big data technology in emergency medicine provides medical practitioners with access to various information databases for each individual and possible treatment options, which will greatly improve teaching efficiency and the ability to diagnose and treat related diseases.

Precision medicine is a medical model that fully considers individual differences in the genes, environment, and lifestyle of patients to achieve the most effective treatment and prevention of diseases. The emergency department is the first critical link in the clinical diagnosis and treatment of critical illnesses and infectious diseases, and individualized accurate assessment and prevention of disease susceptibility is a valuable research direction for precision emergency medicine. [14] Acute infectious diseases are among the most common diseases in the emergency department. However, given the complexity of diseases, lag in detection technology, and lack of multidimensional clinical information integration technology, the diagnosis and treatment of common diseases such as community-acquired pneumonia remain stagnant. In addition, the emergence of drug-resistant pathogens and emerging microorganisms poses a challenge to empirical therapy protocols. Identifying pathogenic microorganisms quickly and accurately is critical for initiating individualized treatment plans and is also the core component of precision emergency medicine systems. The ideal method of monitoring the outbreak of drug-resistant pathogenic microorganisms in communities or hospitals is to analyze the genetic ancestry of pathogenic microorganisms through genome technology. One of the essential tasks of emergency medicine is to use clinical information to provide individualized diagnosis and treatment for cases without a clear etiology. To some extent, it is necessary to establish etiological diagnoses through emergency treatment processes. In addition to molecular etiology diagnoses based on pathogenic specimens (eg, throat swabs, sputum, and body fluids), diagnostic techniques based on omics information have also seen rapid advances, which will improve precision emergency treatment services. For the differential diagnosis of emergency and critical care illnesses, precision emergency medicine can enhance diagnostic effectiveness significantly with the help of multidimensional and omics data, thus creating the ideal conditions for individualized diagnosis and treatment.

With the combination of big data and precision medicine, information technology can promote the growth of scientific research and clinical work in emergency medicine, such as sequencing, information construction, data integration, and analysis, and improve the use of big data in emergency medicine. Under these circumstances, it is possible to achieve breakthroughs in the development of targeted drugs for precision therapy, complete the closed-loop service of precision emergency medicine, and establish a disciplinary system for precision emergency medicine in China.

Artificial intelligence can promote the growth of emergency medicine. [15] Equipped with capabilities in prediction, analysis, and response, artificial intelligence systems can aid emergency staff in diagnosis and treatment. When artificial intelligence tools execute instructions, they can learn from big data through image recognition, speech recognition, human–computer interaction, physical sensing, and other means. After finishing examinations quickly, artificial intelligence tools can formulate a relatively accurate diagnosis and individualized medicine. In addition, artificial intelligence can assist in locating potential risks and threats in advance. In some emergency events, artificial intelligence can assess the situation and predict the required medical services. Another example of artificial intelligence is the use of medical robots. Apart from their application during complex surgeries, medical robots can deliver objects to patients in quarantine and help avoid human contact during virus epidemics. In short, the use of artificial intelligence will undoubtedly benefit emergency medicine in the future.

As more countries are improving their emergency medical systems, the global scale of information exchange is empowering international emergency medicine. Promoting the quality of academic exchange among countries is a priority in the development of international emergency medicine. Moreover, the variety and complexity of emergency diseases pose challenges to timely and accurate emergency medical treatment, and require emergency medical staff to possess rich medical knowledge and accurate judgment.

Although the development of emergency medicine is confronted with quite a few challenges, it has entered the era of communication among various schools of thought. This journey provides opportunities to the field of emergency medicine. With the joint efforts and hard work of stakeholders worldwide, emergency medicine will accomplish more historic advancements.

Conflict of interest statement

Shujian Wei is the Executive Editor of Emergency and Critical Care Medicine . The author declares no conflicts of interest.

Author contributions

Shujian Wei wrote the article.

Ethical approval of studies and informed consent

Acknowledgements.

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Reversing the urgent and emergency care spiral of decline

• Related content
• Peer review
• Tim Cooksley , president 1 ,
• Mark Holland , consultant in acute medicine 2 ,
• Elizabeth Sapey , professor of acute and respiratory medicine 3
• 1 Society for Acute Medicine
• 2 Associate TIRI Professor, School of Clinical and Biomedical Sciences, University of Bolton
• 3 Birmingham Acute Care Research Group, PIONEER Data Hub, University of Birmingham.

NHS urgent and emergency care is under intolerable strain. This strain is increasingly causing harm to patients. 1 Timely and high quality patient care is often not being delivered due to overcrowding driven by workforce and capacity constraints. 2 3 While the covid-19 pandemic has accentuated and arguably expedited the crisis; the spiral of decline in urgent and emergency care has been decades long and unless urgent action is taken, we may not yet have reached its nadir.

In January 2023, 42 725 patients waited more than 12 hours in England’s emergency departments for an inpatient bed. This compares to 16 558 in January 2022 and 2,847 in January 2020. This is further illustrated in the data from March 2023 with 39 700 patients waiting more than 12 hours in emergency departments compared to 22 500 and 1,184 in the same month of 2022 and 2020 respectively. The rate of this rise is gravely concerning with a current trajectory suggesting that winter 2023 will be worse than the dire experience of 2022. In 2022, 1.65 million people waited 12 or more hours in an emergency department. 4 In February 2023, 125 505 patients (around 10% of attendances) waited more than 12 hours from the time of emergency department arrival.

Acute medical care is now routinely being delivered by teams in emergency departments rather than in optimal environments with older patients in particular bearing the brunt of this situation. This causes significant risk and increased mortality. 5

Acute medicine is at the heart of finding opportunities to mitigate the current crisis and future innovative, adaptive, high quality and sustainable urgent and emergency care. The fundamental components of the specialty—well functioning, evidence driven acute medical units and ambulatory emergency care, recently rebranded in England as same day emergency care—alongside enhanced care areas and evolving acute medicine led hospital at home models are essential for urgent and emergency care and whole system recovery. 6 7 8

The Society for Acute Medicine Benchmarking Audit (SAMBA) reiterates the picture of a rapid decline in clinical performance. 9 Acute medical patients are not only enduring long waits in emergency departments; but also increased waits for key indicators of quality such as initial clinical review, time to consultant review and monitoring of their physiology.

Well resourced analysis and understanding of patient flow informing the delivery of local services is imperative. Inadequate or inappropriate use of direct acute medical unit admission or same day emergency care pathways contribute to long waits in emergency departments exacerbated by a lack of inpatient beds to facilitate flow from the acute medical unit alongside a mismatch between staffing levels and peaks of activity exacerbated by workforce shortages. The ideal acute medical unit needs sufficient capacity to process acute admissions and keep patients who do not require transfer to a specialty unit to stay for up to 72 hours, as this continuity reduces length of stay. Bypassing acute medical units to general medical or specialty beds can increase length of stay.

An increasing range of presentations no longer require patients to remain in hospital overnight and are managed through same day emergency care pathways. Acute medicine hospital at home models enable acute care traditionally delivered in hospital to be provided in the patient’s home. The design of these services includes senior clinician decision making, multi-disciplinary assessment and rehabilitation, physiological monitoring utilising digital technologies, delivery of intravenous treatments and escalation plans should there be a deterioration in the patient’s condition. 10 These can be supported by diagnostic investigations at the bedside including point of care blood tests and point of care ultrasound. 11 12

However, for these and other novel services to be optimally utilised and embedded in clinical services, robust evidence is needed to understand how to select patients for each service and what the health economic, service benefit, and opportunity costs are for each model. Recent history has shown that assessment and care pathways that conceptionally appear sensible, but have limited or no evaluation before roll-out, can perform poorly when deployed in real-world healthcare settings. For example, selection tools for same day emergency care, 13 the performance of covid virtual wards, 14 and NHS England’s “Reasons to Reside” criteria, 15 have all failed to meet expected performance levels when evaluated. Acute medicine offers significant opportunities for service innovation, but this must be as part of a learning health system, 16 where services are evaluated and refined in accordance with evidence.

Alongside its core work, acute medicine can promote and deliver important public health messages. 17 Delivering patient health education is often sacrificed in overburdened acute environments, with a lost opportunity to potentially mitigate future unscheduled admissions.

Acute medicine services, like all NHS and social care, are wilting and unable to meet demands. Patient complexity and expectation will continue to increase for the foreseeable future. While acute medicine must continue to evolve and adapt, it is imperative that the proven fundamentals are not overlooked in the likely futile search for the “magic bullet.” High quality research, consistent implementation, and rigorous evaluation of new initiatives to understand acute medicine flow and performance are mandatory.

NHS acute medical pressures are at unsustainable levels and current results are scant justice for the teams who continue to strive to deliver reasonable quality of care for their patients. Critics argue that senior doctors highlighting failings in the delivery of urgent and emergency care is not new; what should we expect in the winter with seasonal illnesses and an increasing population of older people? However, this notion must be dispelled. The decline has been sustained; it existed before covid-19 and has accelerated rapidly in its wake. While it is true that more people are accessing emergency care, this increase alone does not explain the disproportionate drop in performance. This situation must not become an unacceptable new normal or indeed continue the current spiral of decline. The principles of acute medicine are essential to achieve recovery of urgent and emergency care, and it must be resourced to deliver its potential.

Competing interests: None declared

Provenance and peer reviewed: not commissioned, not peer reviewed.

• Henderson K
• Cooksley T ,
• ↵ RCEM Explains: Long waits and excess deaths. RCEM_Explains_long_waits_and_excess_mortality.pdf – accessed 28/2/2023.
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Original research

Exploring barriers and enablers to simulation-based training in emergency departments: an international qualitative study (best-ed study).

1 Department of Emergency Medicine, Galway University Hospitals, Galway, Ireland

Ella Murphy

Etimbuk umana.

2 Department of Emergency Medicine, Mater Misericordiae University Hospital, Dublin, Ireland

Paul O'Connor

3 Department of Medicine, National University of Ireland Galway, Galway, Ireland

Daniel Khamoudes

Brian mcnicholl, john j o’donnell, binchy james, associated data.

bmjopen-2023-073099supp001.pdf

bmjopen-2023-073099supp002.pdf

No data are available.

Introduction

Simulation-based training (SBT) has gained significant traction within emergency medicine. The growing body of evidence describes the benefits that SBT can bring. However, identifying barriers and enablers when establishing successful SBT programmes in busy emergency departments (EDs), and ensuring longevity of such programmes, can be difficult.

We aim to identify barriers and enablers to SBT in busy EDs.

We explored and analysed the thoughts, experience and opinions of professionals involved in SBT and organisational support. 32 participants across 15 international sites were invited to a semistructured interview process. We included participants from a variety of backgrounds, from clinical staff to management staff. Transcribed interview data was classified and coded based on capability, opportunity and motivation behaviour (COM-B) domains and analysed based on theoretical domains framework. Frequency of the most mentioned thematic domain among participants is reported.

The interview data revealed several common themes, including the following: knowledge and skills (90%), support and leadership (96%), mental barriers (87.5%), local culture (96.6%), dedicated space (65.2%), time constraints (46.8%), social influence (87.5%), education (90.6%), professional development (68.75%), exams (59.3%) and personal goals (93.75%). Management staff was observed to prioritise resource, staffing and flow, while the clinical cohort tended to focus on specialty and personal development when it came to simulation training in the ED.

Potential barriers and enablers to SBT and in situ simulation for EDs were identified through interviews conducted in this study. The central themes in terms of barriers and enablers were local culture, leadership, individual needs, resources and optimisation. A tailored approach is vital for establishing a successful SBT and in situ simulation programme.

STRENGTHS AND LIMITATIONS OF THIS STUDY

• The study demonstrated a diverse representation of participants from various geographical locations and roles internationally, contributing to a comprehensive understanding of the topic.
• The utilisation of the COM-B model offered a robust theoretical framework for the research, enhancing the validity and rigour of the findings.
• Employing a qualitative approach facilitated a thorough exploration of participants' perceptions, providing valuable insights into their experiences and perspectives.
• Acknowledgement of the potential for subjectivity in the analysis of interview data, ensuring transparency and flexibility in the research process.
• There may be a selection bias present in the study as a majority of the participants recruited were experienced with the usage of SBT, possibly influencing the generability of the results.

Simulation is a technique where real-life experiences are recreated and replaced with guided ones, creating a controlled learning space to practice a variety of skills before entering a real world setting. 1 It can take on many forms which can be used to recreate a specific scenario or event for the intent of training in a safe environment. 2 Recent studies have demonstrated that simulation-based training (SBT) not only improves knowledge retention, but it is also effective in modifying safety attitudes and improving patient outcomes. 3

The use of SBT to enhance training has gained traction within the field of emergency medicine (EM). 4 A subbranch of SBT frequently used in EM is in situ simulation. This involves SBT to be delivered on-site, and integrated into the real environment, using real equipment and the establishment’s real staff. 5 This blend of simulation within the real working environment offers unique opportunities for EM physicians to train with interdepartmental teams while at work, within their real work setting, enhancing departmental teamwork while learning new skills and procedures, as well as maintaining competencies, and train for crisis management. 6 7

In many instances, although recent literature is growing, it has been difficult to completely assess the challenges in establishing SBT programmes. This is likely, in part, due to the nature of simulation training and data extrapolated from qualitative means. 8 The study aimed to explore the perspectives of various stakeholders, including experts, doctors, nurses, clinicians, administrators, educators, managers and others, to gain a comprehensive understanding of the barriers and enablers of using SBT and in situ simulation within an emergency department (ED) setting. 9–11

• To identify the barriers of running an in situ simulation programme or an SBT programme in an ED.
• To investigate the enablers of running an in situ simulation programme or an SBT programme in an ED.

Study design

Between January 2021 and May 2021, selected participants with experience of simulation and the functions of an ED were invited to partake in a semistructured interview to explore their thoughts on potential barriers and enablers to SBT and in situ simulations within ED’s. An overview of the study is provided in figure 1 . The study is reported in line with Standards for Reporting Qualitative Research.

Overview of study.

Patient and public involvement

There was no patient involvement in this study.

The capability, opportunity and motivation behaviour model

The theoretical framework used is the capability, opportunity and motivation behaviour (COM-B) model. This model provides a theoretically grounded approach to understanding behaviour—in this case, running an SBT programme in an ED. The model proposes that interactions between COM-B cause the performance of a particular behaviour (see online supplemental file 1 ).

Supplementary data

• Capability is defined as the individual’s psychological (eg, the psychological resources and skills, knowledge capacity for understanding) and physical (eg, physical skills) capacity to run SBT. 12
• Motivation is defined as all those brain processes that energise and direct behaviour. Motivation includes reflective (eg, deliberate planning and decision making) and automatic (eg, habit) practices. 12
• Opportunity is defined as the factors that are outside the individual that make the behaviour possible or prompt it. It is possible to distinguish between the physical environment (eg, lack of space) and the social environment (eg, lack of support from leadership). 12

Participant selection, recruitment and sample size calculation

Participants were recruited across multiple international sites. Local participants were identified by the author, national participants were recruited with the help of the Irish Trainee Emergency Research Network. 13 International participants were selected via recommendation of an advisory committee. The participants selected were either known to use simulation for the purpose of medical education or have a good understanding of how an ED functions (level 1 and 2 EDs). All participants were invited to participate via email and have given consent. Participant inclusion and exclusion criteria are provided in online supplemental file 2 .

The study planned to continue with the interviews until data saturation was achieved. 14

The literature suggests this can be achieved within 5–30 interviews. 15

Guest et al found that 73% of codes were identified within the first six interview transcripts, 92% within the next six transcripts and the remaining eight codes were identified by the completion of the thirtieth transcript. 16 This supports Glaser and Strauss’s coding procedures. Creswell et al indicates that a sample size of 20–30 interviews when based on the grounded theory approach, would be appropriate. 17 This study recruited 32 participants to meet the above criteria.

Interview process

Semistructured interviews were conducted in person and virtually by the author from January to May 2021. The interview structure was based on the COM-B Framework, using questions that explored the study aims of looking for barriers and enablers to simulation training for an ED ( online supplemental file 1 ). 16 17 All interviews were recorded and stored on an encrypted solid-state-drive. Only the study author had access to the encryption. Following completion of the interviews, interview data were transcribed verbatim and anonymised.

Data synthesis and analysis

Transcribed interview data were classified and coded using the COM-B model. 18 The authors produced themes from analysing the transcripts. To ensure rigour of the themes produced, three external researchers were recruited to identify the recurring themes. All three of these researchers are EM specialist registrars familiar with using simulation as a training tool. 19 This introduced peer debriefing to provide an external check on the research process, which increase credibility and adequacy. 19 The themes that had the most frequency were recorded and reported in the results section ( table 1 ).

Common themes identified under the theoretical domains framework

CV, Curriculum vitae; ED, emergency department; OSCE, Objective Structured Clinical Examination; QIP, Quality Improvement Plan.

A total of 32 semistructured interviews we conducted, including participants from 15 countries. Interviews duration averaged 26–32 min with most interviews conducted virtually 29 (91%). A summary of the included participant characteristics is provided in table 2 . Nineteen (59.3%) participants were active clinical staff, while 13 (40.6%) were non-clinical participants. Four (12.5 %) were simulation specialists currently working in a simulation centre. The average SBT sessions were 44.8 sessions per year by clinical and simulation based technical staff. Seventeen (53%) were female and 15 (47%) were male, with an average experience of 7.9 years. Seven (21%) worked in a private establishment while 25 (79%) worked in governmental establishments.

Summary of participant and demographics

NGO, Non Govermental Organisation.

Capability dimension

Most participants, 30 (93%) believed that there is sufficient knowledge for the deliverance of simulations training in EDs. However, it was mentioned by 9 participants (28%) that although they have the requisite knowledge, those delivering the simulations lack training. To illustrate, ‘ they might have the knowledge, but they are not trained to do so. Sim is more than just setting up a manikin and running it, you need to be mindful of very niche things like how to run something well, how to use the science of deliberate practice, how to create a safe container, and especially how to debrief. These are only things you know if you’re involved in simulation’ (Participant 009).

Dedicated space (barriers)

All 32 participants (100%) commented on the lack of a dedicated space or a location to run the simulations in a busy ED. For example, ‘ there is usually no space, we just use what we find, but in retrospect that is what an in-situ sim is all about, if you don’t have a space, you’ve got to make one’ (Participant 014).

A total of 15 (47.7%) participants stated that availability of equipment for SBT was not an issue for the ED as most used equipment from the clinical area. However, issues with the fidelity of the simulation equipment were mentioned: ‘ being in the real clinical area, using real equipment, working with your real colleagues brings the fidelity up to a very real level, we have seen real stress response in our learners. Hence, I think even using a low fidelity manikin is enough if you can run it well’ (Participant 014).

A total of 31 (96.9%) of participants believed that there is support for simulation training but only from a non-tangible point. By way of example, ‘ it’s great that when you approach the top people, they say they support this, but then you are left to plan, organise, set up, recruit, and even at times fork out your own money to buy equipment or materials. Worse of all, is that once you set something up, you are now required to do it free of charge and even on your free time’ (participant 003).

Time (barriers)

Lack of time was mentioned for by all of participants, they mentioned that time was a huge factor because most ED run this once a week, and there are some on annual leave, off duty or are postnights; stated ‘ things should be scheduled during your working hours; everyone should have equal access to equal opportunity for training’ (Participant 009).

Staff and engagement (barriers)

A total of 7 (21%) mentioned about high turnover of staff in ED leading to a lack of consistency: ‘ people get trained, people get up a good programme and then they leave, from NCHD up to consultant level. People move on quickly’ .

Twenty-three participants (71.87%) commented on the lack of engagement from upper management; stated; lack of engagement from management. You need it to come from the top down; (participant 025).

Beliefs about capabilities and individual factors (barriers)

When asked what would prevent participation from learners, there was an overwhelming theme that mindset plays a big role. All participants agreed. ‘ People get nervous, they think they are going to be tested (in an in situ simulation), additionally that they might not have adequate knowledge and they do not like that (Participant 006)’. This participant pointed out that there needs to be a new culture that accepts simulation not as a test but as a training tool where mistakes are not penalised but seen as an opportunity to learn. ‘Stress response: participants do not have the confidence, shy, scared, fear of looking stupid among their peers. Simulation exposes people, it puts people in positions who are vulnerable and stress to the point that they don’t want to do it sometimes (Participant 007).’

Cost and Staffing (barriers)

All administrative and management staff mentioned and elaborated on the cost of training and staffing inadequacies. While they could understand the importance of training, they thought that the flow of an ED should not be compromised. One elaborated ‘ For us in management, we don’t really get medicine, it’s easy to just say; it costs this much for this manikin etc and likely, we’d be able to provide a grant of sorts, but in my opinion, training like these takes a lot of time and staff to set up and run. Can we really justify disrupting the flow of the ED during working hours? This significantly increases risk to patient safety with long waiting times. Things gets missed in a high-pressure situation. There really needs to be a balance. I don’t know, maybe in a bigger ED?’

Opportunity dimension

A mean score of 7.5 was given by 32 participants when asked to rank (from 0 to 10) the ‘capability’ of their respective ED’s to run a simulation training programme. A total of 29 participants (90%), however, stated that although capable, there is insufficient training provided to those who would run the programme. Of 32 participants, only 5 were aware of further training in their respective systems/countries in forms of diploma programmes and train-the-trainer programmes.

Reliance on one or two key individuals (barrier)

A total of 19 (59.37%) believed strongly that this is a fundamental issue. Because there is a general lack of support, simulation training is usually centred around one or two key persons of interest. ‘ There is no dedicated time from an organisational level. The university or hospital management does not put aside time for training. They are not given any funding or payment’ (Participant 001). ‘ The registrar that leads this currently does not have protected time, she’s doing it on her own free time, this relies on a person’s enthusiasm entirely’ (Participant 003). ‘ There would be one or 2 who are enthusiastic, if they were gone, I think it wouldn’t work. It hinges on the people who are interested’ (Participant 006).

There was a similar theme around ‘culture of a department’ when asked. There was 50/50 split regarding social influences being a negative factor versus a positive factor. While a new cultural change will permit better training due to the uptake of simulation and acceptance of it being the new ‘norm’. It is also similarly difficult to change the culture of a department that has functioned in a specific way for years.

Identifying barriers

A total of 31 out of 32 (96.8%) were consistent in drawing out similar themes when asked to name barriers for simulation training. Overall, 100% believed that identifying and approaching these are the key to successfully implementing simulation to training.

Motivation dimension

Fourteen participants (43.75%) believed it to be part of their Jobs as a senior doctor/nurse. One participant stated that this should not be the case, as this person who is delivering the training, never had training themselves. ‘ You cannot teach something clinically when you do not use it yourself’ (Participant 031). ‘ It is understood(presumably) that when you’re the consultant, it automatically becomes your job’ (Participant 006). Two participants (6.25%) believe it to be part of the Royal College of Emergency Medicine curriculum.

Research outputs, journals, QIPs (enabler)

A total of 5 (15.6%) mentioned the opportunity of having research, publications and Quality Improvement plan (QIP) being a motivating factor.

A total of 21 (65.6%) mentioned exams as part of the motivating factor believing that it would help the participants particularly in exams with an Objective Structured Clinical Examination (OSCE) format. 20 (62.5%) mentioned that simulation is a better tool to deliver training as compared with a traditional PowerPoint lecture.

All participants (100%) noted the point that when setting up/running such a programme, it will be a good addition for the CV. Thirty (93.75%) believed that this gives the biggest motivation. ‘ Doctors and nurses are extremely ambitious people, and they are very invested in their own professional development. I think it makes complete sense that they want to partake in as much training as possible’ (Participant 007).

Rare cases (enabler)

A total of 7 (21.8%) of the participants believed that simulation could prepare practitioners for rare cases such as major disaster event.

A large majority, 30 (93.7%) believed that there should be a policy in place to enable simulation training. When asked what motivates the participants in your place of work? (One establishment has a 100% participation rate and simulation training is part of the established local culture).

The participant stated, ‘before I say anything, I’d like to say that its mandatory’ (Participant 007).

Testing latent safety hazards (enabler)

A total of two participants that were familiar with the use of in situ simulations mentioned testing latent safety errors as a motivation.

This study aimed to explore the barriers and enablers to implementing an in situ simulation and SBT programme in busy EDs using a semistructured interview approach with 32 participants from international sites to gain collective insights ( online supplemental file 2 ).

One of the biggest barriers identified was the local culture of the establishment, which was considered the root of many additional barriers mentioned by the participants. To overcome this, informal discussions with key stakeholders during the planning stages may be helpful to identify local establishment cultures and potential barriers to the programme’s success. The participants suggested that consistent education about the benefits of simulation training and persistence over time can result in a general acceptance and further development of SBT. Additionally, discussions can be held to propose and include a local simulation champion who is enthusiastic about such an SBT and has the charisma to carry it through.

A clear difference in priorities and language was observed between frontline clinical staff and those working in management and administration. While management staff focused on resources, staffing and flow of an ED, the clinical-based cohort focused on specialty development, personal development and success of a training programme. This is in line with Myllykangas et al ’s and Köbberling’s work referencing a difference in priorities between clinicians and management. 20 21 Including perspectives from a broad spectrum of stakeholders, from management staff to senior clinical decision-makers, may offer additional key insights into potential barriers as well as enablers to SBT programmes. Early buy-in from management staff could potentially minimise barriers in ways that we may have previously underestimated. One suggestion is to get a member of the management staff take part in one of the simulations. This might offer insight and a sense of relatability to clinical roles.

Most participants felt that allocation of protected teaching time for such programmes would increase the likelihood of success. This is in line with works by Shetty et al . 22 Engaging with training bodies and senior staff to ensure that dedicated time is allocated and respected for such programmes can have a positive result on the overall success of any SBT.

Cost of equipment and lack of resources has been cited as a barrier to simulation training in general. 23 Interestingly, in this study, none of the clinical participants mentioned equipment to be an issue for ED in situ simulations. They believed that the ED had all the equipment needed and hence would reduce cost. In contrast, simulation staff felt that cost remained a barrier. It was concluded that most individuals thought of cost from a currency standpoint, and simulation-trained staff elaborated on concealed costs, citing resources such as staff, time, methods of disposing materials, storage and expert inclusion.

The participants believed that overcoming barriers is a slow process that requires time and needs the medical community to embrace simulation as a superior training tool in today’s world. Leadership was mentioned as a crucial factor in both the barriers and enablers section. Lack of good leadership can tremendously impact the actions and mentality of participants, causing fear and anxiety. On the other hand, a good lead can expand enthusiasm, decrease cost, change local culture and ensure a safe space. 24 We propose electing a local simulation champion who is enthusiastic and has the drive to lead such a project is recommended.

Some participants suggested using a standardised framework for setting up an SBT programme. However, others said that this might not be possible as different countries and establishments have varying systems and cultures. Therefore, a tailored solution that only a person working in that establishment can provide is required.

Finally, several motivating factors for participation in SBTs were identified, including personal and professional development. Participants reported that running an educational simulation programme benefits individuals as it provides additional points on their CVs and opens doors for future research and publications. Offering internal continuing professional development points to participants can also help validate learning and growth through a recognised programme in maintaining professional competence.

Due to the recruitment method, we could potentially introduce a selection bias. The selected participants may have been limited to more experienced and well-known SBT candidates. However, the authors noted that experienced SBT participants were essential as they provided better insight through experience. Another limitation of this study was the difficulty in fully studying and comprehending the nuances and challenges of establishing an SBT, owing to various biases. To minimise this, we selected participants from a wide range of ages, sexes, roles, experiences and geographical locations.

The main strength of this study is the diversity of participants in terms of geographical location and role, which ensures the representation of a range of views from a range of stakeholders. Additionally, the use of the COM-B model and grounded Theoretical Domain Frameworks highlights the important facets of qualitative work, allowing for a deeper exploration of perceptions of this topic.

The use of three independent reviewers at the coding stage to produce themes ensures the rigor of themes and is not based on one person’s personal interpretation.

To establish an SBT programme, we need to address the barriers and promote the enablers to increase chances of success. Tailored and bespoke solutions are necessary for successful establishment of an SBT programme.

We suggest an approach to first tackle local issues (such as resources and time windows when SBTs run best) and to involve key stake holders early. We include a recommended hierarchy of priority for SBT establishment in figure 2 . Then proceed to identify the individual needs and intentions of the team, followed by resource needs. Finally, optimisation involving maximising all enablers and minimising the barriers can lead to a programme’s longevity. A Venn diagram of barriers and enablers is visualised in figure 3 .

Pyramid of priority for programme establishment.

Barriers and enablers Venn Diagram.

Conclusions

Balancing barriers and enablers are crucial for the success of an SBT and in situ simulation programme, particularly for an ED. To ensure the successful establishment of such a programme, it is essential to implement tailored and bespoke solutions. Our suggested approach involves first to identify and address local issues, such as resource limitations and identifying optimal time windows for SBT implementation, while actively engaging key stakeholders from the beginning. Subsequently, it is important to identify the specific needs and intentions of the team, followed by determining resource requirements. Ultimately, this systematic approach can lead to program optimisation and longevity, ensuring success of SBT in an emergency department.

Supplementary Material

Acknowledgments.

The authors would like to acknowledge the following: ITERN (Irish Trainee Emergency Research Network) for taking on the responsibility of researching and recruiting suitable participants for this interview in Ireland. ICAPSS (Irish centre of applied patient safety and simulation) for its valuable input to this study. Saolta: Galway University Hospital and The University of Galway, Ireland for help and support in providing and recomending suitable participants for this study.

Twitter: @timburgD

Correction notice: This article has been corrected since it was first published. Figure 2 and 3 legends have been updated.

Collaborators: Bronwyn R McDermott, Dillon Michelle, Ackloo Rajnita, Gobin Avishka, Qurratalain Fatimah, Davis Jamie, Eduard Turcuman, Roche F Adam, Lee Solmi, Madden Marian, Torpey Tracey, McMackie Eamonn, Brennan Simone, Ambyr Reid

Contributors: MJ: planning this study and is responsible for the overall content as guarantor. EM: planning and designing of the study. EU: final edit, data analysis and liaison for ITERN to source suitable participants for this study. PO'C: initial design of this study. DK: planning the study. BM: planning the study and recommending suitable participants, JJO'D: planning the study and recommending suitable participants, BJ: planning the study and recommending suitable participants. All authors have read and approved the final manuscript.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review: Not commissioned; externally peer reviewed.

Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Data availability statement

Ethics statements, patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and ethical approval was granted by the Galway Clinical Research Ethics Committee on the 16 December 2020 (Ref. C.A. 2533). Participants gave informed consent to participate in the study before taking part.

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Tuesday, July 31, 2012

NIH creates Office of Emergency Care Research

Will coordinate and foster research and training in the emergency setting.

To help improve health outcomes of patients who require emergency care, the National Institutes of Health has created a new Office of Emergency Care Research (OECR). The office is a focal point for basic, clinical and translational emergency care research and training across NIH.

“NIH has supported research to advance emergency care for years; however, now we have a single office to coordinate and foster our activities in this arena,” said NIH Director Francis S. Collins, M.D., Ph.D. “The NIH Office of Emergency Care Research will focus on speeding diagnosis and improving care for the full spectrum of conditions that require emergency treatment.”

Although OECR will not fund grants, it will foster innovation and improvement in emergency care and in the training of future researchers in this field by:

• Coordinating funding opportunities that involve multiple NIH institutes and centers.
• Working closely with the NIH Emergency Care Research Working Group, which includes representatives from most NIH institutes and centers.
• Organizing scientific meetings to identify new research and training opportunities in the emergency setting.
• Catalyzing the development of new funding opportunities.
• Informing investigators about funding opportunities in their areas of interest.
• Fostering career development for trainees in emergency care research.
• Representing NIH in government-wide efforts to improve the nation's emergency care system.

The creation of OECR is the culmination of more than five years of discussions between NIH and the emergency medicine community. OECR also responds to reports about the nation's emergency medical system issued in 2006 by the Institute of Medicine.

OECR is housed in NIHs National Institute of General Medical Sciences (NIGMS) , which supports basic research and research training. While a search is being conducted for a permanent director, OECR is being led on an acting basis by Walter J. Koroshetz, M.D., deputy director of the National Institute of Neurological Disorders and Stroke (NINDS) . Assisting him is Alice M. Mascette, M.D., senior clinical science advisor in the Division of Cardiovascular Sciences of the National Heart, Lung, and Blood Institute (NHLBI) .

A steering committee chaired by the director of NIGMS oversees the office. This committee also includes the directors of NHLBI, NINDS and the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institute of Nursing Research .

For more information about the Office of Emergency Care Research, visit http://www.nigms.nih.gov/About/Overview/OECR .

About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov .

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Ready for practice? National recommendations for emergency medicine transition to practice curriculum

Affiliations.

• 1 Department of Emergency Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada. [email protected].
• 2 Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada.
• 3 Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
• 4 Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
• 5 Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada.
• 6 Department of Emergency Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
• 7 Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.
• 8 Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
• 9 Royal College of Physicians and Surgeons of Canada, Ottawa, ON, Canada.
• PMID: 37389772
• DOI: 10.1007/s43678-023-00534-x

Abstract in English, French

Background: Transition from residency to unsupervised practice represents a critical stage in learning and professional identity formation, yet there is a paucity of literature to inform residency curricula and emergency department transition programming for new faculty.

Objective: The objective of this study was to develop consensus-based recommendations to optimize the transition to practice phase of emergency medicine training.

Methods: A literature review and results of a survey of emergency medicine (EM) residency program directors informed focus groups of recent (within 5 years) EM graduates. Focus group transcripts were analyzed following conventional content analysis. Preliminary recommendations, based on identified themes, were drafted and presented at the 2022 Canadian Association of Emergency Physicians (CAEP) Academic Symposium on Education. Through a live presentation, symposium attendees representing the Canadian national EM community participated in a facilitated discussion of the recommendations. The authors incorporated this feedback to construct a final set of 14 recommendations, 8 targeted toward residency training programs and 6 specific to department leadership.

Conclusion: The Canadian EM community used a structured process to develop 14 best practice recommendations to enhance the transition to practice phase of residency training as well as the transition period in the career of junior attending physicians.

Abstrait: ARRIèRE-PLAN: La transition de la résidence à la pratique non supervisée représente une étape cruciale de l’apprentissage et de la formation de l’identité professionnelle, mais il y a peu de documentation pour éclairer les programmes de résidence et les programmes de transition des services d’urgence pour les nouveaux professeurs.

Objectif: L’objectif de cette étude était d’élaborer des recommandations consensuelles pour optimiser la transition vers la pratique de la formation en médecine d’urgence. MéTHODES: Une recension des écrits et les résultats d’un sondage auprès des directeurs des programmes de résidence en médecine d’urgence (GU) ont informé les groupes de discussion des diplômés récents (moins de cinq ans) en GU. Les transcriptions des groupes de discussion ont été analysées à la suite d’une analyse du contenu classique. Des recommandations préliminaires, fondées sur des thèmes déterminés, ont été rédigées et présentées au Symposium universitaire sur l’éducation de 2022 de l’Association canadienne des médecins d’urgence (ACMU). Au moyen d’une présentation en direct, les participants au symposium représentant la communauté nationale canadienne de la GU ont participé à une discussion dirigée sur les recommandations. Les auteurs ont intégré ces commentaires pour élaborer un ensemble final de 14 recommandations, 8 ciblant les programmes de formation en résidence et 6 ciblant le leadership ministériel.

Conclusions: La communauté canadienne de la GU a utilisé un processus structuré pour élaborer 14 recommandations de pratiques exemplaires afin d’améliorer la transition à la phase de pratique de la formation en résidence ainsi que la période de transition dans la carrière des médecins traitants débutants.

Keywords: Competence By Design; Competency based education; Emergency medicine; Medical education; Transition to practice.

© 2023. The Author(s), under exclusive licence to Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).

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