Category: Nevin Manimala

West J Emerg Med. 2025 Dec 23;27(1):99-103. doi: 10.5811/westjem.47302.

ABSTRACT

INTRODUCTION: Patients leaving without being seen is a critical quality metric for emergency department (ED) performance and is associated with negative patient outcomes and operational inefficiencies. In this study we aimed to systematically assess patient- and system-level factors influencing leaving-without-being-seen behavior.

METHODS: We conducted a retrospective cohort study at The Ottawa Hospital, a tertiary-care ED with 85,000 annual ED visits in Ottawa, Canada. We analyzed all patient encounters for two years from May 2022-April 2024. Variables included demographics characteristics (age, sex), visit specifics (arrival day and time, Canadian Triage and Acuity Scale [CTAS] scores, presenting complaints), and operational metrics (ED occupancy metrics). Multivariate logistic regression analyses evaluated the influence of these factors on rates of leaving without being seen.

RESULTS: Of 170,536 ED visits, 15,473 (9.1%) patients left without being seen, and 2,716 (1.6%) left before triage. Each additional 10 years of age reduced the adjusted odds of leaving without being seen by 20.2% (older patients left less frequently). Male patients had 9.4% higher adjusted odds of leaving without being seen compared to females. For every five patients waiting to be seen, the adjusted odds of leaving increased by 16.9% for a newly arriving patient. For every five patients already seen but awaiting disposition, the adjusted odds of leaving increased by 9.6% for a newly arriving patient. Compared to CTAS 2 patients (high acuity), CTAS 3 patients had 67.1% higher adjusted odds of leaving, CTAS 4 patients had 134% higher adjusted odds, and CTAS 5 patients (lowest acuity) had 176% higher adjusted odds of leaving.

CONCLUSION: Younger age, male sex, lower acuity, and ED crowding independently and significantly increase rates of leaving without being seen. Importantly, both crowding and volume of patients waiting impact left-without-being-seen behaviour. Optimizing patient flow through strategic movement within the ED may enhance the perception of progress, encouraging patients to remain for care.

PMID:41554165 | DOI:10.5811/westjem.47302

West J Emerg Med. 2026 Jan 3;27(1):104-113. doi: 10.5811/westjem.48788.

ABSTRACT

INTRODUCTION: In North America, suicide ranks among the top causes of death in individuals 15-60 years of age. In this study we aimed to determine whether an emergency department (ED) presentation for suicidal behaviors accompanied by acute alcohol intoxication was associated with increased six-month suicide or all-cause mortality compared to non-intoxicated presentations of suicidal behaviors.

METHODS: We performed a retrospective cohort study of adults (≥ 18 years) presenting to 16 EDs in Alberta, Canada, between April 2011-March 2021. Suicidal attempt or self-harm was identified via International Classification of Diseases codes, 10th Rev, Canadian Enhancement (ICD-10-CA). Patients were classified as acutely intoxicated if they had relevant ICD-10-CA codes or a blood alcohol concentration ≥ 2 millimoles per liter (9.2 milligrams per deciliter). We excluded patients who died on arrival, were transferred, or were non-residents. The primary outcome was suicide-specific mortality at six months; secondary outcomes included all-cause mortality, use of involuntary holds, psychiatric consultations, admissions, and ED return visits. Median differences with 95% confidence intervals and unadjusted odds ratio (OR) with 95% CI were reported for continuous and categorical variables, respectively.

RESULTS: Among 58,051 suicidal or self-harm patients, 17,488 (30%) were classified as intoxicated. Six-month suicide mortality was similar between intoxicated and non-intoxicated groups (0.3% each; adjusted sub-distribution hazard ratio = 0.98 [95% CI, 0.73-1.38]), indicating no significant association between alcohol intoxication and suicide-specific death. Intoxicated patients were more often male (58% vs 52%; OR 1.26 [1.22-1.31]), arrived by ambulance (70% vs 50%; OR 2.32 [2.23-2.41]), and were more frequently placed on involuntary holds (26% vs 16%; OR 1.92 [1.83-2.00]). They had fewer hospital admissions (10.8% vs 15.4%; OR 0.63 [0.60-0.67]), longer ED stays (411 vs 277 minutes; median difference = 134 minutes [127.7-140.3]), and higher ED return rates at 30 days (19.8% vs 18.3%; OR 1.10 [1.05-1.15]) and six months (45.8% vs 42.1%; OR 1.16 [1.12-1.20]).

CONCLUSION: Acute alcohol intoxication among ED patients presenting with suicidal behaviors was not independently associated with higher six-month suicide mortality. Patients with acute alcohol intoxication had increased use of involuntary holds, longer lengths of stay, and more frequent ED return visits. Future work should explore other psychosocial and clinical factors, including substance use and psychiatric comorbidities, that may influence outcomes beyond the acute setting.

PMID:41554164 | DOI:10.5811/westjem.48788

West J Emerg Med. 2025 Dec 20;27(1):130-136. doi: 10.5811/westjem.46552.

ABSTRACT

INTRODUCTION: The COVID-19 pandemic disrupted care-seeking and respiratory disease epidemiology across healthcare settings, notably for emergency department (ED) care. The scope of this disruption and whether patterns of ED visits have returned to predictable seasonal patterns is of interest in planning ED staffing and resource availability for future illness surges, pandemic or not. We evaluated ED visits for acute respiratory illness among children in a large, integrated healthcare delivery system to describe illness and patient characteristics in the years before, during, and after the pandemic peak.

METHODS: We conducted a cross-sectional study of ED visits among patients 0-17 years of age to the 21 EDs of Kaiser Permanente Northern California, from January 1, 2018-December 31, 2019, pre-pandemic; January 1, 2020-December 31, 2021, pandemic; and January 1, 2022-March 31, 2024, post-vaccine (vaccines for children > 5 years of age approved and available). We electronically extracted eligible ED visits with acute respiratory infection diagnoses and a range of sociodemographic, medical comorbidity, and utilization characteristics.

RESULTS: We observed 151,983 pediatric ED visits with eligible respiratory infection diagnoses, 49,912 (32.8%) visits pre-pandemic, 27,109 (17.8%) visits during the pandemic, and 74,962 (49.3%) visits post-vaccine. Eligible visits dropped every month from 6,361 in February 2020, just prior to the pandemic onset, to their lowest volume (243) in June 2020. In the post-vaccine period, visits peaked at 10,638 in November 2022, the highest of any month during the study period. Sex, race/ethnicity, and tobacco exposure were comparable over time, but the proportion of visits by patients with under-immunized diagnosis trended upward over time. Upper respiratory infection (30% pre-pandemic, 32% pandemic, and 33% post-vaccine periods), asthma (15% pre-pandemic, 12% pandemic, and 12% post-vaccine periods), and cough (9.9% pre-pandemic, 12% pandemic, and 12% post-vaccine periods), were the top three diagnoses across all periods.

CONCLUSION: In this cross-sectional study of acute respiratory illness-related ED visits in an integrated healthcare system, from 2022 onward seasonal variation in respiratory illness ED visits rebounded, with notable and unseasonal peaks in late 2022. COVID-19 appears to be a minor contributor to ED visits for pediatric respiratory illness. However, an increased overall and seasonal burden of ED visits has implications for surge planning and mitigation, with COVID-19 now being endemic and typical respiratory pathogens having resurfaced.

PMID:41554161 | DOI:10.5811/westjem.46552

West J Emerg Med. 2025 Dec 26;27(1):44-50. doi: 10.5811/westjem.48925.

ABSTRACT

INTRODUCTION: Patients with acute stroke may occasionally present as trauma activations, particularly after being found down or sustaining falls. This atypical presentation can delay diagnosis and treatment. Our objective in this study was to compare time to brain imaging, use of reperfusion therapies, and clinical outcomes, including discharge disposition and mortality, between patients with acute stroke presenting as code trauma activations and those presenting as code stroke activations.

METHODS: We conducted a retrospective review of all trauma activations at our Level I trauma center from January 2018-December 2024. Patients diagnosed with acute stroke on initial trauma imaging after trauma evaluation formed the code trauma activation (CTA) group. These patients were compared to all patients diagnosed with acute stroke after a code stroke activation (CSA) in 2024. The primary outcome was door-to-imaging time; secondary outcomes included door-to-intervention time, discharge disposition, and mortality.

RESULTS: There were 208 CSA patients and 198 CTA patients. The CTA patients were older (75.3 vs 70.3 years of age, P < .001) and had a higher percentage of hemorrhagic stroke (43.9% vs 14.4%, P < .001). The CTA patients had a higher National Institutes of Health Stroke Scale score (14.44 vs 9.67, P < .001). Despite minimal injuries (mean Injury Severity Score 3.3), CTA patients experienced longer times to initial brain imaging (47.4 vs 24.8 minutes, P < .001). Mean door-to-thrombolysis (50.3 vs 43.7 minutes, P = .19) and door-to-puncture time (98 vs 82 minutes, P =.18) did not differ significantly. The CTA patients had lower rates of discharge home (23.2% vs 42.8%, P < .001) and higher mortality (24.2% vs 12%, P < .001). On multivariate analysis, trauma activation itself was not independently associated with mortality (OR 1.57, CI, 0.53-4.27, P =.42). Age, stroke severity scores, hemorrhagic stroke, and early imaging were independently associated with mortality after acute stroke.

CONCLUSION: Acute stroke patients presenting as trauma activations face significant delays in imaging and lower rates of thrombolytic treatment, despite low injury burden. While trauma activation designation was not independently associated with mortality, delays in imaging and higher hemorrhage prevalence were strongly linked to worse outcomes. These findings highlight modifiable workflow opportunities, particularly streamlined imaging and early stroke recognition in low-impact trauma presentations, to improve delivery of care.

PMID:41554160 | DOI:10.5811/westjem.48925

West J Emerg Med. 2025 Dec 31;27(1):205-213. doi: 10.5811/westjem.48701.

ABSTRACT

INTRODUCTION: In this study we sought to to assess the extent to which emergency physicians adhered to an institutional protocol for rapid chest pain assessment that incorporates a high sensitivity troponin I (hs-TnI) assay. We also sought to characterize clinical outcomes stratified by protocol adherence.

METHODS: We conducted a retrospective cohort study that included all adult patients presenting to five major metropolitan hospital emergency departments (ED) with suspected cardiac chest pain who had at least one troponin measured. The study period was November 9, 2020-June 20, 2022. The primary outcome was protocol adherence for indeterminate-risk and high-risk patients, as defined by the protocol in use at the time of each patient’s presentation to hospital. Adjusted odds ratios (aOR) are reported with associated 95% confidence intervals.

RESULTS: A total of 14,027 patients were included in the study, among whom 8,962 (63.9%) were classified as low risk, 4,064 (29.0%) as indeterminate risk, and 1,001 (7.1%) who were in the high-risk/rule-in group. Overall, 35.9% of patients had care that adhered to the chest pain pathway protocol-22.1% of indeterminate-risk patients and 91.6% of high-risk/rule-in patients. Protocol adherence among indeterminate-risk patients was 6.6% when the initial troponin was in the range of 4-19 nanograms per liter (ng/L) and 75.4% for initial troponin levels 20-99 ng/L. Male sex was most strongly associated with protocol adherence; among those receiving adherent care, 65.8% were male compared to 34.2% female (aOR 1.67; 95% CI, 1.46-1.91). Patients in the non-adherent group with an initial troponin 4-19 ng/L experienced a significantly higher incidence of major adverse cardiac events (4.5% vs 1.7%, P < .001), compared to those in the low-risk group.

CONCLUSION: Adherence to proposed assessment protocols for patients presenting to the ED with chest pain was low. This lack of adherence appears to disproportionally affect females and is associated with poor outcomes. Improving adherence to evidence-based guidelines in this setting is urgently needed.

PMID:41554159 | DOI:10.5811/westjem.48701

West J Emerg Med. 2025 Dec 26;27(1):33-38. doi: 10.5811/westjem.47285.

ABSTRACT

INTRODUCTION: Effective resuscitation leadership is a critical competency for emergency physicians, with evidence correlating strong leadership with improved team performance and patient outcomes during resuscitations. Despite its importance, the extent and nature of structured resuscitation leadership education in emergency medicine (EM) residency training remains unclear.

METHODS: We conducted a voluntary, anonymous, needs assessment survey of United States (US) EM residency programs between August-October 2021. The survey assessed for the presence, content, and methods of formal resuscitation leadership curricula within these programs. We used descriptive statistics to analyze responses.

RESULTS: Of the 261 US EM residency programs invited to participate, 80 responded (30.7%). Nineteen programs (23.8%) reported offering resuscitation leadership training through formal curricula, with considerable variation in both educational methods and content. Additionally, 68.4% of responding programs offered external generalized leadership development opportunities through partnerships with hospitals, universities, community organizations, and research entities.

CONCLUSION: A minority of surveyed US EM residency programs incorporate formal resuscitation leadership training into their curricula with significant variance in curricular content and educational methods. Given the critical role of resuscitation leadership in EM, our findings highlight the need for further research to evaluate the effectiveness of existing curricula and educational approaches.

PMID:41554158 | DOI:10.5811/westjem.47285

West J Emerg Med. 2025 Dec 20;27(1):184-193. doi: 10.5811/westjem.47360.

ABSTRACT

BACKGROUND: Immediate care clinics (ICC) account for a significant portion of acute, low-severity visits that preclude the use of resources from an emergency department (ED). Given the chronic issue of ED crowding and its detrimental effects on quality of care and health system efficiency, understanding and optimizing the use of ICCs for non-emergent visits could significantly alleviate pressures faced by EDs and improve patient satisfaction, as well as control the overall cost of care. This study describes the application of the Billings/Ballard severity algorithm to ICC visits over a seven-year period and compares the findings to previously published ED literature.

METHODS: We obtained data from ICC visits within a large, academic health system. The analytical sample included 306,395 visits from 125,063 unique patients. We describe ICC patient characteristics and the Billings/Ballard severity classification. We used negative binomial regression analysis to evaluate the associations between patient characteristics and total visits to ICCs and primary care physician (PCP), and multivariate regression analysis to assess the relationship between ICC visit severity and patient characteristics, controlling for multiple visits per patient. The algorithm was also used to identify and classify the most common International Classification of Diseases, 9th and 10th modifications (ICD-9/10) diagnosis codes by severity.

RESULTS: In total, 9.17% of ICC visits were classified as emergent, 81.25% as non-emergent, 0.79% as indeterminate, and 8.79% as unclassified, compared to literature-reported ED distributions of 37.90% emergent, 45.08% non-emergent, 11.32% indeterminate, and 5.70% unclassified. The ICC visits included a greater proportion of non-emergent presentations. The ICD-9/10 diagnosis distribution revealed a distinct ICC environment compared with that of the ED. The most frequent diagnoses among emergent ICC visits included chest pain, asthma exacerbation, and shortness of breath, while non-emergent visits were predominantly for upper respiratory tract infections. Within one year at the same healthcare system, 47% of patients had repeat ICC visits and 41% had primary care follow-up.

CONCLUSION: These results demonstrate that immediate care clinics deliver predominantly non-emergent care as intended (81% vs 45% in the ED), potentially reducing ED crowding and validating current clinician- and patient-initiated referral practices. High rates of repeat ICC visits (47%) and follow-up with primary care physicians (41%) within the same healthcare system suggest these facilities foster care continuity while providing accessible, non-emergent care alternatives. However, user disparities persist as self-pay and uninsured patients show lower overall ICC use, while uninsured and publicly insured individuals present with emergent conditions more frequently than privately insured patients. These findings inform care-seeking education and health service delivery while highlighting the need to improve ICC accessibility across insurance types to optimize efficiency and patient outcomes.

PMID:41554157 | DOI:10.5811/westjem.47360

West J Emerg Med. 2025 Dec 20;27(1):167-176. doi: 10.5811/westjem.45709.

ABSTRACT

INTRODUCTION: The coral snake is the only native elapid in North America. Their venom contains potent neurotoxins. Historically, all confirmed/presumed bites were treated with antivenom whether or not symptoms were present. Production of antivenom ceased in 2003. The resultant national shortage prompted clinicians to investigate alternative treatment strategies such as a wait-and-see approach where antivenom is held until signs of systemic toxicity manifest. Now that production has resumed there is limited research available comparing these two treatment paradigms, empiric administration vs the wait-and-see approach. Our objective in this study was to compare outcomes of the two treatment paradigms to determine whether one is associated with better patient outcomes.

METHODS: This was a retrospective analysis of coral snakebite cases reported to the Florida Poison Information Center Network from January 1, 1998-December 31, 2021. We collected demographic, clinical, and outcome variables. Patients were stratified into two groups, empiric antivenom administration vs the wait-and-see approach in patients who were asymptomatic in terms of systemic symptoms at the time of initial presentation to the emergency department. We used multivariable logistic regression models, controlling for whether the bite occurred during the North American Coral Snake Antivenin (NACSA) shortage period (yes/no), age, sex, and whether systemic effects developed (yes/no), to determine differences between study groups in the incidence of the main outcomes: intensive care unit (ICU) admission; intubation; and death, as well as ICU and hospital length of stay.

RESULTS: We analyzed 301 cases: 171 (56.8%) empiric; and 130 (43.2%) wait-and-see. Patients in the empiric treatment group had approximately three times higher likelihood of ICU admission (empiric 121 [75.2%] and wait-and-see 71 [56.8%]), odds ratio [OR} 3.047, P = .05). There was no difference in the incidence of intubation (empiric 2 [1.2%] and wait-and-see 1 [<1%]), OR 2.486, P = .63) or in ICU length of stay (OR 0.485, P = .08). Of the patients treated with NACSA (191), adverse reactions to the antivenom occurred in 38 (19.9%) patients-35 patients in the empiric group and three in the wait-and-see group who later received antivenom. Of these 38 patients, eight (21.1%) experienced an anaphylactic reaction.

CONCLUSION: Empiric North American Coral Snake Antivenin administration was associated with higher ICU admissions and with a considerably higher risk of adverse reactions, which may serve to impose caution when treating empirically.

PMID:41554154 | DOI:10.5811/westjem.45709

West J Emerg Med. 2026 Jan 9;27(1):78-84. doi: 10.5811/westjem.48540.

ABSTRACT

INTRODUCTION: Patients who report sexual assault in the emergency department (ED) have a legal right to a forensic exam. Emergency departments that do not provide such exams must offer transfer to a forensic site. Little is known about the factors influencing whether patients are offered a forensic exam and complete the transfer. In this study we aimed to identify patient characteristics associated with being offered a forensic exam in an ED that does not perform them on site.

METHODS: We conducted a retrospective chart review of adult patients presenting to a single, urban, academic ED between January 2017-December 2019. The ED receives over 75,000 visits annually and refers patients to an external site for forensic exams. Using keywords “sexual assault” or “rape” we identified charts that included whether the visit involved an initial report of sexual assault. Charts were abstracted for demographics, insurance status, psychiatric history, clinician concern for acute mental illness or substance use, and mode of arrival. The primary outcome was whether a forensic exam was offered. Statistical analyses included chi-square tests and penalized logistic regression.

RESULTS: Of 167 charts reviewed, 108 met inclusion criteria. Of these, 94 patients (87.0%) were offered a forensic exam and 14 (64.8%) accepted transfer. Patients who were offered exams were younger (mean age 29.9 vs 36.8 years, P = .05), more likely to arrive ambulatory (69.1 vs 42.9%, P = .02), and less likely to have a psychiatric history (31.9 vs 71.4%, P = .01). Clinician concern for acute psychiatric illness or substance use was significantly associated with not offering a forensic exam (64.3 vs 16.0%, P < .001). In regression analysis, this concern was the only independent association of not being offered a forensic exam (adjusted odds ratio 0.16, 95% CI, 0.03-0.76, P = .02). Additionally, 23.1% of patients were uninsured, significantly higher than the local rate of 2.7%.

CONCLUSION: Patients in the ED who report sexual assault are less likely to be offered a forensic exam if they present with signs of acute mental illness or substance use disorder. These findings highlight the need for standardized protocols and advocacy to ensure equitable access to forensic exams, especially for patients with behavioral health needs or without insurance.

PMID:41554153 | DOI:10.5811/westjem.48540

West J Emerg Med. 2026 Feb 7;27(1):18-24. doi: 10.5811/westjem.48835.

ABSTRACT

INTRODUCTION: Timely evaluation in the emergency department (ED) is critical for patients with cardiac chest pain. Although racial disparities in ED wait times have been reported, few studies have focused specifically on cardiac-related presentations. In this study we assessed racial and ethnic disparities in ED door-to-clinician time for cardiac chest pain.

METHODS: We conducted a retrospective analysis of adult ED visits for cardiac chest pain (2019-2025) at a tertiary-care academic hospital. Patients ≥ 18 years of age were included. Race/ethnicity was categorized as White, Hispanic/Latino, Black, Native American, Asian, or other/unknown. Multivariable generalized linear modeling assessed the association between race/ethnicity and door-to-clinician time, adjusting for demographics and clinical variables.

RESULTS: The study included 3,925 patients. The overall median door-to-clinician time was 15.9 minutes (interquartile range 8.0-36.0). In unadjusted bivariate analyses, significant differences were observed across racial and ethnic groups (P < .001). Native American patients experienced the longest delays (23.8 minutes [13.9-49.8]), followed by Asian (18.6 minutes [8.4-36.5]) and Hispanic/Latino patients (17.1 minutes [9.3-43.7]). In contrast, White and Black patients had shorter median wait times of 14.9 minutes [7.1-33.9] and 15.0 minutes [8.8-38.7], respectively. After adjustment for age, sex, triage acuity, clinician type, and initial vital signs, Hispanic/Latino patients waited 18.2 minutes vs 14.9 minutes for White patients (absolute +3.3 minutes; 22% longer; relative risk 1.22, 95% CI, 1.09-1.36, P < .001). Adjusted times were also higher for Black (16.5 minutes), Native American (17.7 minutes), and Asian patients (15.1 minutes), but differences were not statistically significant.

CONCLUSION: Hispanic/Latino patients with cardiac chest pain experienced a 22% longer ED wait time than White patients. Our findings highlight the need for targeted interventions and multisite research to ensure equitable, timely care for all patients with acute cardiac conditions.

PMID:41554150 | DOI:10.5811/westjem.48835