Campbell, Ronna L.

ABSTRACT Background One in five emergency department (ED) visits is by older adults aged 65+ years. Clinical practice guidelines are needed to optimize patient care by translating the best available evidence into actionable recommendations to guide person‐centered management for this medically complex and growing patient population. Our objective was to understand contributors' experiences and share best practices to inform other guideline working groups. Methods We conducted a qualitative study based on thematic analysis with an interpretivist paradigm in June–July 2025, using semi‐structured interviews of Geriatric Emergency Department (GED) Guidelines 2.0 contributors to understand their experiences. Interviews were transcribed, independently reviewed by team members, and reflexively coded to identify themes. Results We interviewed 18 participants. Four main themes emerged: (1) motivations for participation, (2) varying opportunities to be involved, (3) personal benefits, and (4) challenges for improvement. Participants contrasted the strengths of shared learning and development with the burdens of organization and coordination. Conclusion Contributors to the GED Guidelines 2.0 reported a positive experience. They joined because they wanted to contribute to better care of older patients and to achieve personal and professional goals. Many cited that their roles aligned with their strengths and expertise. They also gained skills and knowledge on systematic reviews and benefited from networking. Future groups planning a similar process should consider having multiple levels of leadership, experts in systematic reviews, regular reminders, and creative incentives to improve the process and foster improved networking opportunities within their disciplines.

ABSTRACT Objective We sought to characterize patients presenting to emergency departments (EDs) with abdominal pain and to validate risk categories defined by the Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE‐2) for low‐risk recurrent abdominal pain. Methods We conducted a retrospective cohort study of patients presenting with abdominal pain between November 2019 and November 2023 across 21 EDs in Arizona, the Midwest, and Florida. Patients were categorized per GRACE‐2 into recurrent and non‐recurrent pain as well as low‐ and high‐risk groups. Primary outcomes included 72‐h returns and mortality at 30 and 90 days. Results The study included 162,494 visits (112,896 unique patients; median age 46 years; 61.2% female). Among these, 4.3% had low‐risk recurrent abdominal pain. Patients with recurrent and non‐recurrent low‐risk pain had similar ED length of stay and discharge rates to each other, compared to patients with high‐risk pain who had longer length of stay and lower discharge rates. At 30 days after the ED encounter, patients with low‐risk recurrent abdominal pain had similar mortality to patients with low‐risk non‐recurrent pain (0.4% vs. 0.3%; adjusted RR = 1.31, 95% CI: 0.85–2.03), while they had significantly lower mortality than patients with high‐risk recurrent abdominal pain (0.4% vs. 2.3; adjusted RR = 3.14, 95% CI: 2.02–4.89). Conclusions This study highlights the heterogeneity in patients presenting to the ED with abdominal pain. Among these patients, those with low‐risk recurrent pain demonstrated similar lengths of stay, discharges, and mortality rates to those with low‐risk non‐recurrent pain and less favorable lengths of stay, discharges, and mortality rates compared to those with any high‐risk features. These findings suggest that low‐ and high‐risk features may be more useful than recurrent or non‐recurrent pain in identifying patients who could benefit from more robust ED evaluations.

Objectives: Telemedicine is a growing field, with limited data around its utility supporting pediatric emergency care telephone triage. We instituted telemedicine physician support for nurse telephone triage decisions. When the nursing protocols recommended urgent or emergent care, a telemedicine physician reviewed and modified care urgency if appropriate. Our primary study objectives were to evaluate the proportion of patients who were downgraded to less urgent care and assess for potential harm related to the downgrade in care urgency. Methods: We conducted a retrospective observational cohort study of pediatric telephone calls to the Mayo Clinic Health System nurse triage line that were directed to the emergency department telemedicine physician from January 1, 2019, to December 31, 2019. Electronic medical records of patients whose care urgency was downgraded and presented to medical care within 72 hours of the triage call were reviewed. Results: There were 8559 nurse line calls regarding pediatric patients, 882 of which were referred to the telemedicine physician. Among these, 396/882 (44.9%, 95% confidence interval 41.6–48.3) were downgraded. Of downgraded cases, 198 (50.0%) patients sought care within 72 hours of the original call, of which 193 (97.5%) patients were discharged home from that medical visit and 5 (2.5%) patients required admission. No patients were determined to have suffered harm due to the downgrade of visit urgency. Conclusions: Our data suggests that telemedicine physicians can safely downgrade nurse triage care recommendations for pediatric patients. Most downgraded patients sought outpatient care, avoiding unnecessary utilization of the emergency department without evidence of associated harm.

AbstractObjectivesThis needs assessment aimed to improve understanding of flexible endoscopic intubation training and practice in emergency medicine (EM), providing insights to educators and practice leaders seeking to improve education and practices.MethodsWe conducted a multicenter, mixed‐methods needs assessment of emergency physicians (EPs) incorporating focus groups and a survey. Focus groups comprised community EPs, academic EPs, and resident EPs. We analyzed focus group transcripts using grounded theory, qualitatively describing EM endoscopic intubation. The qualitative analysis shaped our survey instrument, which we deployed in cross‐sectional fashion. We report survey data with descriptive statistics.ResultsFocus groups with 13 EPs identified three themes: indications for use of endoscopic intubation, factors impacting a physician's decision to endoscopically intubate, and attaining and maintaining endoscopic intubation competency. Of 257 surveyed EPs (33% response rate), 79% had received endoscopic intubation training during residency, though 82% had performed this procedure 10 or fewer times in their career. Despite 97% acknowledging the necessity of competency, only 23% felt highly confident in their ability to perform endoscopic intubation. Participants (93%) reported scarce opportunities to perform the procedure and identified factors believed to facilitate competency acquisition and maintenance, including opportunities to perform endoscopic intubation in practice (98%), local champions (93%), and performing nasopharyngoscopy (87%).ConclusionsWhile most EPs acknowledged the importance of competency in endoscopic intubation, they reported scarce procedural opportunities and commonly expressed low confidence. Further research is needed on this topic, and we propose avenues to enhance education and practices related to endoscopic intubation. These include development of robust procedural curricula, support of local champions, and incorporating nasopharyngoscopy into EM practice.

Abstract Background Multiple anaphylaxis mediators have been demonstrated to provoke migraine‐like attacks following intravascular infusion, suggesting that anaphylaxis could cause headache; however, headache is rarely noted in anaphylaxis and is not included among diagnostic criteria. Objective Our study objectives were to estimate the frequency of headache among prospectively enrolled emergency department (ED) patients with anaphylaxis and assess the association of headache with patient and anaphylaxis characteristics. Methods A cross‐sectional study of ED patients aged ≥5 years who met anaphylaxis diagnostic criteria from January 8, 2020 to September 9, 2022 was conducted. The primary outcome of interest was headache frequency among patients who met at least one anaphylaxis criterion. We explored the association of headache with patient characteristics and anaphylaxis characteristics. Results We included 63 patients with anaphylaxis. In all, 17 (27%, 95% confidence interval [CI] 17%–40%) patients reported the presence of a headache. Female patients had more than a nine times increased odds of having headache (odds ratio [OR] 9.3, 95% CI 1.14–77.1, p = 0.016). Presentation with headache was associated with the presence of dyspnea (OR 5.5, 95% CI 1.56–19.7, p = 0.006). Conclusion Headache in anaphylaxis may be more common than previously recognized, especially in females. Larger prospective studies are needed to characterize headache as a marker of neurological involvement in anaphylaxis.

Abstract Purpose Twenty five percent of practicing physicians in the US are International Medical Graduates (IMGs) – physicians who completed their medical school training outside of the United States and Canada. There are multiple studies demonstrating higher socio-economic background is associated with medical school matriculation in the US. However, despite a substantial prevalence of IMGs in the American healthcare system, studies of the association between demographics, socio-economic background, and securing a residency position in the match are lacking. Methods We created a survey with questions on residency match-related data and information on personal socio-economic background. An invitation to participate in the study was sent to all IMGs that applied to the included residency programs after the conclusion of the 2022 residency match. We used multivariable logistic regression to compare survey responses to the odds of securing a residency match. Results The total number of survey respondents was 744 (response rate 15.1%). We found that younger age, higher United States Medical License Examination (USMLE) scores, higher-income country of origin (including the United States), fewer match attempts, applying to fewer specialties, having parents with college degree or higher, and coming from higher-than-average or lower-than-average family income were associated with increased odds of matching. Gender, personal income, and visa status did not demonstrate significant associations with residency match. Conclusions Residency match is a significant expense for IMGs, especially for those from lower-income countries. International applicants from higher socio-economic backgrounds might have advantages in securing medical residency positions in the United States when controlling for other variables.

AbstractObjectivesPatients with limited English proficiency (LEP) have been shown to experience disparities in emergency department (ED) care. The objectives of this study were to examine the associations between LEP and irregular ED departures and return ED visits.MethodsWe conducted a multicenter cross‐sectional analysis of 18 EDs within an integrated health system in the upper Midwest from January 1, 2018, to December 31, 2021. ED visits of pediatric and adult patients who were discharged on the index visit were included for analysis. We analyzed the association of LEP with irregular departures, 72‐h and 7‐day return visits, and ED disposition at the time of that return visit. Multivariable model associations were calculated using generalized estimating equations and reported as odds ratios (OR) with 95% confidence intervals (CIs).ResultsA total of 745,464 total ED visits were analyzed, including 27,906 (3.7%) visits among patients with LEP. The most common preferred languages among patients with LEP were Spanish (12,759; 45.7%), Somali (4978; 17.8%), and Arabic (3185; 11.4%). After multivariable adjustment there were no differences in proportions of irregular departures (OR 1.09, 95% CI 0.99–1.21), 72‐h returns (OR 0.99, 95% CI 0.92–1.06), or 7‐day returns (OR 0.99, 95% CI 0.93–1.05) between patients with LEP or English proficiency. Patients with LEP returning within 72 h (OR 1.19, 95% CI 1.01–1.40) and 7 days (OR 1.15, 95% CI 1.01–1.33) were more likely to be admitted to the hospital.ConclusionsAfter multivariable adjustment, we did not find an increased frequency of irregular ED departures or 72‐h or 7‐day returns among patients with LEP compared with people proficient in English. However, we did find that higher proportions of patients with LEP were admitted to the hospital at the time of the return ED visit.

Background: While the liability risks for obstetrics and gynecology (ob/gyn) physicians are widely recognized, little is known about how trainees have been involved in ob/gyn lawsuits. Objectives: To characterize involvement of trainees in malpractice lawsuits related to ob/gyn. Methods: The legal database Westlaw was utilized to collect ob/gyn-related malpractice lawsuits involving trainees reported from 1986 to 2020 in the USA. Outcome: Forty-six malpractice cases involving ob/gyn trainees were identified, including 34 cases related to obstetrics and 12 to gynecology. There were 11 cases alleging lack of informed consent, including 7 cases alleging lack of consent for trainee involvement. Of the 34 obstetrics cases, 27 related to procedural complications, 17 to treatment, 13 to diagnosis, and 4 to informed consent. Of these, 17 were decided in favor of the physician, 6 resulted in findings of negligence, 9 had unknown outcomes, and 3 ended in settlement. For the 6 cases ending in a finding of negligence, the mean award was $2,174,472 compared to $685,000 for those that were settled. Of the 12 gynecology cases, 8 related to procedural complications, 7 to informed consent, 3 to diagnosis, and 2 to treatment. Of these, 6 were decided in favor of the physician, 3 resulted in findings of negligence, and 3 had unknown outcomes. For the cases ending in a finding of negligence, the mean award was $465,000. Conclusions and Outlook: This review of malpractice cases highlights types of situations in which trainees are sued and reveals the importance of designing curriculum around faculty training and supervision regarding trainee involvement in patient care.

Abstract Objective The objective was to derive a risk score that uses variables available early during the emergency department (ED) encounter to identify high‐risk geriatric patients who may benefit from delirium screening. Methods This was an observational study of older adults age ≥ 75 years who presented to an academic ED and who were screened for delirium during their ED visit. Variable selection from candidate predictors was performed through a LASSO‐penalized logistic regression. A risk score was derived from the final prediction model, and predictive accuracy characteristics were calculated with 95% confidence intervals (CIs). Results From the 967 eligible ED visits, delirium was detected in 107 (11.1%). The area under the curve for the REcognizing DElirium in Emergency Medicine (REDEEM) score was 0.901 (95% CI = 0.864–0.938). The REEDEM risk score included 10 different variables (seven based on triage information and three obtained during early history taking) with a score ranging from –3 to 66. Using an optimal cutoff of ≥11, we found a sensitivity of 84.1% (90 of 107 ED delirium patients, 95% CI = 75.5%–90.2%) and a specificity of 86.6% (745 of 860 non‐ED delirium patients, 95% CI = 84.1%–88.8%). A lower cutoff of ≥5 was found to minimize false negatives with an improved sensitivity at 91.6% (98 of 107 ED delirium patients, 95% CI = 84.2%–95.8%). Conclusion A risk stratification score was derived with the potential to augment delirium recognition in geriatric ED patients. This has the potential to assist on delirium‐targeted screening of high‐risk patients in the ED. Validation of REDEEM, however, is needed prior to implementation.