BACKGROUND:  Reducing the frequency of emergency department (ED) patient visits for treatment, particularly in urgent instances, is a global healthcare objective. Additionally, a more extended stay in the ED can harm a patient\'s prognosis during later hospitalization. This study aims to investigate the factors affecting the length of stay in the ED in a teaching hospital.
METHODS: A retrospective chart review study was done between January 1, 2021, and February 31, 2021, involving 122 adult patients who had delayed ED visits to King Khalid Hospital in Najran, Saudi Arabia. Data on the patient\'s characteristics, visit time, and the causes for the delay based on the Canadian Triage and Acuity Scale (CTAS) were gathered and analyzed. Factors associated with more than six hours of delay were investigated in a univariate analysis.
RESULTS: The mean age was 52.3 ±13.5 years, and 42 (34.4%) were more than 65 years of age. More than half of the study population were female (n=66; 54.1%). Most delays occurred among CTAS 4 and 5 cases (47.5%), and 22 (18.0%) occurred during holidays. The mean delay time was 6.1 ±1.8 hours. The leading delay causes were multiple consultations with further investigations (37.7%) and conflict between the teams (36.1%). In univariate analysis, ED visiting at holiday time (OR: 0.14; 95% CI: 0.04-0.40, p <0.001) and CTAS 4 and 5 (OR: 2.22; 95% CI: 0.95-5.30, p = 0.003) significantly had more delay. Factors associated with delay in univariate analysis were multiple consultations with further investigations (OR: 2.82; 95% CI: 1.32-6.26, p = 0.013), various assessments in different ED areas with a late arrival of the specialist (OR: 0.43; 95% CI: 0.20-0.91, p = 0.042), and conflict between the teams (OR: 2.50; 95% CI: 1.17-5.54, p = 0.031).
CONCLUSIONS: In this study, multiple assessments in different ED areas and conflict between the teams were the main factors that caused delays in ED. Implementing a timeframe monitoring system for consultations while emphasizing accelerated decision-making and disposition for patients and understanding teamwork collaboration may reduce patients\' length of stay in the ED. Implementing these strategies and evaluating their impact on the length of stay in the ED requires further investigation.

UNASSIGNED: The aim of this single-institution retrospective study of patients treated with radiotherapy for brain metastases (BM) was to evaluate the timing of the palliative care (PC) decision, the use of health care services, i.e., emergency department (ED) visits and hospitalizations, and the implementation of radiotherapy at the end of life (EOL).
UNASSIGNED: Data on all cancer patients with BM treated in Finland at the Vaasa Central Hospital Radiotherapy Department between March 2011 and November 2020 were retrospectively reviewed. The follow-up period lasted until November 2021. Altogether, 91 patients (54 men, mean age 67 years [range 23-91 years]) were analyzed. Data on timing of PC decision, visits to the PC outpatient unit, and ED and hospitalization periods were collected retrospectively from patients\' records.
UNASSIGNED: The median overall survival from diagnosis of BM was 3.7 months (range 1-62 months) and, after radiotherapy, 2 months (0-61 months). Thirty-two percent of the patients received radiotherapy in the last month of life. During the last 30 days of life, 44 patients (48%) visited the ED and 38 (42%) were hospitalized. Patients with an early PC decision (>30 days before death) had fewer hospitalizations (22% vs. 53%; p = 0.005) and died less often during the hospitalization period (9% vs. 27%; p = 0.047) at EOL. No significant difference was found in ED visits (41% vs. 53%; p = 0.28).
UNASSIGNED: For a large proportion of patients with BM, the prognosis is very poor. It is important to identify these patients and abstain from radiotherapy at EOL to reducing inappropriate health care utilization.

The issue of left against medical advice (LAMA) patients is common in today\'s emergency departments (EDs). This issue represents a medico-legal risk and may result in potential readmission, mortality, or revenue loss. Thus, understanding the factors that cause patients to \"leave against medical advice\" is vital to mitigate and potentially eliminate these adverse outcomes. This paper proposes a framework for studying the factors that affect LAMA in EDs. The framework integrates machine learning, metaheuristic optimization, and model interpretation techniques. Metaheuristic optimization is used for hyperparameter optimization-one of the main challenges of machine learning model development. Adaptive tabu simulated annealing (ATSA) metaheuristic algorithm is utilized for optimizing the parameters of extreme gradient boosting (XGB). The optimized XGB models are used to predict the LAMA outcomes for patients under treatment in ED. The designed algorithms are trained and tested using four data groups which are created using feature selection. The model with the best predictive performance is then interpreted using the SHaply Additive exPlanations (SHAP) method. The results show that best model has an area under the curve (AUC) and sensitivity of 76% and 82%, respectively. The best model was explained using SHAP method.

BACKGROUND: Older adults are too often hospitalized from the emergency department (ED) without needing hospital care. Knowledge about rates and causes of these preventable emergency admissions (PEAs) is limited. This study aimed to assess the proportion of PEAs, the level of agreement on perceived preventability between physicians and patients, and to explore their underlying causes as perceived by patients, their relatives, and the admitting physician.
METHODS: A multi-center multi-method study at the ED of one academic and two regional hospitals in the Netherlands was performed. All patients aged > 70 years and hospitalized from the ED were consecutively sampled during a six-week period. Quantitative data regarding patient and clinical characteristics and perceived preventability of the admission were prospectively collected from the electronical medical record and analyzed using descriptive statistics. Agreement on preventability between patient, caregivers and physicians was assessed by using the Cohen\'s kappa. Underlying causes of a PEA were subsequently collected by semi-structured interviews with patients and caregivers. Physician\'s perceived causes of a PEA were collected by telephone interviews and by open-ended questions sent by email. Thematic content analysis was used to analyze the interview transcripts and email narratives.
RESULTS: Out of 773 admissions, 56 (7.2%) were deemed preventable by patients or their caregivers. Admitting physicians regarded 75 (9.7%) admissions as preventable. The level of agreement between these two groups was low with a Cohen\'s kappa score of 0.10 (p = 0.003). Perceived causes for PEAs related to six themes: (1) insufficient support at home, (2) suboptimal care in the community setting, (3) errors in hospital care, (4) time of presentation to ED and availability of resources, (5) delayed help seeking behavior, and (6) errors made by patients.
CONCLUSIONS: Our findings contribute to the existing evidence that a substantial part (almost one out of ten) of the older adults visiting the ED is perceived as unnecessary hospital care by patients, caregivers and health care providers. Findings also provide valuable insight into the causes for PEAs from a patient perspective. Further research is needed to understand why the perspectives of those responsible for hospital admission and those being admitted vary considerably.

BACKGROUND: Abdominal pain is one of the most common complaints when patients are admitted to emergency departments (ED). Unfortunately, many of these patients are readmitted to the ED shortly after initial discharge. The perspectives of these patients have not yet been explored.
OBJECTIVE: The study aimed to explore how patients readmitted with acute abdominal pain in the ED experienced their initial admission, the time after discharge, and the cause of readmission.
METHODS: The study had a qualitative explorative design with a phenomenological-hermeneutic approach. Semi-structured individual telephone interviews were conducted with 14 patients readmitted with acute abdominal pain.
RESULTS: The analysis showed four themes: 1) being vulnerable during hospitalisation, 2) the meaning of information during hospitalisation, 3) discharged without being diagnosed, and 4) readmitted in the pursuit of relief. The patients wanted more knowledge and better communication despite their vulnerable condition. Patients were discharged whilst still in pain, and uncertainty of the situation at home contributed to mistrust of the health professionals.
CONCLUSIONS: Patients\' experience of the first ED admission due to acute abdominal pain was loneliness, minimal contact with healthcare professionals, and lack of information and involvement in pain management. Discharge was associated with feelings of insignificance and contributed to a fear of death. Pain was the main reason for readmission. Patients described how multiple readmissions contributed to being taken seriously by healthcare professionals.

BACKGROUND: Violence against healthcare workers is a pervasive, yet in many cases, under-reported problem. This is due to various factors, including lack of time, support and a universal understanding of what constitutes a reportable event. This study explored facilitators and barriers to reporting workplace violence among emergency department nurses.
METHODS: In this descriptive, qualitative study, researchers conducted open-ended interviews with emergency nurses considered to be \"high-\" and \"non-reporters\" of violent events and analyzed for themes.
RESULTS: Participants cited consistent factors associated with less reporting, factors associated with more reporting and effectiveness of existing safety measures.
CONCLUSIONS: To encourage the reporting of violent events, frequently cited barriers and facilitators should be addressed. Strategies such as integrating reporting mechanisms into the health record, creating nuanced definitions of reportable events, and consistent education with positive feedback can promote reporting by staff. These efforts should be combined with prevention strategies to ensure we are collecting correct data about the success or failure of these programs.

UNASSIGNED: Persons with disabilities (PWD) are more likely to visit the emergency department (ED) and often have complex health needs when accessing care in the ED. Yet there is limited understanding of ED care experiences among PWD, especially in a Canadian context. The aim of this study was to examine the ED care experiences of PWD in contrast to a comparison group in Kingston, Ontario to better understand their health care needs.
UNASSIGNED: A mixed-methods study with a community-based participatory approach examining participants\' past ED care experiences (within 24 months) was conducted in Kingston, ON. Quantitative data from those with disabilities and those from the comparison group were compared using chi squared tests to identify differences between groups. An inductive and deductive thematic analysis approach was used to identify themes in the shared qualitative data. Convergence of findings across quantitative and qualitative data was undertaken.
UNASSIGNED: A total of 175 participants identified as having a disability. In contrast with the comparison group (N = 949), PWD were more likely to report being given too little attention to their needs (p < 0.001), that it was more important to be treated with kindness/respect than to receive the best possible medical care (p < 0.001), to report feelings of disrespect and/or judgement (p < 0.001), and that better understanding of personal identity/situation/culture and better communication would improve ED care. Qualitative analysis highlighted the following themes: poor communication between PWD and health care providers (HCP), compassionate medical care received, perceived HCP negative attitudes/beliefs related to having a disability and substance misuse, and perceived HCP lack of knowledge/skill to treat the unique health needs of PWD.
UNASSIGNED: Findings highlight the need to improve ED care for PWD. Future quality improvement initiatives should focus on incorporating a deeper understanding of disability into medical education and emergency medicine (EM) residency education, designing curricula that emphasize cultural humility, and implementing community-based placements providing opportunities for health professionals to work with and learn from PWD.

BACKGROUND: Due to the increasing number of older patients in emergency departments (EDs) with frailty, cognitive impairment and multimorbidity, there is a need for geriatric expertise in EDs.
METHODS: This retrospective study is of older patients visiting Turku University Hospital ED between 2 January and 31 December 2022. Patients aged 75 years of older were screened for frailty using Triage Risk Screening Tool (TRST) and Clinical Frailty Scale (CFS). Nonacute, frail patients (CFS ≥4) suitable for Targeted Geriatric Assessment (TGA) (n = 1096) were scanned for the risk of delirium, cognitive impairment, change in functional status, falls, malnutrition and depression. A comprehensive patient record was made with recommendations for future care.
RESULTS: TRST was completed in 70% of the ED visits, and two-thirds of those were considered high-risk. Among the patients assessed by the geriatric team (TGA), nonspecific complaint (38%) and falls (35%) were the main reasons for ED admission. Cognitive impairment was present in over 60% and orthostatic hypotension in 40% of the patients. The 72-hour revisit rate for TGA-patients was 2.3%. For the real-life control group, the 72-hour revisit rate was 4.6% (P = .001). Thirty-day revisit rates were 10% and 16%, respectively (P < .001). The need for rehabilitation, cognitive evaluation and intensifying home care were the main recommendations for future care.
CONCLUSIONS: TGA approach provides structured and accurate information on older patients\' background. This may lead to more precise diagnostics, a thorough consideration of hospital intake and a secure discharge from the ED. Ensuring continuity of care may help to reduce readmissions to EDs.

BACKGROUND: Utilization by low acuity patients contributes to emergency department (ED) crowding. Both knowledge deficits about adequate care levels and access barriers in primary care are important promoters of such presentations. Concurrently, not having a general practitioner (GP) increases the likelihood of low-acuity ED utilization. This pilot study thus investigated feasibility, acceptance, and potential effects of an ED-delivered intervention for low-acuity patients with no regular primary care provider, consisting of an educational leaflet on acute care options and an optional GP appointment scheduling service.
METHODS: Low-acuity ED consulters not attached to a GP were given an information leaflet about alternative care offers for acute health problems and offered optional personal appointment scheduling at a local GP practice. Patients were surveyed on demographics, medical characteristics, health care utilization, valuation of the intervention, and reasons for not being attached to a GP and visiting the ED. A follow-up survey was conducted after twelve months. Trends in health and health care utilization were evaluated.
RESULTS: Between December 2020 and April 2022, n = 160 patients were enrolled, n = 114 were followed up. The study population was characterized by young age (mean 30.6 years) and predominantly good general health. Besides good health, personal mobility was a central reason for not being attached to a GP, but general preference for specialists and bad experiences with primary care were also mentioned. Most frequently stated motives for the ED consultation were subjective distress and anxiety, a belief in the superiority of the hospital, and access problems in primary care. The interventional offers were favorably valued, 52.5% (n = 84) accepted the GP appointment scheduling service offer. At follow-up, GP utilization had significantly increased, while there were no significant changes regarding utilization of other providers, including ED. An additional practice survey showed a 63.0% take-up rate for the appointment service.
CONCLUSIONS: With this pilot study, we were able to show that a personalized appointment scheduling service seems to be a promising approach to promote GP attachment and increase primary care utilization in patients without a regular GP in a highly urbanized setting. Further larger-scale studies are needed to investigate potential quantitative effects on ED visits.
BACKGROUND: German Clinical Trials Register (DRKS00023480); date 2020/11/27.

OBJECTIVE: This study aimed to compare the effects of Macintosh-type and hyperangulated video laryngoscopy (VL) blades on dental force during endotracheal intubation (ETI) using Glidescope and McGrath VL devices.
METHODS: In this randomized, crossover, manikin study conducted at a university emergency medicine (EM) program, 65 EM trainees included interns and residents performed 520 intubations using four different VL blades (GlideScope VL with Macintosh-type Mac T3 and hyperangular Lo Pro T3 blades and McGrath VL Macintosh-type MAC 4 and hyperangular McGrath X3 blades) in normal and difficult airway scenarios. The primary outcome of this study was the dental pressure (Newton) exerted during ETI. The secondary outcomes included c-spine motion (degree), intubation success (%), duration (seconds), successful glottic view (%), and intubator comfort (7-point Likert).
RESULTS: Significant differences were observed in dental force (H(3) = 11.7, P = 0.008), c-spine motion (H(3) = 8.34, P = 0.039), duration (H(3) = 16.56, P = 0.001), and comfort (H(3) = 174.96, P < 0.001) across blade types. Glidescope LoPro T3 provided a significant lower dental force (adjusted P = 0.01), less c-spine motion (adjusted P = 0.031), and shorter intubation duration (adj P < 0.01) than the McGrath Mac 4. First attempt success and intubator comfort were significantly better with all Glidescope blades (z score of 3.7 and 4.7) than with McGrath blades (z score of-4.1 and-4.4).
CONCLUSIONS: The Glidescope LoPro T3 blade demonstrated advantages in dental force, c-spine motion, and intubation duration compared with McGrath Mac 4. Overall, the Glidescope blades provided superior comfort and higher first attempt success rates.