Paediatric myocarditis, a rare inflammatory cardiomyopathy (incidence 1–2/100,000 annually), challenges emergency diagnosis due to nonspecific symptoms mimicking common illnesses. This study assessed electrocardiographic markers of ventricular repolarisation heterogeneity—T-peak to T-end interval, T-peak to T-end/QT, T peak–to–end/corrected QT ratios, and index of cardiac electrophysiological balance—for diagnosing myocarditis and predicting ventricular arrhythmia risk in children aged 0–18 years.

Retrospective case–control study of 76 myocarditis patients (diagnosed by clinical, laboratory, echocardiographic, and cardiac MRI criteria) presenting to our paediatric emergency department from January 1, 2024, to May 30, 2025, versus 75 age-matched healthy controls. Electrocardiographic parameters were measured in leads DII and V5. Receiver operating characteristic analysis evaluated the diagnostic performance of T-peak to T-end and T peak–to–end/corrected QT (Lead II (Derivation II)). Myocarditis cases stratified by arrhythmia development (with: n = 28; without: n = 48); groups compared via t-tests, Mann–Whitney U, and chi-square (p < 0.05 significant).

Myocarditis group: 23 females (30.2%) and 53 males (69.8%); mean age 12.0 ± 4.7 years. Controls: 39 females (52.0%), 36 males (48.0%); mean age 10.3 ± 4.9 years (p = 0.03). Receiver operating characteristic (Lead II (Derivation II)): T-peak to T-end cut-off 62 ms (sensitivity 69.3%, specificity 78.9%, area under the curve 0.725, p < 0.001); T peak–to–end/corrected QT cut-off 0.19 (sensitivity 50.7%, specificity 78.9%, area under the curve 0.625, p < 0.05).

The arrhythmia subgroup showed corrected QT prolongation (470 vs. 435 ms, V5; p < 0.001), T-peak to T-end (110 vs. 90 ms, V5; p < 0.001), higher T peak–to–end/corrected QT, and index of cardiac electrophysiological balance (both p < 0.05).

The T-peak to T-end interval, T peak–to–end/corrected QT ratio, and index of cardiac electrophysiological balance provide high-specificity, noninvasive electrocardiographic biomarkers for paediatric myocarditis diagnosis in the ED. Corrected QT and T-peak to T-end prolongation signals repolarisation heterogeneity and arrhythmia risk, supporting routine triage integration for early risk stratification.

The National Health Service in England has encouraged the development of specialised services for patients with high-intensity use of emergency departments: liaison psychiatry services in emergency departments and community services.

To evaluate the effect of different types of high-intensity use services on attendances at emergency departments, for those with 5 (HU5) or 10 (HU10) or more attendances in the previous 12 months, and the subset of this group with probable mental health problems, versus emergency departments without locality high-intensity use services.

A retrospective longitudinal study was conducted using nationally sourced data from 13 hospitals in England, spanning 1 April 2016 to 1 January 2020. An interrupted time-series analysis assessed the impact of three high-intensity use service models on weekly emergency department attendances: emergency department-based services with and without designated staffing, and community based services. Patients and clinicians contributed throughout the project.

A total of 2 938 510 emergency department attendances were analysed. Statistically significant associations were identified between the implementation of community-based services and reductions in weekly attendances by HU10 patients (rate ratio 0.83, 95% CI 0.71–0.97), and HU5 and HU10 patients with mental health-related attendances (HU5 rate ratio 0.82, 95% CI 0.75–0.91; HU10 rate ratio 0.70, 95% CI 0.59–0.84). Emergency department-based services with designated staff were associated with a reduction in mental health-related attendances among HU10 patients (rate ratio 0.88, 95% CI 0.80–0.98).

Services targeting patients with high-intensity use of emergency departments in England demonstrate promising potential in reducing emergency department attendances among this patient group. Community-based interventions show the most substantial impact, whereas hospital-based services often run by liaison psychiatry teams also contribute to reductions in those with high-intensity use with mental health issues. These findings support further development and expansion of tailored high-intensity use services across the country.

Palpitations are not an uncommon complaint in the paediatric emergency department, causing significant anxiety for families concerned about serious heart disease. However, most cases are benign, often stemming from normal physiological responses like fever or anxiety. Primary cardiac arrhythmias are rare in this clinical setting.

The main challenge is identifying the few children with dangerous arrhythmias among the many benign cases. Fear of missing a life-threatening condition often leads to extensive, costly, and stressful investigations, even in low-risk patients, without significantly improving detection rates.

This review aims to create a structured, risk-based framework for evaluating paediatric palpitations in the emergency department. The goal is to help clinicians efficiently distinguish benign from potentially life-threatening causes, thereby optimising resource use and reducing family anxiety.

A thorough clinical history, physical exam, and a standard 12-lead electrocardiogram are the most effective evaluation tools. “Red-flag” features—such as palpitations with fainting (syncope), onset during exercise, or a family history of sudden cardiac death—successfully identify nearly all children with significant arrhythmias. Barring certain risk factors and any abnormalities on a 12 lead electrocardiogram, a dangerous cardiac condition is highly unlikely.

A stratified approach is recommended. Low-risk children (no red-flag features, normal electrocardiogram) can be safely discharged with reassurance. High-risk patients require immediate, aggressive evaluation, including cardiology consultation and potential hospital admission. This strategy improves accuracy, is cost-effective, and enhances patient safety.

The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) is a validated social needs screening tool widely used in primary care but rarely adapted for the emergency department (ED). We evaluated the feasibility of implementing an abridged PRAPARE tool in a high-volume ED using an operational model designed to minimize burden on clinical staff.

From October 2021 to October 2023, trained student volunteers administered an 11-item abridged PRAPARE survey to adult ED patients during waiting-room time, parallel to routine clinical workflows. This retrospective quality improvement analysis evaluated deidentified data from these encounters. Items were selected via multidisciplinary consensus based on local resource alignment and analyzed descriptively.

Of 6,931 patients approached, 683 (9.8%) completed screening. Most identified as non-Hispanic Black (62%) and female (61%). Nearly all (94%) reported at least one unmet social need, and 56% reported three or more. The most common were food insecurity (47%), medication access (39%), and utility insecurity (37%). Substantial proportions also reported transportation barriers (28%), housing instability (27%), unemployment (26%), and feeling unsafe at home (15%). Black patients were overrepresented relative to the ED census (62% vs 40%). Among those with unmet needs, 96% expressed willingness to engage with assistance.

An abridged PRAPARE tool was successfully implemented using a low-burden, volunteer-driven model and identified a high prevalence of unmet social needs. These findings support streamlined screening delivered outside the clinical workflow and offer operational lessons on volunteer staffing, workflow integration, and referral infrastructure.

Acute musculoskeletal pain is a common reason for emergency department (ED) care, but ED-based cohorts designed to support chronic pain prevention research remain limited. We evaluated first-year recruitment, retention, and baseline characterization in PREVENT, an ED-based observational cohort of adults with acute musculoskeletal pain.

We analyzed first-year data from PREVENT, conducted in an urban academic ED. Adults with acute neck or low back pain were screened and enrolled during the index ED visit. Feasibility outcomes included screening, eligibility, enrollment, and completion of 1-, 3-, and 6-month follow-up assessments. Baseline measures characterized pain-related cognition, psychological symptoms, function, and social needs. Social needs burden (SNB) was categorized as 0, 1, or ≥2 endorsed domains. Associations between SNB and baseline outcomes were examined using general linear models and Fisher’s exact tests.

Between January 21, 2025 and March 22, 2026, 439 individuals were screened, 81 were eligible, and 46 were enrolled. The most common reason for ineligibility was absence of a qualifying traumatic mechanism. Follow-up completion was 22.5% at 1 month, 13.2% at 3 months, and 17.9% at 6 months; 65% completed no follow-up assessments. At baseline, 58.5% endorsed at least one social need domain. Pain catastrophizing, fear of movement, low pain self-efficacy, maladaptive pain beliefs, and disability were common. Greater SNB was associated with higher pain-related distress, anxiety and depressive symptoms, and disability.

PREVENT demonstrated feasible ED-based recruitment and baseline phenotyping, while identifying retention challenges. Findings support refined follow-up procedures and risk-informed approaches to ED-initiated chronic pain prevention studies.

Women from ethnic minorities experience disproportionately high rates of self-harm and suicide. In Ireland, Irish Travellers have an indigenous presence on the island dating back centuries. Although Traveller women are known to be at increased suicide risk, little is understood about their experiences with healthcare during suicidal crisis.

This study sought to explore how Traveller women make sense of their experiences when presenting to emergency departments (EDs) in suicidal crisis, and how they perceive their interactions with clinicians.

Interpretative Phenomenological Analysis (IPA) was employed to capture culturally specific meaning-making around a highly sensitive topic. Two Traveller women were purposively sampled from a deliberately homogeneous subgroup. Each case was analysed independently, followed by a cautious cross-case synthesis to identify shared experiential themes.

Two central themes emerged: (1) “Making sense of Suicidal Behaviours” captured the women’s attempts to understand their actions, the overwhelming emotional pain they endured, and the internal struggle between life and death. (2) “Impact of Clinicians” reflected a profound loss of autonomy, with participants feeling controlled and monitored during their care. While some clinicians demonstrated empathy and provided support, others offered limited engagement, leaving participants feeling isolated and frustrated.

While idiographic in scope (two cases), the study reflects well-recognised challenges recruiting from acute hospital settings and the impact of limited culturally safe services for Traveller communities. Findings underscore the importance of lived experience-informed, culturally safe, person-centred approaches that recognise the distinct challenges faced by Traveller women during suicidal crisis.

Conflict brings excess and changing demands to local civilian health care resources. While conflict-related needs are often easily identifiable, in the aftermath of disaster or conflict, health care systems may struggle to identify changing needs, and humanitarian actors may initiate responses targeted to traumatic injuries while facing different operational realities.

This study aims to quantify the immediate changes in, and short-term trends of, Emergency Department (ED) patient profiles following a break in conflict, informing humanitarian intervention and the prioritization of local health care resources in future contexts.

A single center, retrospective Interrupted Time Series (ITS) analysis was undertaken comprising of every patient attendance to the Nasser Medical Complex (Gaza Strip) ED from September 1, 2025 through November 30, 2025, inclusive, to evaluate the impact of the ceasefire on October 10, 2025. Binomial and negative binomial regression was used, adjusting for day-of-week confounding, with Newey–West robust standard errors. Coefficients were exponentiated to Incidence Rate Ratios for interpretation as the percentage change in the relevant presentations numbers or trend and were presented with 95% Confidence Intervals (95%CI).

There were 107,631 presentations over the study period, a median of 1,217 (IQR 1,120-1,291) per day prior to, and 1,202 per day (IQR 1,083-1,356) following, the ceasefire. There was no significant step-change in total presentation to the ED following ceasefire, but thereafter, relative to the pre-ceasefire trajectory, attendances experienced a sustained decrease of two percent per day (95%CI, 1.0% to 2.0% reduction; P < 0.001).

There were observed changes to the profile of attendances by diagnostic group, with step-change reductions in trauma admissions, gastrointestinal, and pediatric presentations. There were daily trend reductions for multiple diagnostic groups, including traumatic injuries discharged from the ED, respiratory infections, gastrointestinal presentations, and other medical emergencies.

This study demonstrates that the implementation of a ceasefire has the potential to change presentation patterns to a civilian ED in a conflict area. While there was no step-change following the ceasefire, there was a reversal of the previous trend of rising daily presentations. It should be noted that most presentations both before and after the ceasefire were for non-traumatic events. These findings highlight the need to continue support and resource for the non-traumatic workload of emergency care during crises, a pattern described in other contexts.

Hemorrhagic shock represents a major cause of preventable mortality following trauma. Identifying shock early on the scene is critical for survival, particularly within resource-limited settings like Thailand, where prehospital blood products are unavailable. Although several scoring tools exist, uncertainty remains regarding which tool offers the optimal diagnostic accuracy for predicting massive transfusion (MT) and early death in this specific setting.

This research aimed to compare the predictive performance of five prehospital scoring tools – Shock Index (SI), Reverse Shock Index multiplied by Glasgow Coma Scale (rSIG), National Early Warning Score (NEWS), Assessment of Blood Consumption (ABC), and Revised Assessment of Bleeding and Transfusion (RABT) – for predicting MT and 24-hour mortality.

This retrospective prognostic accuracy study included adult trauma patients transported by Emergency Medical Services (EMS) to a university-affiliated Level 1 Trauma Center in Bangkok from January 2019 through December 2024. The primary endpoint was MT; the secondary endpoint was 24-hour mortality. Area Under the Receiver Operating Characteristics (AUROCs) assessed discrimination and the DeLong test compared performance among scores.

A total of 584 eligible patients were included, of whom 63 (10.8%) required MT. The NEWS demonstrated the highest discriminatory power for MT (AUROC 0.84; 95% CI, 0.79–0.90), followed by rSIG (AUROC 0.83; 95% CI, 0.76–0.90) and SI (AUROC 0.78; 95% CI, 0.72–0.86). In contrast, trauma-specific scores showed lower performance, with AUROCs of 0.69 for ABC and 0.74 for RABT. For 24-hour mortality, NEWS and rSIG demonstrated excellent discrimination (AUROCs of 0.93 and 0.91, respectively). At a cut-off of four or higher, NEWS showed a sensitivity of 81.0% for MT, while rSIG ≤ 16 provided a balanced sensitivity of 74.6% and specificity of 88.5%.

Both NEWS and rSIG predicted MT and 24-hour mortality more accurately than ABC and RABT. These tools may support early pre-arrival notification and blood bank preparation without delaying rapid transport.

Out-of-hours primary care (OOH-PC) has been introduced in many health systems to reduce non-urgent emergency department (ED) use. While prior studies suggest potential efficiency gains, economic evaluations rarely stratify outcomes by patient risk, limiting policy relevance. This study assesses the cost-effectiveness of diverting low-risk patients from ED to OOH-PC.

Compare direct medical costs, time spent at the facility, and hospitalization probability across risk and care setting subgroups from a societal perspective.

We analysed data from a cluster-randomized trial conducted in Belgium that examined a nurse-led triage system. Under the study trial’s extended Manchester Triage System (eMTS) protocol, patients eligible for primary care were assigned to OOH-PC and are referred to in our study as low-risk, while those assigned to the ED are defined as high-risk. To complement previous work, we stratified costs and effects by risk group. Mixed-effects regression models estimated costs, time at the facility, and hospitalization, with bootstrap confidence intervals. We also calculated the incremental net monetary benefit (INMB).

Treating low-risk patients at the OOH-PC instead of at the ED reduced costs by €24 (€14–€39) per patient, shortened the time spent at the facility by 69 (52–94) minutes. From a societal perspective, the average INMB was €49.5 per low-risk patient. Aggregately, we estimated that the 37 intervention weekends in 2019 led to an average saving of €14,136 in direct medical costs and cumulative time savings of 28 days.

Diverting low-risk patients from the ED to OOH-PC resulted in cost- and time-savings for low-risk patients at the study site. These findings highlight the potential to improve out-of-hours healthcare delivery to maximize benefits for patients and healthcare systems, although confirmation in other healthcare settings is required before wider implementation.

During the coronavirus disease 2019 (COVID-19) pandemic, emergency departments (EDs) faced unprecedented operational stress compounded by mandatory testing requirements that directly influenced patient flow and length-of-stay (LOS). Two testing modalities were central to pandemic ED operations: (1) rapid point-of-care lateral flow assays (LFAs), which return results in minutes but depend on frontline ED personnel and space, and (2) laboratory-based polymerase chain reaction (PCR), which requires sample transport and centralized processing but functions independently of ED capacity. Whether the relative performance of these modalities remains robust under varying ED operational pressures is unclear.

This retrospective observational study analyzed 31,737 COVID-19 testing encounters (11,098 LFA; 20,639 PCR) during the 11-month dual-testing period (May 2022–March 2023) at a high-volume tertiary ED, when both modalities were concurrently deployed. Propensity score matching (PSM; 1:1 nearest-neighbor, caliper 0.5 SD) generated 8,492 well-balanced LFA–PCR pairs. Turnaround time (TAT) was evaluated as an operational stress indicator modifying the association between testing modality and ED LOS. Variability analyses assessed performance stability under differing capacity levels.

Overall, LFA was associated with longer LOS than PCR (median 8.3 versus 5.8 hours; P < 0.001). Under low-stress conditions (TAT ≤30 minutes), this difference was modest (median difference 1.5 hours; 95% CI, 0.80 to 2.07). As TAT increased, modality performance diverged substantially. At TAT >90 minutes, LOS difference increased to 3.6 hours (95% CI, 2.85 to 4.42). Threshold inflection occurred between 60–90 minutes. Lateral flow assays exhibited higher operational variability (CV ratio 2.09; 95% CI, 1.25 to 3.12), with the greatest instability during high-volume periods, while PCR performance remained comparatively stable across stress levels. Stratified analyses were exploratory; confidence intervals were not adjusted for multiplicity.

Turnaround time and its variability serve as actionable, real-time indicators of ED system capacity. Lateral flow assay performance degrades progressively under operational strain due to its reliance on frontline ED resources, whereas PCR—supported by external laboratory infrastructure—maintains more stable throughput. Capacity-contingent, adaptive testing strategies that shift toward PCR as TAT rises may enhance ED resilience, reduce LOS, and support more predictable patient flow during future outbreaks and surge conditions.

Services for people who are high users of emergency departments (EDs) have developed in a piecemeal fashion, including those embedded within liaison mental health services, over the past decade. We conducted a national survey of all 171 National Health Service hospitals in England with an ED to identify high user services, alongside 20 interviews from exemplar services to characterise the interventions offered.

We had a 100% response rate. Of the 171 hospitals, 76 (44%) had a high user service in the ED without designated staff and 71 (42%) offered services with some designated staff time; 10 (6%) had community services, either separate or with hospital outreach; and 14 (8%) had no service. Interviews revealed great variability among services on most parameters, including staffing levels, entry criteria, case-load and types of intervention.

There is a need for clarity on entry criteria, case-load and types of intervention, to improve consistency and effectiveness of these services to guide decision-making.

Emergency department mental health practitioners (MHPs) decide onward care for individuals presenting with self-harm or suicidal ideation. However, their experiences and practices in making these decisions remain underexplored.

To synthesise research on MHPs’ experiences and practices in making decisions about onward care for patients presenting to emergency departments with self-harm or suicidal ideation.

We searched six databases (inception to July 2024) for empirical studies of MHPs making care decisions for self-harm or suicidal patients in emergency departments. We used a segregated mixed-methods design, applying narrative synthesis of quantitative data and thematic synthesis of qualitative data.

Eleven studies were included (one quantitative, one mixed-methods, nine qualitative). Narrative synthesis of quantitative data produced two themes: (a) subjective decision-making and variability among MHPs and (b) impact of the institutional mandate to discharge within 4 h on referral outcomes. Thematic synthesis of qualitative data generated five themes: (a) risk-centric culture is anti-therapeutic and shapes defensive practice, scepticism toward patients and burnout; (b) time and environmental pressures impact therapeutic potential of assessments; (c) ‘battling’ to access services: gatekeeping, cycles of repeat attendances affecting patient safety and staff moral injury; (d) strategies to facilitate access and extending care to overcome challenges in the emergency department and (e) potential for training to counter negative attitudes and stereotypes.

Intersecting institutional, systemic and emotional pressures shape MHPs’ practices, undermining assessment quality and access to care. System-level reforms and training should promote relational, compassionate care. Limited quantitative evidence restricted integration, and the review reflects high-income Western settings.

Understanding the economic cost of self-harm is essential for evaluating intervention cost-effectiveness and guiding funding allocation and service planning.

To estimate the cost associated with self-harm presentations to hospital emergency departments and investigate key predictors of cost.

Data on presentations to hospital for self-harm in all Irish emergency departments were analysed for 2018 and 2019. Costs of hospital treatment following self-harm were identified (in 2019 euros) using top-down and bottom-up approaches. The perspective taken was that of the health service. Factors associated with costs were investigated using generalised linear models.

There were 25 053 self-harm presentations from 2018 to 2019. The average annual cost of self-harm was approximately €26.5 million; almost half of the total cost was due to repeat self-harm presentations (47.3%). The mean cost per presentation was €2117 (s.d. €1845), which incorporates acute hospital costs (mean €2067, s.d. €2127) and those of initial aftercare (mean €50, s.d. €69). Psychiatric and medical admissions were associated with highest costs, three times that of presentations resulting in emergency department discharge (incidence rate ratio (IRR) 3.01, 95% CI 2.72–3.36 and IRR 2.88, 95% CI 2.72–3.36, respectively). Other factors associated with higher costs included older age, emergency department medical assessment unit admission, receiving a psychosocial assessment and self-harm involving a firearm. Demographic and clinical predictors of cost varied according to care pathway.

Significant costs associated with repeat attendances and hospital admission provide evidence for investment in emergency department services providing comprehensive care for those presenting with self-harm, as well as in community-based mental health services.