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Advancements in Emergency Medicine Practices and Protocols

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Emergency Medicine".

Deadline for manuscript submissions: closed (25 June 2026) | Viewed by 9319

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Dr. Vincenzo G. Menditto

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Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
Interests: emergency medicine; sepsis; cardiopulmonary resuscitation; emergency management; emergency treatment
Special Issues, Collections and Topics in MDPI journals

Dr. Beatrice Gasperini

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Guest Editor

Emergency and Internal Unit, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy
Interests: geriatric; public health; emergency medicine; emergency management; emergency treatment; statistics

Special Issue Information

Dear Colleagues,

The way to provide the right care for the right patient at the right time in contemporary crowding emergency departments is a major topic. For example, an increasing number of accurate strategies have been designed to optimize the determination of pulmonary embolism in the case of chest pain and reduce unnecessary resource wasting. Some issues are very specific in emergency setting. The role of the emergency department observation unit and structural protocols has been studied to better manage geriatric patients. The best management of patients with major trauma remains a challenge for emergency physicians. Moreover, the ”gray areas” of the guidelines are often a real problem in the management of frail patients with comorbidities. In this Special Issue, we welcome authors to submit papers on acute diseases and acute complications of chronic diseases, such as pulmonary embolism, trauma, acute heart failure, poisonings, or delirium, in terms of both diagnosis and treatment in an emergency department.

Dr. Vincenzo G. Menditto
Dr. Beatrice Gasperini
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 250 words) can be sent to the Editorial Office for assessment.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-anonymized peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

emergency
pulmonary embolism
trauma
management
guidelines
frailty
emergency department observation unit

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Published Papers (8 papers)

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13 pages, 1023 KB

Open AccessArticle

Impact of a Hospital Information System-Integrated Automated Dispensing Cabinet on Medication Use and Safety in a Tertiary Hospital Emergency Department: A Prospective Before-and-After Study

by Ryang Soon Lim, Woon-Jeong Lee, Hyen Oh La, Yun-Kyoung Song and Kyung Hee Choi

J. Clin. Med. 2026, 15(13), 4908; https://doi.org/10.3390/jcm15134908 - 24 Jun 2026

Viewed by 160

Abstract

Background/Objectives: Emergency departments (EDs) are particularly prone to medication errors because of urgent treatment environments and high decision density. Automated dispensing cabinets (ADCs) integrated with the hospital information system (HIS) may improve medication safety, yet real-world evidence in centralized-pharmacy settings remains limited. This study evaluated the impact of an HIS-integrated ADC on medication use, medication errors, and nurses’ perception of safety in the ED of a Korean tertiary hospital. Methods: In this prospective before-and-after study, prescribing patterns, medication storage, and related costs were compared in the two months before (Phase 1; September–October 2019) and after (Phase 2; May–June 2020) ADC installation. Medication errors reported through the hospital safety incident reporting system were analyzed over corresponding 6-month windows from July 2019 to June 2020. Long-term sustainability was assessed using follow-up data collected from October to November 2023 (Phase 3), and all 46 ED nurses completed a 5-point Likert-scale survey on perceived medication safety. Results: Daily injectable prescriptions were unchanged (221.1 ± 34.6 vs. 227.7 ± 35.2; p = 0.301), whereas returned injectable prescriptions increased (17.9 ± 5.9 vs. 25.1 ± 6.0; p < 0.001) and non-injectable prescriptions decreased (163.1 ± 42.2 vs. 140.0 ± 22.7; p < 0.001). The number of medication items stored in the ED storage room declined by 95.6%, with a 92.5% reduction in related maintenance cost. Total medication errors decreased from 41 (74.5%) before to 14 (25.5%) after implementation (p < 0.001), with the largest reduction in delivery errors (17 [30.9%] to 2 [3.6%]). These improvements were sustained at the three-year follow-up. Nurses reported high overall satisfaction with medication safety (4.27 ± 0.62 on a 5-point Likert scale). Conclusions: Implementation of an HIS-integrated ADC in the ED was associated with improved prescription patterns, fewer reported medication errors, and enhanced perceived medication safety. In addition, these improvements were sustained over time, indicating stable and consistent implementation of the ADC system. Nurses also reported improved perceptions of medication safety. Full article

(This article belongs to the Special Issue Advancements in Emergency Medicine Practices and Protocols)

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16 pages, 275 KB

Open AccessArticle

Impact of Point-of-Care Ultrasound on the Management of Abdominal Pain in the Emergency Department: A Quasi-Experimental Study

by Laura Carbajo Martín, Ignacio Párraga-Martínez, Luis Matías Beltrán-Romero, Máximo Bernabeu Wittel and Northern Huelva Health Management Area Research Group

J. Clin. Med. 2026, 15(12), 4810; https://doi.org/10.3390/jcm15124810 - 21 Jun 2026

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Abstract

Objectives: To evaluate the impact of Point-of-Care Ultrasound (POCUS) performed by family physicians on the management of abdominal pain in the emergency department, assessing its effect on length of stay, performance of complementary diagnostic tests, diagnostic concordance, and patient satisfaction. Methods: Quasi-experimental pilot study with a control group conducted in a hospital emergency department. A total of 222 adult patients with abdominal pain were included and allocated according to the attending professional (with or without ultrasound training). Clinical, care-related, and patient-satisfaction variables (SERVPERF questionnaire) were analyzed. Non-parametric statistical tests were used, and multiple linear regression analyses were performed. Results: The POCUS group showed a shorter length of stay (3.46 vs. 4.41 h; p = 0.022) and a lower number of plain radiographies (16.8% vs. 69.9%; p < 0.001) and CT scans (p = 0.034). Diagnostic concordance was significantly higher in the experimental group (99.2% vs. 75.7%; p < 0.001). Overall satisfaction with received care was also higher in the intervention group (p < 0.001), with significant differences observed across all evaluated dimensions. The multivariate model explained 26.6% of the variability, with patient satisfaction emerging as a positive predictor. Conclusions: POCUS improves the quality of care in emergency departments by reducing length of stay and the use of complementary diagnostic tests while increasing diagnostic accuracy and patient satisfaction. Its implementation can be considered an effective and potentially cost-effective strategy; however, further studies with greater methodological robustness are required to validate the development of standardized composite indexes. Full article

(This article belongs to the Special Issue Advancements in Emergency Medicine Practices and Protocols)

19 pages, 1278 KB

Open AccessArticle

Nomogram-Based Mortality Prediction in Acute Pulmonary Embolism Using Inflammatory Biomarkers and the Simplified Pulmonary Embolism Severity Index

by Hacı Mehmet Çalışkan, Ömer Jaradat, Burak Şahin, Bilgehan Mutlu, Sedat Koçak, Sinem Deniz, Anılcan Kılıç, Alperen Yıldız and Veli Ağgül

J. Clin. Med. 2026, 15(12), 4531; https://doi.org/10.3390/jcm15124531 - 11 Jun 2026

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Abstract

Background/Objectives: Pulmonary embolism (PE) remains a major cause of mortality, requiring rapid risk stratification. Widely used clinical tools such as the simplified Pulmonary Embolism Severity Index (sPESI) may not fully capture the disease’s inflammatory burden. This study aimed to evaluate the prognostic value of multiple inflammatory indices and to develop a clinically applicable nomogram integrating these indices with sPESI for mortality prediction in acute PE. Methods: This multicenter retrospective cohort study included 338 patients with acute PE. Ten inflammatory indices were calculated from admission laboratory data. The primary outcome was 12-month all-cause mortality; secondary outcomes were 30-day and 90-day mortality. Receiver operating characteristic analysis, multivariable Cox regression, and person-time analysis were performed. A composite inflammatory risk score (0–10) was developed, and a nomogram combining this score with sPESI was constructed. Internal validation used 1000 bootstrap resamples. Results: Overall mortality was 44.1%, with 41% of deaths occurring in the first 12 months. The red cell distribution width-to-albumin ratio (RAR) showed the highest discriminative performance (AUC = 0.755, 95% CI: 0.704–0.806). Each 1-point increase in the inflammatory risk score was independently associated with increased 30-day mortality (HR: 1.21, 95% CI: 1.10–1.34) and 90-day mortality (HR: 1.25, 95% CI: 1.15–1.36). The nomogram improved risk classification, particularly in patients with intermediate sPESI scores (1–2). The combined model achieved an AUC of 0.806 (95% CI: 0.761–0.851), with good calibration (Hosmer–Lemeshow p = 0.342). Platelet-to-lymphocyte ratio (PLR) did not show significant prognostic value. Conclusions: RAR is a strong, independent predictor of mortality in acute PE, providing incremental prognostic value beyond sPESI. The integrated nomogram enables more precise risk stratification and offers a practical, low-cost tool for bedside use. Full article

(This article belongs to the Special Issue Advancements in Emergency Medicine Practices and Protocols)

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19 pages, 2496 KB

Open AccessArticle

Emergency Department Prediction of In-Hospital Mortality in Suspected Pulmonary Embolism: An Explainable Machine Learning Approach

by Meliha Fındık, Tufan Alatlı, Salih Kocaoğlu, Yeltuğ Esra Gelen and Rahime Sema Taş

J. Clin. Med. 2026, 15(4), 1340; https://doi.org/10.3390/jcm15041340 - 8 Feb 2026

Viewed by 793

Abstract

Background: Pulmonary embolism (PE) is a significant cause of cardiovascular mortality, and emergency department (ED) management requires early risk assessment to guide monitoring and disposition. Because key decisions are often needed while diagnostic evaluation is ongoing, the simplified Pulmonary Embolism Severity Index (sPESI) may provide limited discrimination for in-hospital outcomes. We evaluated whether explainable machine-learning (ML) models integrating routine ED variables with validated risk scores can predict in-hospital mortality in adults evaluated for suspected acute PE. Methods: A retrospective single-center cohort study was performed, including 220 consecutive adults evaluated for suspected acute PE in the ED between January 2021 and March 2025, comprising both PE-confirmed and PE-excluded cases. Predictors included demographics, vital signs, arterial blood gas indices, available imaging/echocardiographic findings, and Wells, Revised Geneva, and sPESI scores. Seven ML algorithms were trained and internally evaluated using the area under the receiver operating characteristic curve (AUC) and complementary metrics. Model interpretability was assessed using SHAP (SHAPley Additive exPlanations), and a sensitivity analysis was conducted in the PE-confirmed subgroup. Results: Tree-based ensemble models demonstrated higher discrimination for in-hospital all-cause mortality than simpler classifiers. SHAP analyses consistently highlighted sPESI, oxygenation/arterial blood gas indices, and malignancy as key contributors to mortality risk. Findings were similar in the PE-confirmed sensitivity analysis. Conclusions: Explainable ML models combining established risk scores with routinely collected ED variables may complement risk stratification along the suspected-PE pathway. External multicenter validation and prospective impact studies are warranted before clinical implementation. Full article

(This article belongs to the Special Issue Advancements in Emergency Medicine Practices and Protocols)

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13 pages, 216 KB

Open AccessArticle

Content Validity Assessment of a Newly Developed Emergency Medical Dispatch and Triage Protocol in Thailand

by Thongpitak Huabbangyang, Duangpon Thepmanee, Phudit Buaprasert, Pit Chansomboon, Jiraporn Sri-on and Rapeeporn Rojsaengroeng

J. Clin. Med. 2025, 14(19), 7125; https://doi.org/10.3390/jcm14197125 - 9 Oct 2025

Cited by 1 | Viewed by 1646

Abstract

Background/Objectives: Accurate telephone triage of emergency medical cases plays a crucial role in improving outcomes for critically ill patients. Effective triage enables emergency medical dispatchers to provide appropriate pre-arrival instructions and to deploy operational units according to the patient’s severity level. This study aimed to develop and assess the content validity of the Emergency Medical Triage Protocol and Criteria-Based Dispatch Code (EMTP-CBDC) for Thailand. The objective was to ensure the tool’s content accuracy and applicability in prioritizing emergency responses in line with medical urgency, considering global changes and universal standards. Methods: A cross-sectional descriptive study was conducted from 15–30 April 2024. The content validity of the newly developed EMTP-CBDC, comprising 30 symptom groups, was evaluated by five emergency physician experts with at least 1 year of experience in emergency medical oversight. The assessment focused on four aspects: relevance, clarity, simplicity, and ambiguity. The Content Validity Index (CVI) was calculated at both the item level (I-CVI) and the scale level using the average index (S-CVI/Ave). To adjust for chance agreement, the probability of chance agreement (Pc) and the modified kappa coefficient (k*) were calculated for each item. Results: The content validation revealed I-CVI values ranging from 0.80 to 1.00 across all items. The S-CVI/Ave scores were 0.97 for relevance, 0.93 for clarity, 0.98 for simplicity, and 0.94 for ambiguity. These values surpassed the accepted thresholds for content validity. Conclusions: The EMTP-CBDC developed for Thailand demonstrated good content validity across relevance, clarity, simplicity, and ambiguity. Further studies are needed to establish its reliability and field performance before routine implementation. Full article

(This article belongs to the Special Issue Advancements in Emergency Medicine Practices and Protocols)

9 pages, 218 KB

Open AccessArticle

Comparison of the Kynurenine/Tryptophan Ratio with the Beck Suicide Intent Scale in Patients Admitted to the Emergency Department Due to Suicide Attempt

by Osman Lütfi Demirci, Emin Fatih Vişneci, Demet Acar, Ümmügülsüm Can, Fatih Cemal Tekin, Mehmet Gül and Berke Yıldırım

J. Clin. Med. 2025, 14(19), 6859; https://doi.org/10.3390/jcm14196859 - 28 Sep 2025

Cited by 2 | Viewed by 1080

Abstract

Objective: Suicide is a major public health problem with multiple biological and psychosocial determinants. Although the kynurenine/tryptophan (KYN/TRP) pathway has been implicated in the neurobiology of suicidal behavior, clinical findings remain inconsistent. This study aimed to evaluate serum tryptophan, kynurenine, and the KYN/TRP ratio in patients presenting to the emergency department after a suicide attempt and to examine their association with suicide risk. Methods: This prospective, cross-sectional, and comparative study was conducted between November 2024 and June 2025 in the Emergency Department of Konya City Hospital. A total of 120 participants were enrolled, including 60 suicide attempt cases and 60 healthy controls. Serum tryptophan and kynurenine levels were measured using the ELISA method, and the KYN/TRP ratio was calculated in molar units. The Beck Suicide Intent Scale (SIS) was administered to the case group. Group comparisons and correlation analyses were performed using appropriate statistical tests, and effect sizes with 95% confidence intervals were reported. Results: Compared with controls, patients showed significantly lower levels of tryptophan (median 35.4 vs. 54.4; p = 0.002), kynurenine (median 1534.5 vs. 2384.0; p < 0.001), and the KYN/TRP ratio (40.9 ± 16.2 vs. 48.8 ± 20.8; p = 0.02). No significant correlations were found between SIS scores and tryptophan (p = 0.180), kynurenine (p = 0.668), or the KYN/TRP ratio (p = 0.246). Subgroup analyses based on psychiatric history or psychiatric consultation recommendations also revealed no significant differences. Conclusions: Serum tryptophan, kynurenine, and the KYN/TRP ratio were significantly reduced in patients with suicide attempts compared to healthy controls. However, these biochemical parameters were not associated with SIS scores. Our findings suggest that tryptophan, kynurenine, and the KYN/TRP ratio may serve as complementary biomarkers but cannot replace clinical and psychometric assessments. Larger, multicenter, and longitudinal studies are needed to clarify their potential clinical value. Full article

(This article belongs to the Special Issue Advancements in Emergency Medicine Practices and Protocols)

11 pages, 478 KB

Open AccessArticle

Peripheral Perfusion Index: An Adjunct for the ED Triage or a Powerful Objective Tool to Predict Patient Outcomes?

by Veysi Siber, Serdal Ateş, Tuba Şafak, Ebru Güney, Aycan Uluçay, Şeyda Gedikaslan, Sinan Özdemir, Muhammed Sezai Bazna, Michal Pruc, Pawel Patrzylas, Lukasz Szarpak, Burak Katipoglu and Ahmet Burak Erdem

J. Clin. Med. 2025, 14(13), 4616; https://doi.org/10.3390/jcm14134616 - 29 Jun 2025

Cited by 4 | Viewed by 2055

Abstract

Background/Objectives: Accurate and timely triage is essential for optimizing clinical outcomes and resource allocation in emergency departments (EDs). The Peripheral Perfusion Index (PPI), a non-invasive and objective parameter derived from pulse oximetry, may offer added value in early risk stratification. This study aimed to analyze the correlation between the PPI measured at triage and at Emergency Severity Index (ESI) levels, as well as to determine if the PPI may function as a predictive tool to facilitate early risk identification before patient disposition. Methods: In this prospective cross-sectional study, adult ambulatory patients presenting to a tertiary care ED were enrolled. At triage, PPI and standard vital signs were recorded, and patients were classified using the five-level ESI system. The diagnostic performance of PPI and ESI in predicting ED discharge was assessed using receiver operating characteristic (ROC) curve analysis, with comparative evaluation performed via DeLong’s test. Results: Lower PPI values were consistently associated with higher ESI acuity levels and more intensive care requirements. Patients who were discharged had significantly higher median PPI values (4.0) compared to those admitted to wards (2.1) or intensive care units (1.9). PPI also distinguished survivors from non-survivors (median PPI: 3.60 vs. 1.15). ROC analysis showed that the PPI demonstrated a good discriminative capacity for forecasting ED discharge, equal to the efficacy of ESI (AUC: 0.926 vs. 0.903; p < 0.001). Conclusions: The PPI could improve post-triage risk classification and enhance current triage techniques like ESI, especially in cases of unclear or borderline presentations, but further validation in prospective trials is required. Full article

(This article belongs to the Special Issue Advancements in Emergency Medicine Practices and Protocols)

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7 pages, 178 KB

Open AccessBrief Report

Ultrasound-Guided Pigtail Catheter Drainage of Pleural Effusion in the Emergency Department: Effectiveness, Safety, and Clinical Implications

by Aleksandra Szymczyk, Dominik Płaza and Mariusz Siemiński

J. Clin. Med. 2025, 14(16), 5704; https://doi.org/10.3390/jcm14165704 - 12 Aug 2025

Cited by 1 | Viewed by 2387

Abstract

Background: Pleural effusion is a common clinical condition encountered in emergency departments and often requires timely therapeutic intervention. This study aimed to assess the effectiveness and safety of ultrasound-guided pigtail catheter drainage in patients presenting with symptomatic pleural effusion. Methods: We conducted a retrospective analysis of 134 drainage procedures performed in a tertiary hospital emergency department in 2024. Adult patients who underwent ultrasound-guided drainage were included regardless of primary diagnosis. Results: Clinical improvement was observed in 86.6% of patients, while radiological improvement—assessed only in cases with complete follow-up imaging—was seen in 56.0%. Procedure-related complications were rare (3.7%), and 50% of patients were discharged directly from the emergency department, highlighting the feasibility of ambulatory management. Nearly half of the patients had underlying malignancy and were receiving palliative care. Conclusions: While indwelling pleural catheters (IPCs) are typically used in long-term outpatient settings, our study focused on temporary pigtail catheter drainage performed in-hospital as a symptom-relieving intervention. The findings align with previous studies supporting the safety and effectiveness of small-bore catheter use in this context. Ultrasound-guided pigtail drainage represents a low-risk, patient-centered approach that can reduce the burden on inpatient services and enhance quality of care for individuals with advanced disease. This method may be considered a first-line option in selected patients presenting with large or symptomatic pleural effusions in acute care settings Full article

(This article belongs to the Special Issue Advancements in Emergency Medicine Practices and Protocols)

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