Artificial intelligence (AI) has the potential to revolutionise healthcare delivery, particularly in the domain of emergency medicine. With the rise of telemedicine and virtual care, AI-powered tools could assist in triage, diagnosis and treatment recommendations for patients seeking emergency care remotely. This systematic review aims to synthesise the current state of research on AI applications in virtual emergency care, identify key challenges and opportunities and provide recommendations for future research and implementation.

We will conduct a comprehensive search of multiple electronic databases (PubMed, Web of Science, Embase, CINAHL, MEDLINE, The Cochrane Library, Scopus) from each database’s inception to March 2025. The search will include terms related to AI, machine learning, deep learning, virtual care, telemedicine and emergency medicine. We will include original research articles, conference proceedings and preprints that describe the development, validation or implementation of AI models for virtual emergency care. Two reviewers will independently screen titles and abstracts, review full texts, extract data and assess risk of bias using the PROBAST (Prediction model Risk Of Bias ASsessment Tool) tool for prediction model studies, Cochrane Risk-of-Bias tool for randomised trials for randomised trials and Risk Of Bias In Non-randomised Studies of Interventions for non-randomised studies. Data synthesis will involve a narrative review of included studies, summarising key findings, methodological approaches and implications for practice and research. The results will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

No ethical approval is required for this systematic review as it will use only published data. The findings will be disseminated through publication in a peer-reviewed journal, presentations at relevant conferences and engagement with clinicians, health system leaders, policymakers and researchers. This review will provide a timely and comprehensive overview of the applications of AI in virtual emergency care to inform evidence-based guidelines, policies and practices for leveraging these technologies to enhance access, quality and efficiency of emergency care delivery.

CRD42025648202.

To predict the outcome of patients with traumatic brain injury (TBI) using the optic nerve sheath diameter (ONSD) and the central venous minus arterial CO₂ pressure to arterial minus central venous O₂ content ratio (Pcv-aCO₂/Ca-cvO₂) in prehospital settings.

A prospective cohort study was conducted in China.

The study was conducted from October 2023 to October 2024, enrolling patients diagnosed with TBI. Participants presenting a Glasgow Coma Scale (GCS) 2/Ca-cvO₂: Group A Pcv-aCO₂/Ca-cvO₂ >1.8 mm Hg/mL and ONSD >5.6 mm; Group B: Pcv-aCO₂/Ca-cvO₂ >1.8 mm Hg/mL and ONSD ≤5.6 mm; Group C: Pcv-aCO₂/Ca-cvO₂ ≤1.8 mm Hg/mL and ONSD >5.6 mm; and Group D: Pcv-aCO₂/Ca-cvO₂ ≤1.8 mm Hg/mL and ONSD ≤5.6 mm.

30-day mortality, functional neurological recovery at discharge (measured by Glasgow Outcome Scale (GOS)), and length of intensive care unit (ICU) stay were compared between the 4 groups.

Our findings show that Group D had the lowest 30-day mortality, the shortest ICU stay and the highest good recovery at discharge (GOS score) among the four groups. Survival curves illustrated a decrease in 30-day mortality in group C patients after mannitol administration compared with patients who did not receive mannitol administration. The area under the receiver operating characteristic curve for Pcv-aCO₂/Ca-cvO₂ combined with ONSD (0.907 (95% CI 0.843 to 0.941)) was higher than those for ONSD (0.851 (95% CI 0.791 to 0.911)) alone, Pcv-aCO₂/Ca-cvO₂ (0.814 (95% CI 0.744 to 0.873)) alone or initial GCS (0.823 (95% CI 0.763 to 0.889)). Calibration plots demonstrated a strong alignment between observed and predicted probabilities for ONSD, Pcv-aCO₂/Ca-cvO₂, the combination of ONSD and Pcv-aCO₂/Ca-cvO₂, and initial GCS.

ONSD combined with Pcv-aCO₂/Ca-cvO₂ is a relatively novel method for predicting the outcome in TBI patients, especially in a prehospital setting. This dual approach may improve the prediction of early prognosis and guide osmotherapy treatment in patients with TBI.

Fractures over venous sinuses (FOVSs) are associated with difficulties in diagnosis and treatment resulting in a high level of morbidity and mortality. Despite its importance, there are limited aggregate data to guide the management of these fractures ultimately inflicting a major callenge to neurosurgeons. This protocol describes the methodology of a scoping review that aims to synthesise contemporary evidence on the management and outcomes of FOVSs.

The proposed study will be conducted in accordance with the Arksey and O’Malley’s framework for scoping reviews. The research question, eligibility criteria and search strategy were developed based on the population, intervention, comparator and outcome strategy. The following electronic bibliographic databases will be searched without restrictions on language and date of publication: PubMed, WHO Global Index Medicus, African Journals Online, SCOPUS, Embase, Cochrane and ProQuest Central. All peer-reviewed studies of primary data reporting on the management and outcomes of FOVSs will be included. The data extracted from included articles will be presented through descriptive statistics, pooled statistics and a narrative description.

Because this study did not directly involve human individuals, ethical approval was not necessary. Dissemination strategies will include publication in a peer-reviewed journal, oral and poster presentations at local, regional, national and international conferences and promotion over social media.

Accidental hypothermia (AH) can occur in mild-to-severe cases; however, its management is crucial in severe cases as it can cause ventricular fibrillation and lead to death. Among various rewarming therapies for AH, endovascular catheter rewarming has been the focus of recent studies as a minimally invasive alternative to invasive internal rewarming, such as extracorporeal membrane oxygenation (ECMO). However, no study has demonstrated the efficacy and safety of endovascular catheter rewarming therapy. This study aimed to validate the efficacy and safety of endovascular catheter rewarming for patients with AH.

The intensive care with endovascular catheter rewarming in accidental severe hypothermia (ICE-CRASH II) study is a multicentre, randomised study of patients with AH. This study will include patients with AH (age ≥65 years, core temperature

This study was approved by the Hokkaido University Certified Review Board (approval number: 024-00013). Written informed consent will be obtained from all the participants or their legally acceptable representatives. The results will be disseminated through publications and presentations.

Japan Registry of Clinical Trials (jRCT1012240051).

Medical oxygen supplementation is essential for treating severe illnesses and plays a critical role in managing life-threatening conditions, especially during the period of increased demand, such as the delta wave of COVID-19. The study aims to evaluate oxygen requirements and production to support effective capacity planning for future health crises.

Cross-sectional quantitative study. Data collection was carried out between 15 March and 19 December 2021.

The study used secondary data from Nepal’s Health Emergency Operation Centre. Regarding medical oxygen production, calculations included oxygen generated from both hospital-based oxygen plants and private companies, using their highest capacities for comparison. These production capacities were then assessed using three levels of efficiency (100%, 80% and 50%), revealing significant gaps when compared against the oxygen requirements of hospitalised COVID-19 patients, as guided by WHO recommendations. The results were communicated in terms of J-size cylinders, alongside average daily COVID-19 hospitalizations. Data was inputted and analysed using Microsoft Excel and presented in numbers and percentage.

The country’s oxygen demand relies largely on the production from private enterprises, with meeting approximately 85.2% of the total requirement. Optimal production ensures that national oxygen needs will be met. The analysis highlighted that at 80% operational efficiency, 90.8% of the hospital’s requirements could be fulfilled. However, if operational efficiency drops to 50%, the fulfilment rate diminishes to 56.7%. The differences in requirement and production of oxygen are consistent across the provinces; however, a huge disparity was notable in Karnali and Sudurpaschim.

Continuous assessment of production capacities in both hospital and private enterprises producing oxygen is necessary to plan and address the gaps.

The emergency department (ED) often serves as a crucial pathway for cancer diagnosis. However, little is known about the management of patients with new suspected cancer diagnoses in the ED. The objective of this study was to explore emergency physicians’ experiences in managing patients with a newly suspected cancer diagnosis in the ED.

Between January and April 2024, we conducted a qualitative descriptive study. Interviews were conducted by trained research personnel using a semistructured interview guide. Interviews were conducted until thematic saturation was achieved. The interview transcripts were coded and thematic analysis was used to uncover key themes.

Emergency physicians practising in Ontario, Canada.

20 emergency physicians were interviewed. Four themes around the management of patients with new suspected cancer diagnoses in the ED were identified: (1) healthcare system-level factors that impact suspected cancer diagnosis through the ED, (2) institutional and provider-level challenges associated with managing patients with a suspected cancer diagnosis in the ED, (3) patient-level characteristics and experiences of receiving a cancer diagnosis in the ED and (4) the need for care coordination for patients with suspected cancer in the ED.

Physicians experienced several unique challenges in managing patients with a suspected cancer diagnosis in the ED. Overall, the findings of this study suggest these challenges often make the ED a difficult environment in which to deliver a suspected cancer diagnosis.

Dyspnea is a common chief complaint leading to emergency department (ED) visits. Multiple conditions may cause or be associated with dyspnoea, including bacterial pneumonia, acute heart failure (AHF), exacerbation of chronic obstructive pulmonary disease (COPD) or asthma and pulmonary embolism. Each of these diagnoses has a specific treatment recommended by international guidelines. Inappropriate treatment in the ED is more frequent among elderly patients and is independently associated with in-hospital mortality. Point-of-care ultrasound is immediately available at the bedside. Lung and cardiac ultrasound (LuCUS) offers excellent diagnostic accuracy for bacterial pneumonia, AHF and COPD exacerbations, even in elderly patients. The primary objective of the LUC REED trial is to evaluate the impact of a LuCUS-guided strategy versus standard care on reducing inappropriate treatment of dyspnoea in elderly ED patients.

The LUC REED trial is a prospective, interventional, multicentre, stepped-wedge randomised controlled trial designed to assess the superiority of a LuCUS-guided strategy over standard care in ensuring treatment appropriateness for dyspnoea in elderly ED patients. The study will include 504 patients over 2 years. Patients aged >65 years presenting with acute dyspnoea and signs of severity (respiratory rate ≥22 or SpO₂

Ethics final approval was obtained from the Institutional Review Board of France—Est IV on 4 April 2025 (2024-A01678-39). Results will be published in peer-reviewed international journals.

NCT06807983.

Injury is a major cause of death in Rwanda, with many deaths occurring before hospital admission. Timely transport of injured patients to appropriate hospitals is crucial, ideally within an hour for severely injured patients. However, delays in reaching treatment facilities are common, with ambulance services using inefficient mobile phone communication. This project aims to evaluate the effectiveness and implementation of an innovative electronic communication platform (912Rwanda).

The study will be conducted through the public ambulance service, Service d’Aide Médicale d’Urgence (SAMU), and receiving health facilities in Kigali city and Musanze district in Rwanda. The 912Rwanda intervention will be rolled out in the two locations at different times. The primary effectiveness outcome is the time from ambulance deployment to patient arrival at the health facility. Secondary effectiveness outcomes include disaggregated times of the primary outcome and clinical outcomes, such as length of stay and requirement for intensive care. These outcomes will be evaluated using an interrupted time series analysis, accounting for non-homogeneous variances, auto-regressive errors and non-linear trends where appropriate. Implementation outcomes will be evaluated using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) Qualitative Evaluation for Systematic Translation (QuEST) framework. Cost-effectiveness will be evaluated using a cost-consequence analysis with consequences as determined by the interrupted time series analysis.

Ethical approval was obtained from the Rwanda National Research Ethics Committee (Ref No: 99/RNEC/2023). Dissemination will occur through open-access peer-reviewed publications, relevant national and international conferences.

ISRCTN97674565.

Challenges within prehospital emergency care (PEC) have significant implications for the provision of emergency department (ED) care. However, ED overcrowding is a prevalent issue with negative impacts on patient outcomes. It can be attributed to multiple factors, such as non-emergency attendances, inaccessible alternative care service pathways (ACSPs) and inefficiencies in emergency medical service operations. ED overcrowding has prompted healthcare systems worldwide to implement interventions. These include tele-triaging, virtual ED and non-conveyance protocols that primarily aim to reduce demand for ED care and increase the supply of alternative services. However, despite such efforts, there remain unaddressed limitations that prevent PEC interventions from being successfully implemented. Moreover, prior studies and reviews have found mixed results, and that ED overcrowding interventions remain underused. Therefore, there is a need for this qualitative systematic review and meta-synthesis to capture the complexities of implementation challenges and identify enablers required to complement PEC interventions.

This systematic review and meta-synthesis aims to offer a consolidated overview of PEC interventions intended to reduce ED overcrowding. It focuses on presenting international perspectives on the current challenges these interventions face. The enablers presented in this review could also better inform the actions taken by healthcare systems aiming to implement similar interventions.

A comprehensive search of PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature Complete, PsycINFO, Web of Science and Scopus was conducted to obtain a set of qualitative studies. Following a quality appraisal with the Critical Appraisal Skills Programme tool, data from the included studies were extracted and meta-synthesised.

A final 21 qualitative intervention-based studies were included. Through these studies, four themes were identified: (1) types of PEC interventions to alleviate ED demands and right-site patients, (2) perceived benefits of interventions, (3) challenges in implementing interventions and (4) key enablers for successful implementation of interventions. Our results describe key factors such as the importance of ACSPs and support for PEC healthcare workers in the form of standardised guidelines, as well as education and training.

We further discuss how enablers can integrate into current PEC systems to complement the interventions explored. Discussions are concentrated on several key interventions (tele-triaging, virtual ED and non-conveyance protocols) as they were perceived to hold significant potential in addressing PEC challenges and could be further elevated through various enablers. Overall, we could conclude that each intervention needs to be complemented by enablers to optimise its benefits.

Sepsis-induced coagulopathy (SIC) is an early-stage coagulation disorder associated with increased morbidity and mortality in sepsis. It reflects a dysregulated host response and is considered a precursor to disseminated intravascular coagulation and multi-organ failure. Currently, there is no specific treatment for SIC beyond supportive care. Transcutaneous auricular vagus nerve stimulation (taVNS) is a non-invasive neuromodulation technique that has shown potential in regulating inflammation and coagulation pathways. This study aims to evaluate the efficacy and safety of taVNS in improving coagulation dysfunction in patients with SIC, with the primary outcome being the proportion of patients achieving a ≥2-point improvement in SIC score by day 7.

This is a single-centre, randomised, sham-controlled, single-blind clinical trial designed to evaluate the efficacy of taVNS in patients with SIC. This study will enrol 184 adult patients who meet the diagnostic criteria for SIC. Participants will be randomly assigned in a 1:1 ratio to receive either active taVNS or sham stimulation for 7 consecutive days. The intervention will be applied twice daily for 7 consecutive days using standardised stimulation parameters (25 Hz, 3 mA, 60 min/session). The primary outcome is the proportion of patients achieving an improvement of ≥2 points in SIC score from baseline to day 7. Secondary outcomes include platelet count, international normalised ratio, activated partial thromboplastin time, D-dimer, fibrinogen, procalcitonin, C-reactive protein, interleukin-6, angiopoietin-2, systemic immune-inflammation index, lactic acid, duration of antibiotic therapy, length of hospital stay and 28-day all-cause mortality. Adverse events and protocol adherence will also be recorded. Data will be analysed using intention-to-treat principles. Between-group comparisons for the primary outcome will be performed using X² tests. Repeated measures analysis of variance will be used for longitudinal secondary outcomes.

The study protocol has been approved by the Ethics Committee of Yancheng Third People’s Hospital (approval No. 2023-058-01). The trial has been registered in the Chinese Clinical Trial Registry (ChiCTR2400082378). Findings will be disseminated through peer-reviewed publications and academic conferences.

ChiCTR2400082378.

Dyspnoea frequently leads to admissions in the Emergency Department (ED). Rapid and accurate diagnosis, specifically to distinguish acute heart failure from pneumonia and exacerbations of chronic obstructive pulmonary disease (COPD), is imperative to initiate appropriate therapy. This study aims to evaluate the feasibility and performance of the EMERgency ALgorithm efficiency for Dyspneic patient-UltraSound (EMERALD-US) algorithm using ultrasound (US) to diagnose the etiology of dyspnea in the ED-admitted patients.

225 patients of 50 years and above, presenting with acute non-traumatic dyspnoea, across six participating EDs will be enrolled. Patients will undergo a lung, a simplified four-chamber cardiac and a venous US. A physician, blinded to any clinical data or previous results, will execute the algorithm. The algorithm’s performance will be assessed using a receiver operating characteristic (ROC) curve. Secondary objectives include an evaluation of the protocol’s feasibility in the ED, an assessment of the concordance between the EMERALD-US algorithm diagnoses and results from other diagnostic tests (including laboratory work and imaging), as well as an evaluation of the algorithm’s performance in diagnosing other causes of dyspnoea, such as pulmonary embolism or pleural effusion, and the 30-day mortality rate.

The study protocol was approved by the French Committee for the Protection of Persons (CPP) (RCB n°2018-A02136-49). Misdiagnosis of dyspneic patients on ED admission has been associated with inappropriate treatment, prolonged hospital stays and increased mortality, particularly among elderly patients. The implementation of protocols like the EMERALD-US algorithm can help physicians in expedited decision-making and diagnosis without increasing ED visit durations.

NCT03691857.

The hospital-at-home (HaH) model has gained traction as a viable alternative to traditional inpatient care, allowing patients to receive care in their own homes. Despite its growing popularity, there is a lack of comprehensive research addressing effectiveness, safety and factors critical to the successful implementation of HaH programmes. We conducted a scoping review to comprehensively map and summarise the evidence on both admission avoidance and early-supported discharge up until now.

A scoping review of randomised controlled trials (RCTs), conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis: extension for Scoping Reviews (PRISMA-ScR) guidelines.

Ovid MEDLINE, Embase, CINAHL and Web of Science were systematically searched up to July 2024

We included English-language RCTs published from 2005 onwards, involving adults (≥18 years) receiving acute care at home who would otherwise require hospital admission. Eligible studies evaluated admission avoidance or early supported discharge within HaH settings for acutely ill patients. Studies focusing on outpatient care, non-acute conditions or interventions not aligning with the widely accepted HaH definition were excluded. COVID-19-related studies were also excluded to avoid context-specific bias.

Two reviewers independently extracted data on study characteristics, interventions and outcomes including mortality, length of stay, escalation rates, costs and patient and caregiver satisfaction. Implementation facilitators and barriers were also collected. Discrepancies were resolved by a third reviewer. Results were synthesised descriptively in accordance with PRISMA-ScR guidelines.

Nine RCTs were identified. The review shows that the HaH model is at least as safe as usual care, with lower or comparable mortality rates. Length of stay varied, with some studies reporting longer stays in the HaH group due to cautious clinical practices. Cost analyses often indicate lower healthcare costs with staffing as the largest expense. Patient and caregiver satisfaction was high, but essential implementation factors were not clearly addressed.

The HaH model represents a promising alternative to acute inpatient care for suitable patients. Future research should focus on conducting larger RCTs, expanding the range of conditions suitable for HaH. Despite favourable clinical outcomes, substantial implementation barriers remain underexplored in current RCTs. This underscores the need to identify strategies for successful implementation, including the integration of technological advancements and qualitative insights into patient and caregiver experiences.

Tetanus is associated with very high mortality, but there is currently no consensus on the mortality and risk factors for hospitalised adult patients with tetanus. Therefore, we conducted this systematic review and meta-analysis to explore the mortality and associated risk factors in hospitalised adult patients with tetanus.

Systematic review and meta-analysis.

PubMed, Web of Science, The Cochrane Library and Embase, covering the period from 1 January 2000 to 5 February 2024.

Observational studies with a focus on the mortality and associated risk factors in hospitalised adult patients with tetanus.

Two researchers independently reviewed the studies and extracted the data. The pooled effect sizes for mortality and the total number of hospitalised patients with tetanus were calculated, along with the overall pooled mortality and corresponding 95% CI. Risk factors for mortality were determined using relative risk (RR) and 95% CI. The I² statistic was calculated to describe heterogeneity between studies. Additionally, subgroup and meta-regression analyses were carried out to further explore potential sources of heterogeneity. All statistical analyses were conducted via StataSE V.15.0.

A total of 22 studies were included, comprising 1618 hospitalised adult patients with tetanus. The overall mortality among hospitalised adult patients with tetanus was 32.0% (95% CI: 27.1% to 37.0%). Six risk factors associated with mortality in these patients were identified, including age ≥40 years (RR=1.89, 95% CI: 1.37 to 2.61), incubation period

The study findings have important implications for clinical practice and public health policy. The high mortality underscored the urgent need to strengthen tetanus prevention strategies, particularly by increasing vaccination coverage and enhancing wound care education in adults aged ≥40 years. The six identified mortality risk factors provided a framework for early risk stratification and targeted interventions in hospitalised patients with tetanus. Meanwhile, more well-designed, large-scale studies are needed for further validation and exploration.

CRD42024533554.

International consensus guidelines support the initial administration of 30 mL/kg of intravenous fluids for haemodynamic resuscitation of newly diagnosed septic shock. Practice variation exists between the volume of fluids administered and timing of vasopressor commencement. The optimal approach in patients with septic shock is uncertain.

Australasian Resuscitation In Sepsis Evaluation: FLUid or vasopressors In emergency Department Sepsis is a 1000-participant multicentre, randomised, open-label, parallel group clinical trial conducted in patients with septic shock presenting to the emergency department in participating sites in Australia, New Zealand and Ireland. Participants are randomised (1:1) to either restricted fluids and early vasopressors or a larger initial intravenous fluid volume and later vasopressors. The primary outcome is days alive and out of hospital at day 90 postrandomisation. Secondary outcomes are all-cause mortality at day 90, time from randomisation until death (to day 90), days alive and at home at day 90 and ventilator-free, vasopressor-free and renal replacement-free days to day 28 postrandomisation and death or disability at 6-month and 12-month postrandomisation. Health-related quality of life will be assessed at day 180 and 12 months following randomisation.

The study was approved by Northern Sydney Local Health District Human Research Ethics Committee (HREC2020/ETH02874) on 21 January 2021. Patients will be enrolled under a waiver of prior consent. The patient or next-of-kin (or equivalent according to local jurisdiction) is approached at the first available opportunity and given a trial information sheet. According to local approvals, the patient or next-of-kin chooses to either continue in the trial or opt-out/decline continued participation. Results will be disseminated in peer-reviewed journals and presented at academic conferences.

NCT04569942

Patients with total hip arthroplasties and hemiarthroplasties are both subject to hip dislocations. Although the incidence of complications differs, both patient groups suffer immediate high pain and need acute treatment. The purpose of this study is to design a fast-track pathway for patients with a dislocated hip prosthesis primarily to reduce the time from arrival to reduction and the total hospitalisation time. The secondary aim is to investigate whether quicker prosthesis reduction influences subsequent hip function and quality of life, reduces pain experience immediately and in the long term, and increases patient satisfaction.

This is a prospective observational cohort study, initiated on 1 December 2024 and continuing for 2 years. During the first year, patients admitted to the University Hospital of Southern Denmark, Esbjerg, will follow the current standard treatment pathway. After 1 December 2025, a newly developed treatment pathway (fast-track) will be adhered to. Based on a sample size calculation, 120 patients will be included. The main clinical outcomes (time to reduction (primary outcome), total hospitalisation) are registered from patient files. The patients are followed up for 1 year to measure patient-reported outcomes.

The study is conducted as a treatment quality study and is locally approved by the Executive Board at the University Hospital of Southern Denmark. The results will be published in relevant national and/or international journals and presented at relevant congresses.

NCT06639334.

Transporting critically ill patients between medical facilities can be hazardous and costly. Whether by road, fixed-wing aircraft or helicopter, many professional associations have proposed strategies to efficiently and safely transport patients at high risk of instability. Although these strategies have been assessed in some studies, no comprehensive synthesis of their benefits has been conducted to date. The aim of this study is to assess the effect of strategies to improve the safety and costs of interhospital transports for critically ill patients.

We will conduct a systematic review according to the Cochrane guidelines. The review will include randomised controlled trials (RCTs), cohort studies and case-control studies assessing the effect of interventions to improve interhospital transports of critically ill patients on safety and costs. We will search multiple electronic databases (PubMed, EMBASE, CINAHL, Web of Science, Cochrane Library) from inception to 6 months prior to the submission of the final manuscript. Screening by title and abstract, full-text screening, data extraction and quality assessment will be performed by two independent reviewers. We will assess the risk of bias with the Cochrane revised tool for RCTs and with the risk of bias in non-randomised studies of interventions tool. If possible, we will calculate pooled effect estimates and 95% CIs to assess the effect of the interventions. We will also assess heterogeneity using the I² index and rate the certainty of evidence with the Grading of Recommendations Assessment, Development and Evaluation tool and trial sequential analysis.

Ethics approval is not required for this review. The results of this systematic review will be shared through publication in a peer-reviewed journal, conference presentations and our network of knowledge user collaborators.

International Prospective Register of Systematic Reviews (CRD42024595080).

Delays in getting injured patients to the hospital in a timely manner can increase avoidable death and disability. Like many low-income or middle-income countries, Rwanda experiences delays related to a lack of efficient prehospital communication and formal guidelines to triage patients for hospital care. This study describes the protocol to develop, roll-out and evaluate the effectiveness of a destination decision support algorithm (DDSA) integrated in an electronic communication platform, ‘912Rwanda’. The DDSA will facilitate the linkage of patients to health facilities able to treat their condition(s).

Work will be conducted in the prehospital emergency service ‘Service d'Aide Médicale Urgente’ and health facilities in Kigali city and Musanze district, which serve predominantly urban and rural populations, respectively. We will develop interfaces to capture facility and patient-relevant data, which feed into a guideline-based electronic DDSA to match patients to hospitals. We will assess existing trauma care processes using qualitative and quantitative methodologies. This will be followed by a series of consensus workshops to develop at-scene triage guidelines and agree on variables to capture in the interfaces. The DDSA will be developed based on outputs from these workshops and will be tested against historical ambulance data and expert opinion until acceptable thresholds of performance are achieved. User interfaces will be developed and tested using human–computer interface design principles.

The combined collaborative approach of bringing together experts and software developers, and with deep engagement of Rwandan stakeholders, including leadership of Rwanda Ministry of Health through its technical arm, Rwanda Biomedical Center, should lead to an ambulance communication system which is used, sustained and effective.

The project was approved by the Rwanda National Research Ethics Committee. Annual reports will be disseminated to relevant stakeholders, followed by the public. Publications will be open access as per the funding policy.

ISRCTN97674565. Registered on 29 July 2024. https://doi.org/10.1186/ISRCTN97674565.

Amoxicillin-clavulanate is commonly used to prevent infections following snakebites despite the lack of clinical evidence. We aimed to demonstrate that clinically directed initiation of amoxicillin-clavulanate would be non-inferior to routine use in this setting.

Open-label, randomised, non-inferiority trial with blinded adjudication of endpoints.

Emergency department of a teaching hospital in southern India.

Adults with local swelling following snakebites within 24 hours of bite.

In the routine use strategy, intravenous followed by oral amoxicillin-clavulanate was administered for at least 5 days. In the clinically directed strategy, the antibiotic was only initiated for clinical failures.

Primary outcomes were protocol-defined clinical failure and total antibiotic consumption. Non-inferiority margin was prespecified as 10%. Secondary outcomes were the length of hospital stay, total antivenom consumption, new-onset organ failure, bleeding requiring transfusion, death/need for surgical intervention and drug-related adverse events.

The trial was prematurely stopped due to the COVID-19 situation after randomising 66 patients—34 to clinically directed initiation and 32 to routine use arms. Russell’s viper was the most common (21 (32%)) biting snake species identified; 52 (79%) patients had evidence of haemotoxic envenomation at baseline, and 24 (36%) patients developed AKI. There were 10 clinical failures—six in the clinically directed initiation arm and four in the routine use arm. The difference in clinical failure between the two arms was 5.2% (–12.0%–21.7%; p=0.291); the upper bound of the CI exceeded the prespecified non-inferiority margin. Total antibiotic consumption, expressed in DDDs, was significantly lower in the clinically directed initiation arm (0 (0–1) vs 5.31 (4.67–6.17); p

We could not demonstrate the non-inferiority of clinically directed initiation compared with routine use of amoxicillin-clavulanate among patients with local swelling caused by haemotoxic snakebites. However, the frequency of clinical failures was similar, and antibiotic consumption was substantially lower with the clinically directed initiation strategy.

ClinicalTrials.gov; NCT02570347.

Unplanned pneumonia readmissions increase patient morbidity, mortality and healthcare costs. Among pneumonia patients, the middle-aged and elderly (≥45 years old) have a significantly higher risk of readmission compared with the young. Given that the 14-day readmission rate is considered a healthcare quality indicator, this study is the first to develop survival machine learning (ML) models using emergency department (ED) data to predict 14-day readmission risk following pneumonia-related admissions.

A retrospective multicentre cohort study.

This study used the Taipei Medical University Clinical Research Database, including data from patients at three affiliated hospitals.

11 989 hospital admissions for pneumonia among patients aged ≥45 years admitted from 2014 to 2021.

The dataset was randomly split into training (80%), validation (10%) and independent test (10%) sets. Input features included demographics, comorbidities, clinical events, vital signs, laboratory results and medical interventions. Four survival ML models—CoxNet, Survival Tree, Gradient Boosting Survival Analysis and Random Survival Forest—were developed and compared on the validation set. The best performance model was tested on the independent test set.

The RSF model outperformed the other models. Validation on an independent test set confirmed the model’s robustness (C-index=0.710; AUC=0.693). The most important predictive features included creatinine levels, age, haematocrit levels, Charlson Comorbidity Index scores, and haemoglobin levels, with their predictive value changing over time.

The RSF model effectively predicts 14-day readmission risk among pneumonia patients. The ED data-based model allows clinicians to estimate readmission risk before ward admission or discharge from the ED, enabling timely interventions. Accurately predicting short-term readmission risk might also further support physicians in designing the optimal healthcare programme and controlling individual medical status to prevent readmissions.

Despite expert recommendations to prioritise non-invasive and patient-centred approaches for behavioural crisis management, physical restraints are commonly used in the emergency department (ED). Patients describe the restraint process as coercive and dehumanising. The use of peer support workers, who are individuals with lived experience of mental illness and behavioural conditions, has shown positive patient outcomes when assisting individuals experiencing behavioural crises. However, there is limited evidence of the implementation of such an approach in the ED setting. The goal of this study is to evaluate if the implementation of a Peer support enhanced Agitation Crisis response Team (PACT) for behavioural crisis management in the ED is more effective than usual care to reduce restraint use and improve outcomes among patients presenting to the ED with behavioural crises.

We will first conduct a stakeholder-informed needs assessment to codesign the protocol and then train staff and peers in PACT intervention readiness. Next, a stepped-wedge, cluster-randomised controlled trial will be conducted over 3 years at five ED sites across a healthcare system in the Northeast USA. The PACT intervention will integrate peer delivery of trauma-informed care within a structured, interprofessional, team-based response protocol for behavioural crisis management. The primary outcome is the rate of physical restraint and/or sedation use. The secondary outcome is the level of patient agitation during the ED visit. Analyses of primary and secondary outcomes will be conducted using generalised linear mixed models.

This protocol has been approved by the Yale University Human Investigation Committee (protocol number 2000037554). The study is deemed minimal risk and has been granted a waiver of consent for trial participants. However, verbal consent will be obtained for a subset of patients receiving follow-up data collection. Results will be disseminated through publications in open-access, peer-reviewed journals, via scientific presentations, or through direct mail notifications.

Clinicaltrials.gov: NCT06556069.