This presentation will report on medical evacuation challenges involving pediatric specialty hospitals and the capabilities and challenges identified during the October 2022 National Pediatric Disaster Conference Significant Event Readiness Forum (SERF). The event drew pediatric subject matter experts and entities from across the nation to explore opportunities along the disaster response continuum addressing the multi-state and federal capability in the event of a catastrophic earthquake. Over 351 coalition, pediatric, EMS, air-medical state, regional, and national disaster response partners participated in this hybrid event. The purpose of a SERF is to foster information sharing and relationship development with a targeted group of stakeholders who do not always plan together.

The presentation will discuss how a Significant Event Readiness Forum provided a framework for stakeholders to understand command structures and situational awareness on the first responder and private sector level is needed to operationally manage military, and private sector medical transportation staging, triage, and deployment of ground and air transport associated with a no-notice catastrophic event.

In the event of massive infrastructure disruptions, facilities will be faced with decisions to self-evacuate or shelter in place. Prolonged staging will necessitate going “old school,” informed by lessons learned from our colleagues in war and austere settings.

Lessons learned:

1. 1. Facilitated discussions are needed across disciplines and sectors before community planning for pediatrics and other special populations.

2. 2. SERF format results in improved communication and consensus planning across disciplines and private public partnerships.

3. 3. Improvements are needed in developing and testing plans for interoperable interstate communication, coordination, and response.

4. 4. Addressing the “basic” needs of the workforce and community in the first 24 hours for food, water, restrooms, shelter, and emotional support may be one of the most important factors in resilience and recovery.

Regarding pandemics or bioterrorism incidents, prompt and secure distribution of vaccines and prophylactic antibiotics is crucial. Open Points of Dispensing (PODs) are established to serve the public, and their effectiveness depends on the internal spatial layout and operational workflow design. However, studies on systematic classifications of open POD configurations and comprehensive syntheses of strategies for enhancing operational efficiency are lacking.

This scoping review aimed to classify open POD layout types used for vaccine and antibiotic distribution and to consolidate strategies that improve efficiency across various workflow stations.

A scoping review was conducted following the PRISMA-ScR guidelines. A comprehensive literature search was conducted across PubMed, Embase, and Web of Science databases, spanning from January 2001 through July 2025. The search strategy involved incorporating keyword combinations related to “points of dispensing,” “mass vaccination,” “mass prophylaxis,” and specific pathogens such as anthrax, influenza, and COVID-19. Extracted data included the POD layout typologies, process designs, and efficiency metrics. The findings were synthesized using a narrative approach.

Nineteen studies met the inclusion criteria and were analyzed. Vaccine PODs were classified into four primary layouts, namely station-based sequential-flow, cell-based, fixed-seat service, and pop-up PODs. Antibiotic PODs were categorized into two types, namely sequential processing and selective-expedited processing. Each layout exhibited unique operational characteristics, including sequential versus integrated clinical stations (for vaccine PODs) and standard versus expedited dispensing lines (for antibiotic PODs). Efficiency enhancement strategies across workflow stations included task integration, use of digital tools, simplification of documentation, optimization of medication preparation, and staffing adjustments guided by simulation modeling.

This review provides a systematic classification of open POD layouts and summarizes the strategies for improving efficiency across workflow stations. The derived insights offer practical guidance for planning and operating PODs in future public health emergency responses.

The war in Israel, which began on October 7, 2023, posed significant challenges for breastfeeding mothers. Breastfeeding-focused Facebook groups quickly became crucial sources of information and emotional support. Analyzing posts from the first week of the conflict reveals specific concerns and informational needs of breastfeeding mothers in emergencies. This study identifies three central themes, provides insights into their concerns and informational needs, and formulates actionable recommendations for immediate responses during wartime.

This study employs a qualitative research methodology to examine the experiences of breastfeeding mothers within Facebook communities. A reflective thematic analysis was conducted on messages posted on two primary Facebook groups (total of 90.1K members) from the first day of the war (October 7, 2023) throughout the subsequent week.

Three main themes emerged:

Breastfeeding mothers reported severe stress and anxiety, fearing these emotions might affect their infants through breastfeeding. They sought information on anxiety medications and the safety of continuing breastfeeding while on treatment.

Mothers observed a perceived decline in milk production, raising concerns about their infants’ nutrition and noting increased infant restlessness. They sought advice on enhancing milk production, including pumping techniques and galactagogues.

Posts highlighted concerns for infants whose mothers were killed or missing, with offers to donate breast milk and offers to breastfeed infants in need.

During war or disaster, social media becomes a primary source of information. Breastfeeding mothers’ Facebook groups serve as sources of information, comfort, and connection. Concerns about the war’s impact on breastfeeding lead to a need for evidence-based, reliable information that is immediately accessible. Required information includes the effects of maternal psychological state on lactation, medication use, and milk production. Additionally, these groups function as platforms for offering and receiving support among mothers and lactation professionals.

Managing disasters and public health emergencies presents a complex challenge, especially in maintaining the crucial elements of surge capacity, i.e., the 4S: Staff, Stuff, Space, and System. This study focuses on using alternative care sites, focusing on hotels, during disasters and public health emergencies.

This study used a survey approach in two phases. In the first phase, the willingness to participate as an alternative care site was investigated among hotels in Bangkok, Thailand. In the second phase, the requirements for being an alternative care site were discussed with selected managers through a semi-structured interview session, including the legal implications of such utilization.

The results indicated a general willingness among participating hotels to participate as an alternative care site. However, some hotels lacked the requirements for being an alternative care site.

Based on the requirements in this paper, there is a high potential for using hotels as alternative care sites during disasters and public health emergencies. However, there is a need for further research concerning practical admission criteria and legal implications. This study recommends a Delphi study among medical and legal professionals to investigate the criteria for utilizing hotels in this capacity.

The Louisiana Health Department divides the state into 9 regions. Region 1 includes four parishes: New Orleans Parish, Plaquemines Parish, St Bernard Parish, and Jefferson Parish. Within Region 1, there are 11 ground ambulance agencies, made up of public and private agencies. One might think collaboration between 11 different public and private agencies would be difficult to accomplish; however, in this region, the agencies work exceptionally well together. There are a few key ways collaboration throughout the year increases interagency communication and coordination, and builds capacity during day-to-day operations and mass casualty events. The Metro Ambulance Council (MAC) serves Southeast Louisiana. It is comprised of all Region 1 EMS agencies, as well as the neighboring St. Charles Parish EMS agency. The MAC meets at least once a quarter; during these meetings, agencies report out and support each other’s needs that arise. Agencies work together to create regional plans and protocols. Having the regional protocols and plans results in a single language across the board that all agencies follow, increasing the ease of coordination. In October 2024, regional EMS agencies conducted two mass casualty exercises, including a full-scale exercise with 8 of the 11 agencies participating, involving over 70 volunteer patients. This exercise tested and proved positive interagency communication and incident command structure among the eight responding agencies. The second exercise was a tabletop between regional EMS agencies and 12 regional Hospitals, for EMS, this tabletop tested the Regional Mass Casualty transportation plan. It was found that through good communication and coordination within the regional EMS agencies, they were able to move all 400 simulated patients in a timely manner, as laid out in the regional plan. The high level of coordination between regional EMS agencies has led to a significant increase in pre-hospital EMS capacity.

Out-of-hospital cardiac arrest (OHCA) remains a major cause of mortality world-wide. Early bystander cardiopulmonary resuscitation (CPR) is a critical determinant of survival; however, many witnessed arrests are managed by untrained laypersons. Dispatcher-assisted CPR (DA-CPR) increases bystander intervention rates, but telephone-based guidance limits real-time assessment of compression quality. Video-assisted CPR (V-CPR) may overcome these limitations by enabling visual feedback and demonstration-based guidance.

The aim of this study was to evaluate whether video call-assisted dispatcher guidance incorporating simultaneous real-time demonstration improves CPR performance quality compared with voice call-assisted guidance in untrained laypersons during a simulated adult OHCA scenario.

This prospective, randomized, single-blind, manikin-based trial included 85 university students without prior CPR training. Participants were randomized to telephone-assisted CPR (T-CPR; n = 40) or video-assisted CPR (V-CPR; n = 45). All participants performed standardized hands-only CPR for five minutes following dispatcher instructions. In the V-CPR group, the dispatcher simultaneously demonstrated CPR on a manikin during the video call. The primary outcome was the composite CPR Quality Score generated by the manikin feedback system. Secondary exploratory outcomes included compression depth, compression rate, interruption time, and Emergency Medical Services (EMS)-related time intervals. Robust regression analysis adjusted for age, sex, dominant hand, height, and weight was performed.

The mean age of participants was 20.13 (SD = 1.81) years, and 54.1% were female. The CPR Quality Score was significantly higher in the V-CPR group than in the T-CPR group (median difference −47; 95% CI, −60 to −36; P < .001). The V-CPR group demonstrated greater mean compression depth, higher proportions of compressions within recommended rate and depth ranges, and shorter interruption times between compressions. The T-CPR group showed shorter time from case recognition to EMS call, while the interval from dispatcher contact to CPR initiation was similar between groups. In multivariable robust regression analysis, allocation to the V-CPR group remained independently associated with higher CPR Quality Score and improved compression performance metrics.

Video call-assisted dispatcher guidance incorporating simultaneous real-time visual demonstration significantly improves CPR quality in untrained lay rescuers compared with voice-only guidance. These findings suggest that structured visual modeling integrated into DA-CPR systems may enhance bystander resuscitation performance and help bridge gaps in community CPR training.

Appropriate, evidence-based care of traumatically injured patients in the prehospital setting is essential to saving lives and yielding better outcomes. There exists mixed evidence on the outcome differences between ambulance and helicopter prehospital transport, and on the effects of transport time on outcomes. The purpose of this paper is to examine these in patients presenting to an urban Level-1 trauma center.

A retrospective analysis was conducted with three years of patient information from a trauma registry maintained by a Level-1 trauma center in St. Louis, Missouri (USA). Propensity matching was used to compare helicopter versus ground ambulance outcomes, while regression analysis was used to investigate transport time.

After propensity matching to injury severity, helicopter transport was associated with improved prehospital survival (OR = 4.1; [95% CI, 1.2-21]; P = 0.02), though no difference in in-hospital survival (OR = 0.9; [95% CI, 0.4-1.8]; P = 0.71), intensive care unit (ICU) stay (difference = 0.8 days; [95% CI, -0.9-2.5]; P = 0.36), or hospital length-of-stay (difference = 51 hours; [95% CI, -7-109]; P = 0.08). Decreased transport time was not associated with increased survival (P = 0.31), but when transport times were less than 30 minutes, further reductions were significantly associated with shorter hospital stays (r2 = 0.02; P = 0.05) and fewer ICU days (r2 = 0.02; P = 0.05).

Decreased injury to hospital arrival time and increased use of helicopter transport in specific situations may improve patient outcomes; this indicates the need for prospective studies.

The COVID-19 crisis and future crises stress the medical system and require leaders to rise to the occasion. Some leaders are very successful while others flounder. This was seen at every level of government and health care. Applying the principles of crisis leadership and communication (and avoiding pitfalls) will increase the collective readiness to respond effectively during stressful times.

Literature review and US Centers for Disease Control and Prevention (CDC) guidelines.

While there is robust literature on the topics of crisis communications and leadership, this training is lacking in healthcare circles. This presentation aims to introduce the subject and advocate for increased training in Crisis Communications. The US CDC has developed a freely downloadable training manual, along with tools for rapidly developing a crisis message. Furthermore, a checklist to help with the presentation and a list of communication pitfalls to avoid are included. These tools allow for both pre-crisis preparation and just-in-time training.

Leaders can use these tools to prepare in advance for crisis communications, avoiding common mistakes that reduce communication effectiveness.

The Emergency Paramedic Act (EPA; Notfallsanitätergesetz), implemented in 2014, expanded the legal authority of German paramedics to independently perform defined invasive and pharmacological interventions under specific conditions. However, real-world implementation of these competencies within the physician-based German Emergency Medical Services (EMS) system remains insufficiently described.

The aim of this study was to evaluate the frequency, type, temporal development, and regional variation of invasive and pharmacological/therapeutic interventions performed independently by paramedics over a six-year period.

A retrospective, descriptive multicenter analysis of digital EMS documentation was conducted across three districts in Saxony, Germany, from January 1, 2019 through December 31, 2024. All missions were screened (n = 197,842). Paramedic-led missions without physician presence were included; physician-attended missions and non-emergency interfacility transports were excluded. Interventions were classified according to the 2024 Federal Association of Medical Directors of EMS competency catalogue. Frequencies were analyzed by year and district. Temporal trends were assessed using the Mann–Kendall test, and regional differences were explored using one-way ANOVA with Tukey HSD post hoc testing. All inferential analyses were exploratory.

Of 197,842 missions, 156,417 (79.1%) were paramedic-led without physician presence. Invasive procedures occurred in 7.6% of missions and were predominantly peripheral intravenous (IV) access (5.7%). Advanced airway management and intraosseous (IO) access were rare (<0.1%). Pharmacological/therapeutic administrations occurred in 11.3% of missions and increased from 9.4% in 2019 to 12.1% in 2024 (Mann–Kendall test), whereas overall invasive procedure rates remained stable.

Ten years after implementation of the EPA, invasive and pharmacological interventions performed independently by German paramedics remain relatively infrequent and largely confined to basic measures. Advanced procedures are rarely applied, reflecting continued structural characteristics of the physician-based EMS model.

3D printing technology has demonstrated great efficacy in ad hoc manufacturing of surgical supplies such as needle drivers, forceps, and tissue suture materials. 3D printed nylon sutures manufactured using a fused deposition modeling (FDM) 3D printer exhibited multiple advantages over commercial nylon and polybutester suture materials, including higher ultimate tensile strength and ultimate extension. A mouse model study was conducted to evaluate the healing of laceration wounds repaired using 3D printed nylon suture compared to commercial polybutester (Novafil) suture.

The 3D printed sutures were manufactured using Ultimaker S3 FDM printers and nylon filament, then sterilized using ethylene oxide sterilization. Twenty mice were included in the study, each receiving a 2 cm dermal laceration along their back. Ten mice had their lacerations repaired with simple interrupted 3D printed nylon sutures, and ten with simple interrupted polybutester sutures. All mice underwent daily wound assessments for 7 days, followed by euthanasia and harvesting of local tissue around the laceration site for objective measurement of inflammatory response via FlowJo analysis of F4/80+/80+&CD45+ macrophages and cytokine array.

No wound complications, such as dehiscence or infection, were observed in either group. The mean CD45+&F4/80+ macrophage (%) for 3D printed and polybutester sutures was 29.3 and 27.7 (p=0.59, from 2 two sample t-tests), resulting in no statistically significant difference. Additionally, there was no significant difference in tissue inflammation when evaluating cytokine response.

Data from this study suggests no difference in wound healing, infection, or inflammatory response between 3D printed nylon and polybutester sutures. The cost of manufacturing 3D-printed suture materials is significantly lower compared to the per-unit pricing of commercial suture materials. Furthermore, 3D printers provide the agency to produce critical supplies on an ad hoc basis with potential applications in low-resource medical scenarios such as rural/developing regions, war zones, or refugee encampments.

Following the 7th of October and the Iron Swords war, over 10,000 displaced people are located in the Dead Sea hotel complex, which is far from settlements and health services, and where emergency services are limited. The lack of health infrastructure and the long evacuation distances to the hospitals require a unique operating model.

For this purpose, an assessment of the area and capabilities was carried out. A preparedness ordinance was written for the activation of the response in an MCI in the Dead Sea area, which includes:

A primary triage site will be operated near the event site with the help of the medical teams stationed in the hotels, and they will undergo a refresher on the principles of trauma care. Placing EMS, including an incident commander, and deploying rescue vehicles to their crews, with civil-military cooperation to evacuate casualties.

The hospitalization complex at the MOH will determine evacuation targets: Urgently injured patients will be transferred to the hospitals by airplane and ICU ambulance. Non-urgent casualties will be held at the site until an additional evacuation force, such as a bus or an ambulance, is assembled.

An exercise was held to test readiness and determine the factors involved in MCI. The Ministry of Health’s hospitalization complex led the exercise, which aimed to create a working language and cooperation between the parties and work on the operational concept according to the order.

Points to save:

1. • Cooperation between all the factors in the field and hotels

Points for improvement:

1. • Due to travel distances, car evacuation is less realistic; therefore, there is a need for air evacuation.

2. • Accuracy of the role of the hospitalization complex /EMS/Home Front Command

3. • Training and equipping the medical and nursing staff on MCI

Ambulance diversion has emerged as a strategy to address Emergency Department (ED) overcrowding, but the question of when or whether diversion should be triggered is widely debated. Although the positive and adverse impacts of diversion have been primarily studied using quantitative data, little is known about the experience and perceptions of key stakeholders involved in diversions. Our study aims to explore the challenges and impacts of ambulance diversion as experienced by key stakeholders and their suggestions for improving the diversion process.

Semi-structured interviews were conducted with key stakeholders, including physicians, nurses, and paramedics, across two EDs and four fire stations. All interviews were audio-recorded following consent and transcribed verbatim. The transcripts were subjected to thematic analysis to identify key themes and sub-themes.

A total of 33 stakeholders were interviewed. The primary reasons for ambulance diversions were perceived to be resource constraints in EDs, overcrowding and bed block situations. Challenges during diversions included communication breakdowns, operational delays, lack of clarity in diversion criteria and emotional stress for both EMS and hospital staff. Participants felt diversions impacted patient safety, staff morale, system efficiency and could generate inter-institutional conflict. Suggestions on improvements focused on use of alternative care pathways, improving hospital’s flow issues, better information sharing, and optimizing the diversion process through strategizing the timing and duration of diversions. Reworking the hierarchical approach of dissemination of information to ground staff was also suggested.

This study highlights that while diversions may offer temporary relief for overwhelmed hospitals, they also pose challenges and negatively impact receiving hospitals and EMS operations. The findings underscore the need for systemic improvements to address the root causes of ED overcrowding and enhance understanding among stakeholders involved in diversions.

Nurses often serve as the initial responders in cases of cardiac arrest, making cardiopulmonary resuscitation (CPR) competence essential to effective resuscitation. It is therefore important for nursing students to possess sufficient CPR knowledge and skills for future clinical practice.

The aim of this study was to examine whether CPR post-qualification training is needed in maintaining knowledge and skills and if face-to-face or online training is more effective as an educational method in preserving CPR knowledge and skills in nursing students.

A three-group, parallel randomized-controlled, single-blind design was used. The participants were 133 nursing students, randomly assigned to the face-to-face group (n = 43), the e-learning group (n = 43), and the control group (n = 47). Before randomization, all participants (n = 133) successfully completed the European Resuscitation Council (ERC) standard five-hour Basic Life Support/Automated External Defibrillation (BLS/AED) course (t0) and a questionnaire based on the 2021 ERC Guidelines to assess their knowledge. Six months later, Group A received face-to-face training, Group B received e-learning training, and Group C had no intervention. Six months after interventions, all participants (n = 133) were re-assessed on the same questionnaire, and they were given the same scenario of cardiopulmonary arrest that was used during the initial BLS course to assess the skills that they retained (t1) with the use of the ERC CPR/AED 11-item checklist. The collected data were analyzed with inferential “among group” analysis involving Kruskal-Wallis’s and Pearson’s Chi-Squared test and inferential “within group” analysis including Wilcoxon’s Signed-Rank and McNemar’s test. Multiple linear regression was used for adjusting demographic characteristics.

Based on pairwise differences between independent groups, both intervention groups presented higher scores in knowledge at t1 (P < 0.001) and in skills at t1 (P < 0.001) compared to the control group. Moreover, both training methods demonstrated comparable effectiveness. Based on comparisons between paired groups, there was also a statistically significant decrease in the Skill Score in the control group after one year (P < 0.001). Most skills were notably higher, primarily in the e-learning group, and to a lesser extent in the face-to-face group. In specific, intervention groups demonstrated statistically significant improvement in nine of the eleven assessed skills (all P < 0.05).

The current study showed that post-qualification training is needed to retain CPR knowledge and skills of nursing students, and that face-to-face and e-learning training had similar outcomes.

Prehospital electrocardiogram teletransmission (E-ECG) enables early cardiac diagnosis and triage in the field. This study assessed its diagnostic and operational impact in a real-world Emergency Medical Service (EMS) in Marseille, France.

A retrospective, single-center observational study including adults ≥18 years who underwent E-ECG acquisition by Marseille first responders from January 1 through September 15, 2023 was conducted. Electronically transmitted prehospital ECGs were transmitted via Schiller devices to medical regulators. Patients with trauma, pediatric age, pregnancy, training cases, uninterpretable ECGs, or incomplete files were excluded. The main outcome was the proportion of acute ECG abnormalities (signs of ischemia, rhythm, or conduction disorders).

Secondary outcomes included reinforcement requests, patient orientation, and transport mode.

Among 425 included patients (Median age: 56 years [IQR 40–72]; 61% male), 21.9 % (n = 93) presented abnormal ECGs, including 2.1% with ST-elevation myocardial infarction (STEMI). Transmission results led to management changes in 11.5% of cases (n = 49): 8.2% required additional medical reinforcement and 3.3% underwent direct cardiology triage without medical reinforcement. Technical issues occurred in 15.8% of transmissions (n = 67).

Prehospital ECG teletransmission allowed early detection of cardiac abnormalities and was associated with changes in patient management in a subset of cases. Its integration in emergency workflows could enhance triage, optimize cardiology routing, and strengthen coordination between field teams and regulation centers.

There has been an increase in murders and attempted murders of important persons over the past few years. Assault on important persons is a form of terrorism, and it is necessary to minimize damage for the sake of social peace and order. Healthcare providers (HCPs) are required to respond quickly to save lives when an incident occurs. However, no data have shown whether HCPs and medical institutions are adequately prepared. We conducted a survey on the current status of the medical system for responding to assaults on important persons.

A questionnaire survey was conducted among physicians on the largest medical portal site in Japan. The questionnaires are: A. Experience in receiving request to deal with injuries and/or illness of important persons, B. Specific preparation for providing treatment, C. Capability of dealing with injuries of important persons at your medical institutions, D. Treatment experience for injured important persons, and E. Evaluation of the medical system for important persons in Japan. Participants were asked to give anonymous responses.

A total of 1091 physicians participated in this survey. A. Of the 1091 participants, 78 physicians (7.1%) have received the request, B. Of those, 51 physicians (65.4%) had made specific preparations, C. 109 physicians (10.0%) responded that the medical system was in place, D. Only 18 physicians (1.6%) had experience treatment both gunshot and stab wounds, and E. 58 physicians (5.3%) answered that the medical system has been established. It has become clear that there are very few physicians who can provide proper medical care to injured important persons, and the system has not been well established either.

In order to protect society from the threat of terrorism, further efforts to establish a system that can provide appropriate medical care to injured persons are required.

From January 2023 to March 2024, a project supported by the Japan International Cooperation Agency (JICA) aimed to establish a DMAT in Moldova. The Japan DMAT Secretariat designed a comprehensive training program and provided essential materials. Collaboration with Moldova’s National Center for Emergency Prehospital Medical Assistance (CNAMUP) and the National Agency for Public Health (ANSP) was crucial in enhancing Moldova’s disaster medical capabilities. Key activities included training sessions in Japan, site evaluations, and the implementation of a training course for future trainers in July 2024. More than 20 participants from Moldova’s key medical institutions, including the CNAMUP and the Institute of Emergency Medicine, completed the training. A significant achievement was the successful Training of Trainers course, where Moldovan professionals, who had previously received instruction in Japan, led the sessions. This marked a major step toward self-sufficiency in disaster medical response. The project not only improved the knowledge and skills of medical professionals in disaster scenarios but also laid the foundation for Moldova to develop its own disaster medical system tailored to its unique needs. The initiative highlighted the importance of fostering local expertise to create a sustainable and resilient disaster response framework. Future efforts should focus on adapting the training program to Moldova’s specific disaster risks, incorporating lessons learned from actual disaster experiences, while maintaining cooperation with Japan to ensure ongoing support and development. This project exemplifies the value of international collaboration in building strong, locally-driven disaster response systems that can save lives in critical situations.

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.