bluuebunny/crossref_metadata_2025 huggingface dataset:
MP014: What ultrasonography characteristics predict surgical intervention for children with testicular torsion?
Authors: Shefrin A.E. , Ritcey B. , Perry J.J. , Woo M.
Published: June 2016

Introduction: The timely diagnosis and treatment of testicular torsion is essential as a longer duration of symptoms is correlated with testicular necrosis and infertility. Ultrasound imaging assists in separating this diagnosis from other causes of acute scrotal pain. Our objective was to characterize which ultrasound findings predicted surgical intervention. Methods: We performed a retrospective health records review of all patients, ages 0-17 years that presented to the emergency department of the Children’s Hospital of Eastern Ontario over a 5-year period (2009-14) with scrotal pain <24 hours duration who were assessed by an emergency physician (EP) and received a testicular ultrasound by the Diagnostic Imaging Department. Patients’ records and ultrasound reports were reviewed by two reviewers who recorded ultrasound findings, times of EP assessment, ultrasound and surgical intervention in a standardized data extraction form. Sensitivity, specificity and positive and negative predictive values were calculated for the ultrasound findings. Results: 190 patients were analyzed of which 34 had a final diagnosis of testicular torsion (mean age 11.5 years, range 0-17.3). The mean time from EP assessment to ultrasound was 67.6 minutes (95%CI 50.5-84.6) during the daytime (800-2159) and 83.2 minutes (95%CI 36.7-130.4) for overnight presentations (2200-759). The absence of blood flow on colour Doppler ultrasound of the affected testicle was the best predictor of surgical intervention (sensitivity=94.1% [95%CI 80.3%-99.3%], specificity=99.4% [95%CI 96.5%-99.9%], positive likelihood ratio=146.8 [95%CI 20.7-1037.7] and negative likelihood ratio=0.06 [95%CI 0.02-0.23]. Other ultrasound findings that help rule in testicular torsion were the presence of a heterogeneous testicle on the symptomatic side (specificity=91.0% [95%CI 85.4%-95.0%] and the presence of the whirlpool sign (specificity=99.4% [95%CI 96.5%-99.9%]). Conclusion: The absence of blood flow on ultrasound is the best ultrasound finding for predicting surgical management of testicular torsion. Neither a heterogeneous testicle nor whirlpool sign had strong enough sensitivity to warrant their independent use. Future studies, such as those utilizing point of care ultrasound by EPs, should be conducted to study the affect on delays in treatment.
MP017: Impact of physician payment mechanism on wait times and ED length of stay
Authors: Innes G. , Marsden J. , Kalla D. , Stenstrom R. , Grafstein E.
Published: June 2016

Introduction: Vancouver Coastal Health (VCH) emergency physicians have been on contract based funding models for two decades. On October 1, 2015, physicians at one hospital (SPH) switched to fee-for-service (FFS) payments. Conventional wisdom is that FFS physicians are motivated to see more patients quickly and achieve higher throughput. Our hypothesis was that FFS payment would reduce patient wait times. Methods: This interrupted time series analysis with concurrent control was performed in VCH Region, where there are two tertiary EDs. During the 20-week study period (July 15-Nov 30), VGH remained on contract, while SPH converted to FFS (the intervention). VCH administrative data was aggregated by week. Our primary outcome was median wait time to MD. Secondary outcomes were ED LOS and left-without-being-seen (LWBS) rates. Results: Interrupted time series plots will be presented for the data. Data from 67,214 ED visits were analyzed (31,733 SPH, 35,481 VGH). Figure 1 shows that baseline wait time was 74 minutes at the control and 53 minutes at the intervention site. During the pre-intervention period, there was a non-significant downward trend of 0.4 minutes per week at the intervention hospital relative to control (p=0.26). After FFS conversion, there was a 4.1 minute increase in wait time at the control site (p=0.18), and a significant downward trend of 1.4 minutes per week (p=0.001). After FFS conversion, wait times at the intervention site increased by 4.8 minutes more than control (p-value for the difference=0.27), and the wait time trend increased significantly by 1.3 minutes per week relative to the expected counterfactual trend (p=0.02). Baseline EDLOS for discharged patients was 227 minutes at the control hospital and 193 minutes at the intervention site. There were similar pre-intervention LOS increases at both hospitals. Post-intervention, both sites saw significant increases in EDLOS, followed by a similar downward trends of -2.68 minutes per week (p=0.001). Baseline LWBS rate was 3.86% at the control hospital and 3.56% at the intervention site. Pre-intervention trends, and post-intervention level/trend changes did not differ by site. Conclusion: Conversion to FFS payment was associated with an increase in wait time trend of 1.3 minutes per week relative to control. There were no significant changes in EDLOS or LWBS rates. In this preliminary analysis, FFS payment had little effect on wait times or patient throughput.
MP036: Trauma Resuscitation Using in-situ Simulation Team Training (TRUST): a novel approach to latent safety threat identification in trauma care
Authors: Petrosoniak A. , Gray A. , Fan M. , White K. , McGowan M. , Pinkney S. , Campbell D. , Rizoli S. , Trbovich P. , Hicks C.
Published: June 2016

Introduction: Resuscitation of a trauma patient requires a multidisciplinary team to perform in a dynamic, high-stakes environment. Error is ubiquitous in trauma care, often related to latent safety threats (LSTs) - previously unrecognized threats that can materialize at any time. In-situ simulation (ISS) allows a team to practice in their authentic environment while providing an opportunistic milieu to explore critical events and uncover LSTs that impact patient safety. Methods: At a Canadian Level 1 trauma centre, regular, unannounced trauma ISSs were conducted and video-recorded. A retrospective chart review of adverse events or unexpected deaths informed ISS scenario design. Each session began with a trauma team activation. The on-duty trauma team arrived in the trauma bay and provided care as they would for a real patient. Semi-structured debriefing with participant-driven LST identification and ethnographic observation occurred in real time. A framework analysis using video review was conducted by human factors experts to identify and evaluate LSTs. Feasibility was measured by the impact on ED workflow, interruptions of clinical care and participant feedback. Results: Six multidisciplinary, high-fidelity, ISS sessions were conducted and 70 multidisciplinary staff and trainees participated in at least one session. Using a framework analysis, LSTs were identified and categorized into seven themes that relate to clinical tasks, equipment, team communication, and participant workflow. LSTs were quantified and prioritized using a hazard scoring matrix. ISS was effectively implemented during both low and high patient volume situations. No critical interruptions in patient care were identified during ISS sessions and overall participant feedback was positive. Conclusion: This novel, multidisciplinary ISS trauma training program integrated risk-informed simulation cases with human factors analysis to identify LSTs. ISS offers an opportunity for an iterative review process of high-risk situations beyond the traditional morbidity and mortality rounds; rather than waiting for an actual case to generate discussion and review, we prophylactically examined critical situations and processes. Findings form a framework for recommendations about improvements in equipment, environment layout, workflow, system processes, effective team training, and ultimately patient safety.
P001: Concussion patients in the emergency department: assessing a new triaging tool for follow-up and prompt long term management
Authors: Abourbih D.A. , Bedi S. , Hunt C. , Ouchterlony D. , Ackery A.
Published: June 2016

Introduction: Concussion is a common emergency department (ED) presentation. Most patients improve with expectant management. A subset with risk factors for post-concussion syndrome (PCS) may require closer outpatient follow-up. A novel emergency department (ED)/head injury clinic (HIC) triaging system has been created to allow concussed patients rapid access to educational information and specialized consultant services. This system has been well received by patients and physicians alike; however, objective measures are needed to determine if this system ultimately decreases excessive healthcare utilization (HCU) and improves symptom management of PCS. Methods: Single centered prospective observational study. Control population of 42 mTBI patients referred to the HIC through the Ontario Acquired Brain Injury (ABI) Network within 3-12 months of injury. These patients have received little concussion education or treatment and will be compared to 50 concussion patients seen in the ED and HIC. Rivermead scores, a validated likert scale of PCS symptoms (1-4, maximum score of 64) and HCU (patient reported number of healthcare visits post injury) will be collected on their initial clinic visit and subsequent follow up phone interview. Results: Control ABI network patients were 50% male, mean age 40 yrs (18-90, ± 16.3) while 83% (35/42) reported >1 subsequent visit to ED or family physician and 39% (16/42) visited neurologist. Mean Rivermead Score was 32.6 (7-58, ± 12). Conclusion: A significant proportion of control patients utilized multiple healthcare resources and were still symptomatic 3-6 months following injury. Data collection is currently ongoing to determine if rapid outpatient follow-up and education decreases HCU and PCS symptoms.
P016: Evaluating the impact of a novel mobile care team (MCT) on the prevalence of ambulatory care sensitive conditions presenting to emergency medical services in Nova Scotia
Authors: Brown D.R. , Carter A. , Goldstein J. , Jensen J. , Travers A. , Dobson T. , Cosgrove P.
Published: June 2016

Introduction: Hospitalization due to ambulatory care sensitive conditions (ACSC) is a proxy measure for access to primary care. Emergency medical services (EMS) are increasingly called when primary care cannot be accessed. A novel paramedic-nurse EMS Mobile Care Team (MCT) was implemented in an under-serviced community. The MCT responds in a non-transport unit to bookings from EMS, emergency and primary care and to low-acuity 911 calls in a defined geographic region. Our objective was to compare the prevalence of ACSC in ground ambulance (GA) responses before and after the introduction of the MCT. Methods: A cross-sectional analysis of GA and MCT patients with ACSC (determined by chief complaint, clinical impression, treatment protocol and medical history) one year pre- and one year post-MCT implementation was conducted for the period Oct. 1, 2012 to Sept. 30, 2014. Demographics were described. Predictors of ACSC were identified via logistic regression. Prevalence was compared with chi-squared analysis. Results: There were 975 calls pre- and 1208 GA/95 MCT calls post-MCT. ACSC in GA patients pre- and post-MCT was similar: n=122, 12.5% vs. n=185, 15.3%; p=0.06. ACSC in patients seen by EMS (GA plus MCT) increased in the post-period: 122 (12.5%) vs. 204 (15.7%) p=0.04. Pre vs post, GA calls differed by sex (p=0.007) but not age (65.38 ± 15.12 vs. 62.51 ± 20.48; p=0.16). Post-MCT, prevalence of specific ACSC increased for GA: hypertension (p<0.001) and congestive heart failure (p=0.04). MCT patients with ACSC were less likely to have a primary care provider compared to GA (90.2% and 87.6% vs. 63.2%; p=0.003, p=0.004). Conclusion: The prevalence of ACSC did not decrease for GA with the introduction of the MCT, but ACSC in the overall patient population served by EMS increased. It is possible more patients with ACSC call or are referred to EMS for the new MCT service. Given that MCT patients were less likely to have a primary care provider this may represent an increase in access to care, or a shift away from other emergency/episodic care. These associations must be further studied to inform the ideal utility of adding such services to EMS and healthcare systems.
P017: Does a busy day predict another busy day? A time-series analysis of multi-centre emergency department volumes
Authors: Butler M.B. , Gu H. , Kenney T. , Campbell S.G.
Published: June 2016

Introduction: Variations of patient volumes in the ED according to days of the week and month of the year are well-established. Anecdotally, ED volumes follow ‘waves’ that correlate with previous days. Time-series models have traditionally been used in econometrics to develop financial models, but have been adapted in other fields, such as health informatics. This study uses a time-series approach to assess whether these impressions are valid. Methods: The daily volume of patients presenting to four emergency departments (ED) at the Nova Scotia Health Authority from Jan 2010 to May 2015 were analyzed to assess for the effect of previous volumes on future volumes. Parameters were selected using the auto-correlation (ACF) and partial auto-correlation functions (PACF) for a Seasonal Auto-regressive Integrated Moving Average (SARIMA) model. The Box-Jenkins statistic was assessed for model suitability. To assess for accuracy, a forecast of the model was evaluated with a year of volumes set aside for testing. Results: The EDs saw an average of 365.1 patients per day, with a minimum of 188 patients and a maximum of 479. The increasing trend in volumes consistent with the increasing number of ED presentations nation-wide was detrended using linear regression. There was a significant correlation in ACF with the previous day (ρ1 = 0.297). A seasonal, periodic trend was seen weekly. Significant correlations occurred annually (ρ365 = 0.279) and at 29 days (ρ29 = 0.339), consistent with the lunar cycle. A seasonal model was postulated incorporating an auto-regressive (AR) coefficient, and a moving average (MA) coefficient for the previous day’s volume. An AR and MA seasonal coefficient were each incorporated using the weekly period. When using the model on the test data, the model predicted 4 more patient presentations on average than the true value, with 90% of the values within 37 presentations of the true volume. The Box-Jenkins statistic was non-significant, indicating no problems with model specification. Conclusion: The volume of patients presenting to an ED system is correlated with that of the previous day. A weekly seasonal variation was confirmed. Auto-correlations also occur annually and possibly associated with the lunar cycle. Previous ED volumes may be useful in forecasting patient volumes. The time-series approach may discover further ways to predict ED volumes.
P021: Impact of emergency department surge and end of shift on patient workup and treatment prior to referral to internal medicine
Authors: Charbonneau V. , Stiell I.G. , Kwok E.S. , Boyle L.
Published: June 2016

Introduction: The goal of this study was to determine if emergency department (ED) surge and end of shift assessment of patients affect the extent of diagnostic tests, therapeutic interventions performed and accuracy of diagnosis prior to referral of patients to Internal Medicine as well as the impact on patient outcomes. Methods: This study was a health records review of consecutive patients referred to the internal medicine service with an ED diagnosis of heart failure, COPD or sepsis, at two tertiary care EDs. We developed a scoring system in consultation with senior emergency and internal medicine physicians to uniformly assess the treatments and investigations performed for patients diagnosed in the ED with heart failure, COPD or sepsis. These scores were then correlated with surge levels and time of day at patient assessment and disposition. Rate of admission and diagnosis disagreements were also assessed. Results: We included 308 patients (101 with heart failure, 101 with COPD, 106 with sepsis). Comparing middle of shift to end of shift, the overall weighted mean scores were 92.2% vs. 91.7% for investigations and 73.5% vs. 70.0% for treatments. Comparing low to high surge times, the overall weighted mean scores were 89.9% vs. 92.6% for investigations and 68.6% vs. 71.7% for treatments. Evaluating each condition separately for investigations and treatments according to time of shift or surge conditions, there were no consistent differences in scores. We found overall high admission rates (93.1 % for heart failure, 91.1% for COPD, 96.2% for sepsis patients), and low rates of diagnosis disagreement (4.0 % heart failure, 10.9% COPD, 8.5% sepsis). Conclusion: We found that surge levels and end of shift did not impact the extent of investigations and treatments provided to patients diagnosed in the emergency department with heart failure, COPD or sepsis and referred to internal medicine. Admission rates for the patients referred were above 90% and there were very few diagnosis disagreements or diversion to alternate service by internal medicine. We believe this supports the emergency physician's ability to adapt to time and surge constraints, particularly in the context of commonly encountered conditions.
P024: Extracurricular podcast use behaviour and effect on knowledge retention in undergraduate medical students
Authors: Chin A. , Helman A. , Chan T.M.
Published: June 2016

Introduction: Podcasts have become increasingly popular as a medium for free online access medical education (FOAM). However, little research has examined the naturalistic use of podcasts as a tool in undergraduate medical education. This study aims to determine usage conditions, preferences, and level of retention of information from podcasts by medical students at a Canadian University. Methods: Medical students (Years 1 to 3) were instructed to complete an online test assessing their baseline knowledge on the topics of the podcasts and for qualitative data on podcast usage and preferences. Audio podcasts on two topics (adult asthma, and introduction to toxicology) were then distributed to study participants. One week and two weeks after the initial survey students were asked to complete a follow-up survey for knowledge assessment and further podcast usage data. Simple descriptive statistical generated using Microsoft Excel. Paired samples t-tests were utilized to assess knowledge acquisition using Microsoft SPSS version 23. Results: Participants who successfully completed the knowledge assessments demonstrated a significant effect of learning (Asthma, average test score improvement of 30%, p=0.002; Toxicology, average test score improvement of 13%, p=0.004). The majority of participants who stated a preference in podcast length indicated they preferred podcasts of 30 or less minutes (85%). The top three activities participants were engaged in while listening to the podcasts were driving (46%), completing chores (26%), and exercising (23%). A large number of participants who did not complete the study in its entirety cited a lack of time and podcast length to be the top two barriers to completion. Conclusion: This is one of the first studies to examine podcast usage data and preferences in a Canadian undergraduate medical student population. This information may help educators and FOAM producers to optimize educational tools for medical education.
P036: A clinical decision support intervention to increase usage of probenecid in the ED
Authors: Dowling S. , Lang E. , Wang D. , Rich T.
Published: June 2016

Introduction: In certain circumstances, skin and soft tissue infections are managed with intravenous (IV) antibiotics. In our center, patients initiated on outpatient IV antibiotics are followed up by a home parental therapy program the following day. A significant number of these patients require a repeat visit to the ED because of clinic hours. Probenecid is a drug that can prolong the half-life of certain antibiotics (such as cefazolin) and can therefore avoid a repeat ED visit, reducing health care costs and improve ED capacity. Our goal was to increase probenecid usage in the ED in order to optimize management of skin and soft tissue infections (SSTI) in the ED. The primary outcome was to compare the usage of probenecid in the pre and post-intervention phase. Secondary outcomes were to compare revisit rates between patients receiving cefazolin alone vs cefazolin + probenecid. Methods: Using administrative data merged with Computerized Physician Order Entry (CPOE), we extracted data 90 days pre- and 90 post-intervention (February 11, 2015 to August 11, 2015). The setting for the study is an urban center (4 adult ED’s with an annual census of over 320,000 visits per year). Our CPOE system is fully integrated into the ED patient care. The multi-faceted intervention involved modifying all relevant SSTI order sets in the CPOE system to link any cefazolin order with an order for probenecid. Physicians and nurses were provided with a 1 page summary of probenecid (indications, contra-indications, pharmacology), as well as decision support with the CPOE. Any patients who were receiving outpatient cefazolin therapy were included in the study. Results: Our analysis included 2512 patients (1148 and 1364 patients in the pre/post phases) who received cefazolin in the ED and were discharged during the 180 day period. Baseline variables (gender, age, % admitted) and ED visits were similar in both phases. In the pre-intervention phase 30.2% of patients received probenecid and in the post-intervention phase 43.0%, for a net increase of 12.8% (p=<0.0001). Patients who received probenecid had a 2.2% (11.4% vs 13.6%, p=0.014) lower re-visit rate in the following 72H. Conclusion: We have implemented a CPOE based clinical decision support intervention that demonstrated significant increase in probenecid usage by emergency physician and resulted in a decrease in ED revisits. This intervention would result in health care cost-savings.
P038: How frequently is hypoglycemia found in ambulance calls for “seizure”?
Authors: Eby D. , Robson J. , Columbus M.
Published: June 2016

Introduction: Paramedics often attend seizure patients in the pre-hospital setting. Received wisdom is that hypoglycemia is frequently present during a seizure or is a ‘cause’ of seizures. Recent literature disputes this. The purpose of this study was to determine the frequency of hypoglycemia in patients identified as having “seizure” listed as the primary or final problem code in Ambulance Call Reports from a large regional paramedic base hospital program. Methods: Retrospective analysis of a database of ambulance call reports (ACRs) from January 01-December 31, 2014. All 2854 ACRs with paramedic determined primary or final problem codes of “seizure” were identified from a database of all calls performed by 8 municipal paramedic services covering a total urban and rural population of 1.4 million. Municipal paramedic services used iMedic electronic ACRs. A 10% sample generated by a random number table was analyzed. ACRs were manually searched and data extracted onto spreadsheets. Results were described using frequencies and summary statistics. Results: A total of 285 call were analyzed. 207 (72.6%) calls were adults and 78 (27.4%) were paediatric (age <18). Seizures were witnessed by paramedics in 23/285 (8.1%) calls; adults 17/207 (8.2%), paediatric 6/78 (7.7%). A blood sugar was determined in 237/285 (83.2%) of all calls; adults 182/207 (87.9%), paediatric 55/78 (70.5%). In calls were paramedics witnessed a seizure a blood sugar was determined 17/21 (80.9%) of the time; adults 13/17 (76.5%), paediatric 6/6 (100%) Hypoglycemia (BS < 4.0 mm/L) was found in only 1 case - 1/237 (0.4%); adults 0/ 207 (0%), paediatric 1/78 (1.3%). The child was age 1, had a GCS 13, and the blood sugar was 3.9 mm/L. Conclusion: Hypoglycemia was rarely found in patients who had a seizure and were attended to by paramedics in the pre-hospital setting. The routine determination of blood sugars in all patients who have had a seizure prior to paramedic arrival should be reconsidered.
P058: Improving patient safety and streamlining care at a community hospital through spread and scale of a trauma care bundle: a quality improvement pilot project
Authors: Hahn E. , Andres R. , de Kok T. , Brown A. , Doyle J.
Published: June 2016

Introduction: Non-trauma centers (NTC) and community hospitals commonly deliver medical care during the “golden hour” of trauma, which has significant implications on the health outcomes of patients. The Niagara Health System (NHS) and its 3 community NTC hospitals provide trauma care to over 100 patients annually during this critical period. NTCs lack standardized resources commonly found in trauma centers. Checklists and bundles have been effective in streamlining process to ensure health care providers provide the right care, at the right time and address critical points during patient care. A trauma care bundle was designed and implemented in the NHS as a means to improve trauma care and patient outcomes. Methods: A quality improvement (QI) approach was used to design, implement and evaluate a trauma care bundle at one of the NHS’s community hospitals. These interventions were adapted and modified for community trauma care purposes. We piloted the trauma care bundle using rapid cycle improvements, known as Plan-Do-Study-Act (PDSA) cycles. We assessed outcome and process measures through a chart audit of all trauma care patients in the NHS from July 2015-December 2015. A safety attitudes questionnaire (SAQ) was administered to health system staff who were involved in the pilot to assess balancing measures. Results: Improvements to the bundle and its implementation from 4 PDSA cycles resulted in increased utilization. This continuous monitoring of the bundle and ongoing, conscious efforts to improve the intervention were used to spread and scale across all 3 sites of the NHS. 30% of patients received the trauma care bundle during phase 1 of the pilot from July 1- October 31, 2015. We are presently analyzing preliminary data to understand how the trauma care bundle impacts health outcomes and process and will present a comparative analysis between patient groups. Conclusion: Trauma care bundles may foster safer and more efficient patient care in community hospitals where the golden hour of trauma often occurs. This community trauma care bundle shows promising results for streamlining the care process to ensure patients receive appropriate care during the golden hour. Spread and scale of this bundle across other community hospitals will likely yield similar improvements in patient care.
P076: Delirium prevention in the emergency department using regional anesthesia with ultrasound guidance in the elderly population with hip fracture: a pilot study
Authors: LeBlanc P. , Boucher V. , Émond M. , Courtemanche J. , Ménassa M. , Lee J.S.
Published: June 2016

Introduction: The incidence of delirium following hip fracture is near 60%. The use of regional anesthesia (RA) with ultrasound (U/S) guidance has suggested a decrease in delirium incidence. In this pilot study, we propose to include the use of femoral block with U/S guidance in the management of the elderly population with hip fracture in the emergency department (ED) to lower the risk of delirium. Methods: This paired control case study was conducted from December 2013 to April 2015, and includes patients seen by emergency doctors from the ED of Hospital Enfant Jesus in Quebec City. Patients of the intervention and control groups were paired by age. Inclusion Criteria: Patients with(1) a hip fracture; (2) admitted to the hospital after their ED management; (3) and surgically repaired. Exclusion Criteria: Patients (1) with delirium upon arrival or a known mental/cognitive status (dementia, unconsciousness or severely ill status) (2) less than 60 years old (3) not able to speak English or French. Intervention group: Patients with hip fracture who received femoral blocks by the five emergency doctors who were trained and performed with U/S guidance. Control group: Patients with hip fracture who received standard pain control care by emergency doctors and who did not receive a femoral block. Analysis: Incidence of delirium and blocks performed by EM doctors were tallied. A comparison of absolute pain reduction at 30 minutes was also done. Odd ratios were derived and adjusted for age, sex, total opiates dose, delay before surgery and morbidity scores. Results: A total of 29 femoral blocks were performed through the analysis period. Groups were similar for age, sex and APACHE II and CHARLSON scores. A 30 minutes absolute pain reduction of 3/10 was noted. Two thirds of the blocks were performed by two ED doctors. Need for rescue medication was needed for 7% of patients for pain control at 30 minutes. Adjusted odd ratios for age, sex, morbidity scores, total opiate doses and delay before surgery revealed no decrease in delirium. Conclusion: Ten out of 26 patients hospitalized for hip fracture who received a femoral block under U/S guidance from the ED doctors were diagnosed with delirium. A Canadian prospective study «EDURAPID» is underway to demonstrate more the impact of R/A under U/S guidance on the incidence de delirium in this population.
P081: Adaptation of DECISION+, a training program in shared decision making on the use of antibiotics for acute respiratory infections in primary care, to the context of emergency department: a mixed methods study
Authors: Létourneau J. , Berthelot S. , Labrecque M. , Cauchon M. , Légaré F. , Archambault P.M.
Published: June 2016

Introduction: Antibiotic overuse for acute respiratory infections (ARIs) is a significant problem in Emergency Departments (EDs). DECISION+, a training program on shared decision making (SDM) and a decision aid for antibiotic use in ARIs, reduces patients’ use of antibiotics for ARIs in primary care, but has never been studied in the ED setting. The objectives of this study are to assess the intention of ED physicians to adopt SDM about antibiotic use in ARIs and to identify barriers and facilitators about adopting SDM and a decision aid for antibiotic use in ARIs. Methods: An adapted version of DECISION+ (1-hour seminar) was offered to physicians of two academic EDs (Quebec, Canada) in fall 2015. A validated questionnaire was administered to participants before and after the seminar. This questionnaire contains three items measuring the intention to adopt SDM using a 7-point Likert scale [ranging from 1 (very unlikely) to 7 (very likely)]. We performed descriptive analyses for demographic characteristics and a paired Wilcoxon signed-rank test to compare pre- and post-training intention to adopt SDM (α=.05). A debriefing session with the participants identified potential barriers and facilitators about implementing SDM and using a decision aid regarding antibiotic use for ARIs. Two researchers analysed the recorded audio material. Results: 41% (23/56) of eligible physicians received the intervention. 74 % of participants had already heard of SDM and 40% felt they already used SDM in their practice. The median intention to adopt SDM was 6 (IQR 5-6) before and 6 (IQR 5-6) after the seminar (P = .23). One participant did not answer the questionnaire after the seminar and his results were excluded from the comparative analysis. We identified 20 specific barriers to adopting SDM for deciding about antibiotics use for ARIs in the ED (e.g., lack of time) and 13 facilitators (e.g., public health campaign). Conclusion: ED physicians’ baseline intention to adopt SDM with patients for antibiotic use in ARIs is high. The adapted tutorial of DECISION+ did not change this intention. This could be explained by the social desirability of SDM. Further studies must be conducted to adapt DECISION+ to the ED setting and also to assess the impact of DECISION+ on the actual prescription and use of antibiotics for ARIs.
P087: Overview of reviews: relevant treatment modalities for management of low back pain in the emergency department
Authors: Burgesson B. , Hayden J. , Magee K.
Published: June 2016

Introduction: Low Back Pain (LBP) remains a condition with relatively high incidence and prevalence. It affects 70-85% of people at some point in their lives and causes significant disability. LBP management may be best suited to a primary care setting, yet it is one of the most common reasons for presentation to Emergency Departments (ED). Nationally representative data from the United States found that LBP related disorders are a frequent cause of ED visits, accounting for 2.7 million visits to US EDs annually. There are numerous treatment modalities for LBP, however the task is identifying those that have relevance in an ED setting. Although there is extensive research available on management of LBP in primary care settings, treatment outcomes differ from that in the ED setting. This makes management of LBP a challenge for ED physicians. Few studies and no systematic reviews focus on treatment of LBP in the ED setting. Methods: The objective of our study is to compare effectiveness of treatment modalities relevant for management of LBP in the ED setting. We conducted an Overview of Systematic Reviews following robust methods advocated by Cochrane. We included systematic reviews of randomized controlled trials (RCTs). A medical librarian assisted in completing of an extensive search of the Cochrane Library, PubMed, and EMBASE. We used transparent criteria to select relevant reviews and assess interventions for ED relevance. We collected key data points from the included reviews including pain and functional limitation outcomes. Evidence will be synthesized for important outcome measures following the approach of Jones et al (2012). Results: We screened 4740 citations and identified 346 likely relevant systematic reviews. Comparative effectiveness review synthesis will be completed before the conference. We will report effectiveness of each of the included interventions and as well as make head to head comparisons of said relevant interventions. Conclusion: Currently most LBP patients presenting to the ED are inundated with a variety of potential treatment modalities, all alleging efficacy in LBP management. Physicians may use the evidence from this synthesis, and related knowledge translation tools, to guide decisions in effectively treating patients presenting to the ED with LBP.
P099: Development and qualitative evaluation of an emergency medicine simulation book to facilitate the use of simulation for our local EM program
Authors: Parsons M.H.
Published: June 2016

Introduction / Innovation Concept: Simulation-based medical education (SBME) has seen increased application in medical education. Emergency medicine (EM) trainees must develop a diverse skill set to smoothly transition to clinical practice and ensure optimal patient outcomes. The competency-based medical education (CBME) framework helps ensure residents develop the required expertise relevant to each of the CanMEDs roles. Simulation is a valuable supplement to hands-on clinical experience and allows skill development in a low-risk setting. The EM Simulation book serves to facilitate the effective application of simulation in our curriculum. Methods: A number of resources were compiled to meet the needs of our simulation program within Memorial University of Newfoundland. Personal knowledge/experience of the author and local contacts provide site relevant content. Prior training helped in review and selection of materials on simulation theory and debriefing. Core EM resources were sourced for information on procedural training. Literature review on simulation was used to compile a list of resources and materials for further reading. The development and revision of the manual continues as an iterative process with sequential edits based on review and feedback. Qualitative evaluation of the design and value of this document is planned to get feedback from key stakeholders including learners, faculty and simulation lab staff. Curriculum, Tool, or Material: The final product is a 94-page document provided in print and electronic format to the EM residents and several faculty involved in simulation. It introduces residents to our simulation program, provides relevant background information and orients them to this modality of curriculum delivery. Theory and rationale behind SBME is included. Information on the key role of debriefing is highlighted. Several core EM procedural topics are covered with tips on practice station set up. Additional learning resources are noted, including information on case development for potential teachers. Conclusion: The simulation book brings together key information to optimize the simulation-based medical education experience for EM residents at Memorial University.
P101: Needs assessment study for the inter-professional procedural sedation course: methods of adult procedural sedation (MAPS)
Authors: Perelman S. , Munzar J.C. , Misch M.
Published: June 2016

Introduction: Procedural sedation and analgesia (PSA) is a common practice for non-anaesthesiologists. While complication rates for PSA are low, many of them are preventable. Professional regulatory body requirements state that practitioners should have adequate knowledge and skills to safely administer PSA. However, no certification process currently exists to develop and maintain these competencies. A standardized PSA training course would help close the gap between the best evidence for safe administration of PSA and its implementation in everyday practice. Therefore, we conducted a needs assessment to guide the development of such a PSA training course. Methods: Using modified Dillman methodology, an electronic survey was sent to a convenience sample of 50 potential learners and two groups of stakeholders: 20 hospital administrators and 35 experts in PSA. Questions assessed practice demographics, experience as well as support and interest in the development and attendance of a PSA training course. Prior to distribution, the questionnaire was peer reviewed and pilot-tested for feasibility and comprehension. Responses were stratified based on clinical role. Results: 35 potential learners completed the needs assessment (70% response rate): 15 emergency physicians, 19 registered nurses and 1 nurse practitioner. 48% have been in practice for over 10 years and over 90% participate in PSA at least weekly. 38% received informal training in PSA while 16% obtained no training at all. 86% strongly supported the development of a PSA certification course and were in favour of an inter-professional format. 13 experts responded to the questionnaire within the departments of anesthesia, emergency medicine (EM) and respiratory therapy (37% response rate). 80% supported the need for a PSA training course. 6 hospital administrators responded to the questionnaire within the departments of anesthesia, EM, gastroenterology and respirology (30% response rate). All agreed that standardization of PSA is an important part of patient safety and 80% stated certification in PSA should be a prerequisite for granting privileges to health care professionals to participate in PSA. 60% believed the course should be developed and supported by hospital funds. Conclusion: There is strong support from potential learners and stakeholders for the development of a formal PSA training course.
P106: Healthcare utilization among homeless and/or substance using adults presenting to the ED
Authors: Puri V.V. , Dong K. , Rowe B.H. , Kirkland S.W. , Vandenberghe C. , Salvalaggio G. , Cooper R. , Newton A. , Wild C. , Gupta S. , Khangura J.K. , Villa-Roel C. , McCabe C.
Published: June 2016

Introduction: Substance use and unstable housing are associated with heavy use of the Emergency Department (ED). This study examined the impact of substance use and unstable housing on the probability of future ED use. Methods: Case-control study of patients presenting to an urban ED. Patients were eligible if they were unstably housed for the past 30 days, and/or if their chief complaint was related to substance use. Following written informed consent, patients completed a baseline survey and health care use was tracked via electronic medical records for the next six months. Controls were enrolled in a 1:4 ratio. More than 2 ED visits during the follow-up was pre-specified as a measure of excess ED use. Descriptive analyses included proportions and medians with interquartile ranges (IQR). Binomial logistic regression models were used to estimate the impact of housing status, high-risk alcohol use (AUDIT) and drug use (DUDIT), and combinations of these factors on subsequent acute care system contacts (ED visits + admissions). We controlled for age, gender, comorbidities at baseline, and baseline presenting acuity. Results: 41 controls, 46 substance using, 91 unstably housed, and 31 both unstably housed and substance using patients were enrolled (n = 209). Median ED visits during follow up were 0 (IQR: 0-1.0) for controls, 1.0 (IQR: 0-3.3) for substance using, 1.0 (IQR: 0-4.0) for unstably housed and 4 (IQR: 2-12.3) for unstably housed and substance using patients. The median acute care system contacts over the same period was 1.0 (IQR 0-2.0) for controls, 1.0 (IQR: 0-4.0) for substance using, 1.0 (IQR: 0-5.0) for unstably housed and 4.5 (IQR: 2.8-14.3) for unstably housed and substance using patients. Being unstably housed was the factor most strongly associated with having > 2 ED visits (b=3.288, p<0.005) followed by high-risk alcohol and drug use (b=2.149, p<0.08); high risk alcohol use alone was not significantly associated with ED visits (b=1.939, p<0.1). The number of comorbidities present at baseline was a small but statistically significant additional risk factor (b=0.478, p<0.05). The model correctly predicted 70.1% of patients’ ED utilization status. Conclusion: Unstable housing is a substantial risk factor for ED use; high-risk alcohol and drug use, and comorbidities at baseline increased this risk. The intensity of excess ED use was greatest in patients who were unstably housed and substance using.
P107: Does the use of bedside ultrasound to identify intrauterine pregnancy in the emergency department shorten the length of stay of patients presenting with 1st trimester vaginal bleeding or pelvic pain?
Authors: Ravichandiran M. , Ramkissoon S.
Published: June 2016

Introduction: The use of point of care ultrasound (POCUS) has increased rapidly in the emergency department (ED) over the last 10 years. This study seeks to determine whether the use of POCUS to identify intrauterine pregnancy in the ED shortens the length of stay of patients presenting with first trimester pregnancy-related complaints at The Scarborough Hospital (TSH). Methods: A prospective chart review of women seen at TSH ED for first trimester pregnancy-related complaints was conducted from March 1, 2014 to December 30, 2014. ED physicians were asked to record the names of patients assessed using POCUS in the ED along with their findings during the study period (experimental group). Health Records data was used to find all patients seen in the emergency department during the study period with the chief triage complaint of “Pregnancy Issues < 20 weeks” (control group). Results: A total of 378 patients were identified in the control group and 61 patients were recorded in the experimental group. The outliers were removed from both groups. The POCUS identified an intra-uterine pregnancy (POS IUP) in 47.5% and no definite intrauterine pregnancy (NDIUP) in 52.5%.In the control group, 82.0% proceeded to obtain a formal ultrasound (FUS) after the POCUS. Patients found to have a POS IUP on the POCUS spent 141.48±100.95 minutes in hospital, while patients found to have NDIUP spent 197.10±132.48 minutes in hospital (p=0.07). The POS IUP group spent statistically significantly less time in hospital when compared to the control group (p=0.001). In the POCUS group, patients seen between 1700 and 0800 (i.e. when FUS is not available) spent significantly less time (p=0.02) in hospital (113.13±118.07 minutes, n=24) when compared to patients seen between 0800 and 1700 (208.28±106.35 minutes, n=36). Conclusion: For first-trimester pregnancy-related complaints, POCUS has been shown to be effective in reducing the time that patients spend in hospital at TSH. This difference was especially apparent when POCUS was used at times when FUS was not available. Despite the apparent reluctance of many ED physicians to discharge patients without a FUS, even after identifying a POS IUP on the POCUS, it was evident that this technology was saving time for both physicians and patients.
P113: Presentations for hypoglycemia associated with diabetes mellitus to emergency departments in a Canadian province: a database and cost analysis
Authors: Alexiu C. , Jelinski S. , Chuck A. , Rowe B.H.
Published: June 2016

Introduction: Diabetes mellitus (DM) is a common chronic disease. The Canadian Diabetes Association (CDA) estimated that the national direct cost of DM accounts for approximately 3.5% of public healthcare spending. The economic burden has been estimated to be $12.2 billion in 2010 and projected to increase by $4.7 billion (38%) by 2020. For the province of Alberta, the estimated cost was $1.3 billion in 2015 and $1.7 billion for 2025. The cost of lesser complications of DM like hypoglycemia is not as well understood. The objective of this study was to estimate the health system cost of presentations by adults to Alberta emergency departments (ED) for hypoglycemia associated with type 1 (T1DM) or type 2 (T2DM) diabetes. Methods: A retrospective cohort study was conducted using administrative data for Alberta for a five-year period (fiscal years 2010/11-2014/15). Data were sourced from an administrative database: National Ambulatory Care Reporting System (NACRS). Records of interest were those for ED patients with an ICD-10-CA diagnosis of DM-associated hypoglycemia. A top-down approach was used to estimate costs, excluding physician and ambulance fees. This involved resource intensity weight (RIW), cost of a standard hospital stay (CSHS), and adjustment for inflation (to average value of Canadian dollar for Alberta for January-September 2015). A descriptive analysis was conducted. Results: Data extraction yielded 7,835 presentations by 5,884 patients. The median RIW was 0.0547. RIWs are centered at 1, thus the resource-use/cost of these presentations is well below that of the “average” case. Estimated costs per episode ranged from $108.63 to $4,136.59 with median of $431.11 (IQR: 369.40-639.50). Median episodic subgrouped costs were as follows: sex: $427.72 for males, $439.20 for females; DM type: $411.61 for T1DM, $511.63 for T2DM; date period: $835,862.09/year, $69,655.17/month, $16,030.23/week, and $2,288.78/day. Conclusion: Using population-based administrative data, we identified median costs for DM-associated hypoglycemia of approximately $430/case. Given the frequency, this condition incurs significant healthcare resource use and costs; continued efforts to reduce these ED visits seem worthwhile.