bluuebunny/crossref_metadata_2025 huggingface dataset:
P082: Ethical management of incidental findings in emergency care: A critical interpretive literature review
Authors: Iskander R. , Ells C.
Published: May 2020

Introduction: Incidental findings (IFs) are findings discovered in the course of healthcare (e.g., blood tests, genetic tests, imaging) that are unrelated to the primary purpose for which a test was sought. Some IFs constitute new knowledge that have implications for patient autonomy and welfare. IFs found in emergency departments (EDs) are difficult to manage, with one study reporting that of 392 patients with IFs, 122 had no follow-up and 242 had no electronic record of the finding. Methods: A critical interpretive literature review was conducted to explore current practices regarding identification, disclosure, and management of IFs in EDs, and to identify ethical challenges that require research focus and policy reform. The search strategy included ‘incidental findings’ AND ‘emergency’ and derivatives, retrieving 12,021 studies from databases including PubMed, Scopus, and Web of Science, as well as handsearching and reference list searching. Following screening, 97 studies were included. Data was extracted, analyzed using descriptive statistics, and then critically interpreted to capture key ideas. Results: Of 97 included articles, 75 have relevant empirical data. Of the 75, most literature (89%) presented the frequency of IFs in EDs, with an average frequency of 34%. Most (84%) did not report on patient disclosure rates or follow-up rates. When reported, patient notification rates are as low as 2.6% with an average of 15% over 12 studies. Empirical studies included in the review do not address ethical principles or patient preferences on disclosure. The literature reveals suggestions to manage IFs in EDs, including implementation of automatic feedback or alert mechanisms, clarification of responsibilities within treating teams, protocols in radiology departments, and improvements to patient documentation. Test results by letter are noted as insufficient because patients are unable to ask questions. Authors suggest further research on optimal follow-up recommendations to alleviate patient and physician distress. Further results will be presented, critically interpreted, and discussed, with attention to ethical implications and challenges. Conclusion: The literature on IFs in EDs focuses too narrowly on frequency, with ad hoc suggestions for practice, research, and policy changes to improve the ethical management of IFs. Numerous factors, including crucial knowledge gaps, contribute to inadequate management of IFs arising in EDs. Research and ethics informed policy guidance is needed.
P088: Dextrose 50% versus dextrose 10% or dextrose titration for the treatment of out-of-hospital hypoglycemia; a systematic review and meta-analysis
Authors: Hurtubise M. , Greene J. , Stirling A. , Carter A. , Swain J. , Brown R. , Fidgen D. , Goldstein J.
Published: May 2020

Introduction: Paramedics commonly administer intravenous dextrose to severely hypoglycemic patients. Typically, the treatment provided is a 25g ampule of 50% dextrose (D50). This dose of D50 is meant to ensure a return to consciousness. However, this dose may be unnecessary and lead to harm or difficulties regulating blood glucose post treatment. We hypothesize that a lower dose such as dextrose 10% (D10) or titrating the D50 to desired level of consciousness may be optimal and avoid adverse events. Methods: We systematically searched Medline, Embase, CINAHL and Cochrane Central on June 5th 2019. PRISMA guidelines were followed. The GRADE methods and risk of bias assessments were applied to determine the certainty of the evidence. We included primary literature investigating the use of intravenous dextrose in hypoglycemic diabetic patients presenting to paramedics or the emergency department. Outcomes of interest were related to the safe and effective reversal of symptoms and blood glucose levels (BGL). Results: 660 abstracts were screened, 40 full text articles, with eight studies included. Data from three randomized controlled trials and five observational studies were analyzed. A single RCT comparing D10 to D50 was identified. The primary significant finding of the study was an increased post-treatment glycemic profile by 3.2 mmol/L in the D50 group; no other outcomes had significant differences between groups. When comparing pooled data from all the included studies we find higher symptom resolution in the D10 group compared to the D50 group; at 99.8% and 94.9% respectively. However, the mean time to resolution was approximately 4 minutes longer in the D10 group (4.1 minutes (D50) and 8 minutes (D10)). There was more need for subsequent doses in the D10 group at 23.0% versus 16.5% in the D50 group. The post treatment glycemic profile was lower in the D10 group at 5.9 mmol/L versus 8.5 mmol/L in the D50 group. Both treatments had nearly complete resolution of hypoglycemia; 98.7% (D50) and 99.2% (D10). No adverse events were observed in the D10 group (0/871) compared to 12/133 adverse events in the D50 group. Conclusion: D10 may be as effective as D50 at resolving symptoms and correcting hypoglycemia. Although the desired effect can take several minutes longer there appear to be fewer adverse events. The post treatment glycemic profile may facilitate less challenging ongoing glucose management by the patients.
P091: Essential elements to implementing the paramedics providing palliative care at home program: an application of the Consolidated Framework for Implementation Research (CFIR)
Authors: Carter A. , Harrison M. , Kryworuchko J. , Kekwaletswe T. , Wong S. , Goldstein J. , Warner G.
Published: May 2020

Introduction: Providing comfort care support at home without transport to hospital has not traditionally been part of paramedic practice. The innovative Paramedics Providing Palliative Care at Home Program includes a new clinical practice guideline, medications, a database to share goals of care, and palliative care training. This study aimed to determine essential elements for scale and spread of this model of care through the application of an implementation science model, the Consolidated Framework for Implementation Research (CFIR). Methods: Deliberative dialogue sessions were held with paramedic, palliative care, primary care, and administrative experts in a province that had the Program (Nova Scotia, March 2018) and one that had not (British Columbia, July 2018). Sessions were audio recorded and transcribed. The CFIR was used as the foundation for a framework analysis, which was conducted by four team members independently. Themes were derived by consensus with the broader research team. Results: Inter-sectoral communication between paramedics and other health care providers was key, and challenging due to privacy concerns. Relationships with health care providers are critical to promoting the new model of care to patients, managing expectations, and providing follow up/ongoing care. Training was an essential characteristic of the intervention that can be adapted to suit local needs, although cost is a factor. There were challenges due to the culture and implementation climate as a shift in the mindset of paramedics away from traditional roles is required to implement the model. Paramedic champions can play an important role in shifting the mindset of paramedics towards a new way of practice Conclusion: The CFIR construct of cosmopolitanism, emphasizing the importance of breaking down silos and engaging diverse stakeholders, emerged as one of the most important. This will be helpful for successful scale and spread of the program.
P092: Caregiver perspectives on children's functional outcomes following fracture: a qualitative study
Authors: Golden-Plotnik S. , Ali S. , Poonai N. , Drendel A. , Mackenzie M. , Michael V.
Published: May 2020

Introduction: Fractures are a common childhood presentation to the emergency department (ED). While ED providers are aware of treating pain, we are less aware of the functional impact of these fractures. Eighty percent of children with a fracture experience compromise in their daily function. Understanding the functional outcomes of fractures will help optimize discharge instructions for at-home care. The primary objective of our study was to describe caregivers' perspectives on the impact of their child's fracture on: (1) child functioning, (2) caregiver functioning and (3) family life. Methods: We performed a qualitative study interviewing caregivers of children (5 to 11 years) who received care for acute (< 24 hours old), non-operative long bone fractures at a Canadian tertiary care pediatric ED. Audio-recorded, semi-structured telephone interviews were completed 1-2 weeks post-ED visit, until thematic saturation was achieved. Transcripts were read and coded by two researchers concurrent with data collection. We applied content analysis to the interview material, explicating themes to summarize the data utilizing NVivo software. Results: Twenty-five interviews were completed. Most children (23/25) suffered upper extremity fractures and most participants were mothers (21/25). All caregivers reported a change in their child's function. The most commonly affected areas included: sleep, play and activities of daily living (ADL's; ie. dressing, bathing, eating). Children were impacted by pain and related negative emotional responses. All children required additional help from their caregivers to carry out ADL's. Strategies included changing household routines and missing work. Importantly, caregivers described a disrupted family dynamic. Adapting to their injured child's functional deficits and caring for pain and distress took time and attention away from the household's previously well-functioning routine. This burden was felt by all family members. Key concerns from caregivers included pain management, fracture healing/complications, and regression of their child's independence. Conclusion: Function is universally impaired in younger children with fractures. We suggest 5 main points to include in discharge instructions: (1) monitoring pain and providing analgesia, (2) helping children with ADL's, even if previously independent, (3) allotting extra time for morning and bedtime routines, (4) offering safe choices for play and (5) coaching children in positive thinking and problem-solving.
P093: Evaluating factors related to effective interpersonal communication during mandatory paramedic patches
Authors: Kelton D. , Doran S. , Davis M. , Van Aarsen K. , Momic J.
Published: May 2020

Introduction: Delegation of controlled medical acts by physicians to paramedics is an important component of the prehospital care framework. Where directives indicate that physician input is needed before proceeding with certain interventions, online medical control (a “patch”) exists to facilitate communication between a paramedic and a Base Hospital Physician (BHP) to request an order to proceed with that intervention. Many factors contribute to success or failure of effective interpersonal communication during a patch call. The aim of this study was to examine areas of potential improvement in communication between paramedics and physicians during the patch call. Methods: Prehospital paramedic calls that included a mandatory patch point (excluding requests for termination of resuscitation and those records which were unavailable) were identified through review of all patch records from January 1, 2014 to December 31, 2017 for Paramedic Services in our region. Written Ambulance Call Reports (ACRs) and audio recordings of paramedic patches were obtained and reviewed. Pre-specified time intervals, clinical factors, specific patch requests and resulting orders from the BHP to the paramedics were extracted. Differences between groups were compared using t-tests. Results: 214 records were initially identified and screened. 91 ACRs and audio patch records were included in the analysis. 51/91 (56%) of patch order requests for interventions were granted by the BHP. Clarification of information provided by the paramedic or reframing of the paramedic's request was required less often, but not statistically significant, in calls ultimately resulting in granted requests versus those that were not granted (mean 1.4 versus 1.7, Δ-0.28; 95% CI -0.75-0.18 p = 0.64). The mean time from first contact with the BHP to statement of the request was similar in patches where the request was granted and not granted (44.9 versus 46.3, Δ-1.4; 95% CI -12.9-10.2, p = 0.49). Conclusion: The communication between BHPs and paramedics is an important and under-investigated component of prehospital emergency care. This retrospective review presents some novel targets for further research and potential education in patch communication to improve efficiency and quality of prehospital care for patients.
P094: Use of high fidelity simulation to improve quality of care within Correction Canada's maximum security facilities: A Canada's first
Authors: Gilic F. , Valeriano A. , Johannessen E. , Nickason J. , Irving I.
Published: May 2020

Innovation Concept: Nurses working in corrections facilities are routinely faced with acute care scenarios requiring skilled management. There are also increasing numbers of inmates with chronic health conditions and acute exacerbations. Correctional Service Canada (CSC) has partnered with the Clinical Simulation Lab at Queen's University to develop a simulation-based training program aimed at improving acute care skills of Corrections nurses and staff. This novel quality improvement program encompasses a range of presentations that commonly occur in correctional environments. Methods: The program consisted of two laboratory sessions focused on acute care and trauma followed by an in-situ simulation session. The sessions were organized around the 4-component instructional design that enhances complex learning. Both lab sessions began with scaffolded part-task training (IV insertion, ECG interpretation, airway, circulatory support, etc) and then progressed to six team-based high-fidelity simulations that covered cardiac arrhythmias, hypoglycemia, agitated delirium, drug overdoses, and immediate trauma management. Participants rated the effectiveness of each session. Lastly, an in-situ session was conducted at the Millhaven maximum security facility for nursing and correctional staff. It comprised of five scenarios that incorporated actors, a high-fidelity manikin, and simulated security issues. Participants completed a validated self-assessment before and after the session grading themselves on aspects of acute care. Curriculum, Tool, or Material: Our multi-modal simulation curriculum enhanced self-assessed knowledge of CSC learners. Of 71 attendees in the acute care skills session, 70 agreed or strongly agreed that the exercise enhanced their knowledge, satisfied their expectations, and conveyed information applicable to their practice. All 13 participants in the trauma session agreed or strongly agreed to these sentiments. We used Wilcox signed rank test item by item on the in-situ questionnaire. There was significant improvement in majority of skills sampled: airway management, O2 delivery, team organization and assessment/treatment of cardiac arrest. Conclusion: This initiative is the first time high-fidelity simulation training has been used with Corrections nurses and the first in-situ simulation in a maximum security institution in Canada. The sessions were well-liked by participants and were assessed as very effective, validating the demand for further implementation of clinical simulation in correctional facilities.
P101: Seasonal variations in modes of presentation in ST elevation myocardial infarction
Authors: Forestell B. , Hewitt M. , Mondoux S.
Published: May 2020

Introduction: For patients with ST-elevation myocardial infarction (STEMI), time is myocardium. The sooner STEMI patients receive a definitive intervention, the better their outcomes. The first point of contact with the healthcare system for STEMI patients is either via Emergency Medical Services (EMS), or self-transportation to an Emergency Department (ED). Despite a reduced time to definitive intervention, STEMI patients who use EMS have increased mortality compared to those who self-transport. In an effort to optimize STEMI care pathways, we characterized variations in modes of presentation of STEMI patients in our region. Methods: This study used a retrospective cohort design from a regional STEMI registry. Patients presenting to Hamilton Health Sciences between January 1, 2016, and December 31, 2018 meeting STEMI criteria were included in our analyses. Self-transport patients were analyzed from two academic EDs in Hamilton, Ontario. One hospital was PCI capable and the other, non-PCI capable. Patients transferred from other health regions were excluded from our analyses. Dichotomous variables were compared using χ2 tests. Group means were compared using the Student t-test. Results: Eight hundred and seventy-one patients were included in the analysis, including 675 EMS users, and 196 self-transporting to EDs. Patients self-transporting to EDs were younger (61.5 v. 64.6 y, p < 0.002) and more often male (82.6 v. 69.2%, p < 0.0002) compared to EMS users. There was a non-significant trend towards an increased rate of all STEMI patients self-transporting in the summer months compared to the winter (63 of 215 in summer v. 41 of 185 in winter, 29.3 v. 22.2%, p = 0.10). Comparative analysis between both hospitals yielded an increased rate of self-transportation to the PCI-capable hospital in the summer months compared to winter (46 v. 28, 23.2 v. 16.3%, p = 0.09), but not the other hospital (18 v. 13, 10.6 v. 8.3%, p = 0.57). The majority of self-transporting patients came from postal codes bordering each hospital, and the different rates of self-transportation between hospitals were not associated with recent specialist follow up at those sites. Conclusion: Seasonal trends in modes of presentation in STEMI patients may present an opportunity to optimize STEMI care pathways through resource utilization and patient education. A larger dataset and possible multicenter analysis should be done to determine if significance is obtained with larger sample size.
P103: How knowledgeable are Canadian emergency physicians about the risk factors of completing suicide in patients presenting to the ED with suicidal thoughts?
Authors: Fernandes J. , Chakraborty A. , Scheuermeyer F. , Barbic S. , Barbic D.
Published: May 2020

Introduction: Suicide is the 9th leading cause of death in Canada, and a common reason for patients to present to Canadian emergency departments (ED). Little knowledge exists around Canadian emergency physicians (EPs) knowledge about the risk factors of completing suicide in patients presenting to the ED with suicidal thoughts. Methods: We developed a web-based survey on suicide knowledge, which was pilot tested by two emergency physicians and one psychiatrist for clarity and content. The survey was distributed via email to attending physician members of the Canadian Association of Emergency Physicians. Data were described using counts, means, medians and interquartile ranges. Results: 193 EPs responded to the survey (response rate 16%), with 42% of EPs practicing in Ontario. 35% of EPs were female, the mean age was 48 (95% CI 47.3-48.7), and mean years in practice was 17 (95% CI 16.3-17.7). Academic practice location was reported by 55% of EPs, and 81% reported access to an inpatient psychiatry service. Twenty four (12%) EPs had personally considered suicide, and 45% had experience with suicide in their personal lives. The top three risk factors for suicide identified by EPs were: intent for suicide (90%); a plan for suicide (89%); prior suicide attempt (88%). A majority of EPs were able to correctly identify the other risk factors for completion of suicide except for the following: diagnosis of anxiety disorder (25%), chronic substance use (43%), prior non-suicidal self-injury (37%), low socioeconomic status (34%). Conclusion: Canadian EPs have substantial personal experience with suicide. A majority of EPs were able to correctly identify known risk factors for suicide completion, yet important gaps in knowledge exist.
P106: The BPPV Tool: designing a smartphone app to aid in the diagnosis of benign paroxysmal positional vertigo
Authors: Farnell L. , Anderson M. , Savage D. , Ohle R.
Published: May 2020

Innovation Concept: Dizziness is an increasingly common presenting complaint in the emergency department (ED), accounting for >2% of visits annually or almost 30% of visits in patients aged over 65. Approximately half of all cases of dizziness in older adults are caused by benign paroxysmal positional vertigo (BPPV). The use of computerized tomography (CT) to rule out serious but rare underlying central nervous system (CNS) causes in patients with dizziness in the ED is increasing despite guidelines supporting the use of clinical exam maneuvers such as the Dix-Hallpike test and therapeutic canalith repositioning maneuvers. Evidence indicates that these clinical tools are underutilized due to clinician discomfort or lack of understanding in performing and interpreting the maneuvers, supporting brief and accessible clinical resources that incorporate video examples to address this. Methods: Through an iterative process the authors have developed a smartphone app that is designed to facilitate the clinical diagnosis of BPPV and provide treatment maneuvers where appropriate. The app is being tested by clinicians practicing emergency medicine or primary care in Northern Ontario. Curriculum, Tool, or Material: The BPPV Tool is designed as a step-wise guide to diagnose BPPV. Clinicians will be prompted to perform specific exam maneuvers based on clinical findings, and can follow short example videos or written directions. Potentially precipitated nystagmus is described along with example videos. Provocative tests include the Dix-Hallpike and Supine Roll. If appropriate, the clinician will be prompted to perform therapeutic repositioning maneuvers such as the Epley or Gufoni, with associated sample videos, descriptions, and billing information where available. If at any point a clinician's exam findings are not in keeping with a diagnosis of BPPV, they will be alerted to this and stop progressing through the app. Conclusion: The BPPV Tool is an accessible and easily disseminated smartphone app designed to improve clinician comfort in reliably diagnosing BPPV. Diagnosing this common condition clinically is supported in the literature and can reduce the number of unnecessary CT scans performed, which would reduce healthcare costs and ED length of stay for these visits, and could reduce the number of patient transfers from peripheral sites for imaging.
P108: Alcohol-related emergency department visits by youth aged 12-24: trends over 4 years in one Canadian centre
Authors: Murray H. , Erlikhman L. , Graham T. , Walker M.
Published: May 2020

Introduction: Recent evidence shows an increase in alcohol-related emergency department (ED) visits among youth. Highly publicized collegiate rituals such as Homecoming may create a climate for problematic alcohol use. This study describes the frequency of youth alcohol-related ED visits per year and during pre-specified ritualized drinking dates in one academic centre. Methods: This was a chart review of patients aged 12-24 with alcohol-related ED presentations between Sept 2013-Aug 2017. The National Ambulatory Care Reporting System (NACRS) database was searched for visits with ICD-10 codes related to alcohol. The Canadian Hospital Injury Reporting and Prevention Program (CHIRPP) database was also searched using the keyword alcohol. Duplicate visits were removed. Visits were excluded if patients had a history of psychosis, were held in the ED for involuntary psychiatric assessment, were homeless, were inmates from a correctional institute, if alcohol use was not mentioned and for complaints of sexual assault/domestic violence. Data abstraction by two reviewers used a standard form with variables predetermined. Differences were resolved with third party adjudication. Interrater reliability of the reviewers was assessed through duplicate review of 10% of randomly selected charts. A further 10% were assessed by a 3rd reviewer for extraction accuracy. Results: A total of 3,256 ED visits were identified with 777 meeting exclusion criteria. The remaining 2,479 visits were reviewed and subclassified into injury (51.8%), acute intoxication (45.1%) and mental health issue (3.2%). Interrater agreement was high for extracted variables with Kappa scores > 0.8. Despite a decrease in the region's youth population during the study period (28,325 to 25,125), overall standardized ED visits by youth increased by 12% (66,538 to 78,129). Adjusted for population, youth alcohol-related visits increased by 86.4% from 1,557 in 2013-14 to 2,902 in 2016-17. Co-ingestion of other substances was reported in 292 (11.8%) of visits, with cannabis the most common (57%). The 17 pre-specified ritualized days saw 578 (23.3%) of ED visits. Conclusion: Alcohol-related ED visits in youth are increasing in our region. Ritualized drinking dates appear to be particularly risky for youth with high rates of observed ED utilization. Strategies to manage high volume ritual days are being piloted, including temporary diversion to an in-hospital sobriety centre.
P115: Improving the diagnosis of pulmonary embolism in the emergency department
Authors: de Wit K. , Zarabi S. , Chan T. , Germini F. , Mondoux S. , Kearon C.
Published: May 2020

Background: Emergency physicians (EPs) can choose from several evidence-based pathways to diagnose pulmonary embolism (PE), however literature suggests that EPs frequently use computer tomography (CT) scanning as a stand-alone test for PE. This is a program of research to improve adherence to evidence-based PE diagnosis in the emergency department (ED). Aim Statement: To create a novel approach to PE diagnosis in the ED based on a framework explaining EP diagnostic PE behaviour and barriers to using evidence-based PE testing. Measures & Design: We conducted two types of qualitative interviews: 1). EPs in 5 Canadian cities watched videos of 2 simulated cases and then explained how they would test the patient. 2). Semi-structured EP interviews using the theoretical domains framework (TDF). The results of our analyses informed the construction of an explanatory framework for common EP diagnostic PE behaviours. Barriers to evidence-based behaviour were classified into domains. A Canadian EP expert group reviewed these results along with the existing evidence on ED PE diagnostic implementation. We developed a new approach to diagnosis of PE in the ED which addresses each of our domains. Evaluation/Results: We conducted 71 interviews. We identified 4 domains, each addressed in our pathway. ‘PE in a mythical and deadly beast’ PE kills and can masquerade so EPs look for PE in places where it does not exist and are rewarded for ‘over-testing’. Response: Creating a departmental conversation about missing PE, talking about the facts, busting the myths. EP feedback on PE testing including positive rate. ‘The end goal is CTPE’ PE creates anxiety for EPs and ordering a CTPE hands over responsibility to the radiologist. Response: A departmental protocol for PE testing which starts with D-dimer for every patient. Shifting focus to ruling out PE with D-dimer. Protocol is automated once initiated by EP. ‘PERC eases anxiety’ PERC is documented when it is negative and allows EP to stop. Response: EPs can choose to use and document PERC. ‘No-one has been fighting for the Wells score’ Poor understanding of purpose and function. Often at odds to Gestalt. Response: Protocol does not use Wells score. Discussion/Impact: We have developed a new diagnostic PE pathway which addresses current barriers to evidence-based practice which we will evaluate further.
P118: Impact des bêtabloquants pour les patients souffrant d'un arrêt cardiorespiratoire avec un rythme initial défibrillable : une revue systématique et méta-analyse
Authors: Cournoyer A. , Soucy-Legault J. , Frégeau A. , Iseppon M. , Iseppon A. , Lessard J. , Huard V. , Morris J. , Chauny J. , Marquis M. , Paquet J. , Daoust R.
Published: May 2020

Introduction: Malgré les progrès au niveau des soins de réanimation lors des dernières années, le pronostic des patients souffrant d'un arrêt cardiorespiratoire (ACR) demeure abyssal et aucun médicament ne semble influencer leur devenir au long cours. Cependant, les résultats de quelques études évaluant l'impact des bêtabloqueurs chez cette population s'avèrent cependant très encourageants. L'objectif de cette revue systématique, est d’évaluer l’évidence disponible quant à l'impact des bêtabloqueurs sur le devenir des patients traités pour un ACR dont le rythme initial est défibrillable. Methods: La présente revue systématique a été préalablement enregistrée sur Prospero (CRD42018105453). Les moteurs de recherche Medline, Embase et CENTRAL ont été fouillés de leur création jusqu'au 17 octobre 2018. La recherche de littérature grise s'est faite via Web of Science et Google Scholar. Les références de tous les articles inclus ainsi que des méta-analyses existantes sur le sujet ont également été révisées. Tous les types de devis ont été considérés, sauf les études de cas et les séries de cas. Les études devaient inclure des adultes (16 ans et plus) en ACR dont le rythme initial était défibrillable, dont une partie avait reçu un médicament bêtabloquants par voie intraveineuse pendant leur ACR et l'autre un traitement standard, et présenter une mesure de résultat centrée sur le patient (retour de circulation spontanée [RCS], survie ou bon devenir neurologique). La qualité des articles a été évaluée à l'aide du ‘Newcastle Ottawa scale’. Results: Deux études observationnelles rétrospectives, menées auprès d'un total de 66 patients, ont été incluses. Il y avait une association positive entre l'administration de bêtabloquants et l'occurrence d'un RCS (rapport de cotes [RC] = 5.76 [intervalle de confiance {IC} à 95% = 1.79-18.52], p = 0.003), ainsi qu'avec la présence d'un bon devenir neurologique (RC = 4.42 [IC95% = 1.05 - 18.56], p = 0.04). Une telle association n'a cependant pas été observée par rapport à la survie au congé hospitalier. Conclusion: L'administration de bêtabloquants semble associé à un meilleur devenir chez les patients en ACR avec un rythme initial défibrillable. Étant donné la nature du devis de ces études et leur petite taille, une étude prospective de qualité serait nécessaire afin de déterminer l'efficacité de cette classe de médicament et de faire une recommandation forte à ce sujet.
P128: Emergency physician efficiency benchmarking and diagnostic imaging use
Authors: Weerasinghe S. , Chandratilleke N. , Campbell S.
Published: May 2020

Introduction: As part of our audit and feedback process, Emergency Physicians (EP) are provided feedback on flow metrics and resource utilization. We analysed the relationship between two specific metrics (adjusted workload measurement (AWM), with the number of patients seen per hour adjusted according to CTAS, and percentage of revisits within 72 hours and diagnostic imaging use. Unfortunately, we are unable to evaluate quality of care, nor appropriateness of DI indication at this stage. Methods: We used data from 86 physicians at an academic ED, from June 1, 2015 to May31, 2017. The Data Envelope Analysis (DEA) model incorporated performance quality measures as outputs and efficiency measures as inputs. DEA is a method widely used in physician performance analysis. The method provides a score (optimal performance efficiency-OPE) for each EP based on maximization of the performance (AWM) in proportion to the combination of efficient use of resources, diagnostic imaging (DI). The score was used to regress against demographic characteristics and training. Results: The median AWM was 6.8 (quartiles Q1-Q3 = 6.4-7.4) with the median diagnostic imaging use of percentages of CT (median = 10.1, 8.6-11.9), US (median = 4.7, 3.6-5.6) and x-ray (80, 74-84). The EPs who had highest AWM combined with least use of DI (OPE = 100%), provided median AWM of 9.1 (range 8.9-9.7) with percentage CT, US and x-ray medians at 5.8% (range 5.8-6.2), 2.7% (range 2.4-3.6) and 59% (range 59-72). These provided benchmarks for optimal performance indicators. We found statistically significant differences of OPE scores based on gender (men 4.1 times higher, p < 0.001) and degree (RCPS < CCFPEM, Other < CCFPEM, p < 0.001). Overall AWM diminishes at the rate of 14% (95%CI: 9-20%) for a combination of 100 DI tests ordered. In order to reach the optimal level of performance, to reach an OPE of 100%, the median CT use percentage needs to be reduced by 6% (quartile range 3.9- 7.7%), US by 2.2% (quartile range 1.5-3.4%) and x-rays by 37.2% (quartile range: 26.8-44.3%). Return visit rates were not associated with DI use, possibly due to homogeneity in the percentage of return visits. Conclusion: We found significant performance variations in terms of average workload measurement in proportion to the weighted average of diagnostic imaging use, with increased use of DI being associated with decreasing AWM. Percentage of return visits does not appear to be useful as a performance indicator.
P134: Orthopedic procedural videos as teaching tools in emergency medicine
Authors: Bazaracai N. , Dong J.
Published: May 2020

Innovation Concept: Video has been proven to be an effective educational tool that is valued by learners and objectively improves knowledge and testing scores. It can simplify complex concepts and is more efficient and effective than audio or reading in tests of 3-day material recall. Our objective in this project was to develop a series of instructional videos geared towards emergency and family physicians on proper application of casts and splints in the emergency department. Methods: We created two procedural videos, each 5-6 minutes long. They each reviewed the process, indications, and precise steps for application for each of two splints: the ulnar gutter and the thumb spica. After finalizing the videos, we created a survey to assess feedback, asking questions about the applicability of the videos to the viewer's clinical practice, how interesting they found the content of the videos, what they liked and disliked, and how willing they would be to access future procedural videos if we were to make them. We also had respondents provide suggestions for topics of future videos. We then sent the videos and accompanying survey to a group of McMaster University medical students, residents, and attending physicians in family medicine and emergency medicine. Upon reviewed the results it seemed that there was a large difference in perceived utility of the videos between attending physicians and trainees, and so we proceeded with subgroup analysis of trainees and staff. Curriculum, Tool, or Material: Orthopedic procedural videos as described above. Conclusion: Using a 5-point Likert scale, we found that overall trainees (4.3, SD 0.76 CI 0.41) found the videos more useful and interesting than did attending physicians (3.4, SD 0.68 CI 0.37), with respondents commenting that they were very clear and easy to follow for junior trainees. Most respondents also indicated that they would access future videos we made (4.2 SD 0.74 CI 0.39 for trainees, 3.2 SD 0.65 SI 0.34) for attendings). Future directions include making the videos more concise and adding more visual summaries to improve viewership, and targeting videos for specific learner level. We are hoping to implement these videos into future curriculum development for our learners and, if successful, other Emergency Medicine residency programs across Canada.
P136: What happens to bypassed trauma patients meeting Field Trauma Triage standards?
Authors: Austin M. , Sinclair J. , Leduc S. , Duncan S. , Rouleau J. , Price P. , Evans C. , Vaillancourt C.
Published: May 2020

Introduction: Prehospital field trauma triage (FTT) standards were reviewed and revised in 2014 based on the recommendations of the Centers for Disease Control and Prevention. The FTT standard allows a hospital bypass and direct transport, within 30 min, to a lead trauma hospital (LTH). Our objectives were to assess the impact of the newly introduced prehospital FTT standard and to describe the emergency department (ED) management and outcomes of patients that had bypassed closer hospitals. Methods: We conducted a 12-month multi-centred health record review of paramedic and ED records following the implementation of the 4 step FTT standard (step 1: vital signs and level of consciousness (physiologic), step 2: anatomical injury, step 3: mechanism and step 4: special considerations) in nine paramedic services across Eastern Ontario. We included adult trauma patients transported as urgent that met FTT standard, regardless of transport time. We developed and piloted a data collection tool and obtained consensus on all definitions. The primary outcome was the rate of appropriate triage to a LTH which was defined as: ISS ≥12, admitted to intensive care unit (ICU), non-orthopedic surgery, or death. We have reported descriptive statistics. Results: 570 patients were included: mean age 48.8, male 68.9%, falls 29.6%, motor vehicle collisions 20.2%, stab wounds 10.5%, transported to a LTH 76.5% (n = 436). 72.2% (n = 315) of patients transported to a LTH had bypassed a closer hospital and 126/306 (41.2%) of those were determined to be an appropriate triage to LTH (9 patients had missing outcomes). ED management included: CT head/cervical spine 69.9%, ultrasound 53.6%, xray 51.6%, intubation 15.0%, sedation 11.1%, tranexamic acid 9.8%, blood transfusion 8.2%, fracture reduction 6.9%, tube thoracostomy 5.9%. Outcomes included: ISS ≥ 12 32.7%, admitted to ICU 15.0%, non-orthopedic surgery 11.1%, death 8.8%. Others included: admission to hospital 57.5%, mean LOS 12.8 days, orthopedic surgery 16.3% and discharged from ED 37.3%. Conclusion: Despite a high number of admissions, the majority of trauma patients bypassed to a LTH were considered over-triaged, with a low number of ED procedures and non-orthopedic surgeries. Continued work is needed to appropriately identify patients requiring transport to a LTH.
P138: Parental leave policies and culture for physicians in emergency medicine
Authors: Andruko J. , Green T.
Published: May 2020

Introduction: Medicine demands a sacrifice of physicians’ personal life, but culture has slowly changed towards valuing a balanced work life. Parental leave is linked to better physical and mental health, but policies and culture surrounding parental leave are largely unstudied in the Canadian Emergency Medicine landscape. Anecdotally, experiences vary widely. This study was designed to determine what proportion of Canadian Emergency Departments have formal parental leave policies (maternity, paternity, and other ex. adoption) and what proportion of Canadian EM physicians are satisfied with their department's parental leave policies. Methods: Two surveys were generated; one to assess attitudes and experiences of emergency physicians, and a second survey for department chiefs assessed the policies and their features. These were approved by the UBC REB and distributed through the CAEP Research Committee. Primary outcomes were physician satisfaction with their department's parental leave policy (4-5/5 Likert Scale), and departments with a formal parental leave policy (Y/N). Results: 38% (8/21) of department chiefs reported having a formal policy for maternity leave, 29% (6/21) for paternity leave, and 24% (5/21) other. The survey of Emergency Physicians revealed similar rates at 48% (90/187) maternity, 40% (70/184) paternity, 29% (53/181) other. Among physicians who were aware of them, 69% (62/90) were somewhat or very satisfied with the maternity leave policies, 58% (51/88) with paternity leave policies, and 48% (39/81) with other parental leave. Less than 10% were somewhat or very dissatisfied with any of these. Several department chiefs commented that they had never refused anyone parental leave, but have no formal policy. However, 87% (147/187) of physicians reported a formal maternity leave policy was somewhat or very important to them; similarly 80% (134/187) paternity leave. Less than 15% felt each was somewhat or extremely unimportant. Conclusion: Presence and type of parental leave policy varies across the country. Most physicians were satisfied with the support they had available, but the vast majority felt that a formal maternity and paternity leave policy itself was important. This study would suggest that, without actually changing practice, the introduction of a formal parental leave policy is of value. Our research group will use this data to collaborate on a template parental leave policy to be made available for this purpose.
P139: The impact of a pancreatitis admission algorithm on emergency department length of stay in a tertiary care academic hospital
Authors: Albina A. , Kegel F. , Dankoff F. , Clark G.
Published: May 2020

Background: Emergency department (ED) overcrowding is associated with a broad spectrum of poor medical outcomes, including medical errors, mortality, higher rates of leaving without being seen, and reduced patient and physician satisfaction. The largest contributor to overcrowding is access block – the inability of admitted patients to access in-patient beds from the ED. One component to addressing access block involves streamlining the decision process to rapidly determine which hospital service will admit the patient. Aim Statement: As of Sep 2011, admission algorithms at our institution were supported and formalised. The pancreatitis algorithm clarified whether general surgery or internal medicine would admit ED patients with pancreatitis. We hypothesize that this prior uncertainty delayed the admission decision and prolonged ED length of stay (LOS) for patients with pancreatitis. Our project evaluates whether implementing a pancreatitis admission algorithm at our institution reduced ED time to disposition (TTD) and LOS. Measures & Design: A retrospective review was conducted in a tertiary care academic hospital in Montreal for all adult ED patients diagnosed with pancreatitis from Apr 2010 to Mar 2014. The data was used to plot separate run charts for ED TTD and LOS. Serial measurements of each outcome were used to monitor change and evaluate for special cause variation. The mean ED LOS and TTD before and after algorithm implementation were also compared using the Student's t test. Evaluation/Results: Over four years, a total of 365 ED patients were diagnosed with pancreatitis and 287 (79%) were admitted. The mean ED LOS for patients with pancreatitis decreased following the implementation of an admission algorithm (1616 vs. 1418 mins, p = 0.05). The mean ED TTD was also reduced (1171 vs. 899 mins, p = 0.0006). A non-random signal of change was suggested by a shift above the median prior to algorithm implementation and one below the median following. Discussion/Impact: This project demonstrates that in a busy tertiary care academic hospital, an admission algorithm helped reduce ED TTD and LOS for patients with pancreatitis. This proves especially valuable when considering the potential applicability of such algorithms to other disease processes, such as gastrointestinal bleeding and congestive heart failure, among others. Future studies demonstrating this external applicability, and the impact of such decision algorithms on physician decision fatigue and within non-academic institutions, proves warranted.
LO04: Decreasing emergency department length of stay for patients with acute atrial fibrillation and flutter: a cluster-randomized trial
Authors: Stiell I. , Eagles D. , Perry J. , Archambault P. , Thiruganasambandamoorthy V. , Parkash R. , Mercier E. , Morris J. , Godin D. , Davis P. , Clark G. , Gosselin S. , Mathieu B. , Pomerleau B. , Rhee S. , Kaban G. , Brown E. , Taljaard M.
Published: May 2020

Introduction: CAEP recently developed the acute atrial fibrillation (AF) and flutter (AFL) [AAFF] Best Practices Checklist to promote optimal care and guidance on cardioversion and rapid discharge of patients with AAFF. We sought to assess the impact of implementing the Checklist into large Canadian EDs. Methods: We conducted a pragmatic stepped-wedge cluster randomized trial in 11 large Canadian ED sites in five provinces, over 14 months. All hospitals started in the control period (usual care), and then crossed over to the intervention period in random sequence, one hospital per month. We enrolled consecutive, stable patients presenting with AAFF, where symptoms required ED management. Our intervention was informed by qualitative stakeholder interviews to identify perceived barriers and enablers for rapid discharge of AAFF patients. The many interventions included local champions, presentation of the Checklist to physicians in group sessions, an online training module, a smartphone app, and targeted audit and feedback. The primary outcome was length of stay in ED in minutes from time of arrival to time of disposition, and this was analyzed at the individual patient-level using linear mixed effects regression accounting for the stepped-wedge design. We estimated a sample size of 800 patients. Results: We enrolled 844 patients with none lost to follow-up. Those in the control (N = 316) and intervention periods (N = 528) were similar for all characteristics including mean age (61.2 vs 64.2 yrs), duration of AAFF (8.1 vs 7.7 hrs), AF (88.6% vs 82.9%), AFL (11.4% vs 17.1%), and mean initial heart rate (119.6 vs 119.9 bpm). Median lengths of stay for the control and intervention periods respectively were 413.0 vs. 354.0 minutes (P < 0.001). Comparing control to intervention, there was an increase in: use of antiarrhythmic drugs (37.4% vs 47.4%; P < 0.01), electrical cardioversion (45.1% vs 56.8%; P < 0.01), and discharge in sinus rhythm (75.3% vs. 86.7%; P < 0.001). There was a decrease in ED consultations to cardiology and medicine (49.7% vs 41.1%; P < 0.01), but a small but insignificant increase in anticoagulant prescriptions (39.6% vs 46.5%; P = 0.21). Conclusion: This multicenter implementation of the CAEP Best Practices Checklist led to a significant decrease in ED length of stay along with more ED cardioversions, fewer ED consultations, and more discharges in sinus rhythm. Widespread and rigorous adoption of the CAEP Checklist should lead to improved care of AAFF patients in all Canadian EDs.