bluuebunny/crossref_metadata_2025 huggingface dataset:
P084: “iPads on!”-Does the provision of iPad devices within an emergency department improve the frequency of access to departmental web KT resources?
Authors: Lewis D. , Atkinson P.R.
Published: May 2017

Introduction: Barriers to implementing effective Knowledge Translation (KT) in Emergency Departments include lack of awareness, lack of time and limited access to resources. In our teaching hospital emergency department (ED), we implemented a new department website (www.sjrhem.ca) to provide improved access to our KT resources. Having published the website, we wanted to know if the addition of conveniently situated pre-configured iPads would increase access to the website from within the department. Methods: The website was developed and first published in April 2014. Two iPads (Apple Inc.) were preconfigured with icons linking directly to targeted pages on our website, including the physician schedule, academic calendar. The iPads were securely located at physician charting desks in October 2014. We used Google analytics to record of webpage visits for 25 weeks before and after the installation of the iPads. Comparisons of mean weekly visits were made using the Student T test (GraphPad Prism). Results: The mean weekly page views for the website increased after the installation of the iPads from a baseline of 103 (95%CI 83.9-121) to 198 (181-215); an increase of 95% (71-120; p<0001). Limiting analysis to devices utilising our hospital IP address we saw a 403% increase in mean weekly page views from 6.4 (4.35-8.45) to 32.2 (26.7-37.8; p<0001). There was a clear step increase in website access from the date of iPad installation. Comparing the increases in average weekly views for those pages with direct link iPad icons (Clinical 11.4 before, 16.6 after, 46%, Schedule 30, 39, 30%, Calendar 10.7, 46.3, 330%, Home 84.1, 115.4, 37%) to the top accessed pages without iPad icons (Research 4.3, 6.2, 44%, Ultrasound 4.9, 9.8, 100%) did not, other than for the calendar page, demonstrate an observable difference. However, when analysed by views originating the hospital IP address, the pages with iPad icons were responsible for 88% of landing pages. Over the last two years the department iPads were responsible for 17% of our page views, with 6 of the department guideline pages featuring in the top 20 pages viewed. Conclusion: Provision of preconfigured iPad devices within the clinical environment of a busy ED significantly increases access from within that environment to a department website.
P085: Dental complaints in the emergency department: a national survey of Canadian EM physicians
Authors: Losier J.H. , Myslik F. , Van Aarsen K. , Cuddy K. , Quinonez C.
Published: May 2017

Introduction: Dental complaints and emergencies are a common emergency department (ED) issue that has not been extensively studied. This study aimed to provide an evaluation of Canadian practice patterns and clinical training relating to dental emergencies in the ED. Methods: We conducted an electronic survey inviting 1520 Canadian emergency medicine (EM) physicians from CAEP’s physician distribution network. Thirty-three questions were asked regarding ED physician training with dental emergencies, practice patterns and comfort with dental care, current available ED dental resources, and how dental care may be improved in Canadian EDs. Standard descriptive statistics were calculated. Results: Survey response rate was 15.1%. Respondents were predominantly male (62.8%) with a mean 15.3 years (SD: ±9.8) of practice, and were primarily CCFP-EM (50.7%) or FRCP-trained (25.6%) in either tertiary (48.0%) or community (36.3%) teaching hospitals. They received broad training on dental issues, but this was limited in scope to ≤1 day of residency (61.4%). A combined majority (59.6%) felt their residency left them somewhat to very unprepared for treating dental complaints, and <40% of physicians reported feeling comfortable with specific, common dental emergency procedures, with the exception of avulsed tooth storage (61.1%). For pain management and local trauma exploration, 36.9% felt somewhat to very uncomfortable performing oral and facial nerve blocks. Many respondents do not have access to any dental emergency supplies (48.0%), or do not know if they have any access (14.2%). Furthermore, 18.9% have no access to any professional support for help with dental emergencies requiring advanced management. Respondents believe dental emergency consultant support is an issue at their centre (62.5%). EM physicians want more training with dental emergencies (79.5%) and improved access to dental-specific emergency materials in their departments (63.7%). The greatest barriers to providing good ED dental care were cost to patients (72.7%), physician comfort treating complaints (54.7%), and clear follow-up with outpatient dental professionals (54.3%). Conclusion: ED physicians feel relatively unprepared by their residency training to treat dental complaints, and professional dental support is an issue in the majority of EDs. Dental care may be improved with more access to training, to dental ED resources and professional support.
P087: Cellulitis and erysipelas management at an academic emergency department: current practice vs the literature
Authors: Martin J. , Wilson C.R. , Chaplin T.
Published: May 2017

Introduction: Cellulitis and erysipelas are common presentations for the general practitioner. Antibiotic therapy targeting beta-hemolytic streptococci and Staphylococcus aureus is the mainstay of treatment for children and adults with these infections. Although evidence-based Canadian guidelines for appropriate management exist, inconsistent practices persist. Our objective was to determine the level of adherence to current evidence by emergency physicians at two academic hospitals in Kingston, Ontario. Methods: We conducted a retrospective chart review of 200 randomly selected electronic medical records. Records belonged to patients with a discharge diagnosis of cellulitis or erysipelas who were seen in the emergency departments of Kingston General Hospital or Hotel Dieu Hospital between January 1 and June 30, 2015. We manually collected data describing patient demographics, medical history, and medical management. Results: There were 707 total visits to the emergency departments in the study period for cellulitis or erysipelas. In our random sample, for those diagnosed with cellulitis, 44% received oral cephalexin alone, which was the most common form of therapy for uncomplicated infection. Of all the patients who received any antibiotics, 36% received at least one dose of parenteral antibiotics, despite only 6.7% showing systemic signs of illness. Emergency physicians chose ceftriaxone for 88% of the patients who received parenteral antibiotics. Conclusion: There was wide variation in antibiotic selection and route of administration for patients with cellulitis or erysipelas. Ceftriaxone was chosen for most patients receiving parenteral antibiotics, but it may not have been the most effective antibiotic in some cases. Overuse of antibiotics is common, and we believe medication choice should be justified based on disease severity, spectrum of activity, and regional antibiotic resistance patterns, among other factors. In conclusion, we found that emergency physicians could more closely align management plans with current guidelines to improve management of uncomplicated infection and reduce unnecessary administration of parenteral antibiotics.
P088: Emergency department utilization of point-of-care ultrasound in the assessment and management of shock
Authors: McGuire J. , Van Aarsen K. , Thompson D. , Hassani B.
Published: May 2017

Introduction: Recent studies have shown that point of care ultrasound is a valuable tool in the assessment and management of shock in the Emergency Department (ED). Despite proven utility, data is limited on the current utilization and quality assurance of POCUS in ED management of shock. The aim of this study was to determine the rate of POCUS use, characterize data collection methods and determine rate of quality assurance in both the ED and Intensive Care Unit (ICU) of a tertiary care academic center. Methods: The study included all patients who visited the ED from Jan-Jun 2015 that were transferred to the ICU, and were in shock, as determined by sBP <90, diagnostic code or vasopressor use. Patient charts, as well as wirelessly archived ultrasound studies were reviewed to determine which patients had POCUS performed, and how the results were recorded. By reviewing formal worksheets archived online, it could be determined if a management change was recommended, if studies were over-read for quality assurance and if improvement was recommended to image acquisition or interpretation. Results: Both departments used POCUS in roughly half of patients presenting in shock (53% ED, 41% ICU) with no statistical difference in usage (Δ12, 95% CI −0.01 to 0.25; p=0.06). Most ED studies (87%), had some form of documentation either on paper or online, however few (9%) had a formal worksheet completed. In comparison 71% of ICU studies had a worksheet. There was no difference in the number of performed scans that were saved electronically (66% ED vs 71% ICU; Δ5%, 95%CI −0.13 to 0.21; p=0.60).In the ICU the majority (77%) of the formal reports recommended a management change as a direct result of scan findings. Furthermore, of worksheets submitted for quality assurance (88%), over half the reviews (55%) suggested an improvement in image acquisition or interpretation. Conclusion: To our knowledge, our study is the first to demonstrate that POCUS is only utilized in about half of the shock cases in ED and ICU. Given that the majority of the formally reported studies in the ICU that were over-read for quality assurance found areas for potential improvement and given that the majority of ED studies were reported informally, it stands to reason that POCUS operators in the ED could benefit from a formalized quality assurance program. Future studies should explore potential barriers to implementation of such a program.
P092: Exercise prescription in the emergency department: patient perceptions
Authors: Milne F. , Leech-Porter K. , Lewis D. , Fraser J. , Hull S. , Atkinson P.R.
Published: May 2017

Introduction: The positive health outcomes of exercise have been well-studied, and exercise prescription has been shown to reduce morbidity in several chronic health conditions. However, patient attitudes around the prescription of exercise in the emergency department (ED) have not been explored. The aim of our pilot study is to explore patients’ willingness and perceptions of exercise being discussed and prescribed in the ED. Methods: This study is a survey of patients who had been previously selected for exercise prescription in a pilot study conducted at a tertiary care ED. This intervention group were given a standardized provincial written prescription to perform moderate exercise for 150 minutes per week. Participants answered a discharge questionnaire and were followed up by a telephone interview 2 months later. A structured interview of opinions around exercise prescription was conducted. Questions included a combination of non-closed style interview questions and Likert scale. Patients rated prescription detail, helpfulness and likelihood on a Likert scale from 1-5 (1 being strongly disagree and 5 being strongly agree). Median values (+/-IQRs) are presented, along with dominant themes. Results: 17 people consented to exercise prescription and follow up surveys. 2 were excluded due to hospital admission. 15 participants were enrolled and completed the discharge survey. Two-month follow up survey response rate was 80%. Patients rated the detail given in their prescription as 5 (+/-1). Helpfulness of prescription was rated as 4 (+/-2). Likelihood to continue exercising based on the prescription was rated as 4 (+/-2). 11/12 participants felt that exercise should be discussed in the Emergency Department either routinely or on a case-by-case basis.1 participant felt it should not be discussed at all. Conclusion: Our study demonstrates that most patients are open to exercise being discussed during their Emergency Department visit, and that the prescription format was well-received by study participants.
P096: A peer-reviewed instructional video is as effective as a standard recorded didactic lecture in medical trainees performing chest tube insertion: a randomized control trial
Authors: Saun T. , Odorizzi S. , Yeung C. , Johnson M. , Bandiera G. , Dev S.
Published: May 2017

Introduction: Online medical education resources are becoming an increasingly used modality and many studies have demonstrated their efficacy in procedural instruction. This study sought to determine whether a standardized online procedural video is as effective as a standard recorded didactic teaching session for chest tube insertion. Methods: A randomized control trial was conducted. Participants were taught how to insert a chest tube with either a recorded didactic teaching session, or a New England Journal of Medicine (NEJM) video. Participants filled out a questionnaire before and after performing the procedure on a cadaver, which was filmed and assessed by two blinded evaluators using a standardized tool. Thirty 4th year medical students from two graduating classes at the Schulich School of Medicine & Dentistry in London, ON were screened for eligibility. Two students did not complete the study, and were excluded. There were 13 students in the NEJM group, and 15 students in the ATLS group. Results: The NEJM group’s average score was 45.2% (±9.6) on the pre-questionnaire, 67.7% (±12.9) for the procedure, and 60.1% (±7.7) on the post-questionnaire. The didactic group’s average score was 42.8% (±10.9) on the pre-questionnaire, 73.7% (±9.9) for the procedure, and 46.5% (±7.5) on the post-questionnaire. There was no difference between the groups on the pre-questionnaire (Δ +2.4%; 95% CI: −5.2, 10.0), or the procedure (Δ −6.0%; 95% CI: −14.6, 2.7). The NEJM group had better scores on the post-questionnaire (Δ +11.15%; 95% CI: 3.7, 18.6). Conclusion: The NEJM video was as effective as video-recorded training for teaching the knowledge and technical skills essential for chest tube insertion. Participants expressed high satisfaction with this modality. It may prove to be a helpful adjunct to standard instruction on the topic.
P099: Age related rates of abnormal CT findings in otherwise low risk minor head injury patients over 65
Authors: Parker B.A. , Ertel M. , Angel-Mira J. , Brar P. , James D. , Cheyne M. , Kandola N. , Brar R. , Sidhu H. , Evtushevski B.
Published: May 2017

Introduction: The Canadian CT Head Rules (CCTHR) is the gold standard clinical decision rule for minor head injuries (MHIs) & has been shown to have 100% sensitivity in identifying patients that would have an abnormal CT scan. Within the CCTHR age 65+ is considered to be an independent risk factor for abnormal head CT. However, a previously published Italian study indicated that the rate of pathological findings in otherwise low risk MHI patients under the age of 79 was less than 1% & significantly lower than those over the age of 80, which brings to question whether the traditional age cut off of 65 as a factor in the CCTHR is too conservative when considering the appropriateness for imaging. Therefore this study aimed to quantify the extent to which low risk MHI patients between the ages of 65-79 present with abnormal CT findings or require neurosurgical intervention when compared to patients over 80 years of age as one of the criteria used in the CCTHR is the age threshold of 65. A secondary objective of this study was to explore abnormal CT rates across these age groupings for otherwise low risk patients on anticoagulants. Methods: A retrospective chart review was conducted on all patients over the age of 65 that received a head CT for a MHI in the Kelowna General Hospital ED between 2006-2016. The imaging results for all patients that had no other risk criteria of the CCTHR other than age were reviewed & rates of pathological findings were compared between patients ages 65-79 & 80+ for both patients on anticoagulants & those not on anticoagulants. Differences in rates by age were compared for statistical significance using the chi-squared & Fisher’s exact test. Results: To date 248 patients have been reviewed & meet the criteria of being >65 & with no other CCTHR criteria. 65% of patients were female & 30% of patients were on anticoagulants. For the patients that were not on anticoagulants, 6 of the 75 (8%) individuals between 65-79 & 9 of the 94 (10%) of those over 80 had abnormal findings on CT (p=0.128). Conclusion: Preliminary results of this study population indicate that there are a significant number of abnormal CT findings in patients under the age of 80 suggesting that patients ages 65-79 without any other CCTHR criteria may still benefit from a head CT. Chart reviews are ongoing & updated results including findings for anti-coagulated patients will be presented at CAEP 2017.
P100: Iterative prototype development of a mobile tele-simulation unit for remote training: an update
Authors: Parsons M.H. , Smith A. , Hoover K.J. , Jewer J. , Noseworthy S. , Pollard M. , Dunne C. , Dubrowski A.
Published: May 2017

Introduction/Innovation Concept: Rural and remote practice of emergency medicine presents unique challenges, particularly when faced with infrequently encountered cases and procedures. Simulation-based training is a valuable tool in the acquisition and maintenance of knowledge and skills; however, simulators are often located in larger centers and they are not widely outside these centers due to geographic, cost and time constraints. Mobile tele-simulation has the potential to overcome barriers but challenges such as comfort, technical issues and ability to teach desired content via tele-simulation must be addressed. We are developing a mobile-tele-simulation unit (MTU) prototype that will enable emergency medicine practitioners and trainees to access simulation-based instruction in rural and remote settings. Methods: Through application of a mixed-methods approach with input of a multidisciplinary team we are iteratively developing an MTU prototype to assess key factors in design and function, including: technical issues, environmental features, and human factors. The Delphi method is being used to collect input from experts on key design components and feedback is also being collected from trainees after participating in trial deployments of the MTU in different educational and environmental settings. Curriculum, Tool, or Material: The effective application of the MTU in a variety of learning settings will be optimized through ongoing evaluation in the iterative design cycle. Feedback to ensure a quality learning experience in the MTU will direct features of physical design and technical performance that can be applied in deployment of the unit. In addition, challenges to the delivery of module content and instructional modality/ features of lessons to be executed will be important considerations as we move toward developing content that can effectively be taught using the MTU. Conclusion: To ensure effective use of tele-simulation in the delivery of a meaningful simulation experience to rural and remote trainees a number of important challenges must be overcome. We describe our evolving multidisciplinary mixed-methods approach to develop an effective mobile tele-simulation unit.
P102: Education and training on mild traumatic brain injury among emergency department physicians: a systematic review
Authors: Patrick S. , Gaudet L. , Krebs L. , Chambers T. , Rowe B.H.
Published: May 2017

Introduction: Mild traumatic brain injury (mTBI) is the most common emergency department (ED) brain injury presentation in Canada; however, an evidence-practice gap in mTBI management exists among ED physicians, evidenced by significant practice variation. This review aimed to identify mTBI education and training directed at ED physicians and its relationship with practice patterns and physician knowledge. Methods: A comprehensive literature search of four bibliographic databases and the grey literature was performed using the keywords: concussion, mTBI, medical education, and continuing medical education. Included studies were required to report on mTBI education received by practicing ED physicians. Two independent reviewers screened unique citations for relevance and reviewed the full-texts of relevant articles. Two independent reviewers assessed methodological quality using the Methodological Index for Non-Randomized Studies. Data were extracted in duplicated onto standardized forms. Throughout the review process, discrepancies were adjudicated by an independent third party. Results: A total of 409 unique results were retrieved, and five studies were included. None of the included studies were of high methodological quality. Included studies assessed mTBI educational toolkits (n=3), conference presentations and academic journal articles (n=1), and pediatric fellowship training (n=1). Training primarily occurred after residency (i.e., continuing professional development) and focused on awareness and management of mTBI. Three studies measured ED physicians self-reported knowledge uptake and retention, and all three studies reported positive changes in knowledge uptake including self-reported increases in appropriate return-to-school and return-to-play recommendations. An increase in appropriate return-to-school/sports recommendations was reported in one study, measured by surveying parents of children diagnosed with mTBI. Conclusion: After a systematic and comprehensive search, few studies on mTBI education or training targeting ED physicians were identified and focused on process change rather than outcomes, highlighting an evidence-practice gap that needs to be addressed to improve mTBI patient care. Existing mTBI knowledge translation, including EDP education, needs to be optimized to effectively disseminate evidence-based best-practices for mTBI management in the ED.
P104: Emergency department opioid overdose study: prevalence of adverse outcomes
Authors: Purssell R. , Godwin J. , Kestler A. , Stenstrom R. , DeWitt C. , Scheuermeyer F.X. , Balshaw R. , Buxton J. , Ho V. , Brar R. , Aquino A. , Blackbourn J. , Brubacher J.R.
Published: May 2017

Introduction: The following adverse outcomes have been described in patients treated in hospital for opioid overdose: pulmonary edema, cardiac dysrhythmias, neurologic injury secondary to hypoxia, prolonged opioid toxicity, recurrent opioid toxicity. In addition, patients who take an overdose of fentanyl may develop fentanyl induced chest rigidity, a life-threatening complication that appears to be uniquely related to fentanyl. The prevalence of adverse outcomes and the clinical course of patients that develop these complications have been described in patients who have taken an overdose of heroin. However, in British Columbia there has been a dramatic increase in the number of patients who overdose on fentanyl and other ultrapotent opioids. The proportion of illicit drug overdose deaths in British Columbia for which fentanyl was detected was only 5% in 2012 but, by 2016, this proportion had increased to 62%. It is very important to know the prevalence of adverse outcomes and the clinical course of patients that develop these adverse outcomes in patients with an overdose of fentanyl or another ultrapotent opioid. Methods: We are completing a retrospective cohort study to evaluate the prevalence of the following adverse outcomes for patients treated in hospital for an opioid overdose: i) pulmonary edema, ii) cardiac dysrhythmias, iii) fentanyl induced chest rigidity, iv) neurologic injury secondary to hypoxia, v) prolonged opioid toxicity, vi) recurrent opioid toxicity. Health records of patients treated for opioid overdose in the emergency departments of six greater Vancouver hospitals from Jan 1, 2014 to Dec 31, 2016 are being reviewed. Results: All Institutional approvals have been obtained. The dataset of 3600 ED visits for opioid overdose has been obtained and 160 health records have now been reviewed as of January 8, 2017. We will describe the type and prevalence (with 95% confidence intervals) of complications sustained by these patients. Conclusion: The results of this study will guide management of opioid overdose in a setting were ultrapotent opioids are commonly ingested. All health records will have been reviewed and the data analysis completed by May 2017.
P105: BC’s public health emergency and naloxone administration by the BC Ambulance Service
Authors: Purssell R. , Mathany L. , Kuo M. , Otterstatter M. , Buxton J. , Balshaw R.
Published: May 2017

Introduction: In 2015, there were 476 apparent illicit drug overdose deaths, prompting BC’s Provincial Health Officer to declare a public health emergency on 14 Apr 2016. Paramedics of BC’s Ambulance Service (BCAS) are on the front lines in this crisis. Here we examine recent trends in the number of suspected overdose events attended by the BCAS and the use of naloxone, an opioid antagonist, by BCAS paramedics. Methods: The BC Centre for Disease Control receives a weekly data feed from BC Emergency Health Services that includes all records from the BCAS Patient Care Record where: naloxone was administered by paramedics; the primary impression code indicates poisoning or overdose; or, the originating call is associated with ingestion poisoning (‘card 23’). Here, we report a descriptive analysis of these data for suspected drug overdose events during the period January 1, 2010 to September 30, 2016. Results: Between January 2010 and September 2016 BCAS paramedics attended 164,227 suspected overdose events; 12% of these events (n=16,944) included naloxone administration by BCAS paramedics. Paralleling the rise in illicit drug overdose deaths in BC, naloxone administration by paramedics has been increasing rapidly, doubling from approximately 180/month in 2014, to 370/month in 2016. When naloxone was administered by paramedics, 90% of these patients were transported, whereas 77% were transported when naloxone was not administered. Administrations occurred most frequently on Friday and Saturday evenings. Almost half (46%) of all naloxone administrations by paramedics were recorded as being in a home or residence; 18% were recorded as occurring on a street or highway. The proportion of naloxone administrations among males has increased yearly. In 2010, 58% of naloxone administrations were in males compared to 69% in 2016. Conclusion: The number of overdose deaths in BC has risen drastically in recent years and the proportion of ambulance calls requiring administration of naloxone by BCAS has climbed correspondingly. The vast majority of overdose cases-especially those requiring naloxone-are transported to the emergency department. With the overdose crisis showing little sign of abating, the administration of naloxone by BC paramedics will continue to be a critical element of the provincial response.
P106: Does training with a modified high-fidelity manikin improve junior residents’ ability to establish transcutaneous pacing in an advanced cardiovascular life support course?
Authors: Ranger C. , Paradis M. , Morris J. , Perron R. , Cournoyer A. , Drolet P. , Paquet J. , Robitaille A.
Published: May 2017

Introduction: Transcutaneous cardiac pacing (TCP), a skill taught in Advanced Cardiovascular Life Support (ACLS) courses, is recommended to treat unstable bradycardia. Training manikins currently available fail to reproduce key features of TCP and might be suboptimal to teach this procedure.The objective of this study was to measure the impact of a modified high-fidelity manikin on junior residents’ TCP competency during an ACLS course. We hypothesized that the use of this high-fidelity manikin improves junior residents’ performances. Methods: This prospective cohort study was conducted at the Université de Montréal in July 2015 and 2016. First-year residents undergoing their mandatory ACLS course were enrolled. The control group (2015) received the traditional curriculum, which includes hands-on teaching on Advanced Life Support manikins. The intervention group (2016) received a similar curriculum, but used a modified high-fidelity manikin that reproduces key features of TCP (e.g. use of multifunction pads, TCP induced patient twitching, ECG artifacts). Cohorts were tested with a simulation scenario requiring TCP. Performances were graded based on six critical tasks: turns on pacer function, applies multifunction pads, recognizes TCP is ineffective, achieves captures, verifies mechanical capture and prescribes sedation. Our primary outcome was successful use of TCP defined as having completed all tasks. Secondary outcomes were the success rates for each task. These were compared using Pearson’s chi-squared test. We anticipated that the success rate of TCP would increase from 20% to 50%. To obtain a power of more than 90%, 48 participants were needed in both cohorts. Results: A total of 50 residents were recruited in both cohorts. No resident that received the traditional curriculum was able to successfully establish TCP while 18 residents trained on the modified high-fidelity manikin succeeded (0 vs 36%, P<0.001). Furthermore, the latter were more likely to recognize when pacing was inefficient (12 vs 86%, P<0.001), obtain ventricular capture (2 vs 48%, P<0.001), and check for a pulse rate to confirm capture (0 vs 48%, P<0.001). Conclusion: Successful use of TCP is a difficult skill to master for junior residents. A modified high-fidelity manikin during ACLS training significantly improves their ability to establish effective pacing.
P109: Characterizing spontaneous improvements in vasovagal syncope
Authors: Sahota I. , Maxey C. , Sheldon R.
Published: May 2017

Introduction: Syncope is responsible for up to 5% of emergency department visits. Vasovagal syncope (VVS) is the most common subtype and can have significant quality of life implications as it is often recurrent. Clinicians treating VVS have limited treatment options available to them and often struggle with prognostication. The aim of our study was to identify patient-specific determinants of VVS improvement or cessation. Methods: Patients (pts) from the Prevention of Syncope Trials (POST) 1 and 2 were included in this study. All patients had VVS according to tilt table testing or a diagnostic point score. Patients had fainted ≥1 time in the previous year and all were followed for up to 1 year after enrollment. Data are presented as median (IQR). Complete responders (CR) did not faint in follow-up; partial responders (PR) fainted ≥1/year less than prior year but did not stop; and non-responders (NR) did not improve or stop. Results: There were 392 patients: 126 males, median age 34 (23,50) who had fainted for 10 (3,22) years and followed for a median of 363 (148,376) days. There were 225 CR (57%), 120 PR (31%) and 47 NR (12%). PR subjects were younger: 27 (24,33) years compared to CR (36 (32,42)) years and NR (36 (29,47)) years (p<0.05). Receiver operator characteristic analysis showed age predicted PR (AUC=0.62). Lifetime fainting frequency was 0.67 (0.14,2.00) faints per year, increasing to 4 (2,10) faints in the pre-year and decreasing to 0 (0,1.9) faints in the post-year (p<0.0001). Pts had similar syncope frequency in the distant past (PR, 1.14 faints/year; CR, 0.68 faints/year; NR, 0.58 faints/year) but PR pts worsened markedly prior to enrollment. PR subjects fainted much more in the prior year: 10 (6,18) faints compared CR (3 (2,3) faints, p<0.0001) and NR (2 (2,4) faints, p<0.05). Receiver operator characteristic analysis showed prior year faints predicted PR well (AUC=0.81). There was no significant interaction with treatment (metoprolol in POST 1, fludrocortisone in POST 2). Conclusion: After specialist consultation, 57% of VVS patients stop fainting and 31% improve incompletely without a significant treatment effect. Patients who will improve incompletely can be accurately selected based on younger age and more frequent syncope. Older patients with less frequent syncope are 83% likely to stop fainting. These findings will help counsel pts and select candidates for medical therapy.
P113: Comparison of age-adjusted and clinical probability-adjusted D-dimer for diagnosing pulmonary embolism
Authors: Sharif S. , Kearon C. , Li M. , Eventov M. , Jiang R. , Sneath P.E. , Leung R. , de Wit K.
Published: May 2017

Introduction: Diagnosing pulmonary embolism (PE) in the emergency department can be challenging due to non-specific signs and symptoms; this often results in the over-utilization of CT pulmonary angiography (CT-PA). In 2013, the American College of Chest Physicians identified CT-PA as one of the top five avoidable tests. Age-adjusted D-dimer has been shown to decrease CT utilization rates. Recently, clinical-probability adjusted D-dimer has been promoted as an alternative strategy to reduce CT scanning. The aim of this study is to compare the safety and efficacy of the age-adjusted D-dimer rule and the clinical probability-adjusted D-dimer rule in Canadian ED patients tested for PE. Methods: This was a retrospective chart review of ED patients investigated for PE at two hospitals from April 2013 to March 2015 (24 months). Inclusion criteria were the ED physician ordered CT-PA, Ventilation-Perfusion (VQ) scan or D-dimer for investigation of PE. Patients under the age of 18 were excluded. PE was defined as CT/VQ diagnosis of acute PE or acute PE/DVT in 30-day follow-up. Trained researchers extracted anonymized data. The age-adjusted D-dimer and the clinical probability-adjusted D-dimer rules were applied retrospectively. The rate of CT/VQ imaging and the false negative rates were calculated. Results: In total, 1,189 patients were tested for PE. 1,129 patients had a D-dimer test and a Wells score less than 4.0. 364/1,129 (32.3%, 95%CI 29.6-35.0%) would have undergone imaging for PE if the age-adjusted D-dimer rule was used. 1,120 patients had a D-dimer test and a Wells score less than 6.0. 217/1,120 patients (19.4%, 95%CI 17.2-21.2%) would have undergone imaging for PE if the clinical probability-adjusted D-dimer rule was used. The false-negative rate for the age-adjusted D-dimer rule was 0.3% (95%CI 0.1-0.9%). The false-negative rate of the clinical probability-adjusted D-dimer was 1.0% (95%CI 0.5-1.9%). Conclusion: The false-negative rates for both the age-adjusted D-dimer and clinical probability-adjusted D-dimer are low. The clinical probability-adjusted D-dimer results in a 13% absolute reduction in CT scanning compared to age-adjusted D-dimer.
P115: Limiting functional decline in seniors evaluated for minor injuries in the ED
Authors: Sirois M. , Daoust R. , Émond M. , Blais J. , Aubertin-Leheudre M. , Fruteau de Laclos L. , Martel D.
Published: May 2017

Introduction: In its prospective cohorts of independent seniors with minor injuries, the CETIe (Canadian Emergency Team Initiative) has shown that minor injuries trigger a spiral of mobility and functional decline in 18% of those seniors up to 6 months post-injury. Because of their effects on multiple physiological systems, multicomponent mobility interventions with physical exercises are among the best methods to limit frailty and improve mobility & function in seniors. Methods: Pilot clinical trial among 4 groups of seniors, discharged home post-ED consultation for minor injuries. Interventions: 2x 1 hour /week/12 weeks with muscle strengthening, functional and balance exercises under kinesiology supervision either at home (Jintronix tele-rehabilitation platform) or at community-based programs (YWCA, PIED) vs usual ED-discharge (CONTROL). Measures:
Functional Status in ADLs (Older American Ressources Scale); Global physical & social functioning (SF-12 questionnaire), physical activity level (RAPA questionnaire) at initial ED visit and at 3 months. Results: 135 seniors were included (Controls: n=50; PIED: n=28; Jintronix: n=27; YWCA: n=18). Mean age was 72.6±6.2 years, 45% were prefrail, 86% and 8% had a fall or motor vehicle-related injuries (e.g. fractures: 30%; contusions: 37%). Intervention could start as early as 7 days post-injury. Seniors in interventions (Home, YWCA or PIED) maintained or improved their functional status (84% vs 60%, p≤0.05), their physical (73% vs 59%, p=0.05) and social (45% vs 23%, p≤0.05) functioning. While 21% of CONTROLs improved their physical activity level three months post-injury, 46% of seniors in intervention did (p≤0.05). Conclusion: Exercises-based interventions can help improve seniors’ function and mobility after a minor injury.
P117: Emergency physicians are choosing wisely when transfusing patients with non-variceal upper gastrointestinal bleeding and hemoglobins >70 g/L
Authors: Stebner B. , Vasquez C. , Grigat D. , Joseph C. , Lang E. , Kaplan G. , Novak K.
Published: May 2017

Introduction: Acute non-variceal upper gastrointestinal bleeding (NVUGIB) is a common presentation to the Emergency Department (ED) associated with significant mortality and morbidity. Recent evidence suggests that overt-transfusion is associated with poor patient outcomes and that stable patients above a hemoglobin (hgb) above 70 g/L should be transfused judiciously. This retrospective health records review aims to determine the proportion of NVUGIB patients with hemoglobin greater than 70 g/L who were still appropriately transfused based on clinical parameters. Methods: A retrospective review was conducted on randomly selected patients that presented to one of two major tertiary hospitals with a primary diagnosis of NVUGIB who received blood products, despite a presenting hemoglobin >70 g/L. Standardized case report forms were developed through chart abstraction using a pilot-tested template. The appropriateness of transfusion was then adjudicated separately by a trained medical student and an emergency physician; discrepancies were resolved by discussion. Results: Following independent review of the charts, agreement was met on 94% (45/48) of the charts and after collective discussion 100% consensus was reached and all 48 patients’ transfusion appropriateness and categorized into one of three groups: Appropriate, Potentially avoidable, and clearly avoidable. Only in 22.9% (11/48) of the cases was transfusion deemed to be clearly avoidable while emergency physicians appropriately transfused 45.8% (22/48) of patients based on clinical status and other factors. In 31.3% (15/48) of the cases, transfusion was potentially avoidable in favor of other management options. We calculated the mean GBS for the appropriate, potentially avoidable, and clearly avoidable categories yielding 12.8, 12.7, and 10.2 respectively. Mortality occurred in 2 of the 48 cases (4%). Conclusion: In most instances, emergency physicians are effectively integrating hemoglobin thresholds and clinical status to determine if a patients with NVUGIB and hgb >70 require blood products.
P118: Effects of system design on laboratory utilization in the emergency department: the case for INR & aPTT
Authors: Tawadrous D. , Skoretz T. , Thompson D. , Detombe S.A. , Van Aarsen K.
Published: May 2017

Introduction: In the context of a shrinking healthcare budget, poor physician cost awareness, and continued over-utilization of low-value tests in the emergency department, we re-designed our computerized order entry system to reduce the use of coagulation testing. Methods: A hospital-based prospective pre-post analysis following de-bundling of INRPTT testing in two academic hospital emergency departments (annual visits 140,000). All participants aged 18 years or older undergoing evaluation and/or treatment at either of during the period of August 1, 2015 to July 24, 2016 were included. Primary outcome is coagulation testing utilization rates and associated costs. Results: Unbundling INR and aPTT testing resulted in significantly decreased bundled INRPTT testing relative to baseline (INRPTT tests per patient per day: 0.60 [95% CI: 0.57-0.62] vs. 0.98 [95% CI: 0.98-0.99], p=0.000), with significantly increased targeted testing (INR tests per patient per day: 0.39 [95% CI: 0.37-0.42] vs. 0.00 [95% CI: 0.00-0.01], p=0.000; PTT tests per patient per day: 0.33 [95% CI: 0.30-0.36] vs. 0.01 [95% CI: 0.00-0.01], p=0.000). As a result of unbundling, there was a significant decrease in costs associated with coagulation testing relative to baseline (Cost per day: $958.52 [INRPTT $592.78+INR $183.91+PTT $181.83] vs. $1,074.50 [INRPTT $1,069.76+INR $2.06+PTT $2.68], p=0.000), realizing estimated daily and yearly savings of $115.98 and $42,332.70, respectively. Conclusion: Compared to baseline practice patterns, unbundling coagulation testing resulted in the reduction of coagulation testing suggesting system design and user workflows to be an integral factor to provider practice patterns. Given the significant cost-savings, we recommend institutions carefully re-evaluate their system design and user workflows to optimize emergency department laboratory utilization.
P120: Clinical decision rule evidence ranking and use in clinical practice
Authors: Upadhye S. , Chorley A. , Arora N.
Published: May 2017

Introduction: The 2007 SAEM Knowledge Translation consensus conference proposed areas of research in evidence-based clinical algorithms (EBCAs) using clinical decision rules (CDRs) and practice guidelines (CPGs). This project sought to explore the evidence awareness and utilization of various clinical decision rules (CDRs) in emergency medicine (EM) practice. This project sought to explore the evidence awareness and utilization of various clinical decision rules (CDRs) in emergency medicine (EM) practice. Methods: An international survey was administered via international EM organizations using modified Dillman methods. Categories of CDRs included imaging (7), infections (3), neurology (2), venous thromboembolism (VTE; 2), and other (2). Evidence levels were queried using JAMA User’s Guide CDR rating scales (Levels I-IV). Confidence with supporting evidence and utilization of CDRs in practice were assessed on 7-point Likert scales. Correlation of evidence understanding and practice utilization were calculated using Spearman rho methods. Results: The majority of respondents (n=378) were Canadian (72%), <15 years full practice (64%), residency trained (90%), and trained in CDR methods (73%). Evidence ratings were deemed high for all CDRs, although confidence in evidence ratings and practice utilization were more variable for specific rules. Comfort with evidence ranking and utilization in clinical practice were highly correlated (ρ<0.0002). Conclusion: Among Canadian residency CDR trained physicians, evidence ranking is strongly correlated with use in self-reported clinical practice. There is insufficient data from non-Canadian respondents to draw firm correlations. Their remains opportunity to fully disseminate high quality CDRs and encourage incorporation into EBCA practice.
P126: Are we transfusing wisely? An analysis of transfusion practices among hemodynamically stable patients with anemia in four hospitals
Authors: Wang A.A. , Lonergan K. , Wang D. , Lang E.
Published: May 2017

Introduction: To help mitigated risks associated with red blood cell transfusions, CWC guidelines recommend practicing restrictively. Transfusion Medicine recommends using a Hgb threshold of 70 g/L, and ordering a single unit at a time (with reassessment after). The purpose of this study is to investigate Emergency Department (ED) compliance with these more restrictive thresholds among hemodynamically stable patients. Methods: A retrospective analysis was performed on data from all emergency visits to 4 adult urban ED sites from July 1 2014 to July 1 2016. We excluded unstable patients (CTAS1, temperature >38°C, HR >100 bpm, RR >20 rpm, systolic BP <90 mmHg, and O2 sat <85%) and certain others (patients without a Hgb level, patients who left without being seen, and orders cancelled via patient discharge). After applying exclusion factors, we examined transfusions ordered. Appropriateness was assessed using the stratified Choosing Wisely Canada Guidelines for Transfusion. As an adjunct, IV iron therapy data was also analyzed for the same period between July 1 2014 and July 1 2016, excluding patients who did not have a Hgb level. Results: We identified 1329 eligible patients (54% female), with a mean age of 68 and average first hemoglobin of 72 g/L. Across all groups, 16% of patients received only 1 unit of blood. 19% of transfused patients had a hemoglobin less than 60 g/L, 45% had a Hgb <70 g/L, 32% had a Hgb 70-80 g/L, 14% had a Hgb 81-90 g/L, and 8% had a Hgb >90 g/L. Over the same two-year period, 178 patients received IV iron. The average Hgb for those patients was 82 g/L. Conclusion: A retrospective analysis documents a significant likelihood of pRBC over-transfusion among Emergency Department physicians and an underutilization of IV iron therapy for certain hemodynamically stable and anemic patients. The development of audit and feedback methods, and creation of a clinical pathway may help address the rate of over-transfusion.
P127: Paramedics perception of working in Nova Scotia’s collaborative emergency centres
Authors: Whalen S. , Goldstein J. , Urquhart R. , Carter A.
Published: May 2017

Introduction: The Collaborative Emergency Centre (CEC) model of health care delivery was implemented in rural Nova Scotia in July 2011 without an identifiable, directly comparable precedent. It features interprofessional teams working under one roof with the goal of providing improved access to timely primary health care, and appropriate access to 24/7 emergency care. One important component of the CEC model is overnight staffing by a paramedic/registered nurse team consulting with an offsite physician via telephone. Our objective was to ascertain the attitudes, feelings and experiences of paramedics working within the CEC construct. Methods: We conducted a qualitative study, guided by the principles of grounded theory. Semi-structured telephone interviews were carried out by the principal investigator with paramedics with experience working in a CEC in the province of Nova Scotia. Interviews were recorded, transcribed and analyzed. Analysis involved an inductive and deductive grounded approach using constant comparative analysis. Data collection and analysis continued until thematic saturation was reached. Results: Fourteen paramedics participated in the study. The majority were male (n=10, 71%), with a mean age of 44 years (STD=8.8) and mean experience as a paramedic of 14 years (STD=9.7). Four major themes were identified from the data: 1) leadership support, encompassing support from Emergency Health Services and Government prior to and after implementation of the model, 2) team work and collaboration, including interprofessional relationships among members of the healthcare team, 3) value to patients and the communities, and 4) professional and personal benefits of working in CECs. Conclusion: Paramedics have found working in CECs to be both professionally and personally rewarding. They perceive the CEC model to be of great value to the patients and communities it serves. Key lessons that might help future expansion of the model in Nova Scotia and other jurisdictions across the country include the importance of building and strengthening relationships between paramedics and nurses, and the need for greater feedback and support from leadership.