bluuebunny/crossref_metadata_2025 huggingface dataset:
The brain's kryptonite: Overview of punctate white matter lesions in neonates
Authors: Nguyen Annie L.A. , Ding Yang , Suffren Sabrina , Londono Irène , Luck David , Lodygensky Gregory A.
Published: May 2019

With increasing advances in the field of medical brain imaging, the known spectrum of white matter lesions has expanded, and we can now assess the presence of punctate white matter lesions (PWML). These focal small lesions are quite frequently detected in the preterm infant and in full‐term infants with congenital heart malformations with, some studies reporting a link between these lesions and adverse long‐term outcomes. The etiology of PWML has sparked a lot of questions over the years, some of which still remain unanswered. This narrative review will bring an overview of current knowledge and their significant clinical importance in the newborn brain.
Living with decade-old vulnerabilities in datacentre software
Authors: Goldberg Daniel
Published: May 2019

The underlying assumption that system software is secure by design has proven wrong many times over the past few years. A modern approach to network design requires a new basis – ‘assume vulnerable’. As all defence is inherently a risk management process this assumption requires different methods of quantifying network security, performing changes and monitoring.

The assumption that system software is secure by design has been proven wrong many times and a better approach to network design is – ‘assume vulnerable’.

As all defence is inherently a risk management process, this assumption requires different methods of quantifying network security, performing changes and monitoring. It is reasonable to assume that there are numerous vulnerabilities across different core system programs and libraries, explains Daniel Goldberg of Guardicore.
What can machine learning do for information security?
Authors: Mathews Alex
Published: May 2019

Machine learning is one of the most used and abused terms in information technology today. But what does it actually mean for the security community? When applied correctly, machine learning can significantly improve the effectiveness of security controls, but it is no cure-all. This is especially true while creating or refining a piece of software or an application: developers should first define the problem they want to solve and then select the most appropriate technology, instead of the other way around.
Social Work
Authors: Harms Louise , Connolly Marie
Published: May 2019

Social workers draw on a variety of theoretical perspectives to inform their practice and understand the diverse settings in which they work. Social Work: From Theory to Practice explores practice theories through the discipline's unique interpretive lens and demonstrates how these can be understood and enacted by practitioners in human services settings. This third edition includes new material on trauma-informed practice and Indigenous practice, as well as enhanced content relating to child protection and family violence, and narrative approaches. New practitioner reflections and case studies illustrate how theory influences practice and facilitates change. Thought-provoking case study discussion questions prompt students to reflect on key concepts and develop strategies for practice. Highly readable and engaging, Social Work: From Theory to Practice builds a strong foundation for theoretically informed practice. This text enables practitioners to develop the skills required to confidently and critically evaluate their work as they respond in complex practice contexts.
LO57: Twitter as an educational tool for medical students in their emergency medicine rotation: a prospective cohort study
Authors: Bruneau V. , Paradis M. , Lonergan A. , Morris J. , Piette E. , Castonguay V. , Paquet J. , Cournoyer A.
Published: May 2019

Introduction: Different tools have been developed to complement medical training, and improve student learning. Although social media has been described as an innovative educational strategy, evidence for its use is scarce in emergency medicine (EM). The primary outcome of this study was to evaluate whether brief teaching points (tweets) sent to medical students (MS) via a Twitter feed, would yield better exam score at the end of an emergency medicine (EM) rotation. Methods: Participants included in this prospective cohort study were MS completing an EM rotation at our tertiary care academic center. The control group was recruited from December 2016 to November 2017 and the experimental group from November 2017 to November 2018. The MS in the experimental group were invited to follow a Twitter feed. A total of 32 EM-related tweets based on learning objectives were sent out throughout the 4 week rotation. At the end of the rotation, MS of both cohorts took an exam and completed a survey of assiduity and appreciation. Exam scores were compared using t-tests. Results: A total of 80 MS were recruited for the study, 38 in the experimental cohort. Average exam scores were similar in both cohorts (control = 63 ± 9% vs experimental = 64 ± 8% for a mean difference of -2% [95%CI -6 to 2], p = 0.37). Of the experimental group, only 7 (18%) of the participants reported viewing more than 50% of the tweets. There was no difference between mean exam scores of this sub-group and that of the control cohort (66 ± 10% for a mean difference of 4% [95%CI -4 to 11], p = 0.33). The majority (n = 20, 53%) of the MS in the experimental cohort did not read any tweets. When compared to the rest of the experimental cohort MS who reported viewing ≥50% of the tweets found the Twitter feed to be a useful educational tool. Indeed, on a 3 item Likert scale used to evaluate different aspects of appreciation, they found the Twitter feed to be beneficial to their rotation (86% vs 13%, p < 0.001) as well as helpful in patient management (71% vs 16%, p = 0.001). These same MS would have liked more tweets (100% vs 19%, p < 0.001) and would like to use Twitter in other rotations (100% vs 32%, p = 0.005). Conclusion: In this study, there was no difference in the exam scores between MS having access to regular EM-focused educational tweets in comparison to those who did not. Results also found a lower than expected assiduity of MS to the educational Twitter feed, although those who used it significantly found it useful.
LO68: Does point-of-care ultrasonography change actual care delivered by shock subcategory in emergency department patients with undifferentiated hypotension? An international randomized controlled trial from the SHoC-ED investigators
Authors: Atkinson P. , Hunter S. , Peach M. , Taylor L. , Kanji A. , Lewis D. , Milne J. , Diegelmann L. , Lamprecht H. , Stander M. , Lussier D. , Pham C. , Henneberry R. , Howlett M. , Mekwan J. , Ramrattan B. , Middleton J. , Van Hoving D. , Richardson L. , Stoica G. , French J.
Published: May 2019

Introduction: Although use of point of care ultrasound (PoCUS) protocols for patients with undifferentiated hypotension in the Emergency Department (ED) is widespread, our previously reported SHoC-ED study showed no clear survival or length of stay benefit for patients assessed with PoCUS. In this analysis, we examine if the use of PoCUS changed fluid administration and rates of other emergency interventions between patients with different shock types. The primary comparison was between cardiogenic and non-cardiogenic shock types. Methods: A post-hoc analysis was completed on the database from an RCT of 273 patients who presented to the ED with undifferentiated hypotension (SBP <100 or shock index > 1) and who had been randomized to receive standard care with or without PoCUS in 6 centres in Canada and South Africa. PoCUS-trained physicians performed scans after initial assessment. Shock categories and diagnoses recorded at 60 minutes after ED presentation, were used to allocate patients into subcategories of shock for analysis of treatment. We analyzed actual care delivered including initial IV fluid bolus volumes (mL), rates of inotrope use and major procedures. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: Although there were expected differences in the mean fluid bolus volume between patients with non-cardiogenic and cardiogenic shock, there was no difference in fluid bolus volume between the control and PoCUS groups (non-cardiogenic control 1878 mL (95% CI 1550 – 2206 mL) vs. non-cardiogenic PoCUS 1687 mL (1458 – 1916 mL); and cardiogenic control 768 mL (194 – 1341 mL) vs. cardiogenic PoCUS 981 mL (341 – 1620 mL). Likewise there were no differences in rates of inotrope administration, or major procedures for any of the subcategories of shock between the control group and PoCUS group patients. The most common subcategory of shock was distributive. Conclusion: Despite differences in care delivered by subcategory of shock, we did not find any significant difference in actual care delivered between patients who were examined using PoCUS and those who were not. This may help to explain the previously reported lack of outcome difference between groups.
LO72: Assessing non-technical skills in prehospital ad hoc team resuscitation
Authors: Evans J. , Lingard D. , Peddle D. , Slack M.
Published: May 2019

Introduction: Successful resuscitation in the ED cannot occur without a viable patient, and in many cases patient viability is dependent upon optimal prehospital resuscitation performed by ad hoc teams formed in real time. Currently, little is known about the cognitive and interpersonal skills, or non-technical skills, that are essential for effective team collaboration under these conditions. We have completed a scoping review to provide a state of the literature and develop a taxonomy of the non-technical skills pertinent to ad hoc teams in prehospital settings. Methods: Our scoping review searched four databases (EMBASE, Medline, Cinahl, and Psychinfo) for articles related to resuscitation in acute care settings. No date criteria were applied, but only full text articles written in English were included. Articles underwent two-reviewer title & abstract screening, full text screening, and analysis. A quality review asked three questions: Are keywords defined? Is the article well-situated within the existing literature? Does the article contribute back to the existing body of knowledge? Although statistical analyses are not appropriate for this scoping review, analysis included a descriptive-analytical framework for organizing data. Results: Of 6932 screened articles, 38 were included in analysis, five articles examined prehospital teams, and one addressed the ad hoc nature of these teams. Only one of these articles met our three quality criteria. Nevertheless, our analysis suggests a rudimentary taxonomy whereby the primary objective of a team leader is to overcome this barrier by facilitating the development of optimal team situational awareness, fostered through timely and accurate briefings with closed-loop communication. Conclusion: This scoping review has identified that non-technical skills pertaining to resuscitation in acute care settings are becoming a widely examined phenomenon; however, few studies contribute in any meaningful way to our understanding of how non-technical skills training can be tailored to those performing as members of ad hoc prehospital resuscitation teams. As the need for interprofessional training is becoming more pressing, we anticipate this review will provide essential guidance for future inquiry as well as design for both educational models and organizational systems-based interventions.
LO74: Exploring emergency physicians’ ability to predict patient admission and decrease consultation to admission time
Authors: Lee E. , Kwok E. , Vaillancourt C.
Published: May 2019

Introduction: Delay of hospital admission until completion of assessment by consultants is a major contributor to emergency department (ED) crowding. We measured emergency physicians’ (EP) ability to predict patient admission, and estimated potential time saved if EPs could request a bed at the time of consultation. Methods: This is a prospective cohort study in a tertiary care center over 4 months using a convenience sample of ED patients requiring consultation. We consecutively recruited patients from purposefully selected shifts to balance day of the week and time of day. We excluded patients younger than 18 years or those likely to be admitted (traumas, strokes, STEMI codes, and CTAS1). We asked EPs to predict patient disposition (admission or alternate disposition) just before consultation. We defined admission as: admission to any service, admission within 48 hours of ED discharge, patients held overnight without bed request, or if bed request was delayed by 12 or more hours, and alternate disposition as any other disposition. We present EP prediction test characteristics using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) with 95% confidence intervals (CI). The potential time saved was calculated from consultation to bed request for admitted patients. Results: Characteristics for the 454 included patients were: mean age 60.1 years, 48.4% male, 46.9% evening presentation, 69.4% were admitted (most commonly by Internal Medicine 26.9%), and median consult to bed request time was 3.5 hours (interquartile range 2.0 – 5.3 hours). Overall EP prediction sensitivity, specificity, PPV and NPV were 90.5% (95%CI 86.7-93.5), 84.2% (95%CI 77.0-89.8), 92.8% (95%CI 89.8-95.0) and 79.6% (95%CI 73.4-84.7) respectively. In other words, EPs correctly predicted 92.8% of patient admissions. The PPV for Internal Medicine was 95.7% (95%CI 89.7-98.4) and ranged from 78.9% (95%CI 53.9-93.0) for Psychiatry to 100% (95%CI 78.1-100) for Family Medicine. A total of 1113.5 hours of ED stretcher time (37.1 hours per shift) could have been saved if EPs initiated a concurrent bed request at time of consultation. Conclusion: EPs correctly predicted 92.8% of patient admissions across a broad field of disciplines. We estimate 1113.5 hours of ED stretcher time could have been saved over the study period if EPs triggered an inpatient bed request at the time of consultation, rather than waiting for the consultants’ disposition decision.
LO81: Interrater agreement and time it takes to assign a Canadian Triage and Acuity Scale score pre and post implementation of eCTAS
Authors: McLeod S. , McCarron J. , Ahmed T. , Scott S. , Ovens H. , Mittmann N. , Borgundvaag B.
Published: May 2019

Introduction: In addition to its clinical utility, the Canadian Triage and Acuity Scale (CTAS) has become an administrative metric used by governments to estimate patient care requirements, emergency department (ED) funding and workload models. The electronic Canadian Triage and Acuity Scale (eCTAS) initiative aims to improve patient safety and quality of care by establishing an electronic triage decision support tool that standardizes that application of national triage guidelines across Ontario. The objective of this study was to evaluate triage times and score agreement in ED settings where eCTAS has been implemented. Methods: This was a prospective, observational study conducted in 7 hospital EDs, selected to represent a mix of triage processes (electronic vs. manual), documentation practices (electronic vs. paper), hospital types (rural, community and teaching) and patient volumes (annual ED census ranged from 38,000 to 136,000). An expert CTAS auditor observed on-duty triage nurses in the ED and assigned independent CTAS in real time. Research assistants not involved in the triage process independently recorded triage time. Interrater agreement was estimated using unweighted and quadratic-weighted kappa statistics with 95% confidence intervals (CIs). Results: 1491 (752 pre-eCTAS, 739 post-implementation) individual patient CTAS assessments were audited over 42 (21 pre-eCTAS, 21 post-implementation) seven-hour triage shifts. Exact modal agreement was achieved for 567 (75.4%) patients pre-eCTAS, compared to 685 (92.7%) patients triaged with eCTAS. Using the auditor's CTAS score as the reference standard, eCTAS significantly reduced the number of patients over-triaged (12.0% vs. 5.1%; Δ 6.9, 95% CI: 4.0, 9.7) and under-triaged (12.6% vs. 2.2%; Δ 10.4, 95% CI: 7.9, 13.2). Interrater agreement was higher with eCTAS (unweighted kappa 0.89 vs 0.63; quadratic-weighted kappa 0.91 vs. 0.71). Research assistants captured triage time for 3808 patients pre-eCTAS and 3489 post implementation of eCTAS. Median triage time was 312 seconds pre-eCTAS and 347 seconds with eCTAS (Δ 35 seconds, 95% CI: 29, 40 seconds). Conclusion: A standardized, electronic approach to performing CTAS assessments improves both clinical decision making and administrative data accuracy without substantially increasing triage time.
LO89: A multi-disciplinary quality improvement project to improve adherence to best practice guidelines for emergency department patients with transient ischemic attack
Authors: Verma A. , Kapoor A. , Kim J. , Kujbid N. , Si K. , Swartz R. , Etchells E. , Symons S. , Yu A.
Published: May 2019

Background: Canadian Stroke Guidelines recommend that Transient Ischemic Attack (TIA) patients at highest risk of stroke recurrence should undergo immediate vascular imaging. Computed tomography angiography (CTA) of the head and neck is recommended over carotid doppler because it allows for enhanced visualization of the intracranial and posterior circulation vasculature. Imaging while patients are in the emergency department (ED) is optimal for high-risk patients because the risk of stroke recurrence is highest in the first 48 hours. Aim Statement: At our hospital, a designated stroke centre, less than 5% of TIA patients meet national recommendations by undergoing CTA in the ED. We sought to increase the rate of CTA in high risk ED TIA patients from less than 5% to at least 80% in 10 months. Measures & Design: We used a multi-faceted approach to improve our adherence to guidelines including: 1) education for staff ED physicians; 2) agreements between ED and radiology to facilitate rapid access to CTA; 3) agreements between ED and neurology for consultations regarding patients with abnormal CTA; and 4) the creation of an electronic decision support tool to guide ED physicians as to which patients require CTA. We measured the rate of CTA in high risk patients biweekly using retrospective chart review of patients referred to the TIA clinic from the ED on a biweekly basis. As a balancing measure, we also measured the rate of CTA in non-high risk patients. Evaluation/Results: Data collection is ongoing. An interim run chart at 19 weeks shows a complete shift above the median after implementation, with CTA rates between 70 and 100%. At the time of submission, we had no downward trends below 80%, showing sustained improvement. The CTA rate in non-high risk patients did also increase. Disucssion/Impact: After 19 weeks of our intervention, 112 (78.9%) of high risk TIA patients had a CTA, compared to 10 (9.8%) in the 19 weeks prior to our intervention. On average, 10-15% of high risk patients will have an identifiable lesion on CTA, leading to immediate change in management (at minimum, an inpatient consultation with neurology). Our multi-faceted approach could be replicated in any ED with the engagement and availability of the same multi-disciplinary team (ED, radiology, and neurology), access to CTA, and electronic orders.
LO90: The clock is ticking: using in situ simulation to improve time to blood delivery in bleeding trauma patients
Authors: Petrosoniak A. , Gray A. , Pavenski K. , McGowan M. , Chartier L.
Published: May 2019

Background: Massive transfusion protocols (MTP) are widely used to rapidly deliver blood products to bleeding trauma patients. Every minute delay in blood product administration in bleeding trauma patients is associated with a 5% increased odds of death. In-situ simulation (ISS) is simulation that takes place in the actual clinical work environment. We used ISS as a novel, prospective and iterative quality improvement (QI) approach to identify and improve MTP steps that impact time to blood delivery (TTBD) during actual trauma resuscitations. Aim Statement: To reduce the TTBD for bleeding trauma patients by 20% over a 12-month ISS-based QI initiative. Measures & Design: We conducted twelve high-fidelity, interprofessional ISS sessions at a Level-1 trauma center in Toronto, Canada. We used clinician video review as well as extensive stakeholder involvement, including with nurses, porters, blood bank and human factors experts, to develop Plan-Do-Study-Act (PDSA) cycles for MTP improvement. Our three major PDSA cycles revolved around: 1) decreasing MTP activation time; 2) reducing the unpredictable and inefficient transport times for the blood itself; and 3) improving the notification of blood product arrival in the trauma bay. Each PDSA cycle was iteratively tested with ISS prior to implementation into clinical care. Outcome measure was the mean TTBD for trauma patients requiring MTP (in minutes, standard deviation [SD]). Process measures included time to MTP activation and porter transport times. Balancing measures included stakeholder satisfaction. Evaluation/Results: Our baseline TTBD for MTP patients was 11.58min (n = 41, SD 6.8). There were 54 trauma patients that had MTP during the ISS-based QI initiative, and their mean TTBD was 10.44min (SD 6.1). The TTBD after the QI initiative was 9.12min, sustained over 1 year (n = 50, SD 5.3; 21.2% relative reduction, p < 0.05). A run chart did not show special cause variation chronologically related to our interventions. Patients in each group were similar in demographic data, trauma characteristics and injury severity score. Discussion/Impact: We achieved a 21.2% reduction in TTBD for trauma patients requiring MTP with an ISS-based QI initiative. ISS represents a novel approach to the identification and iterative testing of process improvements within trauma care. This methodology can and should be included in QI projects in order to safely test and improve processes of care before they impact real patients.
MP04: rEDirect: safety and compliance of an emergency department diversion protocol for mental health and addictions patients
Authors: Bismah V. , Prpic J. , Michaud S. , Sykes N. , Amyotte J. , Myre P. , Ohle R.
Published: May 2019

Introduction: Transportation of patients better served at an alternative destinations (diversion) is part of a proposed solution to emergency department (ED) overcrowding. We evaluated the pilot implementation of the “Mental Health and Addiction Triage and Transport Protocol”. This is the first Canadian diversion protocol that allows paramedics to transport intoxicated or mental health patients to an alternative facility, bypassing the ED. Our aim was to implement a safe diversion protocol to allow patients to access more appropriate service without transportation to the emergency department. Methods: A retrospective analysis was conducted on patients presenting to EMS with intoxication or psychiatric issues. Study outcomes were protocol compliance, determined through missed protocol opportunities, noncompliance, and protocol failure (presentation to ED within 48 hours of appropriate diversion); and protocol safety, determined through patient morbidity (hospital admission within 48 hours of diversion) and mortality. Data was abstracted from EMS reports, hospital records, and discharge forms from alternative facilities. Data was analyzed qualitatively and quantitatively. Results: From June 1st, 2015 to May 31st, 2016 Greater Sudbury Paramedic Services responded to 1376 calls for mental health or intoxicated patients. 241 (17.5%) met diversion criteria, 158 (12.9%) patients were diverted and 83 (4.6%) met diversion criteria but were transported to the ED. Of the diverted patients 9 (5.6%) represented to the ED <48rs later and were admitted. Of the 158 diversions, 113 (72%) were transported to Withdrawal Management Services (WMS) and 45 (28%) were taken to Crisis Intervention (CI). There was protocol noncompliance in 77 cases, 69 (89.6%) were due to incomplete recording of vital signs; 6 (10.3%) were direct protocol violations of being transferred with vital sings outside the acceptable range. Conclusion: The Mental Health and Addiction Triage and Transport Protocol has the potential to safely divert 1 in 6 mental health or addiction patients to an alternative facility.
MP05: Diagnostic accuracy of point of care ultrasound in undifferentiated hypotension presenting to the emergency department: a systematic review
Authors: Richardson L. , Loubani O. , Atkinson P.
Published: May 2019

Introduction: Undifferentiated hypotension remains one of the most life-threatening presentations to emergency departments (ED) around the world. An accurate and rapid initial assessment is essential, as shock carries a high mortality with multiple unique etiologies and management plans. Point of care ultrasound (PoCUS) has emerged as a promising tool to improve these diagnostic and management challenges, yet its reliability in this setting remains unclear. Methods: We performed a systematic review of Medline, EMBASE, CINAHL, Cochrane, and clinicaltrials.gov databases from inception to June 8, 2018. Databases were reviewed by two independent researchers and all languages were included. The methodological quality of included studies were evaluated using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Our primary outcome was diagnostic accuracy of PoCUS in hypotension, with secondary outcomes including patient outcomes and changes to management. Results: Our literature search revealed 5345 articles after duplicates were removed, leaving 235 articles for full article review. Following full article review, 9 studies remained and were included in the systematic review. There were 2 randomized control trials, 6 prospective cohort trials, and 1 retrospective cohort trial. For our primary outcome of diagnostic accuracy, eight studies were included; we extracted Kappa values ranging from 0.70 to 0.971, pooled sensitivity ranging from 69% to 88%, and pooled specificity ranging from 88% to 96%. Four studies reported on management change including results reporting shorter time to disposition, change in diagnostic test ordering (18% to 31%), change in consultation (13.6%), change in admission location (12%) and change in management plan (25% to 40%). Only one study reported on patient outcomes, which revealed no survival or length of stay benefit. Conclusion: When assessing for the diagnostic accuracy of PoCUS in the setting of undifferentiated hypotension presenting to the emergency department, we found fair consistency between PoCUS and final diagnosis with high Kappa values, fair to good pooled sensitivities, and good to excellent specificities. There was no strong evidence indicating improved outcomes. However, the large amount of heterogeneity amongst studies has limited our ability to make a strong conclusion except that future research should focus on a uniform study design and patient focused outcomes.
MP10: Does early intervention improve outcomes for patients with acute ureteral colic?
Authors: Innes G. , McRae A. , Grafstein E. , Andruchow J. , Law M. , Scheuermeyer F.
Published: May 2019

Introduction: The optimal initial management approach for ureteral colic is unclear. Guidelines recommend spontaneous passage for most patients, but early stone intervention may rapidly terminate acute episodes. We compared 60-day treatment failure rates in matched patients undergoing early intervention versus spontaneous passage. Methods: We used administrative data and structured chart review to study all emergency department (ED) patients at nine Canadian hospitals who had an index ureteral colic visit and a computed tomography (CT) confirmed 2.0-9.9 mm stone during 2014. Using Cox Proportional Hazards models, we assessed 60-day treatment failure, defined as hospitalization or rescue intervention, in patients undergoing early intervention compared to propensity-score matched controls undergoing trial of spontaneous passage. Results: From 3,081 eligible patients, mean age 51 years and 70% male, we matched 577 patients in each group (total 1154). Control and intervention cohorts were balanced on all parameters and propensity scores, which reflect the conditional probability a patient would undergo early intervention, were similarly distributed. In the time to event analysis, 21.8% in both groups experienced the composite primary outcome of treatment failure (difference = 0%; 95% CI, -4.8 to 4.8%). Early intervention patients required more ED revisits (36.1% v. 25.5%; difference 10.6%; 95% CI 5.3 to 15.9%) and more 60-day hospitalizations (20.1% v. 12.8%). The strongest predictors of adverse outcome were stone size, proximal or middle stone location, and ED length of stay. Conclusion: If applied broadly to patients with 2.0-9.9mm ureteral stones, an early interventional approach was associated with similar rates of treatment failure, but more hospitalizations and emergency revisits. Research clarifying subgroups most likely to benefit will facilitate better targeting of early intervention, potentially reducing patient morbidity and improving system utilization.
MP12: Preparing emergency patients and providers study: patient expectations and factors leading to presentation
Authors: Rose-Davis B. , Cassidy C. , MacPhee S. , Chiasson D. , Nunn J. , Curran J.
Published: May 2019

Introduction: Effective communication to develop a shared understanding of patient expectations is critical to a positive encounter in the Emergency Department (ED). However, there is limited research examining Patient/Caregiver (P/C ) expectations in the ED and what factors lead to P/C presentation. This study aims to address this gap by answering the following questions: 1) What are common P/C reported factors affecting ED presentation? 2) What are common P/C expectations of an ED visit? 3) How do P/C expectations vary based on ED site or factors affecting presentation in the ED? Methods: The Preparing Emergency Patients and Providers (PrEPP) tool was designed to collect P/C expectations, worries, perceived causes of symptoms, and factors affecting presentation from a convenience sample of patient visits to the emergency department (ED). The PrEPP tool was provided to all P/Cs with CTAS 2-5 when they registered at one of 4 EDs in the Halifax area from January to June 2016. Completed tools were collected in a REDCap database where qualitative data was coded into categories (i.e. presenting illness, injury). Descriptive and chi-squared statistical analyses were performed. Results: In total, 11,418 PrEPP tools were collected; representing 12% of the total ED visits to the 4 ED sites during the study period. The main factors affecting ED presentation were: self-referral 68%, family/friends 20%, telehealth 8%, unable to see their GP 7%, GP referral 6%, or walk-in-clinic 5%. P/Cs main causes of worry were: presenting illness 19%, injury 15%, or pain 14%. The main expectations for the ED visit were to get a: physician's opinion 73%, x-ray 40%, or blood test 20%. Most P/Cs indicated they did not expect medication during (63%), or after (66%), their ED visit. There were significant differences in P/C expectations between adult and pediatric EDs (χ2 = 720.949, df = 14, P = 0.000) and those P/Cs unable or able to access primary care prior to ED presentation (χ2 = 38.980, df = 1, P = 0.000). The rate of expecting a physician's opinion at the pediatric ED was higher than the adult ED (77.6% vs 70.9%), while lower for expecting CT/MRIs (4.6% vs 11.4%). P/Cs who were unable to access primary care prior to ED presentation expected services which were available at primary care at a higher rate than those who accessed primary care (58.5% vs 36.7%). Conclusion: Our findings identify some of the factors that influence P/C's decision to present to the ED and their expectations of the ED visit.
MP19: Creation and implementation of an educational emergency medicine clinical handbook
Authors: Anjum O. , Syed S.
Published: May 2019

Innovation Concept: Medical students often face challenges when entering clerkship. The abundance of teaching tools and online resources make it difficult for learners to navigate and apply knowledge in a clinical setting. Although valuable study aids exist across Emergency Medicine (EM) clerkship curriculums, a convenient resource tailored to junior learners for on-shift use is lacking. We created an academic resource with the intent of assessing student engagement with the handbook. Methods: Ottawa's Clerkship Guide to Emergency Medicine was developed using information from a commonly used EM textbook and relevant literature. After a comprehensive peer-review by staff EM physicians, the resource was published online and made available to learners in March 2018. To assess utility of this resource, a national survey was administered followed by a Likert-type analysis. Website metrics and the survey results were used to guide a sustainable model for annual student-driven resource updates. Curriculum, Tool or Material: The handbook contains high-yield EM topics organized into one-page summaries. The main sections include resuscitation, symptoms-based approach, and medical emergencies. Students can access the handbook online, via mobile app, or use a printable version. Over 7300 unique downloads have occurred since launch. Our national survey revealed that of the total respondents (N = 171, 93.6% 3rd-year clerks, 31.6% uOttawa students), 97.1% (n = 166) had used the handbook on shift. A majority were able to find an answer to their clinical question either fully (53%, n = 88) or partially (46.4%, n = 77) and many would recommend this resource as-is (62.7%, n = 104) or with some modifications (34.3%, n = 57). Compared to the student's preferred clinical resource, mean Likert-type scores showed a significant (p < 0.01) positive difference in favor of the handbook regarding themes of organization (3.83 vs. 4.38), length (3.43 vs. 4.76) and ease in accessibility (3.46 vs. 4.79). Conclusion: The value of this handbook for junior learners entering their acute care rotation is evident. We demonstrated that student uptake of this handbook was robust. Compared to commonly used resources, students felt this handbook was more organized, concise in length, and easy to integrate into their clinical workflow. Implementation of this handbook across Canadian EM curriculums may bridge the EM knowledge gap in junior learners and off-service residents.
MP20: Resuscitative thoracotomy: development of a video curriculum to teach a rare procedure
Authors: Ryan J. , Luhoway J. , Leeper W. , Poss C.
Published: May 2019

Innovation Concept: Resuscitative thoracotomy (RT) is a life-saving procedure in select trauma patients. However, RT is infrequently performed, limiting trainee exposure. In a survey of American training programs, graduating residents had performed an average of 3 RTs. There is no published data regarding the number of RTs observed and performed by Canadian trainees. We theorized that RT procedural exposure and comfort level would be low in emergency medicine (EM) trainees at our institution due to lack of exposure. Thus, we aimed to create a first person procedural video using local resources to teach RT. Methods: We first created a needs assessment survey conducted within Western University Division of Emergency Medicine over two months in 2018. Senior residents observed an average of 1.5 RT procedures and participated in an average of 0.6. Furthermore, 88% of senior residents cited a lack of confidence in their ability to perform this procedure and 87% indicated an instructional video would be a valuable educational tool. We created a video described in detail below. Prior to video distribution a survey was distributed asking respondents to list the critical steps in performing an RT. Participants were then asked to view the video and complete the survey again. Responses were scored by two independent reviewers. Curriculum, Tool or Material: An immersive cadaveric simulation video was developed in collaboration with a trauma surgeon at our institution. The video reviewed our thoracotomy tray, RT indications/contraindications, and demonstrated a narrated first-person RT on a floppy embalmed cadaver. Potential difficulties encountered during the procedure are highlighted throughout the video with troubleshooting tips suggested. Conclusion: We had 46 survey respondents from our division (25 residents and 21 consultants). After viewing the video, procedural step scores were significantly higher for junior FRCPC (p = 0.001), senior FRCPC (p = 0.013), and CCFP-EM (p < 0.001) residents as well as consultants (p = 0.016). There was also an increase in the number of respondents who reported confidence in their ability to perform RT post-video (n = 4 pre-video; n = 11 post-video). This video is an inexpensive, effective way to teach the critical procedural steps of RT and can be easily adapted for use at other institutions. Next steps for further education in this topic include development of a hands-on cadaveric simulation curriculum for residents.
MP52: Prehospital opioid administration to acute myocardial infarction patients: a systematic review
Authors: Greene J. , Ainsworth C. , Lambert L. , Wong G. , Cantor W. , Welsford M.
Published: May 2019

Introduction: Opioids are routinely administered for analgesia to prehospital patients experiencing chest discomfort from acute myocardial infarction (AMI). We conducted a systematic review to determine if opioid administration impacts patient outcomes. Methods: We conducted a systematic search using MeSH terms and keywords in Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Central and Clinicaltrials.gov for relevant randomized controlled trials and observational studies comparing opioid administration in AMI patients from 1990 to 2017. The outcomes of interest were: all-cause short-term mortality (≤30 days), major adverse cardiac events (MACE), platelet activity and aggregation, immediate adverse events, infarct size, and analgesia. Included studies were hand searched for additional citations. Risk of Bias assessments were performed and GRADE methodology was employed to assess quality and overall confidence in the effect estimate. Results: Our search yielded 3001 citations of which 19 studies were reviewed as full texts and a total of 9 studies were included in the analysis. The studies predominantly reported on morphine as the opioid. Five studies reported on mortality (≤30 days), seven on MACE, four on platelet activity and aggregation, two on immediate adverse events, two on infarct size and none on analgesic effect. We found low quality evidence suggesting no benefit or harm in terms of mortality or MACE. However, low quality evidence indicates that opioids increase infarct size. Low-quality evidence also shows reduced serum P2Y12 (eg: clopidogrel and ticagrelor) active metabolite levels and increased platelet reactivity in the first several hours post administration following an increase in vomiting. Conclusion: We find low and very low quality evidence that the administration of opioids in STEMI may be adversely related to vomiting and some surrogate outcomes including increased infarct size, reduced serum P2Y12 levels, and increased platelet activity. We found no clear benefit or harm on patient-oriented clinical outcomes including mortality.
P034: Identifying unmet palliative care needs in the emergency department
Authors: Duffy J. , Crump S. , O'Connor E.
Published: May 2019

Introduction: The goal of palliative care (PC) is to improve quality of life for both patients and families facing a life-limiting illness. Many individuals in need of PC present to the Emergency Department (ED) with symptomatic complaints. Therefore, the ED may be a good place to connect patients with PC teams. Unfortunately, a lack of communication between patients and medical teams may result in admission to hospital even if this no longer aligns with the goals of care. The aims of this study were to identify the proportion of ED patients with unmet PC needs and to determine if access to rapid outpatient PC follow-up could reduce unnecessary admissions. Methods: University Health Network (UHN) is an urban academic centre with EDs at two sites, Toronto General Hospital (TGH) and Toronto Western Hospital (TWH). A consecutively enrolled sample of 417 patients that presented to these EDs between July 1-August 14, 2018 was taken. ED nurses and physicians were asked to complete a content validated PC screening tool on all eligible patients. Patients were eligible for screening if they (1) were >18 years of age, (2) had been designated a level 2-5 according to the Canadian Triage and Acuity Score, and (3) had been triaged to the subacute or acute areas of the department. Results: Across both sites, 45% of patients screened had a life-limiting illness and 30% had unmet PC needs. Among those with unmet PC needs, 79% had no identifiable involvement with a PC team. TWH had fewer patients with a life-limiting illness compared to TGH (31% vs 57%), but higher rates of unmet PC needs (81% vs 59%, confidence interval for the difference: 8%-34%, p = .003) and less PC involvement (6% vs 24%, confidence interval for the difference: 4%-30%, p < .01). 73% of patients at UHN with unmet PC needs were likely to be admitted to hospital. In 14% (n = 17) of these cases, admissions were felt by physicians to have potentially been avoided if rapid PC follow-up was available. Conclusion: A high percentage of patients presenting to the EDs at UHN have life-limiting illnesses with unmet PC needs. A rapid access outpatient PC clinic, available for referral from the ED, may help to both connect patients with the resources they need and avoid admission to hospital.
P035: Impact of EMS direct referral to community care on emergency department utilization
Authors: Dukelow A. , Lewell M. , Loosley J. , Pancino S. , Van Aarsen K.
Published: May 2019

Introduction: The Community Referral by Emergency Medical Services (CREMS) program was implemented in January 2015 in Southwestern Ontario. The program allows Paramedics interacting with a patient to directly refer those in need of home care support to their local Community Care Access Centre (CCAC) for needs assessment. If indicated, subsequent referrals are made to specific services (e.g. nursing, physiotherapy and geriatrics) by CCAC. Ideally, CREMS connects patients with appropriate, timely care, supporting individual needs. Previous literature has indicated CREMS results in an increase of home care services provided to patients. Methods: The primary objective of this project is to evaluate the impact of the CREMS program on Emergency Department utilization. Data for all CCAC referrals from London-Middlesex EMS was collected for a thirteen month period (February 2015-February 2016). For all patients receiving a new or increased service from CCAC the number of Emergency Department visits 2 years before referral and 2 years after referral were calculated. A related samples Wilcoxon Signed Rank Test was performed to examine the difference in ED visits pre and post referral to CCAC. Results: There were 213 individuals who received a new or increased service during the study timeframe. Median [IQR] patient age was 77 [70-85.5]. 113/213 (53%) of patients were female. The majority of patients 135/213 (63.4%) were a new referral to CCAC. The median [IQR] number of hospital visits before referral was 3 [1-5] and after referral was 2 [0-4]. There was no significant difference in the overall number of ED visits before versus after referral (955 vs 756 visits, p = 0.051). Conclusion: Community based care can improve patient experience and health outcomes. Paramedics are in a unique position to assess patients in their home to determine who might benefit from home care services. CREMS referrals for this patient group showed a trend towards decreased ED visits after referral but the trend was not statistically significant.
P036: Digoxin immune fab treatment for digoxin and non-digoxin cardioactive steroid toxicity: a scoping review
Authors: Duncan J. , Murphy N. , Fitzpatrick E. , Nelson R. , Hurley K.
Published: May 2019

Introduction: Cardioactive steroid poisoning occurs worldwide with the use of pharmaceutical digoxin and botanical cardiac glycosides. The wholesale price of the antidote, digoxin immune fab, has increased over 300% from 2010 to 2015. Our objective was to identify gaps in the existing literature with respect to the use of digoxin immune fab in cardioactive steroid toxicity in acute care settings. Methods: We used scoping study methodology, as described by Arksey and O'Malley, to assess the range and scope of empiric research and will report: 1) sources of cardioactive steroid toxicity in acute settings; 2) doses of digoxin immune fab used in treatment; and, 3) intervention outcomes of acute cardioactive steroid toxicity following the administration of digoxin immune fab as first or second-line therapy. We collaborated with a library scientist to devise search strategies for PubMed, CINAHL, EMBASE, CENTRAL and Toxnet. We sought unpublished literature through the Canadian Electronic Library, Proquest, and Scopus and searched reference lists of included studies. We hand searched relevant conference proceedings and applicable guidelines. Two reviewers independently reviewed titles and abstracts using predetermined criteria. Using a structured data abstraction form, two reviewers independently extracted data. All discrepancies were resolved through consensus. Results: Our search strategy yielded 3458 results. After screening titles and abstracts 384 underwent full text screening. We included 147 studies and are currently extracting data from 12 French studies and 135 English studies. To date we have extracted data from 90 case reports and case series. Conclusion: Given concerns over rising costs, our findings will shed light on the extent of the evidence for use of digoxin immune fab in acute care settings.