bluuebunny/crossref_metadata_2025 huggingface dataset:
MP09: Canadian Community Utilization of Stroke Prevention Pilot Study-Emergency Department (C-CUSP ED)
Authors: Parkash R. , Magee K. , McMullen M. , Clory M.B. , D’Astous M. , Robichaud M. , Andolfatto G. , Read B. , Wang J. , Thabane L. , Atzema C.L. , Dorian P. , Kaczorowski J. , Banner D. , Nieuwlaat R. , Ivers N. , Huynh T. , Curran J. , Graham I. , Connolly S.J. , Healey J.S.
Published: May 2017

Introduction: Atrial fibrillation (AF) is the most common sustained arrhythmia affecting 1-2% of the population. Oral anticoagulation (OAC) reduces stroke risk by 60-80% in AF patients, but only 50% of indicated patients receive OAC. Many patients present to the ED with AF due to arrhythmia symptoms, however; lack of OAC prescription in the ED has been identified as a significant gap in the care of AF patients. Methods: This was a multi-center, pragmatic, three-phase before-after study, in three Canadian sites. Patients who presented to the ED with electrocardiographically (ECG) documented, nonvalvular AF and were discharged home were included. Phase 1 was a retrospective chart review to determine OAC prescription of AF patients in each ED; Phase 2 was a low-intensity knowledge translation intervention where a simple OAC-prescription tool for ED physicians with subsequent short-term OAC prescription was used, as well as an AF patient education package and a letter to family physicians; phase 3 incorporated Phase 2 interventions, but added immediate follow-up in a community AF clinic. The primary outcome of the study was the rate of new OAC prescriptions at ED discharge in AF patients who were OAC eligible and were not on OAC at presentation. Results: A total of 632 patients were included from June, 2015-November, 2016. ED census ranged from 30000-68000 annual visits. Mean age was 71±15, 67±12, 67±13 years, respectively. 47.5% were women, most responsible ED diagnosis was AF in 75.8%. The mean CHA2DS2-VASc score was 2.6±1.8, with no difference amongst groups. There were 266 patients eligible for OAC and were not on this at presentation. In this group, the prescription of new OAC was 15.8% in Phase 1 as compared to 54% and 47%, in Phases 2 and 3, respectively. After adjustment for center, components of the CHA2DS2-VASc score, prior risk of bleeding and most responsible ED diagnosis, the odds ratio for new OAC prescription was 8.0 (95%CI (3.5,18.3) p<0.001) for Phase 3 vs 1, and 10.0 (95%CI (4.4,22.9) p<0.001), for Phase 2 vs 1). No difference in OAC prescription was seen between Phases 2 and 3. Conclusion: Use of a simple OAC-prescription tool was associated with an increase in new OAC prescription in the ED for eligible patients with AF. Further testing in a rigorous study design to assess the effect of this practice on stroke prevention in the AF patients who present to the ED is indicated.
MP14: Prospective external validation of the Ottawa 3DY screening tool for the detection of altered mental status of elderly patients presenting to the emergency department
Authors: Kim B. , Salehmohamed Q. , Stenstrom R. , Barbic S. , Barbic D.
Published: May 2017

Introduction: Altered mental status (AMS) and cognitive impairment are common problems in elderly patients presenting to the emergency department (ED). The primary objective of this study was to test the diagnostic accuracy of the Ottawa 3DY (O3DY) screening tool for the detection of AMS in the ED. Methods: This was a prospective cohort study conducted at an inner city, academic ED with an annual census of 85,000 visits. Study investigators and trained research assistants screened and approached a convenience sample of patients for informed written consent. Patients completed the O3DY, Short Blessed Test (SBT) and Mini-Mental Status Exam (MMSE). Descriptive statistics using counts, medians, means and interquartile ranges (IQR) were calculated. Sensitivity and specificity of the O3DY compared to the MMSE were calculated in STATA (version 11.2). Results: We screened 163 patients for inclusion, 150 were eligible to participate, and 116 patients were enrolled in the final study. The median age of participants was 81 (IQR 77-85), 44.8% were female, and the most common pre-existing comorbidity was hypertension. The median ED LOS at the time of O3DY completion was 1:40 (IQR 1:34-1:46). Characteristics of patients eligible, yet who declined to participate, were similar to the study population. The sensitivity of the O3DY for AMS was 71.4% (95%CI 47.8-95.1), and specificity was 56.3% (46.7-65.9). Sensitivity of the SBT was 85.7% (67.4-99.9) and specificity was 58.3% (48.7-67.8). Inter-rater reliability for the O3DY (k=0.64) and SBT (k=0.63) were moderate. Conclusion: In a cohort of geriatric patients presenting to an inner-city, academic ED the O3DY and SBT tools demonstrate moderate sensitivity and specificity for the detection of AMS.
MP16: Quality of work life among nurses and physicians in Québec rural emergency departments
Authors: Fleet R. , Dupuis G. , Mbakop-Nguebou M. , Archambault P.M. , Plant J. , Chauny J. , Levesque J. , Ouimet M. , Poitras J. , Haggerty J. , Légaré F.
Published: May 2017

Introduction: Recruitment and retention of healthcare staff are difficult in rural communities. Poor quality of work life (QWL) may be an underling factor as rural healthcare professionals are often isolated and work with limited resources. However, QWL data on rural emergency (ED) staff is limited. We assessed QWL among nurses and physicians as part of an ongoing study on ED care in Québec. Methods: We selected EDs offering 24/7 medical coverage, with hospitalization beds, in rural or small towns (Stats Canada definition). Of Québec’s 26 rural EDs, 23 (88%) agreed to participate. The online Quality of Work Life Systemic Inventory (QWLSI, with 1 item per 34 “life domains”), was sent to all non-locum ED nurses and physicians (about 500 potential participants). The QWLSI is used for comparing QWL scores to those of a large international database. We present overall and subscale QWL scores as percentiles (PCTL) of scores in the large database, and comparisons of nurses’ and physicians’ scores (t test). Results: Thirty-three physicians and 84 nurses participated. Mean age was 39.8 years (SD=10.1): physicians=37 (7.7) and nurses=40.9 (10.7). Overall QWL scores for all were in the 32nd PCTL, i.e. low. Nurses were in the 28th PCTL and physicians in the 44nd (p>0.05). For both groups, QWL was below the 25th PCTL i.e. very low, for “sharing workload during absence of an employee”, “working equipment”, “flexibility of work schedule”, “impact of working hours on health”, “possibility of being absent for familial reasons”, “relations with employees”. The groups differed (p<0.05) on only two subscales: remuneration and career path. For remuneration, scores were similar on fringe benefits (nurses 22nd PCTL, physicians 32nd) and income security (nurses 72nd, physicians 74th), but differed on income level (nurses 74th, physicians 93rd). The groups differed on all 3 career path items: advancement possibilities (nurses 53th, physicians 91st), possibilities for transfer (nurses 51nd, physicians 84th) and continuing education (nurses 18th, physicians 49th). Conclusion: Overall QWL among rural ED staff is poor. Groups had similar QWL scores except on career path, with physicians perceiving better long-term prospects. Given difficulties in rural recruitment and retention, these findings suggest that QWL should be assessed in rural and urban EDs nationwide.
MP23: The yield of computed tomography of the head in patients presenting with syncope: a systematic review
Authors: Viau J.A. , Chaudry H. , Hannigan A. , Boutet M. , Mukarram M.A. , Thiruganasambandamoorthy V.
Published: May 2017

Introduction: Syncope accounts for 1-3% of Emergency Department (ED) visits. Previous studies have reported overuse of computed tomography (CT) of the head among syncope patients. Professional organizations including Choosing Wisely have recommended against its use in the absence of high-risk features. However, a review of CT head use among syncope patients and its diagnostic yield has not been previously reported. Methods: We conducted a systematic review using EMBASE, Medline, and Cochrane databases from inception to August 2016. We included studies involving adult syncope patients that reported CT head use and its diagnostic yield during acute management by a two-step process: first title/abstract review and then full-text review of selected articles. We excluded case reports, narrative reviews and those involving children. We collected the proportion of patients who had CT head performed, and its diagnostic yield. Outcomes included identification of acute intracranial conditions (hemorrhage, mass or infarct) that require further management. Two reviewers independently abstracted the data and discrepancies were resolved by consensus. We calculated inter-observer reliability for inclusion in the systematic review using kappa values. We performed meta-analysis for diagnostic yield of the CT head. Results: Fifteen studies with 2,802 syncope patients in four sub-groups (proportion of patients among whom CT head was performed and its yield in ED and inpatient settings; studies that reported only the yield among those with CT head performed; and the use and yield among syncope patients ≥65 years old) were included. The inter-observer agreement for inclusion of final articles for meta-analysis was κ=0.925 [95% CI: 0.861-0.990]. Seven ED studies (n=1,261) reported 55.7% patients (95% CI: 32.1-78.0%) had head CT performed with a yield of 4.0% (95% CI: 2.7-5.6%); 5 studies with 1138 hospitalized patients reported that 38.6% (95% CI: 20.4-58.6%) had head CT with a yield of 1.1% (95% CI: 0.4-2.2%). The yield among studies that report only outcomes for CT head was 2.3% and the yield among patients’ ≥65 years was 7.7%. Conclusion: Our review found that a very high proportion of syncope patients had CT head performed during acute management with a very low diagnostic yield. The yield is higher among patients ≥65 years old. A robust tool to identify patients who require a CT head will reduce unnecessary testing.
MP24: Effect on pain of an oral sucrose solution versus placebo in children 1 to 3 months old needing nasopharyngeal aspiration; a randomized controlled trial
Authors: Alix-Séguin L. , Desjardins M. , Gaucher N. , Lebel D. , Gravel J. , Gouin S.
Published: May 2017

Introduction: Oral sweet solutions have been accepted as effective pain reducing agents for neonates. However studies in the Emergency Department (ED) setting have conflicting results. The objective is to compare the efficacy of an oral sucrose solution versus placebo in reducing pain in children 1 to 3 months of age during nasopharyngeal aspiration (NPA) in the ED. Methods: A randomized, double-blinded, placebo controlled clinical trial was conducted in a pediatric university-affiliated hospital ED. Participants from 1 to 3 months of age requiring NPA were recruited and randomly allocated to receive 2 mls of an 88% sucrose solution (SUC) or 2 mls of a placebo solution (PLA) orally, 2 mins before NPA. The primary outcome was the mean difference in pain scores at 1 min post NPA as assessed by the Face, Legs, Activity, Cry and Consolability (FLACC) Pain Scale. Secondary outcomes were the difference in pain scores using the Neonatal Infant Pain Scale (NIPS), crying time, heart rate and adverse events. Results: 72 participants were recruited and completed the study, 37 (group SUC) and 35 (group PLA) respectively. Both groups had similar demographic and clinical characteristics and baseline FLACC and NIPS pain scores (all p=value >0.4). The mean difference in FLACC scores compared to baseline was 3.3 (2.5-4.1) (SUC) vs. 3.2 (2.3-4.1) (PLA) (p=.94) at 1 min and -1.2 (-1.7 to 0.7) (SUC) vs. -0.8 (-1.5 to -0.1) (PLA) (p=.66) at 3 mins after NPA. For the NIPS scores, it was 2.3 (1.6-3.0) (SUC) vs. 2.5 (1.8-3.2) (PLA) (p=.86) at 1 min and -1.2 (-1.6 to -0.8) (SUC) vs. -0.8 (-1.3 to 0.2) (PLA) (p=.59) 3 mins after NPA. There was no difference in the mean crying time, 114 (98-130) secs (SUC) vs. 109 (92-126) secs (PLA) (p=.81). No significant difference was found in participants’ heart rate at 1 min 174 (154-194) BPM (SUC) vs. 179 (160-198) BPM (PLA) (p=.32) and at 3 mins 165 (143-187) BPM (SUC) vs. 164 (142-186) BPM (PLA) (p=.86) after NPA. Three patients had vomiting during the procedure (2 PLA and 1 SUC), and one had an episode of chocking (PLA). Conclusion: In infants 1 to 3 months of age undergoing nasopharyngeal aspiration in the ED, administration of an oral sweet solution did not statistically decrease pain scores as measured by the FLACC and NIPS scales. Participants’ heart rate and crying time were not significantly decreased when sucrose was provided.
MP29: Did the Canadian Pediatric Society policy statement in 2007 impact trampoline-related injuries in Halifax, Nova Scotia?
Authors: Wilson G.C. , Sameoto C. , Fitzpatrick E. , Hurley K.F.
Published: May 2017

Introduction: The Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) found a significant rise in trampoline-related injuries from 1999-2005, many of which required hospitalization. In 2007 and again in 2013, the Canadian Pediatric Society (CPS) recommended against the recreational use of trampolines at home. The purpose of this study was to evaluate the impact of this policy statement on trampoline-related injuries in Halifax, Nova Scotia. Methods: Trampoline injury data was obtained from the CHIRPP database at the IWK Health Centre, the paediatric referral hospital for the Maritimes. The data was stratified according to the timing of the CPS policy statement (before: 2001-2006, after: 2008-2013 and after reaffirmation 2013-2015). Data variables included mechanism, site, nature and context of injury. The data were evaluated using SPSS and chi-squared tests. Results: Since the 2007 CPS policy statement, an average of 162 per 10,000 ED visits at the IWK Health Centre were the result of trampoline-related injuries compared to 95 per 10,000 pre-policy. The majority of injuries (76-80%) occurred in children 5-14 years of age. Recreational use at home in the yard was the most common location of the accident (78-88%), with most injuries occurring on the trampoline mat itself (83-85%) due to incorrect landing (32-35%), falls (21-27%), or being struck by a person or object (24-25%). Soft tissue injuries (15-17%), sprains (19-22%) or fractures (40-46%) to the elbow (11-12%), forearm (5-9%) or ankle (19-21%) continued to be the most common nature and sites of injuries. The injury data before compared to after the CPS policy statement did not differ significantly in gender, the mechanism of injury, the type of injury, or body part involved (p-value >0.05). There was a significant difference in the number of injuries between age groups post-policy, with more occurring in children less than 4 and between the age of 10-14 (p<0.009). Moreover, where the trampoline injury was located was also significantly different post-policy with more injuries occurring in sports/recreational facilities (p<0.001). Conclusion: Trampolining is a high-risk activity with injuries occurring predominantly in children and youth. Despite the recommendations brought forth by the CPS, trampoline-related injuries remain an important source of pediatric injuries at the IWK Health Centre in Halifax, Nova Scotia.
MP31: The contrarian effect: how does a Choosing Wisely focused knowledge translation initiative affect emergency physician practice in a high awareness-low investigation environment?
Authors: Chandra K. , Atkinson P.R. , Fraser J. , Chatur H. , Adams C.
Published: May 2017

Introduction: We previously reported that a targeted knowledge translation (KT) intervention was associated with a trend towards increased awareness and knowledge of the Choosing Wisely Canada (CWC) emergency medicine (EM) recommendations. We wished to assess if the intervention changed physician practice, specifically looking at the imperative “do not order lumbar XRs for non-traumatic low back pain unless red flags exist”. Methods: A departmental KT initiative was implemented in April 2016 and consisted of a 1-hour seminar reviewing the CWC-EM recommendations, access to a video cast, departmental posters, and a before and after awareness survey. The effectiveness of our intervention was assessed by analyzing the frequency of lumbar XR imaging conducted for low back pain before and after the introduction of our intervention at a tertiary teaching hospital emergency department. All patient visits for the complaint of low back pain were included. The rates of XR imaging from June 2014 to September 2014 for the pre-intervention period and June 2016 to September 2016 for the post-intervention period were collected and analyzed using Fisher exact tests. A sample size of 683 was required to detect a 5% change with an alpha of 0.05 and a power of 80%. Results: Baseline characteristics of patients were similar for the pre- and post-intervention periods. There was a total of 781 patient visits for low back pain in June to September 2014 and 672 in June to September 2016. The XR imaging rate for low back pain increased from 12% (95% CI 9.9-14.5) to 16.2% (95% CI 13.6-19.2) following the intervention (p=0.023). Conclusion: We previously demonstrated a trend towards increased awareness and knowledge of the CWC EM recommendations following a knowledge translation initiative. Baseline XR imaging rates for low back pain were lower than what has been reported. We observed that our intervention was associated with an increased frequency of imaging for low back pain. This may be due to a contrarian effect. We feel this calls into question the role of knowledge translation initiatives where physician practice already closely adheres to pre-established recommendations.
MP32: The Pulmonary Embolism Severity Index (PESI) score and disposition decisions in Calgary emergency departments
Authors: Brunet S. , Wang D. , Lang E.
Published: May 2017

Introduction: The Pulmonary Embolism Severity Index (PESI) score predicts short-term mortality from pulmonary embolism and low-risk patients suitable for home therapy. However, it is unknown if it is a driver for disposition decisions for emergency department (ED) patients. The primary objective of this study was to define the relationship between disposition decisions and the PESI score in Calgary zone hospitals. Methods: The PESI score was calculated retrospectively for 576 patients presenting to one of four Calgary zone hospitals for pulmonary embolism over the last 2 years. The calculated PESI score allowed the mortality risk of each patient to be estimated for very low risk (Class I, 0-1.6% 30-day mortality rate), low risk (Class II, 1.7-3.5% 30-day mortality rate), intermediate risk (Class III, 3.2-7.1% 30-day mortality rate), high risk (Class IV, 4.0-11.4% 30-day mortality rate), and very high risk (Class V, 10.0- 24.5% 30- day mortality rate). The patients were grouped based on being admitted to the hospital for inpatient care, or discharged for outpatient care. Descriptive statistics were used to describe the data. Results: Of the 576 patients, 317 (55%) were discharged and 259 (45%) were admitted to the hospital for inpatient care. Among admitted patients, 20.5% were considered Class I, 29.3% were Class II, 24.3% were Class III, 17.6% were Class IV, and 8.1% were Class V. Among discharged patients, 53.9 % were Class I, 25.6% were Class II, 15.5% were Class III, 4.4% were Class IV, and 0.6% were Class V. Of the 25 very high-risk (Class V) patients, 2 (8.0%) were discharged from the ED and treated as outpatients. Of the 223 very low risk (Class I) patients, 171 (76.7%) were discharged and 52 (23.3%) were admitted to hospital. Conclusion: A significant percentage of pulmonary embolism patients admitted to Calgary Zone hospital wards are PESI low risk (29.3%) or very low risk (20.5%). Implementation of a PESI score-based disposition pathway could improve the safety, cost-effectiveness and quality of ED disposition decisions for PE.
MP36: Safety and clinically important events in PCP-initiated STEMI bypass in Ottawa: a health record review
Authors: Mitchell S. , Dionne R. , Maloney J. , Austin M.A. , Mok G. , Sinclair J.E. , Cox C. , Le May M. , Vaillancourt C.
Published: May 2017

Introduction: In Ottawa, STEMI patients are transported directly to percutaneous coronary intervention (PCI) by advanced care paramedics (ACPs), primary care paramedics (PCPs), or transferred from PCP to ACP crew (ACP-intercept). PCPs have a limited skill set to address complications during transport.The objective of this study was to determine what clinically important events (CIEs) occurred in STEMI patients transported for primary PCI via a PCP crew, and what proportion of such events could only be treated by ACP protocols. Methods: We conducted a health record review of STEMI patients transported for primary PCI from Jan 1, 2011-Dec 21, 2015. Ottawa has a single PCI center and its EMS system employs both PCP and ACP paramedics. We identified consecutive STEMI bypass patients transported by PCP-only and ACP-intercept using the dispatch database. A data extraction form was piloted and used to extract patient demographics, transport times, and primary outcomes: CIEs and interventions performed during transport, and secondary outcomes: hospital diagnosis, and mortality. CIEs were reviewed by two investigators to determine if they would be treated differently by ACP protocols. We present descriptive statistics. Results: We identified 967 STEMI bypass cases among which 214 (118 PCP-only and 96 ACP-intercept) met all inclusion criteria. Characteristics were: mean age 61.4 years, 78% male, 31.8% anterior and 44.4% inferior infarcts, mean response time 6 min, total paramedic contact time 29 min, and in cases of ACP-intercept 7 min of PCP-only contact time.A CIE occurred in 127 (59%) of cases: SBP<90 mmHg 26.2%, HR<60 30.4%, HR>100 20.6%, malignant arrhythmias 7.5%, altered mental status 6.5%, airway intervention 2.3%, 2 patients (0.9%) arrested, both survived. Of the CIE identified, 54 (42.5%) could be addressed differently by ACP vs PCP protocols (25.2% of total cases). The majority related to fluid boluses for hypotension (44 cases; 35% of CIE). ACP intervention for CIEs within the ACP intercept group was 51.6%. There were 6 in-hospital deaths (2.8%) with no difference in transport crew type. Conclusion: CIEs are common in STEMI bypass patients however a smaller proportion of such CIE would be addressed differently by ACP protocols compared to PCP protocols. The vast majority of CIE appeared to be transient and of limited clinical significance.
P005: Consultations in the emergency department: a systematic review
Authors: Alexiu C. , Gaudet L. , Rowe B.H.
Published: May 2017

Introduction: Consultation in the emergency department (ED) is a common component of emergency health care. Consultation is defined as a case in which an ED physician (EP) requests the services of another physician (consultant) for an ED patient to assist, advise, and/or transfer care when the care required is beyond the expertise of the EP’s practice. While consultation is generally considered required and beneficial for patient care, consultation can also have a negative impact by incurring delays in patient flow and disposition. These delays contribute to ED crowding, patient dissatisfaction and, in some cases, worse health outcomes. Using an a priori protocol and accepted methodology, the aim of this systematic review was to update a previous review on the same topic and determine the proportion of 1) ED visits that involve consultation and 2) consultation cases that result in admission. PROPSPERO registration number: CRD42017054054. Methods: Literature search involved multiple electronic databases (e.g., MEDLINE and EMBASE) and grey literature (e.g., Google Scholar and conference abstracts). Study selection was conducted independently by two reviewers and determined by consensus among the two reviewers with disagreements resolved by a third party. Data extraction was conducted independently by two reviewers and determined by consensus among the two reviewers with disagreements resolved by a third party. A descriptive analysis was conducted. Outcome measure data were aggregated and reported with suitable descriptive statistics such as raw or weighted mean, median, or proportion with 95% confidence interval. Results: Literature search yielded 1,584 studies, of which 65 were included. Two-thirds of studies were conducted in USA or Canada. Of the 65, 54 were focused on a particular patient group or consulting specialty (e.g., psychiatry) while 11 considered the general ED population. Of these 11, the median proportion of ED visits involving consultation was 26%. The median proportion of cases with consultation that resulted in admission was 60%. Conclusion: Consultations in the ED are quite common and many of these cases result in admission. Given their frequency of occurrence and increasing ED crowding, efforts to reduce consult delays and expedite disposition appear warranted.
P009: Improving elderly care transitions through the local adaptation and implementation of the Acute Care for Elderly (ACE) program
Authors: Archambault P.M. , Vaillancourt H. , Drouin V. , Dupuis A. , McGinn C. , Rivard J. , Bernier L. , Savard A. , Girouard C. , Poiré M. , Gilbert J. , Kroon C. , Ruel M. , Melady D.
Published: May 2017

Introduction: Decreasing readmission rates and return emergency department (ED) visits represent a major challenge for health organizations. Seniors are especially vulnerable to discharge adverse events which can result in unplanned readmissions and loss of physical, functional and/or cognitive capacity. The ACE Collaborative is a national quality improvement initiative that aims to improve care of elderly patients. We aimed to adapt Mount Sinai’s Care Transitions program to our local context in order to decrease avoidable readmissions and ED visits among seniors. Methods: We performed a prospective pre/post implementation cohort study. We recruited frail elderly hospitalized patients (≥50 years old) discharged to home and at risk of readmission (modified LACE index score≥7/12). We excluded patients being discharged to long-term nursing homes or institutions. Our intervention is based on selected strategic ACE Care Transitions best practices: transition coach, telehealth personal response services and a structured discharge checklist. The intervention is offered to selected patients before hospital discharge. Our primary outcome is a 30-day post-discharge composite of hospital readmission and return ED visit rate. Our secondary outcomes are functional autonomy, satisfaction with care transition, quality of life, caregiver strain and healthcare resource use at recruitment and at 30-days follow-up. Hospital-level administrative data is also collected to measure global effect of practice changes. Results: The project is currently ongoing and preliminary results are available for the pre-implementation cohort only. Patients in this cohort (n=33) were mainly men (61%), aged 75±10 years and presented an OARS score (Activities of Daily Living instrument that ranges from 0-28) of 5.6±4.9. At 30 days post-discharge, the patients in our cohort had a 42.4% readmission rate (14 hospitalisations) and a 54.5% return ED visit rate (18 visits). For the same time period, readmission and return ED rates for all patients in the same corresponding age-group at the hospital level were 14.4% and 21.9%, respectively. Further results for our post-intervention cohort will be presented at CAEP 2017. Conclusion: Our cohort of elderly patients have high readmission and return ED visit rates. Our ongoing quality improvement project aims to decrease these readmissions and ED visits.
P021: A ‘Pawsitive’ addition to the ER patient experience: A pilot evaluation of the St. John Ambulance therapy dog program in a Canadian hospital
Authors: Broberg L. , Stempien J. , Dell C.A. , Smith J. , Steeves M. , Jurke L.
Published: May 2017

Introduction: Animal-assisted interventions (AAI) have been applied in numerous clinical settings to help reduce pain, stress, and anxiety. This qualitative study sets out to evaluate the St. John Ambulance Therapy Dog program in the emergency department of the Royal University Hospital. Methods: An observer identified patients interested in visiting with a Therapy Dog during their emergency department stay and obtained consent. Participants were asked to indicate on a pictographic scale their physical and mental states before and after the visit. The Therapy Dog team, consisting of a dog and handler, visited the patient for 5-10 minutes. During this time an observer took notes. Participants were asked at the conclusion of the visit to answer questions regarding their overall experience with the Therapy Dog team. Results: 117 patients participated in this study. Pre- and post AAI pictographic faces [c1] scale results showed an average improvement of 1.2. Before AAI, patients most commonly reported feeling pain, anxiety, tiredness, sadness, boredom, weakness, and a desire to go home. Immediately after the AAI, they most commonly reported feeling happiness, relaxation, better, calmness, and good. Observers noted positive participant and family changes during the AAI, including tone of voice, body language, facial expression (e.g., smiling), and openness. Patients often made efforts to make physical contact for the majority of the visit, often despite pain and immobility. There was also frequent sharing of stories about patients’ pets, which seemed to serve as a comfort within the emergency department environment. Conclusion: Animal-assisted interventions with a therapy dog team in an emergency department is a ‘pawsitive’ addition to the patient experience. An important next step is to measure whether the positive impact continued post visit.
P026: Need for training in medical education: staff emergency physician perspectives
Authors: Bryan J. , Al Rawi F. , Bhandari T. , Chu J. , Hansen S. , Klaiman M.Z.
Published: May 2017

Introduction: Emergency medicine physicians in our urban/suburban area have a range of training in medical education; some have no formal training in medical education, whereas others have completed Master’s level training in adult education. Not all staff have a university appointment; of those who are affiliated with our university, 87 have appointments through the Department of Medicine, 21 through the Department of Pediatrics, and 117 through the Department of Family Medicine. Emergency physicians in our area are a diverse group of physicians in terms of both formal training in adult education and in the variety of settings in which we work. The purpose of this study was to gauge interest in formal training in adult education among emergency medicine physicians. Methods: With research ethics board approval, we created and sent a 10-item electronic questionnaire to emergency medicine staff in our area. The questionnaire included items on demographics, experience in emergency medicine, additional post-graduate training, current teaching activities and interest in short (30-60 minute) adult education sessions. Results: Of a potential 360 active emergency physicians in our area, 120 responded to the questionnaire (33.3%), representing 12 area hospitals. Nearly half of respondents had been in practice over 10 years (48.44%). Respondents were mainly FRCP (50%) or CCFP-EM (47.50%) trained. 33.3% of respondents had masters degrees, of which 15% were MEd. Most physicians were involved in teaching medical students (98.33%), FRCP residents (80%) and family medicine residents (88.3%), though many were also teaching off-service residents, and allied health professionals. More than half of respondents (60%) were interested in attending short sessions to improve their skills as adult educators. The topics of most interest were feedback and evaluation, time-efficient teaching, the learner in difficulty, case-based teaching and bedside teaching. Conclusion: Emergency physicians in our area have a wide variety of experience and training in medical education. They are involved in teaching learners from a range of training levels and backgrounds. Physicians who responded to our survey expressed an interest in additional formal teaching on adult education topics geared toward emergency medicine.
P027: Nursing duties and accreditation standards and their impacts: the nursing perspective
Authors: Jaggi P.K. , Tomlinson R. , McLelland K. , Ma W. , Manson-McLeod C. , Bullard M.
Published: May 2017

Introduction: With ongoing medical advances and an increase in elderly and complex patients presenting to the Emergency Department (ED), there is a requirement for nurses to continue to gain new knowledge and skills to provide optimal patient care. Quality initiatives are frequently introduced with the goal of improving patient safety and the effectiveness of care delivery; some being provincial, while others are new requirements from Accreditation Canada. We sought the perspectives of emergency nurses regarding the importance of key ED processes and standards, and their impact on patient care and nurse efficiency. Methods: All Registered Nurses and Licensed Practical Nurses throughout the Edmonton Zone EDs were invited to complete an online survey consisting of 23 statements on nursing attitudes (10 on nursing duties) and beliefs (11 on the importance of Accreditation standards and their impacts; two that involved selecting the 5 most important nursing activities). The survey was constructed through an iterative approach. Response options included a 7-point Likert scale (‘very strongly disagree’ to ‘very strongly agree’). Median scores and interquartile ranges were determined for each survey statement. Results: A total of 433/1241 (34.9%) surveys were submitted. Respondents were predominantly Registered Nurses (91.4%), female (88.9%), and worked 0-5 years overall in the ED (43.7%). Overall, respondents were favourable (‘agree’ or ‘strongly agree’) towards the Accreditation Canada standards and other quality initiatives. They were, however, ‘neutral’ towards universal domestic violence screening, and whether there is a difference between Best Possible Medication History (BPMH) and med reconciliation. The top five nursing activities in terms of perceived importance were: vital sign documentation, recording of allergies, listening to patients’ concerns, hand hygiene, and obtaining a complete nursing history. Best Possible Medication History and the screening risk tools followed these. Conclusion: Despite their heavy workload, nurses strongly agreed on the importance of med reconciliation, falls risk, and skin care, but felt that improved documentation forms could support efficiency. Nursing perspective is valuable in informing future attempts to standardize, streamline, and simplify documentation, including the design and implementation of a provincial clinical information system.
P031: Using machine learning algorithms for predicting future performance of emergency medicine residents
Authors: Ariaeinejad A. , Patel R. , Chan T.M. , Samavi R.
Published: May 2017

Introduction: Background: Medical education is transitioning from a time-based system to a competency-based framework. In the age of Competency-Based Medical Education, however, there is a drastically increased amount of data that needs to be interpreted. With this data, however, comes an opportunity to develop predictive analytics. Machine learning is a method of data analysis that automates analytical model building. Using algorithms that iteratively learn from data, machine learning allows computers to find hidden insights without being explicitly programmed where to look. Machine learning has been successfully used in other fields to create predictive models. Objective: This study evaluates the application of neural network as a machine learning algorithm in learning from historical data in emergency residency program and predicting future resident performance. Methods: We analyzed performance data for 16 residents (PGY1-5) who were assessed at end of each shift. Performance was graded in each of the CanMEDS Roles with scores from 1 to 7 by different attending physicians who observed residents during the shift. We transformed sequences of scores for each resident to a fixed set of features and combined all of them in one dataset. We considered scores under 6 as “At Risk Resident” and scores 6 or more as “Competent Resident”, and then we separated the dataset into training and testing sets using K-Fold cross validation and trained an artificial Neural Network in order to make decision about the future situation of residents in a specific CanMEDS Role and general performance. Results: We used 5-fold cross validation to evaluate the model, one round of cross-validation involves partitioning the whole data into complementary subsets, performing the training phase on the training set, and validating the analysis on the testing set. To reduce variability, multiple rounds of cross-validation are performed using different partitions, and the validation results are averaged over the rounds. Results of cross validation show that accuracy of model was 72%, sensitivity was 81% and specificity was 43%. Conclusion: Machine learning algorithms such (as Neural Network) have the ability to predict future resident performance on a global level and within specific domains (i.e. CanMEDS roles). Used appropriately, such information may be a valuable for monitoring resident progress.
P037: The Ontario Emergency Department Return Visit Quality Program: a provincial initiative to promote continuous quality improvement
Authors: Chartier L.B. , Ostrow O. , Yuen I. , Kutty S. , Davis B. , Hayes E. , Davidek M. , Lau C. , Vigo A. , Yang F. , Fairclough L. , Ovens H.J.
Published: May 2017

Introduction: Analyzing the charts of patients who have a return visit to an emergency department (ED) requiring hospital admission (termed ‘RV’) is an efficient way to identify adverse events (AEs). Investigating these AEs can inform efforts to improve the quality of care provided. The ED RV Quality Program (RVQP) is a new initiative supported by Ontario’s Ministry of Health and Long-Term Care and managed by Health Quality Ontario. It aims to promote a culture of continuous quality improvement through routine audit/investigation of RVs. Methods: The provincial program is mandatory for high-volume EDs and requires auditing of some 72-hour RVs and all 7-day RVs involving ‘sentinel diagnoses’ (subarachnoid hemorrhage [SAH], acute myocardial infarction [AMI], or pediatric sepsis [PS]). A standardized audit template is followed that includes assessment of the type/severity and underlying causes of AEs, and potential actions for improvement. Results: 73 high-volume EDs and 16 smaller EDs (collectively receiving 90% of all ED visits in Ontario) are participating in the program. Nine months’ data have been released to date, comprising 33,956 RVs (1.05% of 3,235,751 ED visits). Of these, 233 RVs (0.69%) were for a sentinel diagnosis (SAH=11, AMI=191, PS=31). The most common presenting complaint on the index visit was abdominal pain (18%). The most common discharge diagnosis following RV admission was acute appendicitis (3.8%). Conclusion: The ED RVQP aims to improve the quality of care provided in Ontario’s EDs by requiring hospitals to conduct audits of RVs and plan actions for improvement when quality gaps are identified. Participating hospitals have completed hundreds of audits to date.
P041: The nursing shift: measuring the effect of inter-professional education on medical students in the emergency department
Authors: Crawford S. , McInnes G. , Jarvis-Selinger S. , Harris D.R.
Published: May 2017

Introduction/Innovation Concept: Inter-professional education (IPE) involves ‘occasions when two or more professions learn with, from and about each other to improve collaboration and the quality of care’. Current literature has found IPE to increase knowledge and skills, improve attitudes towards other professions, and to promote superior clinical outcomes. Health Canada has collaborated to form accreditation standards to support IPE in Canadian medical schools. The proposed educational innovation termed the ‘nursing shift,’ based out of Kelowna General Hospital’s Department of Emergency Medicine, in partnership with UBC’s Southern and Island Medical Programs, endeavors to enhance IPE in our institution. Methods: This nursing shift was first trialed with third year medical students as a pilot rotation beginning in March of 2016. Based on overwhelmingly positive results obtained from narrative feedback, a formal rotation with the same structure will be implemented in the form of a prospective cohort study with 48 medical students from two UBC sites. One group will attend a nursing shift, while the other group will complete the standard emergency medicine rotation without this nursing shift. Impact will be measured using a mixed-method analysis where students will be asked to provide both quantitative feedback in the form of a questionnaire, and qualitative feedback in the form of a narrative response. The primary outcome will be quantitative score differences between the groups of students, and the secondary outcome will be qualitative results for those who completed the nursing shift. Curriculum, Tool, or Material: The innovative educational concept consists of an 8-hour nursing shift where medical students spend the first 4 hours at triage with a nurse learning about patient intake. The remaining 4 hours are in the emergency department where students collaborate with a nurse on a number of tasks including preparing and administering medications, starting intravenous lines, and inserting Foley catheters. Conclusion: Healthcare systems are shifting to a more collaborative team oriented approach, and IPE has been shown to prepare students for this changing workplace. We seek to understand third year medical students’ experience of the nursing shift, and to evaluate any changes in attitudes towards inter-professional collaboration after engaging in this intervention. Evaluation of this novel implementation will enable us to assess and optimize the nursing shift, and if it is well received, encourage widespread adoption.
P044: Factors influencing laboratory test ordering by physicians and nurses in the emergency department
Authors: Delaney L. , Gallant A. , Stewart S. , Curran J. , Campbell S.G.
Published: May 2017

Introduction: Understanding factors that influence laboratory test ordering in emergency departments (EDs) can help to improve current laboratory test ordering practices. The aim of this study is to compare patterns and influences in laboratory test ordering between emergency physicians and nurses at two ED sites, Halifax Infirmary (HI) and Dartmouth General (DG). Methods: A mixed-methods approach involving administrative data and telephone interviews was employed. Data from 211,279 patients at HI and DG EDs were analyzed. Chi-square analysis and binary logistic regression were used to determine significant factors influencing whether a test was ordered, as well as significant factors predicting likelihood of a nurse or a physician ordering a test. All significant associations had a p-value of <0.0001. Interviews were conducted (n=25) with doctors and nurses in order to explore areas of potential influence in a clinician’s decision-making process, and discuss what makes decision making difficult or inconsistent in the ED. These interviews were analyzed according to the Theoretical Domains Framework. The interviews were coded by two individuals using a consensus methodology in order to ensure accuracy of coding. Results: Overall, laboratory tests were more likely to be ordered at DG than at HI (OR=1.52, 95% CI: [1.48, 1.55]). Laboratory tests were more likely to be ordered by nurses at DG than at HI (OR=1.58, 95% CI: [1.54, 1.62]). Laboratory tests were more likely to be ordered if the ED was not busy, if the patient was over 65, had a high acuity, had a long stay in the ED, required consults, or was admitted to hospital. Doctors were more likely to order a laboratory test in patients over 65, requiring consults or hospital admission, whereas nurses were more likely to order laboratory tests in patients with high acuity or long stays in the ED. Data from the interviews suggested differing influences on decision making between nurses and doctors, especially in the areas of social influence and knowledge. Conclusion: Currently, there is limited research that investigates behaviour of both emergency physicians and nurses. By determining barriers that are most amenable to behaviour change in emergency physicians and nurses, findings from this work may be used to update practice guidelines, ensuring more consistency and efficiency in laboratory test ordering in the ED.
P053: Communication interruptum: cellphone technology problems in paramedic-physician communication
Authors: Eby D. , Woods J.
Published: May 2017

Introduction: Approximately 15 years ago cell phones replaced portable VHF radios as the means of communication between paramedics and base hospital physicians. Cellphones, like VHF radio, do not allow voice transmission and reception to occur simultaneously. Radio use requires a learned technique to signal the end of each speaker’s turn talking. These techniques are not used in normal cellphone conversation. Poor cellphone reception and poor technique result in breakdowns in communication. The literature about paramedic-physician telecommunication is almost nonexistent. There is an extensive literature in other industries, such as aviation, concerning problems in radio communication. This literature predicts that communication breakdowns are common and have critical consequences. We sought to determine how frequently problems attributable to cell phone technology arose in paramedic-physician communication. Methods: We conducted a retrospective analysis of all patch calls between physicians and paramedics from 4 municipal paramedic services from January 01-December 31, 2014. MP3 audio files, recorded during normal operating procedures by the Central Ambulance Communication Centre, were anonymized and transcribed. Transcripts were read multiple times by the authors and analyzed using mixed methods-qualitative thematic framework analysis and quantitative descriptive statistics. Results: 161 calls were identified. 155 tapes were usable for analysis. 127 (81.9%) patches involved termination of resuscitation orders, 28 (19.1%) were for advice or other orders. The data set consisted of 567 pages of transcripts. Communication problems were identified in 138 (89.0%) patches. Most had multiple problems. Technical problems included disconnections (13.5%), or difficulty hearing (56.8%)-indicated by phrases such as “what?”, “I can’t hear you”. Disorganized cell phone technique was common-individuals interrupted each other (34.2%), and talked simultaneously (54.8%). Signalling the end of “talk turns”-using terms such as “10-4” or “over”-was never used. Conclusion: In addition to technical problems (poor transmission, disconnections), disorganized cell phone ‘technique’ caused a high incidence of communication problems. This is concerning because critical clinical decisions (e.g. ceasing resuscitation) depend on clear communication. Understanding the limitations of cellphone technology might improve communication.